In patients with early Fuchs’ endothelial dystrophy, how do you determine whether to proceed with cataract surgery alone versus a combined endothelial keratoplasty?

If Corneal thickness is >640 or specular microscopy is lower than 1,000, those are indicative of poor outcome after cataract surgery and patients may benefit from combined procedure. However, some patients with Fuchs can be misleading as having a low corneal thickness but a dense central guttae that may affect the outcome of cataract surgery alone. For these particular patients (especially if the cataract is visually significant), I give them both options and let them decide as long as they are aware that the chance of needing a transplant is high.

I consider there to be three categories of patients presenting with visually significant cataract and Fuchs' dystrophy.

• Category 1 patients have more severe Fuchs' dystrophy that is clearly visually significant with increased CCT and edema or Descemet folds on exam. These patients will almost certainly have progression of corneal disease and be unhappy with post-operative vision following cataract surgery alone. They will almost always benefit from combined cataract + DMEK surgery and I highly recommend it.
• Category 3 patients have very mild Fuchs' dystrophy with no edema, more mild guttae, typically endothelial cell counts >1000, and no symptoms of Fuchs dystrophy (no blurry vision in the morning which clears through the day). These patie...