CORNEA EWAP MARCH 2022 49 blur symptoms, or stromal edema should be seen by a corneal specialist because they might benefit from a combined endothelial keratoplasty procedure. Dr. Hovanesian agreed that it’s important to treat these conditions prior to cataract surgery. For dry eye patients, he said that a month may be an appropriate period to get meaningful improvement. He added that artificial tears, steroid supplements, and other treatments could help with quicker rehabilitation. When using a surgical treatment for pterygium or Salzmann’s nodules, Dr. Hovanesian noted that most corneal specialists wait 2 months or more postop before proceeding with a cataract procedure. “When you’re altering the corneal stroma, there’s more remodeling and epithelial healing that occurs that may take a couple months,” he said. Dr. Rapuano described his treatment prior to cataract surgery for both EBMD and Salzmann’s nodules. Typically, you can treat basement membrane dystrophy with epithelial debridement, which he usually combines with diamond burr polishing to make sure all the microscopic basement membrane elevations are gone. This can be done at the slit lamp, Dr. Rapuano added, and it usually takes about 6–8 weeks before the epithelium is smooth for accurate K readings. For Salzmann’s nodules, he said lamellar keratectomy can be used to treat at the slit lamp. However, he noted the Salzmann’s nodules tend to recur. To try to prevent recurrence, Dr. Rapuano will use mitomycin-C at the time of removal. Dr. Kim described the criteria used in his study that indicated if a patient’s corneal condition should be treated before cataract surgery: 1) If the patient has central corneal involvement of EBMD or Salzmann’s nodules (central 3–4 mm); 2) Distortion on keratometry or inconsistency on biometry; 3) Irregular astigmatism or “dropout” on corneal topography; 4) Subjective complaints of blurred vision or image ghosting. Dr. Kim said he and his colleagues treat a lot of these patients with superficial keratectomy and scraping the corneal epithelium. For Salzmann’s nodules, treatment simply involves peeling the lesions with a 0.12 forceps. “For EBMD, we generally perform a superficial keratectomy with a Maloney spatula followed by a small excimer laser PTK procedure,” he said. After both procedures, topical mitomycin-C 0.02% is applied to the treated corneal surface with a circular Merocel sponge for 30 seconds to help prevent recurrence and scar formation. Dr. Kim said patients are brought back a month after the treatment to confirm complete healing, and sometimes the cataract surgery needs to be delayed. It’s important, he said, to ensure that patients know about these conditions before proceeding with cataract surgery so that they can make an informed decision about treatment with the goal of providing the best visual outcome. EWAP Reference 1. Goerlitz-Jessen MF, et al. Impact of epithelial basement membrane dystrophy and Salzmann nodular degeneration on biometry measurements. J Cataract Refract Surg. 2019; 45:1119–1123. Editors’ note: Dr. Hovanesian is in practice with Harvard Eye Associates, Laguna Hills, California, and has interests with Sun Pharma and Novartis. Dr. Kim is Chief of the Cornea and Refractive Surgery Service, Duke University, Durham, North Carolina, and declared no relevant financial interests. Dr. Rapuano is Chief of the Cornea Service, Wills Eye Hospital, Philadelphia, Pennsylvania, and declared no relevant financial interests. Dr. Schallhorn is Residency Program Associate Director, University of California San Francisco, San Francisco, California, and declared no relevant financial interests. ADVERTISER LISTING Alcon Page 26 - 29 www.alcon.com Johnson and Johnson Vision Page 2, 10 -15 www.jjvision.co Oculus Page 25 www.cornealbiomechanics.com Zeiss Page 42 - 45 www.zeiss.com APACRS Page 5, 6, 38, 59, 67, 68 www.apacrs.org
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