December 2020


Prepping the ocular surface for cataract surgery

by Liz Hillman Editorial Co-Director

This is a 63-year-old female with pellucid pattern keratoconus; because the astigmatism is orthogonal centrally, she is an appropriate candidate for a toric IOL.
Source: William Trattler, MD

In the day and age of refractive cataract surgery, optimizing outcomes is extremely important,” said Kathryn Hatch, MD, as she introduced a webinar hosted by the ASCRS Refractive Surgery Clinical Committee earlier this year. “We have increasing patient expectations, and it’s extremely important that we obtain ideal biometry measurements. To do so, we need to pay specific attention to the ocular surface, especially when treating astigmatism and presbyopia.”
The webinar, “Prepping the Ocular Surface for Refractive Cataract Surgery,” specifically discussed diagnosis and management of EBMD, Salzmann’s nodules, pterygium, dry eye disease, blepharitis, ectasia, and irregular astigmatism. It also included several case presentations.
The audience was given the opportunity to ask some questions of the presenters as well, and the following is a portion of that Q&A.

In patients with keratoconus who have not been crosslinked and in whom you are just identifying keratoconus, do you worry about placing a toric IOL, even if the central astigmatism is fairly regular?

Dr. Trattler: Patients with keratoconus and pellucid marginal degeneration who have relatively regular central astigmatism can consider a toric IOL. Typically, the rate of progression is slow in this age group. If progression is identified, crosslinking can be performed. I typically like to see two to three diagnostic devices arriving at a similar degree of astigmatism magnitude and axis to be most comfortable placing a toric IOL. If there is significant irregular astigmatism, or if the axis is not identifiable or repeatable, I will not recommend a toric IOL.
Dr. Brissette: If they are not a RGP lens wearer and it’s regular and stable, I’m OK with placing a toric.
Dr. Hatch: If the astigmatism is regular, especially in the central 4 mm, I am comfortable placing a toric IOL. I observe if they are correcting their astigmatism in spectacles and for what duration of time. If so, that may likely be a good sign for a toric IOL. If they required RGP for cylinder, I agree that a toric is not a good idea, and there is usually not a clear axis of placement for these eyes.
Dr. Ciralsky: I am comfortable placing a toric if the astigmatism is regular in the central 4 mm zone. I avoid torics for irregular astigmatism or patients in RGP or scleral lenses.

Do all of your patients get MMP and osmolarity testing or just premium IOL patients?

Dr. Brissette: Our technicians ask dry eye questions directly (i.e., fluctuating vision, discomfort, tearing, etc.). If the patient endorses any of them, then we get the testing.
Dr. Hatch: I perform LipiView [Johnson & Johnson Vision] scans on all surgical preops.
Dr. Ciralsky: I get testing on all patients with dry eye symptoms and on all premium IOL patients.

I have had patients whose topographies are still irregular postop s/p SK for Salzmann’s nodules or EBMD. Would you repeat the SK?

Dr. Brissette: Not if the pathology is no longer there. If the measurements are repeatable, I proceed.
Dr. Hatch: It would depend if there is epithelial involvement to the ABMD and its location (if it is in the central 4 mm area or outside). If there are clear topographic changes and residual Salzmann’s tissue to remove, a repeat SK could be done. The slit lamp exam would assist in deciphering whether it is superficial or if stromal scarring is also a factor.
Dr. Ciralsky: I would repeat the SK if the irregularity is attributable to residual EBMD or Salzmann’s nodules, which can be identified on slit lamp examination.

Is there a role for amniotic membrane placement in the treatment of ABMD?

Dr. Brissette: I use this post-SK for EBMD with good results for corneal epithelial healing.
Dr. Hatch: Yes, at the time of SK it could aid with epithelial recovery. It is not always covered by insurance.
Dr. Ciralsky: There can be, although I do not routinely use it.
What is your approach to a positive tear film osmolarity or InflammaDry (Quidel) with good, stable topography and biometry?
Dr. Brissette: I’ll often discuss the results with the patient because the OSD will worsen after cataract surgery. The surgery itself, the prescription drops, etc., can tip someone over to symptomatic OSD, so setting expectations prior to surgery is important.
Dr. Ciralsky: If I see abnormal testing, I will pretreat the patient as cataract surgery will worsen the dry eye. Even with stable topography and biometry, I would pretreat and repeat measurements.

Watch the full webinar at

About the doctors

Ashley Brissette, MD
Assistant Professor of Ophthalmology
Weill Cornell Medicine
New York, New York

Jessica Ciralsky, MD
Associate Professor of Ophthalmology
Weill Cornell Medicine
New York, New York

Kathryn Hatch, MD
Director, Refractive
Surgery Service
Massachusetts Eye & Ear
Waltham, Massachusetts

William Trattler, MD
Center for Excellence in Eye Care
Miami, Florida

Relevant disclosures

: Alcon, Bruder, Carl Zeiss Meditec, Eyevance
Ciralsky: Bruder
Hatch: None
Trattler: None




Take-home pearl

If you had to pick one pearl from this webinar, what would it be?
Dr. Brissette: For me, it would be the number of patients who are asymptomatic for OSD who have signs, which is why clinical examination along with point-of-care testing and other diagnostics have become so vital to the workup.
Dr. Hatch: Take the time to look at the ocular surface and use topography in all cataract evaluations (even when not covered by insurance) to help with your decision-making process.
Dr. Ciralsky: Take time to evaluate the ocular surface before cataract surgery. Pretreating existing conditions will improve biometry and ultimately patient outcomes.

Prepping the ocular surface for cataract surgery Prepping the ocular surface for cataract surgery
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