CORNEA 48 EWAP MARCH 2022 become an important part of preoperative evaluation of patients for Dr. Hovanesian. He also gets an OCT of the macula, which is helpful in identifying any macular disease. Since many dry eye patients are asymptomatic, Dr. Hovanesian said a corneal topography is critical. “If we see corneal staining, that’s not just dry eye, that’s moderate to severe dry eye because the dryness is so advanced that it’s caused a breakdown in the surface,” he said. Fluorescein staining, Dr. Hovanesian said, can also help show irregularities on the cornea. Dr. Kim also discussed the importance of using fluorescein, but he warned against using too much, which can flood the tear film, making EBMD hard to spot. Dr. Kim likes to dab the palpebral conjunctiva with a fluorescein strip moistened with proparacaine and have the patient blink, distributing a thin film that often will highlight the presence, extent, and location of EBMD. Salzmann’s nodules can be missed, Dr. Kim said, because they often sit in the superior cornea. The physician needs to lift the upper lid to examine the superior cornea to spot these lesions, which can cause a lot of irregular astigmatism. Dr. Kim also stressed the importance of using corneal topography to see how much a pterygium is pulling on the cornea and causing astigmatism. The pterygium may look minor at first, he said, but the topography can help you determine the extent of central corneal involvement and if it needs to be treated prior to cataract surgery. “You don’t need a bunch of fancy tests in your office,” Dr. Kim said. Fluorescein staining, tear breakup time, and pressing on the lower lid to look for MGD are all helpful tests that can be easily performed at the slit lamp in 15–20 seconds. For pterygium, EBMD, and Salzmann’s nodules, doing a good slit lamp exam, lifting the upper eyelid to make sure you visualize the entire cornea, and performing corneal topography are all important steps, Dr. Kim said. Dr. Rapuano also uses negative staining, which he said can be a valuable tool, particularly for identifying basement membrane dystrophy. These alterations in the tear film indicate elevations in the corneal surface, which are often from subtle EBMD changes. While frequently mild, they can distort the vision and affect biometry, he said. Most of his cataract patients will also get a topography. He mentioned that this can be helpful to show if a pterygium needs to be treated. People often know if they’ve had a little pterygium for years and might not be bothered, he said. But if the topography is being affected by the pterygium, it should be treated first. Dr. Schallhorn performs topography on every patient having cataract surgery, calling it incredibly useful for toric planning in patients with normal exams and to detect any irregular corneal contours that might be due to one of the conditions mentioned. “Topography is a critical part of the preoperative evaluation for any cataract patient,” she said. “This should be combined with a careful exam to identify conditions that could result in a suboptimal outcome and to guide treatment.” Treatment and when to delay cataract surgery While Dr. Schallhorn said that no condition is a true contraindication to cataract surgery, addressing issues that can cause problems with biometry is mandatory before proceeding. Patients with dry eye should receive treatment until they have a smooth, stable epithelial surface and are asymptomatic. Dr. Schallhorn said that patients with EBMD, Salzmann’s nodules, or pterygia causing corneal cylinder should undergo treatment before surgery. Cataract surgery should be delayed to allow for complete epithelial healing, she said, which usually takes 3 months for full stabilization and sometimes longer in patients with EBMD. Fuchs patients should be counseled about their increased risk for corneal edema. Patients with confluent guttata, morning 8isWaNNy siInificant centraN '$/& chanIes are hiIhNiIhted Dy neIatiXe staininI WsinI ƃWorescein dye and coDaNt DNWe NiIht. Source (all): Christopher Rapuano, MD
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