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A Cornea Specialist's Approach to the Refractive Surgery Evaluation

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A Cornea Specialist's Approach to the Refractive Surgery Evaluation REFRACTIVE SURGERY FEATURE STORY A Cornea Specialist’s Approach to the Refractive Surgery Evaluation The perspective of a corneal specialist reinforces the importance of the ocular surface, corneal stroma, and endothelium. BY PREEYA K. GUPTA, MD; AND SHERMAN W. REEVES, MD, MPH aser vision correction surgery is generally a suc- cessful procedure for which a thorough preopera- Identifying ocular surface tive evaluation is key to success. Patients who are disease is vital to the success of dissatisfied with their outcomes after laser vision Lcorrection may have undetected dry eye syndrome, ble- refractive surgery. pharitis, and/or anterior basement membrane dystrophy (ABMD). Preoperative detection and treatment of these eye syndrome may report that their eyes often feel worse conditions will not only improve outcomes but will also when they are not wearing their contact lenses, which increase patient satisfaction. In this article, we review the can mask symptoms with chronic use. Others will report essential components of the preoperative refractive eval- having tired eyes at the end of a long day of contact lens uation, highlighting key points in clinical history, exami- wear that improves somewhat with lens removal. A nation, and diagnostic testing. Additionally, we discuss screening tool to determine disease severity is to ask the how to manage common corneal conditions encoun- patient how often he or she uses artificial tears or other tered in this patient population. lubricants. Blepharitis, often coincident with dry eye, should be CLINICAL HISTORY diagnosed and treated preoperatively. Patients with ble- Identifying ocular surface disease is vital to the success pharitis may complain of red and irritated eyes, crusting of refractive surgery. As technology has evolved to wavefront- on the eyelids and lashes, frequent stye formation, or guided ablations, it has become even more crucial to having an overall reddish hue to the eyelid margins. detect and treat ocular surface abnormalities to avoid Uncontrolled blepharitis alters the lipid composition of treating higher-order aberration artifacts induced by tear the meibomian gland secretions; these oils are essential film abnormalities. to maintaining tear viscosity and stability. Alteration in Significant dry eye syndrome can be easily diagnosed this pathway negatively affects tear film function, there- when patients complain that their eyes are always dry, fore impairing overall vision quality. red, and tired. Most patients, however, do not readily ABMD is a common condition affecting the corneal report these symptoms, and therefore dry eye syndrome epithelium and can be difficult to recognize unless one is can be overlooked during the preoperative assessment. A specifically looking for it. ABMD can not only induce simple screening question is to ask your patient how his corneal surface irregularities but can also predispose or her eyes feel without contact lenses. Patients with dry patients to intraoperative complications such as slough- SEPTEMBER 2011 CATARACT & REFRACTIVE SURGERY TODAY EUROPE 35 REFRACTIVE SURGERY FEATURE STORY TABLE 1. COMPONENTS OF THE PREOPERATIVE SLIT-LAMP EXAMINATION Eyelid Position • Rule out floppy eyelids and ectropion, which may exacerbate dry eyes • Determine if palpebral fissure is too narrow or tight to achieve adequate suction for performing LASIK Meibomian Glands • Apply digital pressure to assess secretion quality and flow • Look for eyelid margin erythema and vascularity, and determine if there is any degree of blepharitis and/or meibomian gland dysfunction Tear Film • Tear film height less than 1 mm and tear break-up time Figure 1. Placido–disc-based topography highlighting an less than 10 seconds is suggestive of dry eye syndrome irregular corneal surface with loss of color map information is • Have a low threshold to stain with fluorescein and/or suggestive of ocular surface disease. lissamine green to laser vision correction procedures. Although the Cornea genetics of corneal ectatic disorders are variable, a posi- • Epithelium: rule out anterior basement membrane tive family history can be an important clue, prompting dystrophy, especially in the superior cornea greater scrutiny and caution. In our practice, we routinely • Stroma: rule out scarring that may affect femtosecond ask patients about any family history of corneal trans- laser flap creation; rule out thinning or striae suggestive of plantation and blindness or severe vision loss. ectatic disorders • Endothelium: rule out cornea guttata (sign of Fuchs CLINICAL EXAMINATION dystrophy and posterior polymorphous corneal dystrophy) Slit-lamp examination. A detailed slit-lamp examina- tion is essential to recognizing many of the conditions discussed above. Table 1 describes the crucial compo- ing of the epithelium during LASIK. Patients with ABMD nents of the refractive preoperative slit-lamp exam. often have recurrent corneal erosions, which can be of Diagnostic testing. Corneal topography and tomogra- any magnitude. It is important to ask your patient about phy provide both qualitative and quantitative assess- eye pain or irritation upon waking up in the morning, ments of the cornea. They are vital tools when evaluating which is a common time to experience erosions with a refractive surgery patient, as they can alert the surgeon ABMD. Although the condition is more common in to check for keratoconus, ocular surface disease, and older patients, young patients with a history of trauma many other irregularities of the cornea. We routinely per- or corneal abrasion may also have ABMD and a history of form Placido–disc-based corneal topography (Humphrey recurrent erosion symptoms. The presence of ABMD is a Atlas; Carl Zeiss Meditec, Inc., Jena, Germany) in addition relative contraindication to LASIK, as there is an to tomographic imaging of the cornea, using either increased risk of epithelial complications including Scheimpflug imaging (Pentacam; Oculus Optikgeräte epithelial slippage with resultant diffuse lamellar keratitis GmbH, Wetzlar, Germany) or optical slit scanning (DLK), recurrent erosions, epithelial ingrowth, and (Orbscan; Bausch + Lomb, Rochester, New York). ABMD-induced irregular astigmatism. Tomographic imaging in particular may reveal subclinical Finally, it is important to ask patients about their fami- forms of corneal ectasia or structural weakening such as ly history of eye diseases. Ectasia after laser vision correc- elevated posterior corneal curvature or abnormal pat- tion is a devastating complication and most often is a terns of corneal thickness. result of unrecognized topographic abnormalities and The first step in evaluating topography is to ensure that structural weakness. Keratoconus is a noninflammatory you are aware of the color scale markings. We typically ectatic disorder of the cornea and is a contraindication use an axial topography map with 0.50 D intervals, which 36 CATARACT & REFRACTIVE SURGERY TODAY EUROPE SEPTEMBER 2011 REFRACTIVE SURGERY FEATURE STORY Figure 2. Inferior steepening consistent with keratoconus. provides sufficient screening for significant shape abnor- malities. Topography may be the first clue to ocular sur- face diseases such as dry eye, blepharitis, and ABMD, in which there will be a loss of color information on the Figure 3. Scheimpflug image of a patient with keratoconus. topography maps (Figure 1). Next, evaluate for any asym- Note how the posterior float is elevated, the keratometric metry. Ectatic disorders such as keratoconus and pellucid map shows inferior steepening, and the corneal apex is marginal degeneration often show asymmetric maps with slightly inferiorly displaced. inferior steepening (Figure 2). Pentacam and Orbscan tomographic printouts will display the anterior and pos- coincident acne rosacea, which can be managed with terior corneal float, pachymetry, and keratometric maps. oral doxycycline. Regardless of the treatment methods We recommend that surgeons look at all four maps to chosen, it is crucial to achieve good control of the ocular identify abnormalities consistent with structural abnor- surface disease prior to proceeding with surgery. This malities; for example, one should suspect keratoconus in a may not be what the patient prefers, as it takes time to patient with an inferiorly displaced corneal apex, elevated treat dry eyes and blepharitis; however, you and your posterior float, and thin pachymetry (Figure 3). patient will be much happier if the time is taken to address this chronic problem. MANAGEMENT OF COMMON CORNEAL ABMD. A refractive surgery patient with ABMD is best CONDITIONS treated with surface ablation techniques rather than Ocular surface disease. It is of utmost importance to LASIK, as this treats not only the refractive error but also aggressively treat any ocular surface disease prior to the underlying ABMD. As mentioned previously, there are refractive surgery. In our practice, patients with dry eye a number of intraoperative complications that can be syndrome are asked to use artificial tears on a regular associated with performing LASIK on a patient with basis in addition to cyclosporine 0.05% (Restasis; ABMD, such as erosions, DLK, and epithelial ingrowth. Allergan, Inc., Irvine, California) twice daily. If the condi- Careful preoperative recognition of the condition can help tion is severe, a short course of topical steroids may also to avoid such complications. Techniques that we com- be considered. Some patients have reported improved monly use to identify subclinical
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