On Friday, September 12, 2025, at the ESCRS Congress in Copenhagen, Dr. Dr. Emilio A. Torres-Netto, MD, PhD, FWCRS presented “Cataract surgery and keratoconus” during the session Cataract Surgery in the Patient with Corneal Pathology (chaired by Paolo Vinciguerra and Beatrice Cochener-Lamard).
The Challenge
As Dr. Torres-Netto emphasized, modern cataract surgery is expected to deliver near-perfect refractive outcomes. Yet when cataract develops in keratoconus, this expectation becomes difficult:
IOL power calculation is far less predictable because of irregular corneal topography, anterior/posterior asymmetry, and unstable keratometric readings.
Astigmatism estimation is particularly challenging, with significant variation depending on whether one measures the central pupil zone or peripheral corneal regions.
Practical Pearls
Dr. Torres-Netto shared several strategies to optimize outcomes:
Focus on the central pupil area when evaluating keratometry, as this better reflects the patient’s functional vision.
Target postoperative myopia, which is safer than hyperopia, particularly in patients who will require scleral or rigid contact lenses after surgery.
Use monofocal IOLs in most cases; toric lenses may be considered in stable, regular corneas with good spectacle-corrected acuity.
Plan corneal optimization: procedures such as ELZA-PACE customized cross-linking or selective laser treatments may be performed before or after cataract surgery to improve corneal regularity and enhance refractive predictability.
Looking Ahead
Dr. Torres-Netto concluded that cataract surgery in keratoconus requires careful planning, realistic patient counselling, and sometimes a staged approach that combines corneal and lenticular procedures. With this strategy, outcomes can be significantly improved, even in eyes with advanced irregularity.
