Here at Miami Eye Center I am seeing a gradual trickle of RK alumni who had their surgery in the 80’s now coming back for cataract surgery.  While the outcome from cataract surgery following prior RK can be excellent, there are a number of important issues that should be understood by the patient. The cornea is a very complex tissue that is perfectly designed to help focus light on the retina and the result of making radial incisions vastly alters the optical properties.  Most importantly is that the cornea loses its stability.  As the years have past since the RK, the cornea has flattened.  In addition, within any given day the cornea shape changes from flat in the morning to steep in the evening.  This often makes people farsighted in the morning and nearsighted later in the day.  When we make the preoperative calculations for the intraocular lens we are in effect shooting at a moving target.  When the calculation is off, the patient will be either nearsighted or farsighted following the surgery.  In addition, the algorithms applied to normal corneas are impacted by the flatness of the RK cornea further making the calculations difficult.  While I have a pathway of making the appropriate calculation adjustments I still warn patients about the above possibilities.  Also that one can not be certain of the outcome until several months following the surgery as the cornea continues to flatten.  If the power of the eye is not satisfactory there are several options for improving the outcome.  Eyeglasses are easiest but perhaps not the first choice.  Contact lenses might be worn.  Lastly, it is possible to insert a second intraocular lens into the eye to add or subtract the power necessary to yield good vision without glasses.  I have done this on a number of occasions  at which time the calculation of the “piggyback lens” is straight forward. I would recommend against a multifocal lens implantation because the multifocals don’t perform well if there is any significant power error.  A second reason is that there could be too much glare as a result of the optical properties of the RK cornea combining with the optics of the multifocal lens.  In many instances the Toric Lens has been helpful in managing astigmatism that is often seen after RK surgery.  It is important that the surgeon understand the type of astigmatism since the lens is not optimally effect in irregular astigmatism. My advice to any post-RK cataract surgery candidate is to be certain that their visual loss is due to cataract and not a cornea related issue and find a surgeon who has been there, done it and has a T-shirt.