On this episode of Interventional Mindset, Niraj Desai, MD, reviews conditions that are frequently missed during refractive cataract evaluations which require ocular surface optimization prior to surgery.
Dr. Desai is a cataract, cornea, and laser assisted in situ keratomileusis (LASIK) surgeon who practices at Milan Eye Center in Atlanta, Georgia.
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Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.
Conditions to assess patients for during cataract evaluations
Cataract surgery has evolved into a refractive procedure,1 Dr. Desai noted, and as such, it is of utmost importance to ensure that the ocular surface is optimized to limit errors in pre-operative diagnostic testing and for the success of advanced technology intraocular lens (AT-IOL) implants.
Anterior basement membrane dystrophy (ABMD)
One of the more common diseases that Dr. Desai encounters during cataract evaluations is anterior basement membrane dystrophy (ABMD). He explained that it can show up as central or paracentral irregular astigmatism on topography, but if it is significant enough, it may impact the overall topography and cause an increased higher-order aberration profile.2
Dr. Desai’s treatment approach for ABMD is to perform corneal debridement and supplant this with an amniotic membrane graft (if needed) prior to cataract surgery. He added that he usually treats one eye at a time, typically 1 month apart, and once both eyes are treated, he waits 2 to 3 months before performing cataract surgery. At the time of surgery, he performs a simple debridement and then places an amniotic membrane.
He added that while not all ABMD needs to be treated, more often than not, it can interfere with the quality of vision if patients want diffractive or toric IOLs.3
Carousel 1: Slit lamp images of anterior basement membrane dystrophy.
Carousel 1: Images courtesy of Niraj Desai, MD.
Salzmann nodules
Salzmann nodules can be missed during evaluations because they are often peripheral and can be confused for scarring, noted Dr. Desai.3 He added that patients are often asymptomatic and have been seen by an eyecare practitioner for years without having been informed of the nodules.
Consequently, part of the challenge in managing these patients is informing them that they have a condition that requires treatment prior to cataract surgery, explaining the condition to them, and outlining what is required to get rid of the nodules. To treat Salzmann nodules, Dr. Desai performs a superficial keratectomy and post-operatively uses an amniotic membrane concurrently with mitomycin C in most patients.4
In his surgical experience, this protocol results in good outcomes for the patient, sometimes dramatically improving the corneal surface and astigmatism profile to such a degree that the patient no longer feels they need cataract surgery.
Carousel 2: Slit lamp photographs of Salzmann nodules.
Carousel 2: Images courtesy of Niraj Desai, MD.
To learn how surgeons can effectively manage patient treatment expectations through roadmapping, watch the full video!
Dry eye
Dry eye disease (DED) is also often looked over during cataract evaluations, and as a complex and multifactorial condition, it is critical to identify the root cause, such as evaporative or aqueous deficient DED.5
During cataract evaluations, Dr. Desai likes to review the patient’s medication list and discuss any habits that may contribute to dry eye to identify easy ways to improve the patient’s ocular surface health. For example, patients may benefit from a simple swap, such as switching from daily oral antihistamines to a nasal steroid, to help the patient regain moisture levels.
Beyond medication and ergonomic (ex., adding a humidifier) adjustments, DED patients often require further therapies, such as punctal plugs and interventional meibomian gland treatments, to manage their dry eye. Dr. Desai noted that one of the applications for newer-generation amniotic membranes, such as CAM360 AmnioGraft (BioTissue, Inc.), is for dry eye, particularly when seeking to improve the ocular surface.7
Carousel 3: Slit lamp images of corneal staining caused by dry eye disease.
Carousel 3: Images courtesy of Niraj Desai, MD.
The case for amniotic membrane grafting
In Dr. Desai’s opinion, amniotic membrane grafts are a great adjunctive tool for cataract surgeons to optimize the ocular surface. Cryopreserved amniotic membrane (CAM) has demonstrated efficacy in sustained ocular surface improvement by (1) reducing the inflammatory load on the ocular surface and (2) promoting corneal nerve regeneration with several applications over time.8
The official indications for CAM include:9
- DED
- Superficial punctate keratitis (SPK)
- Ocular surface optimization
- Glaucoma-medication-induced dry eye
- Stage 1 neurotrophic keratitis (NK)
He has found CAM to be particularly useful for treating stage 1 NK, though it can be challenging to identify NK patients during earlier stages, meaning it is of utmost importance to know how to assess patients for NK, make the diagnosis early, and utilize effective and appropriate therapies to deliver optimal visual outcomes.
Conclusion
Cataract surgery can deliver outstanding visual outcomes; however, in cases where patients are unhappy with the result, Dr. Desai has found that this is often connected to the patient’s pre- and post-operative ocular surface health rather than the IOL itself.
Consequently, it is crucial to address ocular surface and corneal disease appropriately prior to surgery, especially if the patient is requesting AT-IOLs that work best with a visual system that can transmit light uninterrupted.
