EyeWorld India March 2019 Issue

EWAP SECONDARY FEATURE 29 March 2019 Treatment plan for corneal irregularities before cataract surgery by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • Pterygia, ABMD, and Salzmann’s nodules all require special consideration in a patient who needs cataract surgery. • Treating these lesions before cataract surgery is usually advisable, although there are some circumstances when they are best left alone. • Surgeons must consider lesions size and patients’ visual goals when setting treatment plans for ocular surface lesions. • Toric IOLs are not recommended in patients with ocular surface lesions. Assess carefully, consider potential postop visual outcome B etter management of ocular surface lesions before cataract surgery can help ensure better postop outcomes. However, surgeons must first decide which lesions need to be managed and which ones can be left alone. A group of ophthalmologists recently shared with EyeWorld how they typically approach common ocular surface lesions and degenerations, such as pterygia, anterior basement membrane dystrophy (ABMD), and Salzmann’s nodules before cataract surgery. Managing pterygia A pterygium in a patient who needs cataract surgery deserves special attention, Joshua Teichman, MD, MPH, Department of Ophthalmology and Vision Sciences, Trillium Health Partners, University of Toronto, Toronto, Canada. “I am more aggressive to remove a pterygium prior to cataract surgery, especially in patients who are hoping for spectacle independence after surgery,” he said. Other surgeons concurred. “The pterygium should be removed if it is encroaching on the visual axis and/ or the patient wants it removed,” said David Goldman, MD, Goldman Eye, Palm Beach Gardens, Florida. “In either of those cases, it should be removed prior to cataract surgery, with time for the cornea to heal and normalize.” Dr. Teichman also will consider the presence of topographic changes, such as localized flattening, that may occur with smaller pterygia. This makes him more likely to remove the pterygium prior to surgery. He also analyzes the topography, looking for asymmetry between the eyes. “If the affected eye is substantially different than the contralateral eye, that should alert the examiner to the possibility of pterygium-induced corneal changes,” Dr. Teichman said. Jeremy Kieval, MD, Lexington Eye Associates, Lexington, Massachusetts, said that if there is a smaller pterygium, it can be left alone. However, he will let patients know that the refractive outcome can be more unpredictable and that the patient may have more significant postop astigmatism. “For the most part, topography is the most important of the criteria I use, looking for the typical flattening of the cornea where the pterygium is present and the corresponding steepening in the opposite meridian,” he said. Another important consideration is the severity of the pterygium, said David Hardten, MD, Minnesota Eye Consultants, Minneapolis. When he removes a pterygium in a patient with milder cataract that isn’t the main vision issue, he will remove the pterygium, and then follow the patient until the cataract is visually significant. “In some eyes with severe pterygium with corneal scarring and irregular astigmatism that remains after the pterygium surgery, it may be a three-step or five-step procedure involving the pterygium surgery, followed by a PTK 6 to 12 months later, followed by the cataract surgery, then a YAG and another PTK,” he said. In a patient with a longstanding pterygium that now has very dense cataract, I will sometimes remove the cataract, and the patient understands that their vision will still be slightly impaired from the pterygium as it had before the cataract developed. Once a pterygium is removed, Dr. Teichman generally repeats the topography and biometry after 3 months. “There is evidence Photograph of negative fluorescein staining superimposed over a slit lamp photograph of obvious ABMD. Source: Joshua Teichman, MD Continued on page 30