Fuchs Dystrophy and Cataract: Diagnosis, Evaluation and Treatment

FECD, first described in 1910, primarily affects the corneal endothelium and Descemet’s membrane, leading to accelerated endothelial cell loss, guttae, and corneal edema. It is typically inherited, more common in women, and often manifests in middle age, coinciding with cataract development. Cataract surgery can precipitate decompensation in FECD eyes, necessitating careful evaluation and surgical planning. The purpose of this review is to summarize contemporary diagnostic approaches and surgical strategies for managing coexisting FECD and cataract to optimize visual outcomes.

The review summarizes: (1) Clinical presentation and staging of FECD, including Krachmer grading and symptoms across stages; (2) Non-surgical management (limited benefit of hyperosmotics; potential benefit of ROCK inhibitor netarsudil in reducing edema in small trials); (3) Evolution of keratoplasty from PK to EK (DLEK, DSAEK, DMEK), with DMEK now widely adopted due to superior outcomes and lower risk; (4) Epidemiology of keratoplasty: FECD is the leading indication in the US and common in Europe/Australia; most FECD transplants are EK; (5) Decision-making for combined vs staged surgery by distinguishing the primary cause of vision loss (history, slit lamp, tomography/specular/pachymetry); (6) Diagnostic risk stratification using Scheimpflug tomography features for subclinical edema and models (e.g., CCT thresholds, tomographic features, RISC/RIPT scores) to predict EK need after cataract surgery; (7) Surgical options: phakic DMEK in younger patients without cataract; cataract surgery alone with endothelial-sparing techniques when no subclinical edema; triple DMEK vs sequential approaches with comparable vision and rebubbling outcomes but mixed EC loss results; (8) Technique modifications for combined procedures and IOL selection (prefer hydrophobic acrylic; consider myopic targeting due to hyperopic shift after DMEK); (9) Role and outcomes of FLACS vs conventional phaco (mixed findings, some advantages regarding EC loss and detachment in subsets); (10) Refractive outcomes including hyperopic trend in FECD and after DMEK, formula performance, contralateral-eye referencing; (11) Premium IOLs: feasibility of toric IOLs and staged presbyopia-correcting IOLs; light-adjustable IOLs as an option; (12) Emerging therapies: Descemet stripping only (DSO), ROCK inhibitors adjuncts, synthetic DM scaffolds, cell injection/cell sheet therapy, and gene therapy approaches.

Narrative review based on previously conducted studies; no new human or animal studies were performed. The article synthesizes clinical studies, registry reports, and trials cited throughout the text; no systematic search strategy or meta-analytic methods are described.

• DMEK has become the standard surgical treatment for FECD due to superior visual outcomes and lower risk compared with PK/DSAEK.
• Epidemiology: In the US (2021), FECD accounted for 35.8% (n=16,780) of all keratoplasties; 94.5% were EK, 5.5% PK. FECD is also a leading indication in Europe and Australia.
• Risk stratification for cataract-only vs EK: Scheimpflug tomographic features (irregular isopachs, displaced thinnest point, focal posterior surface depression) predict progression—5-year risk of progression: 7% with 0 features, 48% with 1–2 features, 89% with 3 features. A combined score (CCT plus tomography) estimates 2-year EK risk post-phaco from 0.8–7.5% (score <4) to 96.5% (score 8).
• Additional models (RISC and RIPT) using anterior corneal backscatter or pachymetry-derived metrics predict need for EK with high performance (RISC sensitivity 96%, specificity 95%; RIPT similar performance using pentacam thickness metrics).
• Phakic DMEK: Lens status does not adversely affect DMEK outcomes; subsequent cataract surgery after DMEK is feasible with minimal additional EC loss; 5-year phaco rate after phakic DMEK in FECD without cataract is 16.9%.
• Cataract surgery alone in FECD without subclinical edema is preferred; endothelial-sparing techniques (tri-soft shell, phaco-chop, low-flow irrigation) reduce EC loss; intraoperative complications are the main factor associated with endothelial failure; hydrophobic IOLs preferred to avoid opacification risk.
• Triple DMEK vs staged: Comparable visual outcomes, EC loss, and rebubbling rates in many series; some report higher EC loss at 1 month and 1 year with triple DMEK. Decision should consider surgeon experience, ocular comorbidities, and patient factors. Prior glaucoma surgery increases risk of rejection/failure and repeat keratoplasty; short-term outcomes can still be good.
• FLACS: Mixed evidence; some studies show no refractive advantage over conventional phaco; others show reduced postoperative EC loss and lower graft detachment/need for rebubbling when combined with DMEK in certain cohorts.
• Refractive considerations: FECD and DMEK are associated with a hyperopic shift; surgeons should target slight myopia in combined or anticipated DMEK cases; Haigis formula may perform differently than others in DMEK triple; first-eye refractive shift can inform second-eye targeting.
• Premium IOLs: Toric IOLs in DMEK triple reduce refractive cylinder and improve UDVA/BCVA but require attention to rotational stability; presbyopia-correcting IOLs can be considered staged after DMEK to optimize biometry; light-adjustable IOLs show promising early results.
• Emerging treatments: DSO can resolve edema by facilitating peripheral EC migration, with variable outcomes; ROCK inhibitors may enhance clearance and outcomes, including as DSO adjuncts; synthetic DM scaffolds support EC migration in preclinical models; cell-based therapies and gene-editing strategies are advancing toward clinical translation.

The review addresses the central clinical question of how to evaluate and manage patients with concurrent FECD and cataract by integrating history, slit-lamp examination, and advanced diagnostics (Scheimpflug tomography, pachymetry, specular microscopy) to identify subclinical edema and predict the risk of postoperative decompensation. It outlines when cataract surgery alone is appropriate versus when to combine or stage DMEK with cataract surgery, balancing risks of EC loss, graft detachment, and refractive outcomes. Evidence suggests DMEK provides superior endothelial rehabilitation, while cataract removal should be planned to minimize endothelial trauma. Predictive models (tomographic features, RISC/RIPT) help individualize surgical planning. Refractive strategy is critical due to the hyperopic tendency in FECD and after DMEK, guiding IOL power selection and candidacy for premium lenses. For patients with glaucoma or prior glaucoma surgery, counseling is tailored given higher risks of rejection or failure. Overall, the synthesis supports a personalized approach leveraging diagnostic risk stratification, surgical techniques that protect the endothelium, and considered sequencing of procedures to optimize vision and reduce complications.

FECD frequently coexists with cataract, requiring nuanced evaluation to determine the primary cause of visual impairment and to plan surgery that minimizes endothelial risk. DMEK is the preferred endothelial procedure, and cataract surgery alone is reasonable in FECD without subclinical edema using endothelial-sparing techniques and appropriate IOL selection. Combined DMEK–cataract (triple) and staged approaches yield comparable vision and rebubbling outcomes, with the choice guided by surgeon experience, ocular comorbidities, and patient preferences. Tomography-based risk models improve prediction of EK need after cataract surgery and support individualized care. Refractive planning should anticipate hyperopic shift in FECD and after DMEK. Emerging treatments—including DSO with or without ROCK inhibitors, synthetic DM scaffolds, cell-based therapies, and gene therapies—may expand future options. Further comparative and long-term studies are warranted to refine risk models, optimize refractive accuracy, and define the role of premium IOLs and novel therapies.

This is a narrative review without a specified systematic search strategy or meta-analysis, and it includes data from heterogeneous study designs (retrospective series, registries, small prospective trials), which may introduce bias and limit generalizability. Many cited studies have small sample sizes or short follow-up, and results are sometimes mixed (e.g., FLACS benefits, EC loss after triple DMEK). The applicability of advanced diagnostics (e.g., confocal backscatter) may be limited by availability. No new clinical data were generated.