Eyeworld

The offi cial publication of the American Society of Cataract & Refractive Surgery A S C R S September 2014 Volume 19 • No. 9 Publisher Donald R. Long don@eyeworld.org Editorial Editor Erin L. Boyle erin@eyeworld.org Managing Editor Stacy Majewicz stacy@eyeworld.org Staff Writer Ellen Stodola ellen@eyeworld.org Staff Writer Lauren Lipuma lauren@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org 703-383-5702 Production Assistant Carly Peterson carly@eyeworld.org Contributing Writers Vanessa Caceres Lakeland, Fla. Michelle Dalton Reading, Pa. Matt Young Malaysia Enette Ngoei Dublin Rich Daly Arlington, Va. Senior Contributing Writer Maxine Lipner Nyack, N.Y. Advertising Sales ASCRSMedia 4000 Legato Road Suite 700 Fairfax, VA 22033 703-591-2220 fax: 703-591-0614 eyeworld@eyeworld.org www.eyeworld.org Advertising Sales Jeff Brownstein jeff@eyeworld.org 703-788-5745 Paul Zelin paul@eyeworld.org 703-383-5729 Classifi ed Sales Cathy Stern cathy@eyeworld.org 703-383-5702 EyeWorld Special Projects and Events Jessica Donohoe jessica@eyeworld.org 703-591-2220 ASCRS Publisher: EyeWorld (ISSN 1089-0084) is published monthly by ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; telephone: 703-591-2220; fax: 703-591-0614. Printed in the U.S. Editorial Offi ces: EyeWorld News Service, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. Advertising Offi ces: ASCRSMedia, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. Copyright 2014, ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. Subscriptions: Requests should be addressed to the publisher. Annual subscription prices: Individual: 1 year, $120; 2 years, $220; 3 years, $320. Institutional: 1 year, $250; 2 years, $330; 3 years, $425. Foreign: 1 year, $240, 2 years $470, 3 years, $700. Back copies: Subject to availability. Contact the publisher. Cost per copy is $15; $30 foreign. All orders for individual or back copies must be accompanied by payment. Requests to reprint, use, or republish: Requests to reprint or use material published herein should be made in writing only to Cathy Stern, EyeWorld, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. EyeWorld reprints: To order reprints of material published in EyeWorld, contact Cathy Stern, EyeWorld, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: cathy@eyeworld.org or your salesperson. Change of address: Notice should be sent to the publisher six weeks in advance of effective date. Include old and new addresses and label from recent issue. The publisher cannot accept responsibility for undelivered copies. POSTMASTER: Send change of address to EyeWorld, 4000 Legato Road, Suite 700, Fairfax, VA 22033. Periodical postage paid at Fairfax, VA 22033 and at additional mailing offi ces. The ideas and opinions expressed in EyeWorld do not necessarily refl ect those of the editors, publisher, or its advertisers. P U B L I S H I N G S T A F F World view Cataract surgery and corneal comorbidities H ere are three corneal nightmare scenarios, post-cataract surgery. After cataract surgery, your patient sits in the examination chair and says he does not notice a difference in his vision. You instill fl uorescein drops and examine his eye at the slit lamp. Your heart drops as you notice a patch of central epithelial irregularity with negative staining. Another scenario is your patient, after seem- ingly uncomplicated cataract surgery, complains of persistent poor vision due to mild corneal edema a month postop. You check the patient's fellow eye and notice a layer of guttae that was missed preoperatively. Final nightmare: Your multifocal patient is unhappy and complains that her vision fl uctuates all the time, yet she measures 20/20 at far and J1 at near. You examine more closely and notice that her tear break-up time is signifi cantly decreased, and she has a band of inferior punctate epithelial erosions on her cornea. The quality of the tear fi lm, dry eye, and corneal abnormalities such as ABMD and Fuchs' dystrophy play a crucial role in the assessment and man- agement of patients with cataracts—preop, intraop, and postop. Other ocular surface irregularities, such as a pterygium, keratoconus, or a corneal scar, while more obvious, can still be a challenge to manage in a patient requiring cataract surgery. Many patients also have a history of either herpes simplex virus or herpes zoster virus infectious and/or infl ammation-related keratitis. These corneal co-morbidities will be explored in the context of cataract surgery in this issue of EyeWorld. Specifi cally, Deborah Jacobs, MD, Steven Rosenfeld, MD, and Stephen Kaufman, MD, PhD, discuss how to best handle a cataract patient with a pterygium growth. Questions of when the pterygium removal should take priority, when both issues could be resolved simultaneously, and when the pterygium could be left alone will be discussed. John Hovanesian, MD, Christopher Ketcherside, MD, and Charles Thompson, MD, review ocular surface irregularities such as anterior basement membrane dystrophy and Salzmann's nodule degeneration, which can affect cataract surgery outcomes. Dry eye and blepharitis can also cause a plethora of ocular surface problems and seem to be pandemic in the prime older patient cataract surgery population. The experts share how they man- age these ocular surface issues and how to best time a patient's cataract sur- gery. This topic should be of interest to cataract and refractive surgeons alike, who strive to achieve excellent outcomes for patients with lofty expectations. Coexisting corneal diseases such as keratoconus or corneal scarring add a layer of complexity to treating typical cataract patients. Christopher Rapuano, MD, William Trattler, MD, and Mitch Weikert, MD, discuss how a cornea transplant may be avoided in certain patients with a corneal scar through PTK prior to cataract surgery and how to best manage patients with stable keratoconus and cataract. If a patient does need both a corneal transplant and cataract surgery, which procedure should be done fi rst versus in combination? These experts will also address options for intraocular lens selection in these challenging cases. Francis Price, MD, Mark Terry, MD, Kashif Baig, MD, Kenneth Goins, MD, and I discuss the decision-making process in managing patients with cataracts and endothelial corneal disease such as Fuchs' dystrophy. Ideal lens selection, target spherical equivalent, surgical pearls, timing of staged surgery versus a "triple procedure" (where cataract surgery and endothelial keratoplasty are performed simultaneously), and usefulness of advanced imaging technology will be reviewed. Finally, we have Vincent de Luise, MD, Sophie Deng, MD, PhD, Bennie Jeng, MD, and Francis Mah, MD, providing tips on how to treat patients with a cataract who have a history of herpes zoster virus (HZV) or herpes simplex virus (HSV) keratitis. Prophylaxis regimens, timing of surgery to episodes of infl ammation, pitfalls, and postoperative adjustments to medications are addressed. We hope you enjoy this issue of EyeWorld and learn from the best how to incorporate their tips into your practice. Thank you to all the physicians above for taking the time to share their expertise. EW Clara Chan, MD, FRCSC, FACS, cornea editor

• Cover