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Compromised corneas affect timing of cataract surgery
When cataract surgery alone or a combined procedure is being considered, the deciding factor is the magnitude of cataract vs. endothelial disease.
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In cases of compromised corneas, several factors affect the timing of cataract surgery, Audrey Talley Rostov, MD, said in a presentation at Hawaiian Eye 2015.
“We have different situations with patients who may have coexisting corneal disease or different tricky situations involving the cornea,” she said. “And the question is: What do we do, and how do we time or perform the cataract surgery?”
Intracorneal ring segments
Talley Rostov recommended surgical management with corneal cross-linking, cornea transplant or intracorneal ring segments before cataract surgery in patients with pre-existing corneal ectasia.
When performing cataract surgery in patients with intracorneal ring segments, a monofocal, toric or accommodating IOL could be used, but Talley Rostov said she would not recommend a multifocal IOL. Careful IOL calculations and placement of cataract surgery incisions are important to prevent complications.
“You can use a toric IOL to help with a little bit of irregular astigmatism,” Talley Rostov said. “As long as you really know your axis and the astigmatism and are careful about the ring segments, you can get a nice result.”
Cataract surgery after cornea transplant
In addition to improved visualization, actual keratometry readings rather than estimated readings are an advantage to performing cataract surgery after cornea transplant, Talley Rostov said.
If a femtosecond laser-assisted keratoplasty is done, a soft shell technique with a carefully selected ophthalmic viscosurgical device and planned corneal relaxing incisions are recommended, she said.
Like in patients with intracorneal ring segments, careful incisions and IOL calculations are important, as is avoiding the use of multifocal IOLs.
Incisions may need to be sutured, or sealant may be needed in some of the more “tricky” cases, she said.
Ocular surface disease, pterygium and dry eye disease
Ocular surface disease and pterygium should be managed before cataract surgery to optimize refractive results, Talley Rostov said.
“It’s all about our refractive result, and if you don’t have good readings on the cornea, then you’re basically not going to get a good refractive result,” Talley Rostov said.
Regardless of the type of ocular surface disease, it should be treated first, potentially by doing a superficial keratectomy, she said. In such cases or after pterygium surgery, she recommended waiting 6 weeks before retaking measurements to ensure there is stability before proceeding with cataract surgery.
Dry eye disease, which can cause refraction instability, should be managed before, during and after cataract surgery, she said.
“I think we’ve all seen these patients you think may have some postoperative myopia and in fact they have dry eye disease,” Talley Rostov said.
After aggressive treatment with topical cyclosporine, artificial tears, fish oil supplements or punctal plugs, “a lot of this irregular astigmatism or what you thought was postoperative myopia can in fact resolve,” she said.
Deciding on a procedure
When cataract surgery alone or a combined cataract and keratoplasty procedure is being considered, the deciding factor is the magnitude of cataract vs. endothelial disease. The patient may defer the keratoplasty procedure when there is less concern for endothelial cell loss and potential for greater anterior chamber stability with cataract surgery alone. Cataract surgery after keratoplasty may be necessary when there is a poor view for cataract surgery or in young pre-presbyopic patients, Talley Rostov said.
“Essentially the question is whether to do cataract surgery first vs. combined,” she said. “You can decide whether you have greater cataract or greater endothelial dystrophy.” – by Kristie L. Kahl
For more information:
Audrey Talley Rostov, MD, can be reached at Northwest Eye Surgeons, 10330 Meridian Ave. N., Suite 370, Seattle, WA 98133; email: atalleyrostov@nweyes.com.Disclosure: Talley Rostov reports she is a consultant for Allergan, Bausch + Lomb and Nicox and a speaker for Allergan and Bausch + Lomb.