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April 2012 Corneal diagnoses and systemic disease February 2011 EW FEATURE 39 "Always worry about infection in these eyes," Dr. Deng said. "Culture, culture, culture to ensure there's no secondary infection. Only after you're certain there's no addi- tional infection would I recommend systemic steroid first to control the inflammation." If surgery is deemed necessary, Dr. Deng recommended tissue adhe- sives post-keratectomy and conjunc- tival resection, and amniotic membrane transplantation can be helpful in Mooren's ulcer cases. (She's seen cases of 360-degree melt associated with PUK.) Future surgery concerns For patients with systemic autoim- mune disorders and who have had PUK, "ideally the inflammation should be controlled for at least 3 months before considering cataract surgery," Dr. Thorne said. In this group of patients, surgeons need to be particularly mindful of the area of corneal thinning, she said. "It may affect the method of cataract removal planned. Addition- ally, surgeons might have some astigmatism to take into account be- cause of the thinning," she said. Be "very careful about wound construction and possible melting," Dr. de Luise said. "Just the trigger of a diamond knife or femto laser can incite ulcerations." When the sys- temic disease is quiet both locally and systemically, "one can cau- tiously proceed with cataract or elective anterior segment surgery, but always be vigilant about wound healing issues." For patients undergoing cataract surgery after successfully managed PUK, Dr. de Luise said "the place- ment of the cataract wound in these cases is even more crucial than in complicated cases, to avoid prob- lems with wound healing." He rec- ommended using a more scleral incision, one that is self-sealing, and under a conjunctival flap, and to avoid clear/near-clear incisions. "These eyes are at risk for recur- rent inflammation and ulceration," he said. Whether or not to use 10-0 nylon has been debated, as the su- ture may help with wound healing but is another inflammatory stimu- lus, he added. In PUK, up to "a third of the stroma can already be gone," Dr. de Luise said, and suggested waiting at least 3 months before recommend- ing that patient for anterior segment surgery. "Weeks is too early for sur- gery post-PUK; ideally you should wait about 6 months," he said. Dr. Deng said during an acute phase melting may be so severe, she'd recommend putting off sur- gery as long as possible. If the eye has excessive thinning, it can quickly become ectatic and develop cataract after PUK resolution because of the inflammation, she said. "For these patients, I use sys- temic steroids perioperatively, then taper the steroids gradually to get them over the stressful period," she said. "Patients do pretty well that way." The bottom line for these pa- tients—as long as the systemic dis- ease is well controlled, the ocular manifestations will be controlled ac- cordingly, Dr. Deng said. EW Editors' note: The doctors mentioned have no financial interests related to this article. Contact information de Luise: 203-263-3300, vdeluisemd@gmail.com Deng: 310-206-7202, deng@jsei.ucla.edu Thorne: 410-955-2966, jthorne@jhmi.edu An ASCRS Membership For every stage of your career Whether you're just beginning or experienced in cataract and refractive surgery, ASCRS is the professional society that's right for every stage of your career. Established Anterior Segment Ophthalmologists Mid-career is perhaps the most challenging period for today's ophthalmologist. The clinical and technological changes have never come faster and the regulatory concerns have never been greater. ASCRS' Annual Sympo- sium and Winter Update offer the education and networking needed to help your practice excel, and our ASCRS MediaCenter provides targeted online content addressing the issues most pressing to you. ASCRS' monthly Journal of Cataract and Refractive Surgery reports on all aspects of anterior segment surgery, and our meetings are focused, well-organized, and highly interactive. eyeCONNECT, ASCRS' online clinical service, lets you share questions and answers with like-minded peers in a private and supportive environment. ASCRS' commitment to fostering excellence through collaborative exchange is unmatched by any other ophthalmic organization. Join ASCRS today! The Society for Surgeons AMERICAN SOCIETY OF CATARACT AND REFRACTIVE SURGERY 4000 Legato Road, Suite 700, Fairfax, VA 22033 • 703-591-2220 • www.ASCRS.org