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EW CORNEA 100 April 2017 by Liz Hillman EyeWorld Staff Writer Treating ABMD, Salzmann's nodules, and pterygium before cataract surgery A nterior basement mem- brane dystrophy (ABMD), Salzmann's nodules, and pterygium—these "lumps and bumps," or corneal irregularities, in addition to or out- side of dry eye conditions, need to be diagnosed early and often treated ahead of cataract surgery. "[This] is the most important part of the whole thing because the patient is at least informed that his or her ocular surface is not normal, so it's not a surprise later," said Thomas Harvey, MD, Chippewa Valley Eye Clinic, Eau Claire, Wis- consin. "What we are worried about in patients who have basement membrane changes, corneal degen- eration, nodules—concomitant dry eye is always a big thing—is the superficial sloughing of epithelium, both in areas that look involved and areas that are adjacent, and also re- fractive surprises are also noted. I al- ways like to pick up on these things early and to try to get the patient on the same page right away." In Dr. Harvey's clinic, techni- cians use a TopCon autorefractor (TopCon Medical Systems, Oakland, New Jersey) that, in addition to the patient's autorefraction, provide what Dr. Harvey called a "poor man's corneal topography." "The TopCon autorefractor has a mini Placido, and it will show if the central cornea is regular or irregular based on how round the central mire is. The patient is auto- matically flagged if that's abnormal before they ever make it out of that first starting room. The autorefrac- tor is one of the most critical pieces of equipment in our office, even though it seems like something that is so trivial," Dr. Harvey noted. In addition to the information that is entered into the patient's electronic medical record, Dr. Har- vey said he receives a paper copy that tells him if refractions were inconsistent and if the mires were irregular. "In a way, it's almost like getting topography, but it's not truly topog- raphy," he said. Other ways to diagnose more subtle basement membrane dystro- phy include sclerotic scatter at the slit lamp or vital dye staining with fluorescein and illumination with cobalt blue light. Another pearl, Dr. Harvey offered included using red- free light. "The green light on the slit lamp can actually highlight it with diffuse illumination, the basement membrane changes that might be otherwise missed with the regular white light or even blue light if it did not have the fluorescein," he said. Preeya K. Gupta, MD, assistant professor of ophthalmology, Duke Eye Center, Durham, North Caroli- na, said she uses fluorescein strips, instead of flooding the eye with liquid fluorescein, to assess ABMD preoperatively. She also advised surgeons to look in the superior cornea, which she said is a common location for this condition that can be overlooked. Of course, there are more ad- vanced diagnostics to reveal base- ment membrane changes, such as corneal topography. The best ones, Dr. Harvey said, are Placido devices. Jessica Ciralsky, MD, assistant professor of ophthalmology, Weill Cornell Medicine, New York, said Prepping the ocular surface: Lumps and bumps A s we all know, refractive outcomes are critical after cataract surgery. Irregular astigmatism from condi- tions such as map-dot-fingerprint dystrophy, Salzmann's nodules, and pterygia can decrease vision directly, but patients often live with these conditions for years. Unfortu- nately, they can all degrade keratometry and therefore affect IOL calculations, leaving it to the cataract surgeon to provide education and guidance. Topography is valuable in these situations not only for deciding whether the ocular surface requires surgical manage- ment but also for educating patients. Being able to show the effect of these "lumps and bumps" helps patients understand why a two-step approach to cataract surgery may be in their best interests. This month, Thomas Harvey, MD, Preeya Gupta, MD, and Jessica Ciralsky, MD, share their approaches to these com- mon conditions. Superficial keratectomy or phototherapeutic keratectomy can both treat map-dot-fingerprint dystrophy and nodules, with or without use of amniotic membrane. Similarly, there are different effective ways to do pterygium surgery, including conjunc- tival autograft, amniotic membrane, and the modified Anduze method that Dr. Harvey describes here. All of these surgeries are uncomfort- able and do not noticeably improve vision because there is usually still a visually significant cataract. However, getting the patient through this process is worth it for the improvement in outcomes and often greater choice of IOLs. Because this is my final YES Connect column, I want to thank ASCRS, the YES Committee, the wonderful EyeWorld staff, and my co-editor Charles Weber, MD, for their hard work to launch this column. It has been a privilege to be part of its first year, and I look forward to its bright future with the new co-editors Zachary Zavodni, MD, and Naveen Rao, MD. Bryan Lee, MD YES Connect co-editor Small pterygium can be removed at the time of cataract surgery, while larger growths should be removed in a separate OR visit prior to cataract surgery. Source: Thomas Harvey, MD Not all Salzmann's nodules have to be removed before cataract surgery, particularly those in the periphery that are not affecting the central optical zone. Source: Preeya K. Gupta, MD continued on page 102 YES connect

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