EyeWorld Asia-Pacific December 2012 Issue

22 EWAP CATARACT/IOL December 2012 and premium IOL implantation, said Steven G. Safran, MD, Lawrenceville, NJ, USA. The process of clearing the cornea can take 2-3 months. “That time is a small investment to make,” Dr. Safran said. Patients who do not want to wait those few months to treat ABMD are probably not good candidates for a premium IOL, Dr. Safran said. However, he finds his patients are open-minded about treatment. “I tell patients it’s like painting a house. You’d be stupid to do it with leaves blowing against the paint,” Dr. Safran said. Another good analogy for ABMD and lens surgery is likening it to a moving target, Dr. Verdier said. “If it’s more than a very mild case of ABMD, you’re going to have some irregular astigmatism and areas of involvement that change over time.” Without pre-op treatment, the ABMD patient may experience poorer visual quality post-cataract surgery, said Natalie Afshari, MD, director, Cornea and Refractive Surgery Fellowship Program, and assistant professor, Department of Ophthalmology, Duke University, Durham, NC, USA. Additionally, a lack of pre- op treatment can make it difficult to obtain accurate keratometry measurements, Dr. Henderson said. Confirm, treating, and to scrape or not to scrape? When the ABMD patient presents for cataract surgery, Dr. Safran first confirms the true source of the visual problem. “Sometimes it’s the cornea and not a cataract causing problems,” he said. He has also seen the reverse situation: “I’ve also seen patients unhappy after cataract surgery who have not had their corneal problems addressed,” he said. Dr. Safran commonly finds that ABMD patients also have other conditions such as pannus, blepharitis, or Demodex mites, all of which he will treat as necessary with doxycycline, Restasis (cyclosporine ophthalmic emulsion, Allergan, Irvine, Calif., USA), or tea tree oil. Drs. Safran and Verdier typically scrape the cornea pre- op and perform a superficial keratectomy. Dr. Afshari performs a phototherapeutic keratectomy (PTK), a laser smoothing treatment. Although some patients can get by without PTK, Dr. Afshari tends to be more conservative with her approach in patients who want a premium IOL. “Perfection is the goal, especially with those patients,” she said. Dr. Safran tries to limit scraping to before surgery as he finds that scraping after cataract surgery can induce a change in refraction. However, Dr. Henderson prefers not to scrape the cornea before surgery in mild ABMD cases. She instead discusses with patients the associated potential risks for pain and blurred vision, which might cause the need for scraping after surgery. She also discusses the possibility of a refractive surprise caused by the difficulty in measuring keratometry values. “Scraping before surgery is a reasonable approach. However, I have found that the majority of patients who have ABMD do not develop postoperative issues and have accurate K measurements,” Dr. Henderson said. However, if K measurements are inconsistent pre-op, Dr. Henderson will go ahead and scrape the cornea to obtain reproducible and accurate measurements. “Also, if a pre-operative topography shows a significant irregular surface, then the patient may benefit from scraping,” she said. Dr. Henderson finds it useful to perform the K readings for these patients in up to four different methods—manual, auto, noncontact biometry, and topography—to compare their values and obtain consistency. “If the values differ even after repeated measurements, then I do not implant a toric or presbyopia- correcting IOL,” she said. Post-treatment considerations Once the ABMD is treated, the surgeon can usually proceed with premium IOL implantation. “Once it’s stabilized, you can do what you want,” Dr. Safran said. Still, these patients require some extra monitoring during and after surgery. Dr. Verdier is cautious about recommending multifocal lens implants for ABMD patients, as the issues of contrast sensitivity loss and increased glare can further compromise optical aberrations associated with ABMD. Some premium lenses, including toric lenses and the Crystalens (Bausch + Lomb, Rochester, NY, USA), are not associated with contrast sensitivity loss or increased glare. “I do not find them contraindicated for ABMD,” Dr. Verdier said. “My primary goal is to maximize the patient’s quality of vision and in doing so preserve the patient’s ability to drive safely and maintain his or her independence. This is more important than spectacle independence, thus my reluctance to recommend multifocal intraocular lens implants.” Dr. Henderson will be careful during cataract surgery with patients who have mild ABMD to avoid trauma to the epithelium and keep the epithelium well lubricated. She uses a dispersive viscoelastic to help avoid damage from excessive phaco energy. “Advanced phaco technology such as torsional ultrasound, burst, and pulse modes can decrease the total amount of energy delivered inside the eye,” she said. EWAP Editors’ note: Dr. Henderson has financial interests with Alcon (Fort Worth, Texas, USA/ Hünenberg, Switzerland) and ISTA Pharmaceuticals (Irvine, Calif., USA). The other physicians have no financial interests related to this article Contact information Afshari: 919-681-3937, Natalie.afshari@duke.edu Henderson: 800-635-0489, bahenderson@eyeboston.com Safran: 609-896-3931, safran12@comcast.net Verdier: 616-949-2001, daverdier@aol.com Treating - from page 21