ESCRS - Coming to Grips with OSD in Cataract Patients ;
Cataract, OSD

Coming to Grips with OSD in Cataract Patients

Helping patients own their condition minimises dissatisfaction. Dermot McGrath reports from Milan.

Coming to Grips with OSD in Cataract Patients
Dermot McGrath
Dermot McGrath
Published: Wednesday, November 9, 2022

Ocular surface disease (OSD) is a major cause of suboptimal cataract surgery outcomes, but having a clear strategy and ensuring careful preoperative screening to detect potential issues can help to avoid many of the pitfalls associated with OSD in cataract patients, according to Allan R Slomovic MD.

“OSD is very prevalent in the cataract patient population,” Prof Slomovic said. “Remember, these are elderly patients [who] are often on numerous medications—especially anti-glaucoma medications—which can affect the ocular surface. Moreover, OSD can significantly affect keratometry and biometry, leading to refractive postoperative surprises and patient dissatisfaction following cataract surgery.”

The best approach, he said, is to perform a staged procedure, taking care first of the ocular surface disease and waiting six to eight weeks before repeating biometry and topography prior to cataract removal.

Prof Slomovic focused on three principal ocular surface problems: pterygium, epithelial basement membrane dystrophy (EBMD), and dry eye disease (DED).

To effectively deal with a patient presenting with both pterygium and cataract, it is critical to understand the effects pterygium has on corneal topography. “It causes flattening of the cornea in the area of the pterygium [and] results in irregular with-the-rule astigmatism and an increase in higher-order aberrations,” he said.

Prof Slomovic advised first removing the pterygium with a conjunctival autograft, then waiting six to eight weeks to obtain stable keratometry and topography. Once achieved, the surgeon can proceed with biometry and phacoemulsification to remove the cataract.

“We looked at patients treated this way in a previous study, and it showed pterygium surgery successfully reduces the topographic and refractive astigmatism, thereby making biometry more accurate,” he said. “The best-corrected visual acuity also improved, and pterygium excision reduced higher-order aberrations caused by the pterygium.”

Anterior basement membrane dystrophy is the most common corneal dystrophy and is especially significant if the changes manifest in the visual axis, Prof Slomovic explained.

He presented the case of a 75-year-old male with declining visual acuity referred for consideration of cataract surgery. The patient had two central Salzmann nodules and irregular astigmatism. Six weeks after superficial keratectomy to remove the nodules, the best-corrected visual acuity recovered to 20/25, avoiding cataract surgery.

For cases of DED, Prof Slomovic emphasised the importance of addressing the problem preoperatively.

“DED can cause corneal staining and abnormalities in keratometry, topography, and biometry,” he said. “Dry eye treatment leads to changes in IOL power calculations and postoperative refractive outcomes. Therefore, assessing and treating patients for dry eyes prior to cataract surgery is important in maximising refractive outcomes.”

Prof Slomovic stressed that the ophthalmologist’s role is to optimise the ocular surface before and after surgery and set realistic expectations by explaining to the patient how they have two separate conditions needing treatment.

“If you tell the patient about their ocular surface disease before the surgery, they own it,” he said. “However, if they only become aware of it after the cataract surgery, they will presume the surgeon caused the problem.”

Particular vigilance is needed in the use of non-steroidal anti-inflammatory drugs (NSAIDs) in the presence of DED, as it can lead to corneal melts and perforation, Prof Slomovic warned.

“We now have seven studies in the scientific literature reporting the association of NSAIDs and corneal melts in the setting of cataract surgery,” he said.

Allan R Slomovic MD is professor of ophthalmology at the University of Toronto, Canada. allan.slomovic@utoronto.ca  

Assessing and treating severely dry eyes like this one before cataract surgery, said Dr Slomovic, is vital for maximising refractive outcomes.
Tags: 40th Congress of the ESCRS
Latest Articles
Finding a Keratoconus Consensus

Evolving new consensus should help guide diagnosis and management.

Read more...

Ray of a New Dawn in Corneal Infection Research

Will UVC light the way as a potential treatment for microbial keratitis?

Read more...

Towards a More Inclusive Ophthalmology

The only way to face challenges to inclusivity and equity is to work together without barriers.

Read more...

Refractive Femtosecond Laser

There are many different femtosecond laser surgical platforms to choose from, and it can be hard to keep them all straight. We have prepared a table allowing you to compare these at a glance, along with some comments from some of our members who use these lasers regularly.

Read more...

Survey Informing New Leadership and Business Programmes in 2024

A year-round programme will complement Leadership and Business Innovation Day at the 2024 Annual Congress.

Read more...

Overcoming Obstacles to Presbyopia-Correcting IOLs

New technology can smooth the path to premium IOL acceptance.

Read more...

The Power of Four

Finding uses for corneal lenticules, once considered a waste product.

Read more...

Alternative to Penetrating Keratoplasty

Cornea findings and comorbidities considered in surgical decisions for endothelial dysfunction.

Read more...

Flexing Four-Flanged Scleral Fixation

Study results reveal 80% of patients end up with good refractive outcomes.

Read more...

New Approach to Keratoconus

Corneal regeneration with lenticule implantation.

Read more...