November 2018


Improving the ocular surface: Challenges facing the cataract and refractive surgeon

Clara Chan, MD, Cornea editor

If only every cataract and refractive patient were easy. It only takes one or two unhappy patients to make a day in the office miserable. The most common reasons patients are unhappy postoperatively are dry eye symptoms and undiagnosed ocular surface disease. Issues with dry eye are also important for patients undergoing corneal crosslinking where the epithelium is typically removed in the “epi-off” standard technique. Retinal surgery and glaucoma drops can exacerbate ocular surface disease. And don’t forget the corneal surface where a variety of lumps and bumps can erupt. The saying “The tear film is the most important refracting surface of the optical system” should be respected especially in today’s environment of exceedingly high patient expectations. In this month’s feature series, we explore a potpourri of unique and challenging scenarios related to the ocular surface.
We begin with Melissa Daluvoy, MD, Deborah Jacobs, MD, and Bennie Jeng, MD, who discuss their approaches to the following challenging patients: a patient with progressive keratoconus needing corneal crosslinking who has active atopic blepharoconjunctivitis; a patient with graft-versus-host disease and severe dry eye needing cataract surgery; and a myopic patient with limbal stem cell deficiency from soft contact lens wear.
Next, Ali Djalilian, MD, Marjan Farid, MD, and Steve Sarkisian, MD, review the effects that glaucoma eye drops have on not just the cornea and conjunctiva, but also the eyelids. They then discuss how to optimize and manage ocular surface disease issues in glaucoma patients who use multiple eye drops, and when to consider surgical options for therapy to prevent vision-threatening complications associated with ocular surface damage.
“Pain without stain,” or keratoneuralgia, is a rare phenomenon that can arise typically after refractive surgery. Unfortunately, there is no reliable way to screen for patients who will develop this pain syndrome postoperatively. Anat Galor, MD, and Rony Sayegh, MD, review diagnosis and management strategies, the role of treating dry eye in these patients, and the importance of involving mental health professionals.
Neurotrophic keratitis is the opposite of keratoneuralgia. Unfortunately, due to the lack of corneal sensation in these patients, they may not present with complaints until their vision is compromised. Deborah Jacobs, MD, and Stephen Pflugfelder, MD, share the most common etiologies for this condition and their management algorithm. Use of soft bandage contact lenses, scleral lenses, amniotic membrane grafts, tarsorrhaphy, and topical medical therapies coming down the pipeline are all reviewed.
Finally, a variety of lumps and bumps on the corneal surface can significantly alter the accuracy of measurements needed in cataract and refractive surgery. David Goldman, MD, David Hardten, MD, Jeremy Kieval, MD, and Joshua Teichman, MD, comment on what special attention is required to address pterygium, anterior basement membrane dystrophy, and Salzmann’s nodules. These should be treated as a first step always. The physicians also discuss the importance of avoiding toric lenses in a patient with an irregular corneal surface.
Please enjoy this issue of EyeWorld, and thank you to all the physicians above for taking the time to share their expertise.

Improving the ocular surface: Challenges facing the cataract and refractive surgeon Improving the ocular surface: Challenges facing the cataract and refractive surgeon
Ophthalmology News - EyeWorld Magazine
283 110
283 110
True, 11