CORNEA EWAP MARCH 2022 47 because they are so common. There has been more emphasis on addressing these conditions prior to cataract surgery in the past 5–10 years, he added, with the procedure potentially exacerbating these conditions. Dr. Rapuano highlighted EBMD, which can cause wrinkles on the surface of the cornea. If it’s mild and in the periphery, it won’t change the corneal shape or curvature, and you can leave it alone, he said. If it’s more significant and in the central cornea, it can create distortions in the vision. These distortions would likely show up on topography or K readings. Patients may notice a little shadow vision, he added. Salzmann’s nodules, creamy white nodules on the corneal surface, are another issue that Dr. Rapuano discussed. These tend to distort corneal curvature. Often, they are in the periphery, not causing too many visual problems, but they can be an issue if they are closer to the center of the cornea. They can cause astigmatism and potentially irregular astigmatism, he added. “For all patients we treat, we need to be attentive to the cornea before doing biometry measurements because problems on the surface of the cornea are going to lead to undesirable outcomes,” said John Hovanesian, MD, adding that patient expectations are higher than ever. The most common issue is dry eye, he said, adding that about three-fourths of those who have it are not symptomatic. “If we’ve got an aim of giving the patient the refractive result they want, we need to pay attention first to dry eye,” he said. When pterygium and Salzmann’s nodules are visually impactful, they need to be addressed prior to surgery, Dr. Hovanesian said. He avoids putting a toric lens in a patient with a Salzmann’s nodule causing astigmatism because the nodule will cause irregular astigmatism so the correction with the toric is less than ideal. “If you remove the nodule and make the cornea more regular, there may not even be astigmatism, and you’ll at least reduce irregularity,” he explained. Terry Kim, MD, spoke about many of the previously mentioned conditions as well. He said they may appear benign in nature, but surgeons need to do their due diligence in terms of examining patients, looking for these conditions, and determining if they are functionally or visually significant. “I think that’s a critical step because they can not only affect the visual outcome after surgery, but they can affect biometry measurements.” He cited a paper he co-authored1 that showed that biometry measurements and IOL calculations were significantly impacted in patients with epithelial basement membrane dystrophy and Salzmann’s nodules, which would have resulted in major alterations in spherical and toric IOL power if not treated prior to cataract surgery. Are patients already aware of these conditions? EBMD and Salzmann’s nodules are usually a new diagnosis, Dr. Schallhorn said. “The patients are most commonly unaware of these conditions, as they usually don’t cause symptoms, unless the patient has had previous erosions in the case of EBMD,” she said. “Therefore, it is important to do a careful exam to look for evidence of these before surgery.” She added that patients are usually also unaware if they have mild keratoconus. Dr. Hovanesian said patients will often attribute poor vision to the cataract rather than corneal problems. “As important as making the diagnosis is the conversation with the patient,” he said. For example, if the patient has dry eye, he will explain to the patient that he or she has two diseases, not one. The first (the cataract) can be fixed, but the second (the dry eye) is up to the patient to treat, sometimes long term. “The emphasis is placed on the patient, and the conversation covers the idea that dry eye will affect vision after surgery,” he said. “I can’t give them perfect vision because their eye is not perfect even with the cataract removed.” Tests to perform Corneal topography has A small, elevated Salzmann’s nodule is present in the periphery but some subepithelial fiDrosis can De seen eZtendinI centraNNy resWNtinI in soOe irreIWNarity on corneaN topography. Removal should be considered prior to cataract surgery.
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