Eyeworld

I NOVEMBER 2019 | EYEWORLD | 37 Figure 1. Corneal topography of an eye with Salzmann's nodules prior to superficial keratectomy (left) and 3 months after superficial keratectomy, prior to cataract surgery (right). Source: Terry Kim, MD, and Mark Goerlitz-Jessen, MD About the doctors Mark Goerlitz-Jessen, MD Resident Duke Eye Center, Duke University School of Medicine Durham, North Carolina Lawrence Hirst, MD The Australian Pterygium Centre Brisbane, Australia Terry Kim, MD Professor of ophthalmology Chief, Cornea and External Disease Service Director, Refractive Surgery Service Duke Eye Center, Duke University School of Medicine Durham, North Carolina W. Barry Lee, MD Partner Cornea, External Disease & Refractive Surgery Service Eye Consultants of Atlanta Medical director, Georgia Eye Bank Atlanta, Georgia Shahzad Mian, MD Vice chair, Clinical Sciences and Learning Professor, Department of Ophthalmology and Visual Sciences University of Michigan Ann Arbor, Michigan Christopher Rapuano, MD Director and attending surgeon, Cornea Service Wills Eye Hospital Professor, Sidney Kimmel Medical College, Thomas Jefferson University Philadelphia continued on page 38 treatment; and corneal topography, which may reveal irregular astigmatism centrally. In any case, corneal irregularities must be "thoughtfully evaluated and treated when present in cataract patients," wrote Dr. Kim and Dr. Goerlitz-Jessen. They cited a paper they published in the Journal of Cataract and Refrac- tive Surgery, which highlights the impact that Salzmann's nodules and EBMD in particular have on biometry, 1 "the foundation for success- ful visual outcomes in cataract surgery." They suggest assessing cases using patient symptom- atology, slit lamp examination, corneal topogra- phy, and biometry. While they agreed that "small, peripheral or astigmatically neutral corneal disease may not require intervention," they noted that "it can be difficult to be confident with the degree to which potentially minor corneal changes may be impacting a patient's optical system. If there is a reasonable concern that these lesions could affect a patient's visual outcome, treatment is recommended. Certainly, patients with central disease, visual and ocular surface symptoms, corneal topographic changes, and/or biometric inconsistencies require intervention prior to cataract surgery." Timing procedures Dr. Lee will always manage these conditions prior to cataract surgery. "If I see significant asymmetry between the topography in both eyes, and the eye with the corneal pathology has induced astigmatism, I will always remove the lesion prior to cataract surgery." Lawrence Hirst, MD, whose practice focus- es solely on pterygium removal, agrees. "If they cause irregular astigmatism, then they should be dealt with first before lens surgery," he wrote in an email. The doctors suggest delaying cataract sur- gery by at least 30 days after the management corneal irregularities (ideally 90 days or more) to allow the cornea to stabilize. In any case, repeat measurements at several, separate time points are valuable to confirm the stability of corneal parameters prior to cataract surgery. "Giving the surface time to heal ensures the correct lens implantation power is used at the time of cataract removal," wrote Dr. Lee. Premium IOLs As demonstrated by the case shared by Dr. Kim and Dr. Goerlitz-Jessen, premium IOLs such as toric IOLs "can absolutely be used" in cases with corneal abnormalities, provided the abnor- malities are managed properly and the stability of the cornea is carefully assessed. EBMD, however, presents a particular chal- lenge. "I would be worried about using a toric IOL if the EBMD is obvious and present in the visual axis," wrote Dr. Lee. "If a

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