Cataract Surgery & Corneal Disease Treatment – James S. Lewis, MD

Serving Bucks County, Philadephia, Warminster, King of Prussia, Delaware Valley, Phoenixville, Montgomery County and Conshohocken

Sometimes patients have been told their cornea is “weak” and may not tolerate cataract surgery. Most of these patients have too few corneal endothelial cells and are described as having corneal endothelial dystrophy. Sometimes too few of these cells are the result of severe trauma, prolonged inflammation (uveitis), or previous surgery.

Although it is difficult to predict whether the cornea will tolerate cataract surgery, we use multiple techniques including endothelial cell examination, specular microscopy, and optical coherence tomography of the cornea to make that determination. If it is likely the cornea will fail, we perform what is called a triple procedure which includes cataract surgery, intraocular lens insertion, and endothelial cell transplant (DSEK).

In the last few years the prolonged recovery period forced surgeons to delay triple procedures until a patient’s vision was extremely poor. These cases involved full thickness corneal transplants (Penetrating keratoplasty, PK), 16 or more sutures, restricted activities, and high degrees of postoperative astigmatism. Now that we can transplant only the deficient portion of the cornea, the endothelial cells, patients recover very quickly, have only a handful of sutures, have almost no postoperative astigmatism and virtually no limitation of activities.

In cases in which cataract surgery has been performed and the corneal endothelial cells fail, DSEK (Descemet’s Striping Endothelial Keratoplasty), a 20 minute, out patient procedure, is frequently done in our practice.

Other cases of corneal disease like Herpetic Scarring, Corneal Lacerations, Stromal Dystrophy and Microbial Ulcers with Scarring can be addressed with our Excimer Laser using what is called PTK (Phototherapeutic Keratoplasty). When the scarring is too deep an MDALK technique can be performed. MDALK (Maximum Depth Automated Lamellar Keratoplasty, or the Big Bubble) removes the diseased corneal tissue leaving only the healthy endothelial cells. This technique reduces corneal rejection, large degrees of postoperative astigmatism, and achieves excellent visual results. Furthermore, MDALK has a significantly reduced level of activity restriction and suture removal two to four times earlier than standard Penetrating Keratoplasty.

When full thickness corneal transplantation is needed, with or without combined cataract surgery, we have two options. The latest, FAK (femtosecond assisted keratoplasty) which is also known as IEK (Intralase™ enabled Keratoplasty). A laser like the one used for flap creation during LASIK is used to fashion both the donor and recipient cornea using a specialized tongue in groove template. The precision of this laser allows for outstanding tissue apposition, rapid healing, earlier recovery, and reduced postoperative astigmatism. Dr. Mike Aronsky of Kremer Eye Center and I are the only approved and experienced IEK team in the region.

Sometimes full thickness corneal transplantation and cataract surgery with posterior chamber lens implantation using a mechanical trephine is the best option. Although recovery can take 10 to 12 months our results have been outstanding. Much of this is the result of our ERAPK system.

ERAAPK, (Excessive Regular Ammetropia/Astigmatism following Penetrating Keratoplasty) was the subject of a paper I published in 1991. We now have the world’s largest pool of ERAAPK patients (approximately 500 eyes). ERAAPK uses the excimer laser to perform an advanced surface ablation on post-operative corneal transplant patients. Few if any ERAAPK patients require RGP (rigid gas permiable) contact lenses after surgery. In fact, many are either entirely spectacle free or in need of “normal” glasses.

We also perform Femtosecond Assisted INTACS for Keratoconus and will begin ribo-flavin cross-linking after FDA approval is granted.

Cataract Surgery in conjunction with Corneal Disease Management has been revolutionized in the last few years. We are proud to provide the most up to date surgical and laser techniques.