EyeWorld Asia-Pacific March 2019 Issue

30 EWAP SECONDARY FEATURE March 2019 to suggest that the larger the pterygium, the more induced astigmatism and the longer the cornea will take to normalize. If I am ever unsure, I repeat the measurements and proceed once the measurements are stable,” he said. ABMD and Salzmann’s nodules The key step with ABMD is to spot it in the first place. “I think most of us can look right through the cornea and start examining the cataract we will need to address, but if you stop and look closely, you can sometimes see subtle ABMD,” Dr. Kieval said. The use of retroillumination or a red-free filter can help find subtle disease, he said. Topography is also helpful, he added. “Subtle irregularities may be present on topography, and one should always inspect the rings image,” Dr. Teichman said. The use of negative fluorescein staining can be used, and surgeons can look out for a Shahinian’s sign—a scalloped line of tear film thinning—across the top third of the cornea, he explained. A patient may benefit from a superficial keratectomy before cataract surgery if there is any irregularity in the central to mid- peripheral cornea, followed by topography and biometry 3 months later, Dr. Teichman said. “Similar to the pterygium situation, it isn’t rare to need a YAG and then another PTK for maximum vision recovery,” Dr. Hardten said. If it has been fairly stationary and the cataract is the main issue, he prefers to perform cataract surgery. “A PTK could be done later if their vision needs require,” he said. “ABMD or Salzmann’s nodules do not always have to be removed prior to or during cataract surgery,” Dr. Goldman said. “If it is going to be addressed, it should be treated prior to cataract surgery. While I do corneal scrapings for ABMD in the office, for Salzmann’s nodules I will perform surgery in the OR. In the majority of these cases, you can undermine an edge of the nodule and just peel them off. … I was trained that if you just scrape the epithelium over the area of the nodule and start to use a beaver blade or something similar to tease at the edge of the lesion, you can grasp the edge and peel the nodule off of the cornea.” Dr. Teichman shared another pearl for Salzmann’s nodules. “Another important factor in treating them is identifying the underlying etiology. Often overlooked is chronic low-level inflammation from meibomian gland disease and dry eye. Simply removing the nodules may result in recurrence unless the underlying pathology is addressed,” he said. Yet again, surgeons need to think about a patient’s visual goals and the size of the lesion. If the goal is to see better with glasses and it’s something small, first, Dr. Goldman will leave it alone. Dr. Kieval added another circumstance when lesions may not need treatment. “I think it is reasonable, and more likely advisable, to leave well enough alone if the patient has poor visual potential due to other ophthalmic or neurological disease,” he said. Toric lenses? A patient with an ocular surface lesion is usually not the best fit for a toric IOL. “I will not consider a toric lens in a patient undergoing cataract surgery who has a pterygium. In those cases, I’ll recommend pterygium surgery first, then determine if a toric lens is truly needed,” Dr. Goldman said. “I have seen many patients with toric IOLs that had refractive surprises because of ABMD or a pterygium that wasn’t addressed prior to surgery, and I have seen patients who have those irregularities removed after phaco. They have refractive shifts that are very upsetting,” Dr. Kieval said. For this reason, he believes it is crucial to see what the unadulterated cornea looks like and remove any deposits, degenerations, or lesions to maximize the potential postop outcome. Teichman also uses MMC on aggressive recurrences that have occurred in the context of a previous conjunctival autograft. 3. Use a Tooke Corneal Knife. “I find this allows one to remove lesions at a plane that does not proceed too deeply yet allows the underlying scar to be removed well,” Dr. Teichman said. 4. Find your best fibrin glue choice. “I use conjunctival autograft in all cases and use fibrin glue to secure the graft,” Dr. Teichman said. “There is a study that demonstrated Tisseel [Baxter Health, Deerfield, Illinois] is likely a superior adhesive for pterygium surgery, and I have found that to be the case in my hands as well,” he said. 5. Be patient after treating a lesion. “Sometimes it can take months to achieve a stable state that can be reliably used for cataract surgery,” Dr. Kieval said. EWAP Editors’ note: The physicians have no financial interests related to their comments. Contact information Goldman: david@goldmaneye.com Hardten: drhardten@mneye.com Kieval: jkieval@lexeye.com Teichman: josh.teichman@gmail.com Treatment plan - from page 29 Surgical pearls To help better manage pterygia, ABMD, or Salzmann’s nodules, the surgeons interviewed shared a few pearls. 1. Use Goniosol. “Goniosol is useful to coat the cornea, improving visualization visualization and also to protect the epithelium,” Dr. Hardten said. 2. Consider dissection of the underlying Tenon’s for pterygium. Dr. Kieval recommends this along with placement of a conjunctival autograft and the use of mitomycin-C (MMC) on recurrent lesions—but not on primary pterygium. Dr. ...it is crucial to see what the unadulterated cornea looks like and remove any deposits, degenerations, or lesions to maximize the potential postop outcome.