Eyeworld

EW CORNEA 102 April 2017 were not available previously to them," Dr. Harvey said. For patients with ABMD, how- ever, Dr. Harvey said he'll avoid mul- tifocal and extended depth-of-focus IOLs. "These patients get glare just from their cornea alone. If you throw that on top of an implant, that's splitting the light, I think that's a recipe for discontent," he said. Overall, the most important thing with these conditions is early diagnosis before cataract surgery. "Discuss all findings with pa- tients prior to surgery," Dr. Ciralsky said. "The conversation about a preexisting condition after surgery is a much more difficult conversation to have." How to treat is an art unto itself, Dr. Harvey said. "I think there are some good topical options, and now we have some good nutraceutical options that are systemic and they can be just as good or better than some top- ical options," he said. "We should never forget about punctal plugs … sometimes you can do a punc- tal cautery at the time of cataract surgery so you don't have to have a foreign body resting down there, and that will boost the tear film and hide some of the irregularities in the cornea." Even after the corneal symp- toms have been taken care of for these patients, Dr. Harvey noted they may not have the best of visual outcomes and should be counseled as such. "Although we've had some major successes in which we've been able to do some amazing surgery with amazing uncorrected visual results, but that's probably in a mi- nority of patients. This is a lifelong issue and certainly people need to be observed over time," he said. "When we do superficial keratecto- my, I tell patients I think I can buy you 10 years before this could come back. It certainly can reoccur and is not something that is a guaranteed fix." EW Editors' note: Dr. Harvey has financial interests with Rapid Pathogen Screening and Physician Recommended Nutri- ceuticals (PRN, Plymouth Meeting, Pennsylvania). Dr. Gupta has finan- cial interests with Bio-Tissue (Doral, Florida). Dr. Ciralsky has no financial interests related to this article. Contact information Ciralsky: jessciralsky@gmail.com Gupta: preeya.gupta@duke.edu Harvey: tm.harvey@sbcglobal.net she always gets topography for pa- tients with corneal pathology. "The first thing to decide is often why the patient has poor vi- sion. Sometimes vision loss is more attributable to the corneal pathology than to the cataract, and treatment should first focus on the cornea pathology to see how the vision improves. Corneal pathology also can affect the keratometry readings and IOL calculations, and treatment of the corneal pathology is necessary first. Once the cornea has healed, more reliable measurements can be obtained. Also, cataract surgery can worsen ABMD, and patients may have epithelial sloughing following cataract surgery," Dr. Ciralsky said. When it comes to treatment, Dr. Harvey prefers superficial keratec- tomy with or without amniotic membrane, and not in combination with cataract surgery. "We don't have good informa- tion from the start, and then we're asking them to heal on the inside of the eye as well as on the outside of the eye and it's too much for most folks," he said. "We try to get the surface of the eye in the best shape prior to doing any form of what I consider more utilitarian cataract surgery or vision-correcting cataract surgery for people who want to not have glasses." Unlike AMBD, pterygium or Salzmann's nodules are harder to miss during the exam. Although, Dr. Harvey said some people who aren't familiar with looking at the cornea might mistakenly have called a Salzmann's nodule a scar, when in reality it's an elevation. "They're most easily seen using fluorescein and cobalt blue light, dif- fuse illumination. It's elevated above the surrounding, healthy corneal tissue," Dr. Harvey said. Not all Salzmann's nodules have to be removed before cataract surgery, particularly if they're in the periphery and don't seem to affect the regularity of the central optical zone. "If you look at the keratometry and autorefraction and there's not a lot of astigmatism and it's complete- ly consistent, then it's much less likely to be visually significant," Dr. Harvey said. Both Drs. Ciralsky and Gupta said they prefer superficial keratec- tomy as a first-line treatment for Salzmann's nodules, but Dr. Gupta added that she'll perform photother- apeutic keratectomy if the surface is very irregular. Dr. Harvey said because these nodules are frequently associated with dry eye, he'll perform a dry eye workup—Schirmer's without anes- thesia, InflammaDry (Rapid Patho- gen Screening, Sarasota, Florida), and tear-breakup time—to deter- mine where the patient stands and if they need rehabilitation before even removing the nodule. When a nodule is removed, Dr. Harvey also said he will do it before cataract surgery—not the same day. He also prefers superficial keratecto- my at the slit lamp. "I use a Maloney spatula with the eyelid speculum after a drop of tetracaine and a drop of povidone– iodine. Then, it's just peeling the lesion, sometimes with forceps, but sometimes that's not even necessary; sometimes it can be removed with the spatula itself," he said, adding that any loose surrounding epithe- lium can be removed with forceps. "Then they're given one more drop of povidone–iodine (5%) and a ban- daged contact lens with or without amniotic membrane." And finally, pterygia. Dr. Gupta said she'll remove pterygium larger than 1 mm as well as any that cause asymmetric flattening on topogra- phy. "If the pterygium is small and not inducing much flattening, I will give patients the option to avoid resection," she said. "However, I do tell them that their vision will likely change as the pterygium grows." Dr. Harvey said if the pterygi- um is small, he'll remove it at the time of cataract surgery, but larger growths in the central optical zone are removed in a separate OR visit prior to cataract surgery. The earliest he would perform cataract surgery after this procedure was 1 month, but he said he would prefer to wait 2 months. Dr. Ciralsky said she'll wait 2 to 3 months—or until topography and keratometry readings are stable. As for technique, Dr. Harvey uses a modified Anduze technique, which he said is minimally disrup- tive and doesn't involve too much burrowing into the tissue under- neath. "I just try get a tissue plane and remove it with sharp instruments with the thought that there is less stimulation of haze and scar," he said, adding that he will use dilute mitomycin C (0.02%), making sure it's in contact with only subcon- junctival tissue (not the sclera). "It's irrigated so there's no chance of scleral necrosis where it would be considered a longer term risk." Dr. Gupta performs resection with extensive Tenon's dissection. She then uses a conjunctival auto- graft because she finds it comes with the lowest rate of recurrence. "Amniotic membrane is an excellent choice as well, especially for replacement after large or double head pterygium excisions," Dr. Gup- ta added. For primary pterygia, Dr. Ci- ralsky said she'll do a conjunctival autograft with sealant, but she'll use amniotic membrane and mitomycin C for reoccurring cases. How would these lumps and bumps affect use of toric, multifocal, or extended depth-of-focus IOLs? Dr. Gupta said she insists on addressing ABMD, Salzmann's nodules, and pterygium prior to any refractive cataract surgery, as they can have a significant effect on refractive outcomes. For Salzmann's patients, Dr. Harvey said they're often told they have a significant amount of astig- matism. After their surface is treated for dry eye and any ocular surface induced astigmatism, he said these patients can actually end up with a very uniform and minimally astig- matic cornea. "That may open them up to a host of implant options that maybe Prepping continued from page 100 " What we are worried about in patients who have basement membrane changes, corneal degeneration, nodules—concomitant dry eye is always a big thing— is the superficial sloughing of epithelium. " —Thomas Harvey, MD

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