How do you approach cataract surgery in a patient with a history of radial keratotomy (RK) who desires postoperative independence from glasses?

Carefully.

I would say I'm abrupt and dispel the notion they will be spectacle independent at all, given they are not candidates for MTF lenses and, even EDoF lenses, would have issues of aberrations in the visual system caused by the RK incisions. I literally hang the "black drape." That sort of shocks the expectations out the window up front. I then reset those expectations based on what I know of RK eyes' behavior post-op.

MTF/EDoF lenses, in my opinion, behind RK incisions create way too many problems, and I won't implant these and state that. I'm not getting involved in unrealistic expectations, frankly, when I know better that this will induce issues in the vast majority of these patients. I'm not opposed to doing some version of mono...

If he is serious about glasses independence, he needs an LAL.
Nothing else will give him the 99% odds of being glasses-free in the distance, and usually up close as well.

Otherwise, assuming he is even a candidate, the standard disclaimers about refractive surprise with an MF or EMV lens. May need PRK after.

Agree with all of the above. Note that there is a big difference between a 2 or 4-cut RK and a 12-cut with astigmatic AK cuts. I can also remember a patient that I targeted for mild myopia afterwards and ended up hyperopic. She was bitterly unhappy, and after about nine months, badgered me into exchanging out the IOLs adjusting for her actual outcome. And everything was great until 18 months later, when she abruptly shifted again. We both ruefully noted that if she had kept the original implant, she would've had perfect vision. To this day, I'm not exactly sure what happened. At that time, we did not have the good corneal imaging technology we have now. So on the whole, up until I retired from cataract surgery nine years ago, I would always...

I'd hope they consider scleral contacts as glasses independence.

Between the irregular astigmatism and continued hyperopic drift, long-term glasses independence is pretty unlikely (unless they have very limited RK).

People who have had RK have more unstable corneas; the more cuts, the worse. If the expectations are too high, you need to quash them BEFORE surgery. Complete spectacle independence is a high bar at a baseline.

Inform the patient of a 50% chance of needing a second procedure or enhancement.

It's been stated above, and there isn't much to add.

Avoid premium IOLs in these patients. Be frank with the patient and just tell them that any idea of spectacle independence is pure fantasy. If somehow they achieve that with a single vision lens and their irregular shifting cornea, then you can walk on clouds around them. Underpromise and hope to overdeliver, but most of the time, I find RK is the gift that keeps giving well past the hyperopic shifts that occur during cataract formation. And patients very rarely argue with me about the way their eye (cornea) is just an unstable mess due to their RK.

I do not mind losing a patient to a competitor if they have unreasonable expectations and do not appreciate my recommendation that simple is ...

Agree with much of what has been said. I discourage MFIOLs due to aberrations and the RK cuts. However, after having many patients have hyperopic outcomes in spite of using every formula I could find, I tried using ORA on an 8 cut RK patient (no AKs). The ORA adjusted the IOL power I chose by 3 full diopters. I reluctantly put in the recommended IOL. First RK patient ever with 20/20 distance OU uncorrected. Now 3 years out - no shift yet. So, now I don't promise 20/20, but I am much more confident using ORA and getting much closer that I used to.