Eyeworld

DECEMBER 2021 | EYEWORLD | 73 C Contact Hovanesian: jhovanesian@harvardeye.com Kim: terry.kim@duke.edu Rapuano: cjrapuano@willseye.org Schallhorn: jschallhorn@gmail.com Relevant disclosures Hovanesian: Sun Pharma, Novartis Kim: None Rapuano: None Schallhorn: None Most of his cataract patients will also get a topography. He mentioned that this can be helpful to show if a pterygium needs to be treated. People often know if they've had a little pterygium for years and might not be bothered, he said. But if the topography is being affected by the pterygium, it should be treated first. Dr. Schallhorn performs topography on every patient having cataract surgery, calling it incredibly useful for toric planning in patients with normal exams and to detect any irregular corneal contours that might be due to one of the conditions mentioned. "Topography is a critical part of the preop- erative evaluation for any cataract patient," she said. "This should be combined with a careful exam to identify conditions that could result in a suboptimal outcome and to guide treatment." Treatment and when to delay cataract surgery While Dr. Schallhorn said that no condition is a true contraindication to cataract surgery, ad- dressing issues that can cause problems with bi- ometry is mandatory before proceeding. Patients with dry eye should receive treatment until they have a smooth, stable epithelial surface and are asymptomatic. Dr. Schallhorn said that patients with EBMD, Salzmann's nodules, or pterygia caus- ing corneal cylinder should undergo treatment before surgery. Cataract surgery should be delayed to allow for complete epithelial healing, she said, which usually takes 3 months for full stabilization and sometimes longer in patients with EBMD. Fuchs patients should be counseled about their increased risk for corneal edema. Patients with confluent guttata, morning blur symptoms, or stromal edema should be seen by a corneal specialist because they might benefit from a combined endothelial keratoplasty procedure. Dr. Hovanesian agreed that it's important to treat these conditions prior to cataract surgery. For dry eye patients, he said that a month may be an appropriate period to get meaningful improvement. He added that artificial tears, steroid supplements, and other treatments could help with quicker rehabilitation. When using a surgical treatment for pterygium or Salzmann's nodules, Dr. Hovane- sian noted that most corneal specialists wait 2 months or more postop before proceeding with a cataract procedure. "When you're altering the corneal stroma, there's more remodeling and epithelial healing that occurs that may take a couple months," he said. Dr. Rapuano described his treatment prior to cataract surgery for both EBMD and Salzmann's nodules. Typically, you can treat basement membrane dystrophy with epithelial debridement, which he usually combines with diamond burr polishing to make sure all the microscopic basement membrane elevations are gone. This can be done at the slit lamp, Dr. Rapuano added, and it usually takes about 6–8 weeks before the epithelium is smooth for accu- rate K readings. For Salzmann's nodules, he said lamellar keratectomy can be used to treat at the slit lamp. However, he noted the Salzmann's nod- ules tend to recur. To try to prevent recurrence, Dr. Rapuano will use mitomycin-C at the time of removal. Dr. Kim described the criteria used in his study that indicated if a patient's corneal condi- tion should be treated before cataract surgery: 1) If the patient has central corneal involvement of EBMD or Salzmann's nodules (central 3–4 mm); 2) Distortion on keratometry or inconsis- tency on biometry; 3) Irregular astigmatism or "dropout" on corneal topography; 4) Subjective complaints of blurred vision or image ghosting. Dr. Kim said he and his colleagues treat a lot of these patients with superficial keratec- tomy and scraping the corneal epithelium. For Salzmann's nodules, treatment simply involves peeling the lesions with a 0.12 forceps. "For EBMD, we generally perform a superficial ker- atectomy with a Maloney spatula followed by a small excimer laser PTK procedure," he said. Af- ter both procedures, topical mitomycin-C 0.02% is applied to the treated corneal surface with a circular Merocel sponge for 30 seconds to help prevent recurrence and scar formation. Dr. Kim said patients are brought back a month after the treatment to confirm complete healing, and sometimes the cataract surgery needs to be delayed. It's important, he said, to ensure that patients know about these condi- tions before proceeding with cataract surgery so that they can make an informed decision about treatment with the goal of providing the best visual outcome.

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