Cataract surgery in ocular surface disease patients requires careful approach

LONDON — When considering cataract surgery in patients with ocular surface diseases such as corneal scars, conjunctivalization and limbal stem cell deficiency, surgeons should first determine whether surgery is warranted and if it will provide a meaningful improvement, according to a surgeon speaking here.

If there are sufficient indications for proceeding with cataract surgery, the surgeon must also be prepared to handle specific preoperative, intraoperative and postoperative problems, Thomas Neuhann, MD, said.

"In many cases, the cataract behind those surface diseases is not the primary problem of the patient," he said. "By doing surgery, you may elicit more problems than you actually solve." Dr. Neuhann spoke during a symposium on external eye disease at the European Society of Cataract and Refractive Surgeons meeting.

Preoperative problems are mainly related to IOL calculation, he said. Lubrication and multiple readings can help obtain usable keratometry data. In more severe cases, data from the healthy contralateral eye can instead be used to make an estimate. But if the second eye is just as bad, the only option is "an educated guess," Dr. Neuhann said.

Intraoperatively, problems are due to poor visualization, which "is critical in performing capsulorrhexis," he said.

To aid visualization, Dr. Neuhann said the use of trypan blue can be helpful and that it is important to proceed carefully with surgery. "It is better to invest some extra time at this stage because an intact [continuous curvilinear capsulorrhexis] makes surgery a lot easier," he said.

Lifting the nucleus more than usual may also improve visualization. But when doing this, surgeons must protect the endothelium with generous dispersive viscoelastics, he said. A gentle approach is also needed for capsular polishing, he added. Postoperatively, Dr. Neuhann recommended generous lubrication with preservative-free eye drops for all patients, calling it "even more important than aggressive anti-inflammatory therapy."

"Don't forget that, postoperatively, you have to compromise between the conflicting therapeutic goals of the ocular surface disease ... and the requirements of postoperative inflammation suppression ... . Steroids slow down re-epithelialization, but NSAIDs may induce corneal melt in these patients," he said.

"If you use drops, follow those patients frequently ... and consider subconjunctival injection as a possible alternative," Dr. Neuhann said.