Reply: Drs. Price and Feng’s analogy of the cornea resembling a windshield is useful. We agree on the importance of a holistic approach to the patient’s visual problems and the involvement of corneal transplantation as a possible treatment early in the planning process before cataract surgery.
Our study, involving nearly 900 corneal patients with guttata, found that these patients benefit considerably from cataract surgery as a group. However, corneal guttata was associated with worse visual acuity results and worse patient self-assessed visual function than in cataract patients without corneal guttata. The negative effect of corneal guttata on visual acuity was most prominent during the first 3 weeks.
Data on grading of the corneal guttata was not available for our study. Undoubtedly some patients in our cohort had substantial discomfort resulting from their corneal guttata; however, the need for future corneal surgery was beyond the scope of our article and would be an intriguing subject for future studies. Still, the median postoperative Snellen decimal CDVA in the guttata group was 0.8 compared with 0.4 preoperatively. The probability of achieving even better visual acuity (≥0.9 Snellen) after 3 weeks was well over 40% (Figure 4 in article). The median value of patients’ self-assessed visual function improved by more than 3 logit units, just slightly less than for patients without corneal guttata. These substantial improvements after cataract surgery in the guttata group makes it questionable whether further surgery is relevant for most of the patients.
With that said, it is crucial to identify patients with posterior corneal dystrophy who do not have improved visual function after cataract surgery and who thus require further surgery. As Drs. Price and Feng point out, improvement of corneal surgical techniques shifts the risk-benefit evaluation toward earlier corneal transplantation. We believe that there is room for more use of DMEK and other corneal surgeries for patients with corneal guttata and Fuchs endothelial dystrophy. Nevertheless, cataract surgery is a less complex surgery than lamellar corneal transplantation, especially from a postoperative perspective in terms of the risk for graft detachment and rejection. Corneal transplantation also requires human donor tissue, which today is scarce worldwide. Although Descemet stripping only is an exciting method, it seems hasty to recommend it more widely in corneal guttata patients, especially when in combination with cataract and when keeping the results in our study in mind.
Lamellar corneal transplantation, as DMEK, is a fantastic surgical technique that helps patients with troublesome corneal guttata and should be offered to these patients. Our clinical experience is that patients with corneal guttata and seemingly minimal cataracts can have improved visual function after cataract surgery. Based on that and the results in our study, we endorse performing cataract surgery before corneal transplantation as a standard strategy, even in cases in which transplantation is likely. However, we advocate an individual risk-benefit assessment with the patient’s interest in focus and as part of treatment planning, which can lead to other treatment approaches in each individual case.
We based our recommendations on patient-reported outcomes, which means the patients’ perspective. It is well known that patient-reported outcomes and clinical outcomes can diverge, like reality and a map might.
None of the authors has a financial or proprietary interest in any material or method mentioned.