The authors compared approximately 100 DSEKs in eyes with PCIOLs with approximately 50 combined DSEKs and cataract surgery. The finding of somewhat better visual acuity after the DSEK triples compared to the straight DSEKs is interesting, but in this retrospective study the two patient populations are not the same. While most, if not all, the DSEK triple eyes had never undergone previous surgery, every DSEK eye had previously undergone cataract surgery. Some of these cases may have been complicated, ending up causing corneal edema and possible other problems such as CME.

The other finding of note was more graft dislocations in the DSEK triple group. The reason for this is unclear. Perhaps more viscoelastic was retained, perhaps a less stable PCIOL did not allow the IOP to be raised as high during surgery, or perhaps there was more inflammation in these cases, any of which might increase the risk of dislocation — we don’t know.

For me, the take home message is that in eyes with cataract and some degree of corneal edema, both sequential cataract surgery followed by DSEK at a later date if needed, and a DSEK triple are viable options, each with pros and cons. The main limits of this study are its retrospective nature and relatively small size. The best way to attempt to determine which is better is a randomized controlled trial of patients with both cataracts and mild corneal edema, half undergoing a DSEK triple and the other half cataract surgery first and DSEK later. Until then, I generally recommend cataract surgery first, unless the corneal pathology is such that the poor view increases the risk of successful cataract surgery or significant corneal edema postoperatively.