MOST SPECIALTY LENS wearers will require cataract surgery at some point in their lifetime. The comanaging optometrist can often be of great assistance in both the preoperative and postoperative roles. Corneal GP lens wearers may be particularly challenging to guide through this process. Concerns of corneal molding, intraocular lens (IOL) calculation, and visual fluctuations during the postoperative healing period may require additional consideration.
To collect the most accurate preoperative data, contact lens wear should be discontinued prior to the initial evaluation to allow for any corneal molding to resolve and for corneal shape to stabilize. This process has been shown to take anywhere from 4 to 16 weeks in corneal GP lens wearers, and it varies greatly between patients (Wang et al, 2004; Tsai et al, 2004).
Although most surgeons prefer a specific approach, the most conservative one is to refer only when stability is demonstrated via serial topographical analysis over time. However, this is impractical when a patient who has advanced corneal disease and irregular astigmatism is unable to function visually with spectacles during the washout period.
Even if great care is taken to ensure corneal stability, IOL calculation in patients who have irregular corneas can be difficult for several reasons. Tear film irregularities (commonly found in patients who have corneal disease) can reduce the accuracy of corneal measurements (Singh and Joshi, 2023). Instruments used to measure keratometry that do not consider abnormalities in the posterior cornea can make erroneous assumptions about corneal power (particularly in patients with Kmax steeper than 55 D), which can lead to a postoperative refractive “hyperopic surprise” (Singh and Joshi, 2023; Gonzalez-Salinas et al, 2022). Keratoconus patients may also have deeper anterior chambers and longer axial lengths due to a heightened and/or off-center corneal apex, which can cause unexpected variances in axial length measurements and effective IOL power (Gonzalez-Salinas et al, 2022).
Monofocal IOLs are recommended for patients who have irregular corneas to avoid increased higher-order aberrations that may arise from multifocal or extended depth of field IOLs. Toric IOLs may be effective if corneal disease is mild to moderate (Ling et al, 2023; Sarnicola et al, 2025), but are not indicated for severe keratoconus or highly irregular corneas and can complicate the use of GP lenses postoperatively when the toric axis of the IOL, combined with a GP-neutralized corneal cylinder, results in residual astigmatism. In many cases, it is advisable to “underpromise and overdeliver,” warning patients that both GP lenses and spectacles may still be required after surgery.
Postoperatively, if GP lenses are required and corneal shape remains similar to what it was preoperatively, the patient may use their previous GP lenses as trial lenses to obtain an over-refraction and new adjusted powers. Eyes with corneal disease may require a longer time to heal, and resuming contact lens wear (while often desirable for better vision) may need to be delayed until it can be done safely. Understanding that the entire process of cataract surgery can be longer and more frustrating for GP lens wearers encourages the comanaging optometrist to better support these patients from start to finish.
References
1. Wang X, McCulley JP, Bowman RW, Cavanagh HD. Time to resolution of contact lens-induced corneal warpage prior to refractive surgery. CLAO J. 2002;28(4):169-171. doi:10.1097/01.ICL.0000018042.02034.AB
2. Tsai PS, Dowidar A, Naseri A, McLeod SD. Predicting time to refractive stability after discontinuation of rigid contact lens wear before refractive surgery. J Cataract Refract Surg. 2004;30(11):2290-2294. doi:10.1016/j.jcrs.2004.05.021
3. Singh C, Joshi VP. Cataract surgery in Keratoconus revisited - An update on preoperative and intraoperative considerations and postoperative outcomes. Semin Ophthalmol. 2023;38(1):57-64. doi:10.1080/08820538.2022.2112702
4. Gonzalez-Salinas R, Franco JJ, Reyes-Luis JL, et al. Cataract surgery in patients with underlying keratoconus: focused review. J Cataract Refract Surg. 2023;49(1):97-102. doi:10.1097/j.jcrs.0000000000001069
5. Ling JYM, Qiao G, Iovieno A, Yeung SN. Visual Outcomes of Cataract Surgery in Patients With Keratoconus Using Toric and Non-toric Lenses. J Refract Surg. 2023;39(5):319-325. doi:10.3928/1081597X-20230301-01
6. Sarnicola C, Sarnicola E, Sarnicola V. Cataract surgery in keratoconus: current challenges and future directions. Curr Opin Ophthalmol. 2026;37(1):11-15. doi:10.1097/ICU.0000000000001180