Financial Disclosures. Corneal Problems for the Cataract Surgeon. Four Common Problems. Dry Eye syndrome. Rose-Bengal 3/27/16
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1 Corneal Problems for the Cataract Surgeon Financial Disclosures Consultant: AMO/VISX Consultant: Angiotech/Sharppoint Michael J Taravella, MD Director: Cornea and Refractive Surgery University of Colorado The author has no financial interest in the material presented 3/27/ Four Common Problems Dry Eye Anterior Membrane Dystrophy Keratoconus Fuch s dystrophy 3/27/16 3 Dry Eye syndrome Dx: Symptoms Reading and computer fatigue Foreign body sensation Light sensitivity Symptoms worse as the day goes on Signs: Fluoroscein and Rose Bengal Staining Decreased tear meniscus Schirmer s test 3/27/ Fluoroscein stain: Sjorgren s Syndrome Rose-Bengal 3/27/ /27/16 6 Devitalized epithelium/mucus 1
2 Slitlamp Examination Topography Irregular mires on placido disc Missing data on color images Evaluation of Tear Meniscus Fluorescein Staining Rose Bengal/ Lissamine Green Staining 3/27/16 7 3/27/16 8 Schirmer Test Without anesthesia Measures reflex tear secretion With anesthesia Eliminates stimulated tearing Other tests MMP-9 (InflammaDry ) Sjorgren s Syndrome Blood draw LipiView Lipid layer interferometry 3/27/16 9 3/27/ Consequences of Dry Eye IOL measurments Inaccurate K-readings Poor vision/fluctuating vision after surgery Multifocal IOL s especially impacted Consequences of Severe Dry eye Sterile Ulcerations Filamentary Keratitis Bacterial Keratitis 3/27/ /27/
3 Sterile Ulceration Filamentary Keratitis 3/27/ /27/16 14 Prevention and Treatment 1 st : Identify patients at risk 2 nd : Pre-treat if appropriate Topical Cyclosporine (Restasis ) 1month pre-op (loteprednol may speed response) Supplement with tears, Omega-3 (fish oil) Punctal plugs if appropriate 3 rd : Minimize Toxicity Choose preservative free drops when possible Moxifloxacin 0.5% (Vigaomox ) Taper meds as quickly as possible Which NSAID? Ketorolac 0.4% Nepafanec (Nevanac) Can use less; stings less: 3 times per day? Toxicity? Illevro Can use once per day 3/27/ /27/ LRI s ***Punctal occlusion can trap tears containing inflammatory mediators Can decrease corneal sensation Especially adjacent to incisions Corneal sensation decreased between 1-3 months post op May be more pronounced if incision at 3 and 9 o clock (against the rule astigmatism) 3/27/ /27/
4 Anterior Basement Membrane Dystrophy Basement Membrane (Cogan s Dystrophy) Signs: Map, Dot, Fingerprints Symptoms: Recurrent Erosions POST OP PROBLEMS Focal Corneal edema In areas where epithelium poorly adherent DECREASED UCVA AND BCVA 3/27/ /27/16 20 Treatment If mild: observation If symptomatic recurrent erosions Consider Muro 128 5% ointment at night Often associated with dry eye Topical cyclosporine helpful Consider Superficial Keratectomy For decreased BCVA or UCVA PTK AMOIL S BRUSH 3/27/16 21 Superficial Keratectomy If PTK or superficial keratectomy performed, this will change K-readings and influence IOL calculations 3/27/ Keratoconus Identify: Screen All patients with topography Especially candidates for toric and multifocal IOL Do not implant multifocal IOL 3/27/ /27/
5 Keratoconus, pellucid marginal degeneration: Not a candidate for incisional correction 3/27/ /27/16 26 Toric IOL in Keratoconus? Consider if: Not able to wear RGP Will often prefer vision in RGP, ***If toric IOL placed; RGP will not correct astigmatism after toric implantation If cornea not too irregular If topography, IOL master K readings, and manifest agree Fuch s corneal dystrophy Diagnosis: Guttate at Slit lamp Corneal edema Specular microscopy 3/27/ /27/16 28 Fuch s Endothelial Dystrophy Fuch s Dystrophy and Cataract If corneal pachymetry > or symptoms of corneal edema Consider combined procedure Phaco with IOL and DSAEK/DMEK If corneal pach s < 600, no sx s Phacoemulsification: (VISCOELASTIC) NO MULTIFOCAL IOL s*** Guttate degrade contrast sensitivity ***Unless able to do DMEK? USE BSS (+): has glutathione 3/27/ /27/
6 RK and cataract: Incision placement Main Incision placement 2.4 mm keratome 8 incision RK: between incisions 16 incision: Scleral tunnel Be prepared to suture ReSure Glue? 3/27/ /27/ Cataract: Compromised Corneal View Endoillumination-Assisted Cataract Surgery in Eyes with Corneal Opacities ASCRS 2014 Poster 2822 Alobaidy: Endoillumination assisted cataract surgery in eyes with corneal opacities Illustrates and describes in detail method of chandelier illumination for performing capsulorhexis when view through cornea is compromised Fig. 1 Fig. 2 3/27/16 33 Corneal opacities cause haziness and decrease depth perception by 3/27/16 scattering light from the operating microscope Figure 1 & 2 reproduced from Farjo et al 2003 AIRES Acute Intraoperative Rock Hard Eye Syndrome acute intraoperative shallowing of the anterior chamber and a marked increase in intraocular pressure (IOP) during phacoemulsification surgery ** without evidence of choroidal hemorrhage starts sometime between the conclusion of nucleus removal and before the insertion of the IOL TREATMENT Diamox + Mannitol + Time Pars plana aspiration 3/27/ /27/
7 Contact Information 3/27/
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