Finding the Right IOL After Corneal Surgery

Surgeons will note a lack of research on performing cataract surgery after cornea surgery, especially regarding simultaneous vision intraocular lenses (SVL). According to Ruth Lapid-Gortzak MD, PhD, this research has contradictory results.

“One paper showed that patients reported higher satisfaction with worse refractive outcomes. I wish they’d come to my clinic, because this doesn’t reflect my experience.”

Dr Lapid-Gortzak drew on her own experience to provide some clarity, starting with an outline of the two strategies currently used for treating this highly specific group of patients.

The first is to restore corneal asphericity before cataract surgery, followed by the procedure with an SVL. Dr Lapid-Gortzak said this strategy has the benefit of providing more control to the clinician, but as with any extra procedure, there are associated costs and risks.

The second strategy is to deal with these patients “within the limitations our daily practices allow.” This more cautious approach is easier to apply, and naturally has fewer costs and risks, but it is “not academic.” Both approaches, she said, also require more research.

Conductive keratoplasty (CK) came under criticism too. Dr Lapid-Gortzak said she had treated several patients who had undergone CK, describing the results with SVLs as suboptimal due to corneal irregularity. She advised against using SVLs in patients post-radial keratotomy as well, describing its results as “suboptimal, with an unstable cornea, higher-order aberrations, and irregular topographies leading to very unpredictable outcomes.”

The key to successfully treating cataract patients post-cornea surgery is choosing the right IOL, Dr Lapid-Gortzak said. Simultaneous vision IOLs may appear as an “easy way out,” but she cautioned that some of these lenses are actually “plain bifocal diffractive lenses that do not give anything on reading distance.”

Dr Lapid-Gortzak also added that refractive lenses tend to create more side effects due to their different refractive surfaces, which can have a considerable impact on patient outcomes, depending on the lens.

“I’ve seen a lot of people who have had different types of laser surgery,” she said. “From my own experience, I learned that the moment they have had surgery for more than five dioptres of myopia, the cornea won’t always work with a trifocal or diffractive lens.”

The key to selecting the right lens for those good outcomes, therefore, lies in screening patients, Dr Lapid-Gortzak said. Those with a K value between 40 D and 45 D, a good tear film, etc., could be candidates for a diffractive premium IOL, while those with more negative indications could be candidates for a different SVL. Their personal circumstances should also be considered too.

“If someone comes to you and they got divorced two months before, they may project their frustration on you, so be careful,” Dr Lapid-Gortzak advised. “I always discuss the possibility of dissatisfaction, but you should always take their behaviour into account.”

Dr Lapid-Gortzak spoke at the 2025 ESCRS Annual Congress in Copenhagen.

Ruth Lapid-Gortzak MD, PhD is a cataract, cornea, and refractive surgeon at the Amsterdam University Medical Centers, Netherlands. r.lapid@amsterdamumc.nl