Eyeworld

DECEMBER 2021 | EYEWORLD | 71 C endothelial dystrophy. "Diagnosing Fuchs before surgery is important because this allows you to take extra precautions to protect the endotheli- um," she said. "It is also important to alert the patient to this condition so that they know there is a risk of endothelial decompensation after surgery." Christopher Rapuano, MD, said that dry eye and blepharitis are the primary corneal conditions to look out for because they are so common. There has been more emphasis on addressing these conditions prior to cataract surgery in the past 5–10 years, he added, with the procedure potentially exacerbating these conditions. Dr. Rapuano highlighted EBMD, which can cause wrinkles on the surface of the cornea. If it's mild and in the periphery, it won't change the corneal shape or curvature, and you can leave it alone, he said. If it's more significant and in the central cornea, it can create distor- tions in the vision. These distortions would likely show up on topography or K readings. Patients may notice a little shadow vision, he added. Salzmann's nodules, creamy white nodules on the corneal surface, are another issue that Dr. Rapuano discussed. These tend to distort cor- neal curvature. Often, they are in the periphery, not causing too many visual problems, but they can be an issue if they are closer to the center of the cornea. They can cause astigmatism and potentially irregular astigmatism, he added. "For all patients we treat, we need to be attentive to the cornea before doing biometry measurements because problems on the surface of the cornea are going to lead to undesirable outcomes," said John Hovanesian, MD, adding that patient expectations are higher than ever. The most common issue is dry eye, he said, adding that about three-fourths of those who have it are not symptomatic. "If we've got an aim of giving the patient the refractive result they want, we need to pay attention first to dry eye," he said. When pterygium and Salzmann's nodules are visually impactful, they need to be ad- dressed prior to surgery, Dr. Hovanesian said. He avoids putting a toric lens in a patient with a Salzmann's nodule causing astigmatism because the nodule will cause irregular astigmatism so the correction with the toric is less than ideal. "If you remove the nodule and make the cornea more regular, there may not even be astigma- tism, and you'll at least reduce irregularity," he explained. Terry Kim, MD, spoke about many of the previously mentioned conditions as well. He said they may appear benign in nature, but surgeons need to do their due diligence in terms of examining patients, looking for these condi- tions, and determining if they are functionally or visually significant. "I think that's a critical step because they can not only affect the visual outcome after surgery, but they can affect biom- etry measurements." He cited a paper he co-au- thored 1 that showed that biometry measure- ments and IOL calculations were significantly impacted in patients with epithelial basement membrane dystrophy and Salzmann's nodules, which would have resulted in major alterations in spherical and toric IOL power if not treated prior to cataract surgery. continued on page 72 A small, elevated Salzmann's nodule is present in the periphery, but some subepithelial fibrosis can be seen extending centrally, which resulted in some irregularity on corneal topography. Removal should be considered prior to cataract surgery. Source (all): Christopher Rapuano, MD

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