-: Hello, this is Lisa Brothers Arbisser,
at the American Academy of Ophthalmology in San Francisco.
And I have the pleasure of talking to Preeya Gupta about
optimization of the ocular surface,
specifically for cataract surgery.
So please tell us a little bit about
your thoughts on the subject and your protocol.
-: Absolutely.
Well the ocular surface is such an important structure
as it relates to our cataract patients.
When we are doing our biometry and topography,
ocular surface disease can really alter our measurements.
And really there's a broad gamut
when we say ocular surface disease.
There's common things like dry eye,
meibomian gland dysfunction,
but also things that we don't want to miss
are Salzmann's nodules,
anterior basement membrane dystrophy, pterygium.
All of those really have significant refractive impact.
-: Well given the fact that often the age-range
is very, very elderly for these patients,
do you give them an option of optimizing their surface
or is it a requirement
or is it only for people looking
for really a refractive outcome?
-: Well I think that when we talk about
common conditions like dry eye disease,
really everybody should have optimization
of the ocular surface.
And the reason being, that we know
from the vast amount of literature that's out there,
that patients often get worse
in terms of their dry eye symptoms
after an eye surgery and it doesn't really matter
whether its cataract surgery or glaucoma surgery
or retina surgery.
And patients really find that disturbing.
They go in to have their vision issue addressed
and they come out having foreign body sensation,
irritation and so it's really important, I think,
to address those conditions.
There are certain ones where I might
give the patient the option.
For example, a small peripheral pterygium
that might not be causing a lot of irregular astigmatism,
peripheral anterior basement membrane dystrophy that's mild,
even very mild Salzmann's nodules.
If the patient doesn't have a specific refractive goal,
a glasses-free spectacle independence type goal,
I'm willing to do cataract surgery in that setting.
But anybody that has a refractive goal,
I think you have to address all those things before.
-: Yes, and then of course there's cleaning the surface
for lesser risk of endophthalmitis,
since most of our germs come from the ocular surface.
-: Absolutely.
-: So tell us about your protocol
and how you treat and the timing.
-: Yeah, so the ASCRS Corneal Clinical Committee
came out with an algorithm earlier this spring
on addressing ocular surface disease,
not only from a diagnostic but also treatment perspective.
So first, we all need to be screening for it,
whether you choose to administer a questionnaire
or use point of care testing,
that can help you to identify some of these conditions.
A good slit lamp exam is critical
and it doesn't have to take a long time
but I highly recommend everybody to look at the lids,
look at the lid position,
look for things like anterior basement membrane dystrophy
and Salzmann's nodules and, once you've identified that,
so for dry eye and meibomian gland dysfunction,
I have a low threshold to use topical steroids,
especially on anybody that has corneal staining.
So corneal staining or an abnormal point of care test,
to me, is potentially visually significant or impactful.
So topical steroids can be used two to four times a day
for a couple of weeks
and that really helps to rapidly resolve
any of that punctate staining.
If patients have meibomian gland dysfunction,
there's a number of treatments that are available,
all really focused on heating and relieving
the obstruction of the lids
and those can easily be performed
at the time of the diagnosis.
I like to wait three or four weeks
and then reassess the corneal surface but also repeat
my biometry and keratometry topography readings
because we want to make sure that there's no irregularity.
We want the most consistent measurements
to give the patients the best outcomes.
-: Of course.
And contact lens wearers, of course.
That's a whole other -: Absolutely, holiday
-: Another story, yes.
Excellent.
I've certainly seen up to four diopters of change
after superficial keratectomy
and Cogan's map-dot-fingerprint.
So how do you go about treating that?
-: Absolutely.
So things like anterior basement membrane dystrophy,
Salzmann's nodules can have a large refractive impact.
We just published a study earlier this year
that showed that 80% of our patients in the study
had a change in their IOL spherical power,
if they had Salzmann's nodules
or anterior basement membrane dystrophy
and up to 80% of the patients that were toric candidates
also had a change in their cylinder power
pre and post superficial keratectomy.
And so superficial keratectomy
can be an easy procedure to do in the office,
debridement of all the epithelium,
if there's nodules, using forceps to peel them,
placement of a contact lens
and then waiting until there's stability
of re-epithelialization but also stability of the surface
in terms of healing any dryness that's on the surface.
In these patients, I think it's really important
to get serial topography and biometry
and you want to establish stability
before you proceed with surgery.
But, as you pointed out, these are the patients
that can have a big refractive surprise if you don't
address it before. -: Indeed.
Well, it's such an important topic
and it's so oft talked about but not so much in detail.
So thank you so much for informing us.
-: Oh thanks for having me.