Eyeworld

EW CORNEA 71 keratitis. Effects of systemic immunosuppression. Ophthalmology. 1984; 91(10):1253–1263. is usually irregular and which must be taken into account in preoper- ative planning and counseling of the patient. Wound construction is crucial, and vigilance against possi- ble melting must be preemptively considered. The trigger of a diamond knife or femtosecond laser can incite a recurrence of PUK. When the systemic disease is quiet both locally and systemically, one can cautiously proceed with cataract or elective anterior segment surgery, with vigi- lance about wound healing issues. The placement of the cataract wound in these cases is critical to avoid problems with wound healing. Use of a scleral incision and one that is self-sealing is recommended. Consider creating the incision under a conjunctival flap. Avoid clear/near- clear corneal incisions because these incisions, even if they were properly constructed way from areas of corneal thinning, may not heal well. These eyes are always at risk for recurrent inflammation and ulceration. Whether or not to use a suture in the corneal incision has been debated, as the suture may help with wound healing but is another inflammatory stimulus. In PUK, up to a third of the stroma can already be destroyed, and avoiding these areas is critical. Self-sealing manual or laser-created corneal incisions in areas of normal and intact cornea should help in this regard. Beginning a few days before cataract surgery, if a preoperative evaluation shows no contraindi- cation, a course of oral corticoste- roids should be started, maintained through the surgical date, and grad- ually tapered postoperatively over a few weeks. If oral corticosteroids are employed perioperatively, an oral H2 receptor antagonist should also be added. These patients should be closely monitored after surgery, to ensure that any postoperative in- flammation is identified and treated promptly. Cataract surgery in the setting of PUK is challenging, but adhering to these recommendations will help ensure a better result. EW Reference Foster CS, Forstot SL, Wilson LA. Mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripheral ulcerative Editors' note: Dr. de Luise is assistant clinical professor of ophthalmology, Yale University School of Medicine, New Haven, Conn. He has no financial interests related to his comments. Contact information de Luise: eyemusic73@gmail.com September 2014

• Cover