Eyeworld

World view Improving the ocular surface: Challenges facing the cataract and refractive surgeon I f only every cataract and refractive patient were easy. It only takes one or two unhappy patients to make a day in the office misera- ble. The most common reasons patients are unhappy postoperatively are dry eye symp- toms and undiagnosed ocular surface disease. Issues with dry eye are also important for pa- tients undergoing corneal crosslinking where the epithelium is typically removed in the "epi-off" standard technique. Retinal surgery and glauco- ma drops can exacerbate ocular surface disease. And don't forget the corneal surface where a va- riety of lumps and bumps can erupt. The saying "The tear film is the most important refracting surface of the optical system" should be respected especially in today's environment of exceedingly high patient expectations. In this month's feature series, we explore a potpourri of unique and challenging scenarios related to the ocular surface. We begin with Melissa Daluvoy, MD, Deborah Jacobs, MD, and Bennie Jeng, MD, who discuss their approaches to the following chal- lenging patients: a patient with progressive keratoconus needing corneal crosslinking who has active atopic blepharoconjunctivitis; a patient with graft-versus-host disease and severe dry eye needing cataract surgery; and a myopic patient with limbal stem cell deficiency from soft contact lens wear. Next, Ali Djalilian, MD, Marjan Farid, MD, and Steve Sarkisian, MD, review the effects that glaucoma eye drops have on not just the cornea and conjunctiva, but also the eyelids. They then discuss how to optimize and manage ocular surface disease issues in glaucoma patients who use multiple eye drops, and when to consider surgical options for therapy to prevent vision-threatening complications associated with ocular surface damage. "Pain without stain," or keratoneuralgia, is a rare phenomenon that can arise typically after refractive surgery. Unfortunately, there is no reliable way to screen for patients who will develop this pain syndrome postoperatively. Anat Galor, MD, and Rony Sayegh, MD, review diagnosis and management strategies, the role of treating dry eye in these patients, and the importance of involving mental health professionals. Neurotrophic keratitis is the opposite of keratoneuralgia. Unfortunately, due to the lack of corneal sensation in these patients, they may not present with complaints until their vision is compromised. Deborah Jacobs, MD, and Stephen Pflugfelder, MD, share the most common etiologies for this condition and their management algorithm. Use of soft bandage contact lenses, scleral lenses, amniotic membrane grafts, tarsorrhaphy, and topical medical therapies coming down the pipeline are all reviewed. Finally, a variety of lumps and bumps on the corneal surface can signifi- cantly alter the accuracy of measurements needed in cataract and refrac- tive surgery. David Goldman, MD, David Hardten, MD, Jeremy Kieval, MD, and Joshua Teichman, MD, comment on what special attention is required to address pterygium, anterior basement membrane dystrophy, and Salzmann's nodules. These should be treated as a first step always. The physicians also discuss the importance of avoiding toric lenses in a patient with an irregular corneal surface. Please enjoy this issue of EyeWorld, and thank you to all the physicians above for taking the time to share their expertise. EW The news magazine of the American Society of Cataract & Refractive Surgery A S C R S November 2018 Volume 23, number 11 ASCRS Executive Director Steve Speares sspeares@ascrs.org Editorial Editor Amy Goldenberg amy@eyeworld.org Managing Editor Stacy Jablonski stacy@eyeworld.org Senior Staff Writer/Digital Editor Ellen Stodola ellen@eyeworld.org Senior Staff Writer Liz Hillman liz@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org Editorial Production Assistant Taylor Wise taylor@eyeworld.org Contributing Writers Stefanie Petrou Binder, MD Berlin, Germany Vanessa Caceres Bradenton, Florida Rich Daly Arlington, Virginia Lauren Lipuma Washington, D.C. Chiles Aedam R. Samaniego Muntinlupa, Philippines Michelle Stephenson Roanoke, Virginia Senior Contributing Writer Maxine Lipner Nyack, New York Advertising Sales ASCRSMedia 4000 Legato Road Suite 700 Fairfax, VA 22033 703-591-2220 Fax: 703-591-0614 eyeworld@eyeworld.org www.eyeworld.org Paul Zelin paul@eyeworld.org Molly Phillips molly@eyeworld.org Cathy Stern cathy@eyeworld.org EyeWorld Special Projects and Events Jessica Donohoe jessica@eyeworld.org Shelly Dixon shelly@eyeworld.org Anne Le anne@eyeworld.org ASCRS Publisher: EyeWorld (ISSN 1089-0084) is published monthly by ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; telephone: 703-591-2220; fax: 703-591-0614. Printed in the U.S. Editorial Offices: EyeWorld News Service, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org Advertising Offices: ASCRSMedia, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org Copyright 2018, ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. Subscriptions: Requests should be addressed to the publisher. Annual subscription prices: Individual: 1 year, $120; 2 years, $220; 3 years, $320. Institutional: 1 year, $250; 2 years, $330; 3 years, $425. 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Postmaster: Send change of address to EyeWorld, 4000 Legato Road, Suite 700, Fairfax, VA 22033. Periodical postage paid at Fairfax, VA 22033 and at additional mailing offices. The ideas and opinions expressed in EyeWorld do not necessarily reflect those of the editors, publisher, or its advertisers. P U B L I S H I N G S T A F F Clara Chan, MD, Cornea editor

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