Eyeworld

EW FEATURE 50 Improving the ocular surface for cataract and refractive surgeons • November 2018 AT A GLANCE • Pterygia, ABMD, and Salzmann's nodules all require special consideration in a patient who needs cataract surgery. • Treating these lesions before cataract surgery is usually advisable, although there are some circumstances when they are best left alone. • Surgeons must consider lesion size and patients' visual goals when setting treatment plans for ocular surface lesions. • Toric IOLs are not recommended in patients with ocular surface lesions. by Vanessa Caceres EyeWorld Contributing Writer should be removed prior to cataract surgery, with time for the cornea to heal and normalize." Dr. Teichman also will consider the presence of topographic chang- es, such as localized flattening, that may occur with smaller pterygia. This makes him more likely to remove the pterygium prior to surgery. He analyzes the topography, looking for asymmetry between the eyes. "If the affected eye is substan- tially different than the contralateral eye, that should alert the examiner to the possibility of pterygium-in- duced corneal changes," Dr. Teich- man said. Jeremy Kieval, MD, Lexington Eye Associates, Lexington, Massa- chusetts, said if there is a smaller pterygium, it can be left alone. However, he will let patients know that the refractive outcome can be more unpredictable and that the patient may have more significant postop astigmatism. "For the most part, topography is the most import- ant of the criteria I use, looking for the typical flattening of the cornea where the pterygium is present and the corresponding steepening in the opposite meridian," he said. Another important consider- ation is the severity of the pteryg- ium, said David Hardten, MD, Minnesota Eye Consultants, Minne- apolis. When he removes a pterygi- um in a patient with milder cataract that isn't the main vision issue, he will remove the pterygium and follow the patient until the cataract is visually significant. "In some eyes with severe pterygium with corneal scarring and irregular astigmatism that remains after the pterygium surgery, it may be a three-step or five-step procedure involving the pterygium surgery, followed by a PTK 6–12 months later, followed by the cataract surgery, then a YAG and another PTK," he said. "In a patient with a longstanding pterygium that now has very dense cataract, I will sometimes remove the cataract, and the patient understands that his or her vision will still be slightly im- paired from the pterygium as it had been before the cataract developed." Once a pterygium is removed, Dr. Teichman generally repeats the topography and biometry after 3 months. "There is evidence to sug- Assess carefully, consider potential postop visual outcome B etter management of oc- ular surface lesions before cataract surgery can help ensure better postop out- comes. However, surgeons must first decide which lesions need to be managed and which ones can be left alone. A group of ophthalmologists recently shared with EyeWorld how they typically approach common ocular surface lesions and degenera- tions, such as pterygia, anterior base- ment membrane dystrophy (ABMD), and Salzmann's nodules, before cataract surgery. Managing pterygia A pterygium in a patient who needs cataract surgery deserves special attention, said Joshua Teichman, MD, MPH, Department of Oph- thalmology and Vision Sciences, Trillium Health Partners, University of Toronto, Canada. "I am more aggressive in removing a pterygium prior to cataract surgery, especially in patients who are hoping for spec- tacle independence after surgery," he said. Other surgeons concurred. "The pterygium should be removed if it is encroaching on the visual axis and/ or the patient wants it removed," said David Goldman, MD, Gold- man Eye, Palm Beach Gardens, Florida. "In either of those cases, it gest that the larger the pterygium, the more induced astigmatism and the longer the cornea will take to normalize. If I am ever unsure, I re- peat the measurements and proceed once the measurements are stable," he said. ABMD and Salzmann's nodules The key step with ABMD is to spot it in the first place. "I think most of us can look right through the cornea and start examining the cataract we will need to address, but if you stop and look closely, you can sometimes see subtle ABMD," Dr. Kieval said. The use of retroillumination or a red-free filter can help find subtle disease, he said. Topography is also helpful. "Subtle irregularities may be present on topography, and one should always inspect the rings im- age," Dr. Teichman said. The use of negative fluorescein staining can be used, and surgeons can look out for a Shahinian's sign—a scalloped line of tear film thinning—across the top third of the cornea, he explained. A patient may benefit from a su- perficial keratectomy before cataract surgery if there is any irregularity in the central to mid-peripheral cornea, followed by topography and biometry 3 months later, Dr. Teich- man said. Treatment plan for corneal irregularities before cataract surgery Slit lamp photograph of obvious ABMD, with a photograph of negative fluorescein staining superimposed Source: Joshua Teichman, MD continued on page 52

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