September 8, 2016

Preparing the Ocular Surface for Cataract Surgery: Q&A with Niraj Desai, MD

published on September 08, 2016 by Niraj Desai, MD, Milan Eye Center

With the high prevalence of ocular surface disease and its affect on cataract surgery outcomes, ensuring a healthy ocular surface prior to and post cataract surgery is very important. BioTissue recently spoke with Niraj Desai, MD, about his experience with preparing the ocular surface for cataract surgery.

Q: Are all pre-cataract patients evaluated for ocular surface disease?

A: Every patient, whether we are planning surgery or not, is evaluated for ocular surface disease. In particular, tear film stability is assessed and these complaints are differentiated from cataract related visual symptoms. At times these symptoms are why the patient is considering cataract surgery, and we are able to avoid surgery by optimizing the ocular surface. Other processes are genetic and become more pronounced with time such as ABMD/MDF. These are often overlooked on cursory exams.

Q: How common is it for your pre-cataract patients to have ocular surface disease?

A: In general, a majority of patients in the cataract age demographic display some form of ocular surface disease. Sub-clinical and clinical dry eye is encountered commonly. Meibomian gland dysfunction (MGD) with secondary dry eye is a close second. ABMD is not uncommon, but its manifestation is variable. Some patients have mild corneal changes outside the visual axis that do not result in any degree of irregular astigmatism. Others have central and paracentral involvement resulting in irregular and inconsistent topographies. Should the ocular surface disease be sub-clinical and the patient not voice complaints, most surgeons will defer aggressive management for those having ‘routine’ cataract surgery without advanced technology IOLs (ATIOLs). To the contrary, the threshold to treat even sub-clinical disease is much lower when the patient has made the decision to pursue ATIOLs.

Q: Why is optimizing the ocular surface so important for pre-cataract surgery?

A: The term ‘Refractive Cataract Surgery’ is well known to most of us now. Cataract surgery has moved into a new realm where available technology can often meet patients’ expectations. However, the technology can only work as well as the tear film. This cannot be emphasized enough. Planning cataract surgery is often an opportunity to introduce the concept of ‘Ocular Surface Disease’ and set the tone for the need for chronic management well beyond the perioperative period of cataract surgery. For patients with ABMD or Salzmann’s nodules, a pre-cataract surgery evaluation presents a similar opportunity, albeit one where more procedural management is necessary before cataract surgery.

Q: What treatments do you use for ocular surface diseases?

A:  A myriad of regimens come into play when treating ocular surface disease. If we are dealing with tear deficiency and mild symptoms in the absence of meibomitis, punctal plugs and artificial tears are often sufficient. On the other hand, if we are dealing with significant meibomitis, blepharitis and lash sleeving, several treatment options can be entertained including doxycycline, Cliradex® wipes, artificial tears and even purified fish oil.

In addition to typical dry eye and blepharitis, and perhaps as a result of their presence chronically, other surface issues such as Salzmann’s nodular degeneration are approached very differently. Salzmann’s nodules and ABMD generally have to be surgically treated before cataract surgery. Corneal debridement or superficial keratectomy paired with Prokera® has been a mainstay for me that provides accelerated regenerative healing with high quality outcomes. To this end, presenting a ‘road map’ for treatment to the patient is key. This will set expectations on why the procedure is necessary, duration of corneal therapy, and the timeline for cataract surgery. I also discuss potential visual outcomes based on topography.

Q: What have been the results of optimizing the ocular surface prior to cataract surgery?

A:  Most of these patients have significant irregular astigmatism with surprisingly good visual acuity on exam. When pressed however, many patients will tell me that although they can “see,” the quality of their vision isn’t very good or consistent. I use topography as an educational tool for these patients and they are often amazed at the change. I’ve had consistent comments that the visual quality is improved even before cataract surgery is performed. For me, the rapid return of a lustrous epithelium within 3-5 days of the debridement or keratectomy procedure is gratifying. It justifies the time spent by the patient before cataract surgery and their endurance of some discomfort that goes along with a corneal resurfacing procedure.

Q: Does any particular case come to mind where Prokera was used successfully with a pre-cataract patient?

A: I recently had a patient referred from a local optometrist. Upon examination I noted large Salzmann’s nodules in both eyes that had been termed “corneal scarring.” As discussed above, I helped the patient get an understanding of Salzmann’s nodules, her irregular astigmatism and necessity for superficial keratectomy along with my preference for Prokera placement to follow. We then discussed potential timelines for the cataract surgery. Upon receiving my consultation letter, the optometrist called me to discuss the case. She was concerned about the need for a corneal procedure prior to cataract surgery. I told her that I’d send her a corneal topography within 5 minutes of completing the superficial keratectomy – before I placed the Prokera Slim graft (see topographies). After I sent her the anterior curvature images, she was a believer. In all honesty, I too was amazed at the instantaneous difference!

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