EyeWorld India September 2020 Issue

EWAP SEPTEMBER 2020 3 EDITORIAL Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific Abhay Vasavada Deputy Regional Editor EyeWorld Asia-Pacific EyeWorld Asia-Pacific • September 2020. Vol 16 No. 3 T he September issue of EyeWorld Asia-Pacific addresses the importance of the corneal surface in cataract and refractive surgery. The surface of the cornea is the most important refractive element and disruptions can have a major impact on outcomes. This is apparent in day to day assessments of patients for cataract surgery, where a poor tear film can lead to misinformation regarding the power of the cornea, particularly in relation to astigmatism. It is common practice to try and optimize the corneal surface prior to cataract surgery with lubricants and sometimes attention to the lid margin. For many surgeons, this is an integral part of their preoperative planning and is part of the routine work up for all patients. Personally, I use topography or tomography to determine whether reassessment after a period of lubricants and attention to the ocular surface is required. I also use the K calculator, which provides a mean vector for astigmatism to determine a more accurate representation of keratometry as different devices often disagree in their assessment of the magnitude and axis of astigmatism. Less frequently, we encounter pterygium, and the description of the surgical techniques from various authors in this issue is informative. Removal of the pterygium with conjunctival autograft has become the most favored technique to prevent recurrence, with mitomycin only being considered for those cases with recurrent pterygia. Amniotic membrane as an alternative to a conjunctival autograft has a place but mainly when insufficient conjunctiva is available. The presence of pterygia can also be a problem in assessing the power of the corneal surface. If the pterygium is small, it is not likely to impact biometry, but even a modest pterygium can lead to misleading keratometry and astigmatism. Depending on the age of the patient and their enthusiasm to be spectacle-free, pterygium surgery prior to cataract surgery may be preferable over proceeding with the pterygium in situ. In some instances, however, the patient may be unwilling to consider two procedures, and this is one of the rare circumstances where I would consider the refraction (prior to significant cataract) to assist with determining the astigmatism and whether a toric lens and what power of toric cylinder is required. Finally, the impact of medications on the ocular surface in the management of glaucoma can be a limiting factor. There is a wide range of responses to medications such as prostaglandin analogue but we are all familiar with the well-controlled glaucoma patients in whom injection and irritation become a major issue. Nonpreserved medications have a role in providing symptomatic relief and hopefully a new medication such as Rho kinase inhibitors, which are covered in the section on glaucoma, may prove to be an alternative that provides glaucoma control with less adverse effects on the ocular surface. It is interesting to reflect how important the ocular surface is and how its health and vitality impact on so many areas of our practice. T he focus of this issue is ocular surface considerations for different surgeries. Although it seems like common sense, often basic examination and management of the ocular surface can be missed prior to surgery, leading to problems in making the right surgical decision or in outcomes of the surgery. A particular case is that of corneal transplants. With options available in terms of penetrating and endothelial keratoplasty, it is relevant that surgeons make the right choice of procedure. As has been pointed out by the experts, eyes may often have multiple problems, such as corneal decompensation with presence of past inflammation/ infection involving the ocular surface. Simple tests such as slit lamp examination of tear film and the absence of corneal sensations may alert the surgeon that they need to treat and let the eye quieten before planning any procedure. Therefore, carefully treating the ocular surface is of paramount importance. If there is one issue that can potentially mar the outcome of a perfectly executed cataract surgery, it is the presence of dry eye. Quite often, dry eyes go undetected during a preoperative evaluation. Although there are several modern diagnostic tools, even simple examination of the eyelid margin, conjunctiva and tearfilm breakup time can guide surgeons towards the presence of significant dry eye. In my opinion, this is one of the most important reasons for unreliable biometry, dissatisfied patients, and refractive surprises after any cataract surgery. Therefore, as cataract surgeons, we should all keep in mind that counseling and managing patients for dry eye will go a long way towards making patients happier. Pterygia can be bothersome due to their cosmetic issues, ocular surface disturbances, astigmatism, and recurrences. Treating ocular surface pre- and postoperatively will go a long way in achieving these objectives. It makes sense to consider surgery for glaucoma at an early stage before the ocular surface develops severe changes. What is exciting is also the introduction of newer and longer lasting preparations of glaucoma medications, which promise to offer better effectivity and compliance. Finally, as we all cope with the COVID-19 pandemic and yet restart our practices, we will need to make many changes— to the way we approach our clinics and our patients. Digital ophthalmology is going to play an increasing role. Yet, the bottomline is that there is hope for the better, both in terms of more options for treatment, diagnosis, and overall better practices for both ophthalmologists and patients.