Eyeworld

EW FEATURE 80 Challenging cataract cases • October 2017 seeing as a true astigmatism," she said. Drs. Yeu and Mian do not al- ways perform specular microscopy, but it can sometimes provide infor- mation on lens density. "For academic interest, we will also do specular microscopy for endothelial cell counts and corneal thickness, but this does not replace a good history inquiring about morn- ing blurring that improves after some time and a clinical exam for corneal edema," said Clara Chan, MD, assistant professor, University of Toronto. Meibography and tear osmolar- ity tests can provide concrete infor- mation for some patients who may need to clear up their ocular surface before cataract surgery, especially if they want a refractive cataract option, Dr. Yeu said. Preop treatments for the cornea Cataract surgeons will start a vari- ety of treatments with the goal of helping the ocular surface before surgery. For Dr. Chan, this can include lubrication, topical steroids, omega-3 fatty acids, topical cyclo- sporine (Restasis, Allergan, Dublin, Ireland), and warm compresses and lid hygiene scrubs twice daily. "In more severe cases, we may need to use doxycycline if facial rosacea is present," Dr. Chan said. One component of treatment is preparing patients to potential- ly continue certain therapies after surgery as well. "Patients have to understand that if they're not already on therapy, they will have to commit to being on some form of therapy, including nutraceuticals," Dr. Yeu said. "If they're not willing to do that, you may still have an unhappy patient [postoperatively]. That conversation needs to be had, especially if the patient is looking for spectacle independence." Newer treatments available within the office such as LipiFlow (TearScience, Morrisville, North Carolina), BlephEx (Franklin, Ten- nessee), and intense pulsed light can also be used, Dr. Mian said. He finds out if patients have a history of herpetic keratitis, which could flare again after cataract surgery. In these patients, he will manage with anti-viral medications before and after surgery. Dr. Yeu realizes how eager patients are to get their cataract surgery done, so while turnaround for surgery is usually 3 to 4 weeks, she will typically push the surgi- cal schedule 6 to 8 weeks out for tentially indicate low aqueous tear dysfunction. "I also look for other causes of surface irregularity. Some are subtle, and some are easy to see," he said. This includes searching for signs of anterior basement membrane dystrophy, which can be identified carefully with a narrow slit beam, Salzmann's nodules, corneal scarring from previous trauma, and limbal conditions such as pterygium or pseudopterygium. "With those, it's very helpful to perform corneal im- aging such as topography to see the impact on the cornea curvature," Dr. Mian said. One finding Dr. Yeu evaluates is Placido disk imaging, which she uses as part of her astigmatism evalua- tion. "If the Placido disk image is poor, I know I can't take what I'm University of Michigan, Ann Arbor. Tests that he will use include tear breakup time, fluorescein staining, and lissamine green staining. "Many patients in the age group for cataract surgery have dry eye disease, and it's associated with increased tear evaporation caused by lid disease," he said. Sometimes Dr. Mian will obtain a Schirmer's score, which can po- Ensure continued from page 78 OPHTHALMOLOGY'S ONLY READY-LOADED IRIS EXPANDER READY-LOADED Made in the U.S.A. DIAMATRIX ® featuring by Stop by Booth #3932 at AAO or visit Diamatrix.com to learn why surgeons call the XpandNT "the most elegant ring on the market". continued on page 82

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