Cornea Society News

SUM 2013

Cornea Society International Organization Advancing the treatment of corneal disease

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Vo l . 9 , N o . 3 News A Cornea Society publication Summer 2013 Experts offer tips and pearls at Cornea Day 2013 A ddressing the ocular surface— especially in cases of pterygium or Salzmann's nodules— before having patients undergo cataract surgery is highly recommended, according to one surgeon who spoke at Cornea Day 2013. "Patients who undergo cataract surgery first and then have these entities removed will have their vision impacted after the removal," Richard S. Davidson, MD, N.Y., said. Ptergyia, in particular, induces withthe-rule astigmatism, especially if the lesion is under 1 mm, he said. Salzmann's nodules tend to occur bilaterally, and affect patients older than 50 years. Dr. Davidson also recommended surgeons perform manual keratectomy "to inspect mires," and said the irregularity "does not often completely disappear." He recommends performing a superficial keratectomy to the peripheral axis using a 69 or 57 blade, and the excision should steepen the underlying cornea. He also recommends waiting three months before proceeding with cataract surgery. Fuchs' and cataracts Two surgeons presented on whether or not protecting or replacing the endothelium in patients with Fuchs' dystrophy results in better visual outcomes. Francis S. Mah, MD, La Jolla, Calif., said among the reasons to perform cataract surgery separately from endothelial keratoplasty is that "it's faster, there's a faster recovery of best corrected visual acuity, it's less expensive, there are fewer postoperative follow-up visits, and no need for topical immunosuppression medication." He noted that in recent years, there's been a shift away from concentrating on a patient's numbers to concentrating on the density of the cataract, the ocular "Make sure your paracentesis is steep and peripheral," he advised. "Make your capsulorhexis smaller than the optic," and keep the IOL in the bag to help prevent anterior chamber shallowing during graft surgery. "A continuous capsulorhexis will greatly simplify this step," he said, and advocated the used of a capsular stain for better visibility. When to consider torics comorbidities, and the patient's signs and symptoms. Surgeons who perform cataract surgery alone need to protect the endothelium, but "there is no difference between a scleral or tunnel incision," and likewise, no difference in what kind of viscoelastic used. "The soft-shell technique does have some benefits," he said. If there is the possibility of a Descemet's stripping automated endothelial keratoplasty down the road, "aim for myopia with your IOL implant—somewhere around –0.75 D to –1.0 D," he said. Bryan D. Ayres, MD, Philadelphia, countered that among the advantages of the triple procedure is that surgeons are preventing a prolonged recovery period with little compromise in visual outcomes. Dr. Ayres performs a three-plane incision (about 4 mm) but said his effective incision is only 2.2-2.8 mm. Should toric IOLs be considered if a patient has abnormal topography? Yes, said Chaz Reilly, MD, San Antonio. However, surgeons have a better chance of success if they create realistic patient expectations. "Further, make sure the magnitude and axis of cylinder are in agreement between the corneal topography and refraction. Make sure there's reasonable visual potential, too—beware of meridional amblyopia, consider anisometropia, and be aware of how the posterior cornea contributes to cylinder," Dr. Reilly said. Mild cases of keratoconus (those that can be corrected with spectacles) can also be considered for toric lenses, he said. Most premium brands and services are customizable, but that's not the case with toric lenses, and that creates a potential issue, said Michael W. Belin, MD, Tucson, Ariz. Toric IOLs compensate for the corneal astigmatism on the lens plane, while rigid gas permeable (RGP) lenses correct the astigmatism on the corneal plane. continued on page 3

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