Eyeworld

I JUNE/JULY 2020 | EYEWORLD | 35 W. Barry Lee, MD, said he addresses Salzmann's nodules at the same time as the EK. "I perform a lamellar keratectomy with a Tooke corneal knife, place topical mitomycin-C 0.02% onto the central cornea with a sponge for 30–60 seconds, rinse with two bottles of balanced salt solution, then start my EK," he said. "I put these patients in a therapeutic bandage lens after I have managed the air bubble, which typically occurs during a check 1 hour after surgery." For subepithelial scarring, he always eval- uates the depth of the scarring at the slit lamp. If it is truly subepithelial, he uses superficial keratectomy at the time of EK. If the scar ex- tends into the stroma, he uses anterior segment OCT to help determine whether PTK would be beneficial or whether a full thickness transplant should be considered. OSD, dry eye, blepharitis, and glaucoma drop toxicity Dry eyes and blepharitis often occur concur- rently in these patients, so both diseases must be checked and adequately treated prior to EK, Dr. Lee said. "If tear deficiency is present, I start with preservative-free tears, topical cyclo- sporine, or lifitegrast," he said. "Punctal plugs may be used as well, but I avoid these if con- current blepharitis is present." Dr. Lee prefers cornea needs to be as smooth and regular as possible for optimal calculations for cataract surgery. If the patient already had cataract surgery and there are lumps and bumps, you can treat beforehand or go in for EK. Doing a superficial keratectomy at the time of EK and scraping off irregularities often works well, he said. "When I see a lot of subepithelial fibrosis, basement membrane dystrophy, corneal haze, it doesn't bother me because I can do a superficial keratectomy intraoperatively," Dr. Dhaliwal said, adding that she tries to separate cataract surgery and corneal transplants if she can rather than combining the procedures. Generally, she will address whichever condition is more serious first. "If they need both, I like to separate and stage the two procedures," she said, adding that the keratometry can be significantly off in these patients when you're doing combined surgery. If they have a lot of scarring, haze, and bullae, Dr. Dhaliwal will use the Ks from the other eye if doing the cataract surgery first. When doing a transplant first, she will get new Ks after the cornea becomes clear and compact and the surface becomes smooth. Dr. Dhaliwal uses a bandage contact lens in these patients postoperatively. If the patient is neurotrophic, amniotic membrane may help, and she also likes to use collagen shields soaked in an antibiotic. continued on page 36 About the doctors Deepinder Dhaliwal, MD Director of Refractive Surgery and the Cornea Service UPMC Eye Center Pittsburgh, Pennsylvania W. Barry Lee, MD Eye Consultants of Atlanta Atlanta, Georgia Christopher Rapuano, MD Chief of the Cornea Service Wills Eye Hospital Philadelphia, Pennsylvania Relevant disclosures Dhaliwal: None Lee: None Rapuano: None Fluorescein staining demonstrating severe superficial punctate keratopathy Moderately elevated Salzmann's nodular degeneration; the brown iron line indicates chronicity Source (all): Christopher Rapuano, MD

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