EyeWorld India December 2017 Issue

20 EWAP FEATURE December 2017 Very central epithelial basement membrane dystrophy (EBMD) that causes irregular astigmatism, which could be misinterpreted as ectasia, without the proper clinical exam and correlation; repeat topography and cataract surgery diagnostics were performed 6 weeks after the super cial keratectomy, which demonstrates much more regular astig- matism, with a drastically reduced magnitude and average keratometric value. Source (all): Elizabeth Yeu, MD Ensure optimal – from page 19 pseudo-pterygium. “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 evaluation. “If the Placido disk im- age is poor, I know I can’t take what I’m seeing as a true astigmatism,” she said. Drs. Yeu and Mian do not always perform specular micros- copy, but it can sometimes provide information 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 morning blurring that improves after some time and a clinical exam for corneal edema,” said Clara Chan, MD, assistant profes- sor, 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 op- tion, 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 potentially continue certain therapies after surgery as well. “Patients have to understand that if they’re not al- ready 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 patients with ocular surface disease with corneal staining. She will see such patients in 3 weeks for a follow-up appointment with repeat cataract diagnostics preoperatively. If they’re not quite ready for sur- gery, she’ll use the extra time for corneal treatments and may stretch out surgery for the second eye to provide a bit more time for ocular surface treatment and recovery. However, patients with moder- ate to severe disease often require even more time before cataract surgery. One resource Dr. Yeu has found helpful is self-retaining amniotic membrane therapy. It can be uncomfortable for a patient for 3 to 4 days, but it helps improve their corneal surface rapidly, allowing for more accurate diagnostic imaging, she said. Corneal, cataract surgery timing If a patient requires endothelial keratoplasty and cataract surgery, surgeons carefully weigh how to time the procedures. “For a surgeon just starting out with Descemet’s membrane endothelial keratoplasty [DMEK] or Descemet’s stripping