Cataract: I wish I had …
Summer 2024

by Liz Hillman
Editorial Co-Director

“My eyes are irritated … they weren’t before cataract surgery.”
“My vision fluctuates … it goes in and out.” 
“I got a lens to correct my astigmatism … now my vision seems even more off.” 
“I chose a presbyopia-correcting IOL, and my quality of vision isn’t great.”

These are the phrases an ophthalmologist might hear when ABMD is missed prior to cataract surgery, causing the surgeon to wish they had found and treated it preoperatively. 

Saba Al-Hashimi, MD, said he thinks ABMD needs to be more on ophthalmologists’ radar during their preop examinations. 

“It’s easier to address ahead of time, and your measurements for cataract surgery are going to be more accurate,” he said. “If it is something you catch after, you can treat the [ABMD], and when the dust settles, you may find you’re off target … that becomes a harder issue.”

Rahul Tonk, MD, thinks identifying and treating ABMD preop is on the radar of most cornea/refractive surgeons, but it should, he added, be something every comprehensive ophthalmologist is thinking about as well. “We’ve been beating on this drum about managing the ocular surface for years, but it’s not universal yet.” 

Identification

While it might not be obvious on slit lamp examinations, Dr. Al-Hashimi and Dr. Tonk said fluorescein dye on the cornea can reveal areas of negative staining that are indicative of ABMD. Dr. Al-Hashimi also said epithelial mapping is becoming more popular and can highlight areas that require further investigation. 

Dr. Tonk said the mires on Placido imaging allow you to get more information about the patient’s quality of vision. Interruptions in the mires clue you in to areas of ocular surface disease, such as ABMD or dry eye. 

Preop management

Dr. Tonk said once he has identified ABMD, he asks the patient a variety of questions about ocular irritation, recurrent erosions, or visual fluctuation related to the ABMD. Further, he will assess if the patient has high expectations or refractive demands or is looking for increased spectacle independence with their cataract surgery. 

Even if the patient says they don’t have symptoms, Dr. Tonk said it’s important to inform them of their condition and let them know it could affect their postop recovery and outcomes. 

That said, in general, just about every patient with ABMD deserves at least conservative medical management. This may involve lubricants, nighttime hypertonic saline ointment, topical anti-inflammatories, and management of co-morbid blepharitis.

“In many cases, more aggressive or even procedural care may be indicated,” Dr. Tonk said. “This can involve superficial keratectomy with or without diamond burr polishing or phototherapeutic keratectomy.” While outcomes are generally good, he noted that the procedure can be taxing for older patients, delay cataract surgery, or rarely be complicated by poor epithelial healing, particularly in older patients or those with ocular surface disorders. 

Dr. Al-Hashimi said he will wait 6–12 weeks after a procedure for ABMD to move forward with cataract surgery, making sure there is regularizing of the epithelium and repeatability/stability with biometry measurements. With patients, he said he emphasizes that their cataract surgery is a once-in-a-lifetime procedure that with preop surface optimization can lead to better outcomes. This, he said, gets them on board with the procedures they might need preop and the delay they could cause to their cataract surgery.

Postop management

If ABMD is discovered to be the cause of quality of vision issues and/or ocular irritation postop, Dr. Tonk said first and foremost to be honest with the patient. 

“Most patients are glad to know there is a specific reason for their postoperative issues. Once you’re on the same page with the patient, they typically want to work hand-in-hand with you to get better,” Dr. Tonk said. 

Management of the condition depends on the nature of the patient’s symptoms. If the symptoms include mild irritation and some vision fluctuation in a patient with minimal refractive demands, Dr. Tonk is more conservative in his treatment, using lubricants, topical eye drops, a light steroid, and watchful waiting as the patient continues to heal. He said it’s likely this patient’s ABMD will settle down to an acceptable level.

Another scenario is the patient who received a toric IOL and is finding that their vision is unclear postop. ABMD, Dr. Tonk said, can throw off the amount of astigmatism. He said he would follow the same topical protocol as described previously and, if necessary, would consider a procedure. In the right situation, a one-time PRK could treat the ABMD and the residual refractive error, but Dr. Tonk said it may be necessary to stage superficial keratectomy followed by PRK for the best outcome.

In a third scenario, Dr. Tonk laid out the experience of a patient with a diffractive multifocal IOL. He said to pay extra attention to the symptoms related to quality of vision. He starts with a similar protocol—topical therapy and possible procedural treatments—for these patients. But if quality of vision is notably affected, he has a low threshold to exchange the diffractive IOL for a monofocal, EDOF, or the Light Adjustable Lens (RxSight). 

Dr. Tonk said he likes to avoid getting to these situations, with preoperative identification being critical. 

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About the physicians 

Saba Al-Hashimi, MD
Associate Professor of Ophthalmology, Cornea Division
Stein Eye Institute 
University of California, Los Angeles
Los Angeles, California

Rahul Tonk, MD, MBA
Associate Professor of Clinical Ophthalmology
Associate Medical Director
Bascom Palmer Eye Institute
Miami, Florida

Relevant disclosures

Al-Hashimi: None
Tonk: None

Contact 

Al-Hashimi: alhashimi@jsei.ucla.edu
Tonk: rtonk@med.miami.edu