Eyeworld

EW FEATURE 52 Text goes here "Similar to the pterygium situa- tion, it isn't rare to need a YAG and another PTK for maximum vision recovery," Dr. Hardten said. If it has been fairly stationary and the cataract is the main issue, he prefers to perform cataract surgery. "A PTK could be done later if their vision needs require," he said. "ABMD or Salzmann's nodules do not always have to be removed prior to or during cataract surgery," Dr. Goldman said. "If it is going to be addressed, it should be treated prior to cataract surgery. While I do corneal scrapings for ABMD in the office, for Salzmann's nodules I will perform surgery in the OR. In the majority of these cases, you can undermine an edge of the nodule and peel them off. … I was trained that if you scrape the epithelium over the area of the nodule and start to use a blade to tease at the edge of the lesion, you can grasp the edge and peel the nodule off of the cornea." Dr. Teichman shared another pearl for Salzmann's nodules. "An- other important factor in treating them is identifying the underlying etiology. Often overlooked is chron- ic low-level inflammation from meibomian gland disease and dry eye. Simply removing the nodules may result in recurrence unless the underlying pathology is addressed," he said. Yet again, surgeons need to think about a patient's visual goals and the size of the lesion. If the goal is to see better with glasses and it's something small, Dr. Goldman will leave it alone. Dr. Kieval added another circumstance when lesions may not need treatment. "I think it is reasonable, and more likely advis- able, to leave well enough alone if the patient has poor visual potential due to other ophthalmic or neuro- logical disease," he said. Toric lenses? A patient with an ocular surface lesion is usually not the best fit for a toric IOL. "I will not consider a toric lens in a patient undergoing cataract surgery who has a pterygium. In those cases, I'll recommend pteryg- ium surgery first, then determine if a toric lens is truly needed," Dr. Goldman said. "I have seen many patients with toric IOLs that had refractive surprises because of ABMD or a pterygium that wasn't addressed prior to surgery, and I have seen patients who have those irregu- larities removed after phaco. They have refractive shifts that are very upsetting," Dr. Kieval said. For this reason, he thinks it is crucial to see what the unadulterated cornea looks like and remove any deposits, de- generations, or lesions to maximize the potential postop outcome. Surgical pearls To help better manage pterygia, ABMD, or Salzmann's nodules, the surgeons interviewed shared a few pearls. 1. Use hydroxypropyl meth- ylcellulose. "This is useful to coat the cornea, improving visualization, and also to protect the epithelium," Dr. Hardten said. 2. Consider dissection of the underlying Tenon's for pterygium. Dr. Kieval recommends this along with placement of a conjunctival autograft and the use of mitomy- cin-C (MMC) on recurrent lesions— but not on primary pterygium. Dr. Teichman also uses MMC on aggressive recurrences that have oc- curred in the context of a previous conjunctival autograft. 3. Use a Tooke Corneal Knife. "I find this allows one to remove lesions at a plane that does not proceed too deeply yet allows the underlying scar to be removed well," Dr. Teichman said. 4. Find your best fibrin glue choice. "I use conjunctival autograft in all cases and use fibrin glue to secure the graft," Dr. Teichman said. "There is a study that demonstrated Tisseel [Baxter, Deerfield, Illinois] is likely a superior adhesive for pteryg- ium surgery, and I have found that to be the case in my hands as well," he said. 5. Be patient after treating a lesion. "Sometimes it can take months to achieve a stable state that can be reliably used for cataract surgery," Dr. Kieval said. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Goldman: david@goldmaneye.com Hardten: drhardten@mneye.com Kieval: jkieval@lexeye.com Teichman: josh.teichman@gmail.com 10560 N Ambassador Dr Suite 210 Kansas City MO 64153 © 2018 Vital Tears LLC. All rights reserved. C O N T A C T U S T O B E C O M E A P R O V I D E R vitaltears.org | ( 800 ) 360-9592 Autologous serum eye drops made easy. Simple. Vital Tears eye drops are easy to order and even easier to use. Precise. Available in your choice of dilution options in a 3 or 6 month supply. Accessible. 300+ outpatient blood collection facilities. Direct delivery to your patient. Treatment continued from page 50

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