Maximizing Your Cataract Surgery Outcomes in Corneal Disease W. Barry Lee, M.D., F.A.C.S. Cornea & Refractive Surgery Eye Consultants of Atlanta Piedmont Hospital Co-Medical Director Georgia Eye Bank Atlanta, Georgia
Financial Disclosures Allergan (S) Bausch & Lomb (S) BioTissue (S) Merck (S) Medevex Imaging System (C) (S = Speaker Bureau, C= Consultant) 2
Cornea Considerations Before Cataract Surgery Dry Eye Disease / Blepharitis Corneal Ectatic Disorders Anterior Corneal Dystrophies (EBMD) Corneal Degenerations (Salzmann s, pterygium) Posterior Corneal Dystrophies (Fuchs) IOL selection in corneal disease
Cornea Considerations Before Cataract Surgery Dry Eye Disease / Blepharitis Corneal Ectatic Disorders Anterior Corneal Dystrophies (EBMD) Corneal Degenerations (Salzmann s, pterygium) Posterior Corneal Dystrophies (Fuchs) IOL selection in corneal disease
Anterior Corneal Dystrophies Epithelial Basement Membrane Dystrophy Most common
Basement Membrane Dystrophy
Basement Membrane Dystrophy Alters corneal surface May obscure visual axis Distorts biometry and topography Inaccurate IOL prediction
Basement Membrane Dystrophy Alters corneal surface May obscure visual axis Distorts biometry and topography Inaccurate IOL prediction Best post-operative visual results Staged Procedures Epithelial debridement first Cataract removal 4-6 weeks later Repeat biometry and topography prior to cataract removal
Epithelial Debridement
Epithelial Debridement
Pterygium / Salzmann s Nodule Corneal Degenerations
Corneal Degenerations Induced astigmatism Abnormal biometry and topography
Treatment Remove pterygium or Salzmann s nodule first Cataract removal in 6-8 weeks Repeat biometry and topography prior to surgery
Salzmann s Nodular Degeneration Visual acuity - 20/80 (Best-corrected acuity) Pre-op Sim K s (39.62 / 44.25) x = 41.9 10
Salzmann s Nodular Degeneration Visual acuity - 20/80 (Best-corrected acuity) Pre-op Sim K s (39.62 / 44.25) x = 41.9 10
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Repeat Topography 12
Repeat Topography 6 Weeks after Lamellar Keratectomy Visual acuity 20/40 (Best-corrected acuity) 12
Repeat Topography 6 Weeks after Lamellar Keratectomy Visual acuity 20/40 (Best-corrected acuity) Post-op Sim K s (43.37 / 44.62) x = 44.0 4.6D (41.9) 1.2 D (44) 12
Posterior Corneal Dystrophies Fuchs Dystrophy most common Make the diagnosis of guttae! Postop vision affected by degree of guttae Risk of corneal decompensation Blurred vision in AM Increased corneal thickness Seitzman et al. Ophth 2005;112:441-6 Dense guttae
Considerations (Fuchs & Cataract) Counsel regarding future of Endothelial Keratoplasty (EK) Alter cataract surgical technique to maximize endothelial protection Stage surgery or combine with EK IOL Selection If EK needed in future, leave myopic Avoid hydrophilic acrylic lenses Avoid multifocal lenses
Refractive Outcomes of DSAEK AUTHOR EYES (n) REFRACTIVE CHANGE (D) Jun 2009 45 +0.9 Price 2008 40 +0.9 Yoo 2008 12 +1.5 Koenig 2007 34 +1.2 Covert 2007 21 +1.1 Koenig 2007 26 +1.2 Price 2006 216 +0.7 Lee 2009 159 +1.1 [ Hyperopic shift ]
IOL Opacification after DSAEK
IOL Opacification Has been described in eyes following DSAEK after cataract surgery Occurs with Hydrophilic acrylic lenses Hydroxyapatite deposition on IOL surface Often requires IOL exchange Werner et al. JCRS 2010 Patryn et al. Cornea 2012
Corneal Reasons to Avoid Multifocal Lenses Corneal dystrophies (EBMD, Fuchs dystrophy) High corneal astigmatism Corneal degenerations Pterygium Salzmann s nodules Severe dry eye disease Prior refractive surgery (controversial)
Summary 19
Summary Look for corneal disease Pre-operatively 19
Summary Look for corneal disease Pre-operatively Be aware that corneal conditions can affect biometry / topography 19
Summary Look for corneal disease Pre-operatively Be aware that corneal conditions can affect biometry / topography Be aware that corneal conditions can create IOL calculation inaccuracy if untreated 19
Summary Look for corneal disease Pre-operatively Be aware that corneal conditions can affect biometry / topography Be aware that corneal conditions can create IOL calculation inaccuracy if untreated Be prepared to stage treatments in the setting of cataract surgery and corneal disease to maximize visual outcomes 19
THANK YOU 20