Eyeworld Daily News

12 | EYEWORLD DAILY NEWS | MAY 18, 2020 DAILY NEWS ASCRS VIRTUAL ANNUAL MEETING by Liz Hillman Editorial Co-Director O cular surface disease before cataract sur- gery, ectasia, herpetic infectious keratitis, and more were presented in the Sunday afternoon case- based symposium "Cornea Essentials." One presentation by Clara Chan, MD, Toronto, Canada, focused on corneal lumps and bumps. She led with a case of a 56-year-old female referred for cataract surgery. Uncorrect- ed vision in her left eye was 20/400 and in the right eye it was 20/80; with glasses her vision was 20/20-2 in the right eye and 20/30-1 in the left. Manifest refraction showed more cylinder in the left eye. Corneal keratometry was also higher in the left eye (44.25 vs. 41.25). Topography in the left eye showed an area of steep- ing superiorly that Dr. Chan described as "fairly focal" and a little abnormality inferiorly. In the right eye, topography showed "a hint of superior and inferior" abnormality. Placido images correlated with the area of abnormality highlighted by topography. "What would be our dif- ferential increased cylinder in an area of focal steepening? Currently, we think of kerato- conus, however, the location in this case of the abnormality being superior would be very atypical for keratoconus," Dr. Chan said, adding that pellucid marginal degeneration is also more likely to have inferior steepening. Salzmann's nodu- lar degeneration could have an area that's steepened like that, she said. Tomography can be useful to show corneal thickness to help confirm some of these conditions as well. The cor- nea would be thinner in the steeper area in keratoconus, for example, and thicker in the steeper areas for Salzmann's nodules. These findings and clinical exam at the slit lamp confirmed that this patient had a Salzmann's nodule. Dr. Chan noted iron deposition around the Salzmann's nodule. She went on to discuss removal of the Salzmann's nodule with superficial kera- tectomy, but also noted that optimizing any blepharitis lid disease that could have led to formation of the nodule would be important as well. Dr. Chan showed in a video how she peeled the lesion under topical anesthetic in a "rhexis motion." "Scrape away from the ac- tual lump itself so you can get the edge," Dr. Chan said, not- ing that the smooth basement membrane underneath helps confirm you got everything off. Dr. Chan said this proce- dure could be done at the slit lamp or with the patient laying down in a procedure room or on a laser bed. "The procedure itself is fairly routine," she said, adding that she still drapes to keep eyelashes away and uses betadine or povidone iodine to sterilize the surface. She puts an antibiotic-ste- roid drop and bandage contact lens on the eye. Pain relievers are prescribed to the patient, and Dr. Chan said she warns them the first 48 hours are the worst. "Get over the hump, and the pain gets much better. Also use a lot of lubrication drops," she said. Dr. Chan sees the patient after the first week to remove the bandage contact lens and to confirm the epithelium has healed. She then sees patients Cornea Essentials symposium runs the gamut continued on page 14 Topography for a 56-year-old cataract patient Source: Clara Chan, MD, screenshot from presentation 4–6 weeks later, after steroid drop taper. After superficial keratecto- my, the patient had a reduction in cylinder in the left eye from –3.75 D preop to –1 D postop. The patient was correctable to 20/20 in both eyes and did not need cataract surgery. Dr. Chan said if a surgeon had gone ahead with cataract surgery, the patient likely would have still been unhappy because of the amount of cylinder. She then moved to a case of a 50-year-old male referred for cataract surgery who complained of blurred vision and foreign body sensation. His refraction was not correct- able with glasses. Slit lamp examination with fluorescein showed a "world map pattern" indicative of epithelium base- ment membrane degeneration (also called anterior basement membrane dystrophy or map- dot fingerprint dystrophy). Dr. Chan cautioned that this condi- tion can be subtle and said the key is to not flood the eye with too much fluorescein. "In summary," Dr. Chan said, "the management of corneal lumps and bumps can help surgeons avoid an unhappy patient. Superfi- cial keratectomy is a simple treatment for Salzmann's nodules and epithelial base- ment membrane degeneration. It's important to ensure cor- neal regularity and stability is achieved prior to any intra- ocular lens calculations and prior to cataract or refractive surgery." Another presentation in the session by Marjan Farid, MD, Irvine, California, looked at neurotrophic keratitis, which she described as the "underly- ing cause of a lot of frustrating, non-healing corneas that we have to deal with as cornea specialists." Dr. Farid presented a case of a 75-year-old male with a non-healing epithelial defect. He had previous bilateral LASIK, herpes zoster ophthal- micus, and a "corneal abrasion" a year prior that healed after 2 weeks with aggressive lubri- cation and antibiotics. This patient also had profound loss of corneal sensitivity, Dr. Farid said. Previous treatments for his current condition includ- ed bandage contact lenses, amniotic membrane, and autol- ogous serum drops. "Just looking at that medi- cal history there are some red

• Cover