A significant proportion of patients with Fuchs endothelial dystrophy also develop cataracts; both conditions are age-related, and they frequently present together. When both diseases are affecting vision simultaneously, performing cataract removal and DMEK corneal transplantation at the same anaesthetic can be the most efficient and clinically appropriate approach. This combined procedure is sometimes called the "triple procedure" or combined phacoemulsification-DMEK.
What is the Triple Procedure?
The triple procedure combines phacoemulsification cataract surgery with IOL implantation and DMEK corneal transplantation at the same operative session. The cataract is removed and a lens implanted first, then the recipient's diseased Descemet membrane is stripped and replaced with donor endothelial tissue, all through small self-sealing incisions, without sutures for the graft. The procedure requires a surgeon with subspecialty expertise in both cataract and corneal surgery.
The triple procedure combines phacoemulsification cataract surgery (with IOL implantation) and DMEK corneal transplantation at the same operative session. The cataract is removed first, an intraocular lens is implanted, and then the recipient's diseased Descemet membrane is stripped and replaced with donor tissue, all through small self-sealing incisions, without sutures.
The procedure is technically demanding. It requires a surgeon with subspecialty expertise in both cataract and corneal surgery; not all ophthalmologists perform combined procedures. At Northpark Private Hospital in Bundoora, I perform both components of the triple procedure.
Who is a Candidate?
The combined approach is appropriate when a patient has both a visually significant cataract and moderate to advanced corneal endothelial disease, most commonly Fuchs dystrophy or bullous keratopathy, where cataract surgery alone is unlikely to restore satisfactory vision. Not all patients with both conditions need the combined approach; in mild Fuchs dystrophy, cataract surgery alone can sometimes substantially improve vision. The decision depends on endothelial cell count, corneal thickness, cataract severity, and the patient's visual goals.
The combined approach is appropriate when:
- The patient has both a visually significant cataract and corneal endothelial disease affecting vision
- The corneal disease is moderate to advanced Fuchs dystrophy or bullous keratopathy
- Cataract surgery alone is unlikely to produce satisfactory vision due to the degree of corneal disease
- The patient is medically fit for a longer procedure (typically 45–60 minutes)
Not every patient with both conditions needs the combined approach. In mild to moderate Fuchs dystrophy with a significant cataract, removing the cataract alone can sometimes improve vision substantially. The reduced intraocular stress from removing the lens reduces fluid production in the anterior chamber, and the cornea may partially compensate. Whether the cornea can carry this increased load, or whether DMEK is also required, depends on the endothelial cell count, corneal thickness, and clinical findings at the slit lamp.
Advantages of the Combined Approach
The main advantages of the combined approach are: one anaesthetic rather than two, a single recovery period covering both sources of visual impairment simultaneously, and avoidance of cataract surgery through a previously transplanted cornea (which is more technically demanding and carries higher risk to the graft). For older patients with medical comorbidities, minimising anaesthetic exposure is an additional consideration in favour of the combined approach.
For patients where combined surgery is appropriate, the advantages include:
- One anaesthetic — patients over 60 often have medical comorbidities that make minimising anaesthetic exposure sensible
- Single recovery period — rather than cataract surgery, recovery, then corneal transplant, recovery; the two recoveries overlap
- Avoidance of cataract surgery through a transplanted cornea — cataract removal after DMEK is technically more challenging and carries higher risk to the graft. Removing the cataract first is cleaner.
- Simultaneous treatment of both sources of visual impairment
The Challenge of IOL Power Calculation
IOL power calculation is more challenging in the combined procedure because the diseased, swollen cornea in Fuchs dystrophy has abnormal curvature and refractive power at the time of pre-operative measurement. After DMEK, as the donor endothelium begins functioning, the cornea gradually thins and its refractive power shifts. Nomograms and target adjustments are used to account for this expected change, and patients are counselled that some residual spectacle correction is possible after full recovery.
One of the most technically challenging aspects of the combined procedure is selecting the correct IOL power. In Fuchs dystrophy, the cornea is oedematous and thicker than normal — its refractive power and curvature are abnormal. After DMEK, as the healthy donor endothelium begins functioning, the cornea gradually thins and its refractive power changes.
This means that the IOL power calculated before surgery (based on the diseased, swollen cornea) will not perfectly match the ideal power for the post-DMEK cornea. Various nomograms and adjustments have been developed to account for this expected refractive shift; most surgeons aim for a mildly myopic target to allow for the post-operative corneal change. Patients should be counselled that residual spectacle correction is possible and that a DMEK-adjusted IOL target is being used.
My Approach at Northpark
As a subspecialist in both cataract and corneal surgery, I perform combined phacoemulsification-DMEK procedures at Northpark Private Hospital in Bundoora. Pre-operative assessment for these cases includes specular microscopy (endothelial cell count), corneal tomography, slit-lamp examination, and biometry to determine whether combined or staged surgery is the appropriate path for each individual patient's degree of disease.
As a subspecialist in both cataract and corneal surgery, I perform combined procedures regularly. Pre-operative assessment includes specular microscopy (endothelial cell count), corneal tomography, slit lamp examination, and biometry. Based on these findings, I discuss in detail with each patient whether a combined or staged approach is the right choice, and what to expect in terms of visual recovery from each component of the surgery.
For patients in Melbourne with combined Fuchs dystrophy and cataract, referral via your GP or optometrist to Northern Eye Consultants allows me to perform a comprehensive assessment and discuss the full range of surgical options. For more on DMEK and corneal transplantation, see the DMEK article on this site, and the detailed patient guide at corneaeyedoctor.com.