Eyeworld

55 EW FEATURE August 2014 © 2014 OASIS Medical, Inc. All Rights Reserved. 514 S. Vermont Ave, Glendora, CA 91741. OASIS name and logo are registered trademarks of OASIS Medical, Inc. Intacs name and logo are registered trademarks of Addition Technology, Inc. OASIS is the exclusive US distributor of Intacs. Exclusively Available Through USER GROUP MEETING Learn more at the Limited seating available. E-mail intacs@oasismedical.com for reservations. Hyatt Regency Chicago, Grand Ballroom 151 East Wacker Drive, Chicago, IL 60601 Friday, October 17, 2014, 6:00 PM – 8:00 PM TIMELINESS AND DIAGNOSIS IS KEY. Are your keratoconus patients being referred to a specialist in time to qualify for effective treatments? around the 3 o'clock and 9 o'clock positions. When operating tempo- rally, he pointed out that this can interfere with the cataract incision and visualization. "In addition, the pterygium can cause astigmatism so you don't get accurate keratotomy measurements used for your IOL calculation," Dr. Kaufman said. "If you are considering a toric lens, you couldn't get accurate astigmatism readings." Dr. Rosenfeld also adamantly believes that pterygium surgery should be performed first because it yields a more regular pattern to the cornea and possibly eliminates astigmatism or corneal distortion. In addition, he recommends waiting to perform cataract surgery until the patient has had 2 visits in a row, at least 1 week apart, where both the refraction and the corneal topography are relatively stable. In Dr. Jacob's view, deciding when to remove the pterygium depends upon the circumstance. "If it's inducing astigmatism and there's any question that loss of best correction is related to the astigma- tism rather than the lens opacity, I recommend removing it first," she said, explaining that the practitioner may be pleasantly surprised with the vision after it's removed. However, if the pterygium is being removed for cosmetic reasons, Dr. Jacobs finds this can be done at the time of cataract surgery. From the patient's perspective this may be preferable, she noted. "Patients like if it's all at once," she said. However, reimburse- ment may be less in these cases. If the 2 procedures are done at once, Dr. Jacobs recommends slightly altering the postoperative regimen. "Typically, with an un- eventful cataract surgery, a patient is off a steroid at the 1-month point," she said. The pterygium surgery re- quires a longer taper, she explained. This involves use of steroids 4 times a day for the first month with IOP monitoring and then twice a day for the second month. Dr. Jacobs takes the sutures out at the 1-week mark. "Even though surgeons say the vicryl is dissolving, it biodegrades much more slowly than 1 week and can be irritating," she said. Dr. Kaufman stressed the impor- tance of covering the scleral surface after removal of the pterygium to help prevent recurrence. "With a primary pterygium, I use a modified conjunctival autograft," he said. This is not derived from the superior conjunctiva, so it does not inter- fere with possible future needs for glaucoma surgery in that region. He then glues down the conjunctival autograft with fibrin tissue adhesive and places an amniotic membrane over the surface of the involved sclera and cornea. "The amniotic membrane does not prevent recur- rence of the pterygium, but it's more comfortable for the patient and aids in the healing of the surgical field," Dr. Kaufman said. Anecdotal evidence suggests that it may also reduce corneal scarring. Dr. Rosenfeld agrees that put- ting some kind of replacement tissue back after excising the pterygium is a good idea to prevent recurrence. In his view, amniotic membrane works equally as well as an autograft. "You can either use an amniotic mem- brane transplant or a conjunctival autograft, but you need to replace the tissue in the bed when you remove the pterygium," he said. Overall, if the patient has a significant pterygium or the practi- tioner is not comfortable doing the surgery, Dr. Rosenfeld recommends referring to a corneal specialist. "I think it's important enough to have a smooth, regular corneal surface, and if you're not sure that the pterygium is contributing to the trouble, or you're not comfortable doing the surgery, then it's OK to refer to the corneal specialist just to do the pterygium surgery," he said. "Then the patient will come back to you and you can still do the cataract surgery." EW Editors' note: Dr. Kaufman has financial interests with IOP Ophthalmics (Costa Mesa, Calif.) and Bio-Tissue (Doral, Fla.). Drs. Jacobs and Rosenfeld have no financial interests related to their comments. Contact information Jacobs: djacobs@bostonsight.org Kaufman: Stephen.Kaufman@downstate.edu Rosenfeld: srosenfeldmd@gmail.com

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