Eyeworld

40 | EYEWORLD | SUMMER 2024 ATARACT C I WISH I HAD … by Liz Hillman Editorial Co-Director About the physicians Saba Al-Hashimi, MD Associate Professor of Ophthalmology Cornea Division Stein Eye Institute University of California, Los Angeles Los Angeles, California Rahul Tonk, MD, MBA Associate Professor of Clinical Ophthalmology Associate Medical Director Bascom Palmer Eye Institute Miami, Florida assess if the patient has high expectations or refractive demands or is looking for increased spectacle independence with their cataract surgery. Even if the patient says they don't have symptoms, Dr. Tonk said it's important to inform them of their condition and let them know it could affect their postop recovery and outcomes. That said, in general, just about every pa- tient with ABMD deserves at least conservative medical management. This may involve lubri- cants, nighttime hypertonic saline ointment, topical anti-inflammatories, and management of co-morbid blepharitis. "In many cases, more aggressive or even procedural care may be indicated," Dr. Tonk said. "This can involve superficial keratectomy with or without diamond burr polishing or pho- totherapeutic keratectomy." While outcomes are generally good, he noted that the procedure can be taxing for older patients, delay cataract sur- gery, or rarely be complicated by poor epithelial healing, particularly in older patients or those with ocular surface disorders. Dr. Al-Hashimi said he will wait 6–12 weeks after a procedure for ABMD to move forward with cataract surgery, making sure there is regularizing of the epithelium and repeatabil- ity/stability with biometry measurements. "My eyes are irritated … they weren't before cataract surgery." "My vision fluctuates … it goes in and out." "I got a lens to correct my astigmatism … now my vision seems even more off." "I chose a presbyopia-correcting IOL, and my quality of vision isn't great." T hese are the phrases an ophthalmolo- gist might hear when ABMD is missed prior to cataract surgery, causing the surgeon to wish they had found and treated it preoperatively. Saba Al-Hashimi, MD, said he thinks ABMD needs to be more on ophthalmologists' radar during their preop examinations. "It's easier to address ahead of time, and your measurements for cataract surgery are go- ing to be more accurate," he said. "If it is some- thing you catch after, you can treat the [ABMD], and when the dust settles, you may find you're off target … that becomes a harder issue." Rahul Tonk, MD, thinks identifying and treating ABMD preop is on the radar of most cor- nea/refractive surgeons, but it should, he added, be something every comprehensive ophthal- mologist is thinking about as well. "We've been beating on this drum about managing the ocular surface for years, but it's not universal yet." Identification While it might not be obvious on slit lamp examinations, Dr. Al-Hashimi and Dr. Tonk said fluorescein dye on the cornea can reveal areas of negative staining that are indicative of ABMD. Dr. Al-Hashimi also said epithelial map- ping is becoming more popular and can high- light areas that require further investigation. Dr. Tonk said the mires on Placido imaging allow you to get more information about the patient's quality of vision. Interruptions in the mires clue you in to areas of ocular surface dis- ease, such as ABMD or dry eye. Preop management Dr. Tonk said once he has identified ABMD, he asks the patient a variety of questions about ocular irritation, recurrent erosions, or visual fluctuation related to the ABMD. Further, he will I wish I had … identified and treated ABMD before cataract surgery This is a photo of a patient with ABMD and cataract. Note the irregular lines that resemble a coastline (map), small punctate opacities (dot), and thickened epithelial ridges (fingerprint)—hence the name map-dot-fingerprint dystrophy. This patient had both irregular astigmatism and recurrent epithelial erosions. Superficial keratectomy with diamond burr polishing was performed to prepare the cornea for future cataract surgery. Source: Rahul Tonk, MD, MBA

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