Complex corneas and cataract surgery: addressing the higher-order aberrations

A 65-year-old woman with an ocular history of cataracts, radial keratotomy (RK), and laser in situ keratomileusis (LASIK) enhancements in both eyes had severe difficulty wearing scleral lenses and wanted a solution that could make her less dependent on contacts. On initial examination, her manifest refraction was +9.25 −12.00 × 089 20/250 in the right eye and +7.25 −10.25 × 099 20/800 in the left eye. With scleral lenses, she was correctable to 20/40 in the right eye and 20/70 in the left eye. Owing to highly irregular cornea and poor contact lens tolerance in the left eye greater than in the right eye, she underwent a penetrating keratoplasty (PKP) in the left eye and a light-adjustable lens (LAL) 1 year later. Postoperatively, she enjoys 20/30 uncorrected vision in her left eye despite residual anterior corneal astigmatism. On subsequent examination, pertinent findings were a manifest refraction of +9.25 −12.00 × 089 20/250 with spectacles and 20/80 with a scleral lens in the right eye and +1.25 −2.50 × 151 20/20-2 with spectacles in the left eye. Motility, pupils, intraocular pressure, and confrontation visual fields were normal in both eyes. The cornea in the right eye had 8-cut RK with irregular lengths and depth with the 8:30 cut most ectatic. The right eye had a clear PKP without evidence of rejection. Irides were normal with a dilation size of 7 mm. She has 3+ nuclear sclerotic and cataract in the right eye and a well-positioned LAL with an open capsule in the left eye. All other findings in the anterior and posterior segment were unremarkable. Corneal topography and corneal tomography revealed significant irregular astigmatism in the right eye greater than in the left and irregular mires/Placido imaging in the right eye greater than in the left (Figure 1 JOURNAL/jcrsoc/04.03/02158035-202601000-00028/figure1/v/2026-05-27T201018Z/r/image-tiff , Supplemental Figure 1, available at http://links.lww.com/JC9/A433). A staged procedure approach of a PKP followed by cataract surgery was recommended. However, the patient insisted that she would prefer her contact in the right eye postoperatively and could not endure waiting 1 year to visual recovery after a PKP. She underwent cataract surgery only in the right eye and wanted to use the same LAL technology. I advised the patient that any monofocal intraocular lens (IOL) would work and her best vision would be with a scleral lens. The patient elected to have the LAL. Postoperatively, she was only correctable to 20/60-2 with a scleral contact and complained of constant blurred vision at all distances (Figure 2 JOURNAL/jcrsoc/04.03/02158035-202601000-00028/figure2/v/2026-05-27T201018Z/r/image-tiff ). On slitlamp examination, the right eye revealed a hazy opaque ring on the LAL. How would you proceed with this patient? What diagnostic information would you use to assess the complaints? What are the surgical solutions to consider?