EyeWorld Asia-Pacific June 2017 Issue

June 2017 50 EWAP cornea A moderately large pterygium can be seen nasally in this right eye. An iron line (Stocker line) can be seen near the leading edge, indicating chronicity. Several small midperipheral Salzmann’s nodules are noted. While not involving the visual axis, they often cause irregular astigmatism and affect vision and keratometry readings. Map and dot changes of epithelial basement membrane dystrophy (EBMD) are apparent centrally, which can cause irregular astigmatism. Moderate central map changes with subepithelial fibrosis are apparent centrally in this eye with EBMD. Source (all): Christopher Rapuano, MD “If we have a patient who has severe dry eye, anterior basement membrane, corneal dystrophy, or Salzmann’s degeneration, those patients make excellent candidates for ocular surface optimization with amniotic membrane,” Dr. Donaldson said. “For the patients that have anterior basement membrane dystrophy and the patients who have Salzmann’s degeneration, those patients are often undergoing superficial keratectomy 4–6 weeks before cataract surgery, so when we do a superficial keratectomy, I find the amniotic membranes can be a useful tool to supplement healing when we do that minor procedure to optimize their ocular surface. It can also be used with severe dry eye patients who have a lot of punctate epitheliopathy.… [In these cases, it] can help heal the surface and make the topography more regular making axis and power calculations more accurate.” When to use it? While biologics like amniotic membrane can be a powerful tool, Dr. Desai said they are “not an end- all-be-all panacea.” “Since ocular surface disease is typically seen as a chronic condition, all available modalities for treating the underlying contributors to ocular surface disease must be instituted simultaneously. Since many of these treatments take time to perform and work before I can rationally proceed to a refractive cataract surgery, I often find myself counseling patients that due to co-existing problems, I want to do things not the fast way, but rather the right way,” he said. Treatments Drs. Desai and Gupta consider prior to or in conjunction with amniotic membrane, depending on the patient’s pathology, include artificial tears, immunomodulators (eg. Steroids, cyclosporine, lifitigrast), nutraceuticals, and warm compresses. If the patient has meibomian gland disease, ocular rosacea, or evaporative tear deficiency, Drs. Desai and Gupta advise LipiFlow (TearScience, Morrisville, North Carolina) coupled with Intense Pulsed Light (IPL) therapy. Dr. Gupta said she’ll treat ocular surface inflammation with topical therapies first, but if the condition doesn’t improve with that treatment, she’s apt to turn to amniotic membrane as a next resort. “One caveat is in patients in whom I am looking for a relatively rapid response—often [amniotic membrane] can rapidly restore the surface, but you will often still need Optimizing – from page 49