TREATING ABMD IN PREMIUM IOL PATIENTS

Cornea Irregularities should be addressed pre-op

Patients with anterior basement membrane dystrophy (ABMD) present
with a number of corneal and visual challanges. However, if that patient is going
to have cataract surgeryand possibly a premium IOL implantation, treatment
becomes even more challenging, said Bonnie An Henderson, MD, partner,
Ophtalmic Consultants of Boston and EyeWorld cataract editor.
One of my unhappiest patients was a woman with ABMD who underwent
cataract surgery, Dr. Henderson said. The corneal findings were fairly mild and
because she had other serious ocular comorbidities, I did not focus the
discussion on the possible post-operative problems that could occur from AMBD
but rather on her significant glaucoma and macular disease. The patient had
uneventful cataract surgery but then had a good deal of pain at week 1 post-op
due to epithelial loss.
Because I had not discussed the risks of ABMD and variable healing, she
was very unhappy with her outcome and care even though herr surgery went
well and her final vision was 20/20, Dr. Henderson said.
By adding a premium IOL to the surgical mix, you set the bar higher in
patients whose expectations are usually already high, said David D. Verdier, MD,
Verdier Eye Center, Grand Rapids, Mich., USA.
For this reason, careful pre-op diagnsis and treatment are crucial in
patients with ABMD who want to have a premium IOL.
Explaining the condition
A patient who has anything but the mildest form of ABMD will require
treatment before undergoing cataract surgery and premium IOL implantation,
said Steven G. Safran, MD, Lawrenceville, NJ, USA. The process of clearing that
cornea can take 2-3 months. That time is a small investment to make, Dr.
Safran said. Patients who do not want to wait those few months to treat ABMD
are probably not good candidates for a premium IOL, Dr. Safran said. However,
he finds his patients are open-minded about treatment.
I tell my patients its like painting a house. Youd be stupid to do it with
leaves blowing againts the paint, Dr. Safran said.
Another good analogy for ABMD and lens surgery is likening it to a moving
target, Dr. Verdier said. If its more than a very mild case of ABMD, youre going
to have sme irregular astigmatism and areas of involvement that change over
time.
Without pre-op treatment, the ABMD patient may experience poorer visual
quality post-cataract surgery, said Natalie Afshari, MD, director, Cornea and

Refractive Surgery Fellowship Program, and assistant professor, Department of

Ophtalmology, Duke University, Durham, NC, USA. Additionaly, a lack of pre-op
treatment can make it difficult to obtain accurate keratometry measurements,
Dr. Henderson said.
Confirm, treating, and to scrape or not to scrape?
When the ABMD patient present for cataract surgery, Dr. Safran first
confirms the true source of visual problem. Sometimes its the cornea and not a
cataract causing problems, he said. He has also seen the reverse situation: Ive
also seen patients unhappy after cataract surgery who have not had their
corneal problems addressed, he said.
Dr. Safran commonly finds that ABMD patients also have other conditions
such as pannus, blepharitis, or Demodex mites, all of which he will treat as
necessary with doxycycline, Restasis (cyclosporine ophtalmic emulsin, Allergan,
Irvine, Calif., USA), or tea tree oil.
Drs. Safran and Verdier typically scrape the cornea pre-op and perform a
superficial keratectomy. Dr. Afshari performs a phototherapeutic keratectomy
(PTK), a laser smoothing treatment.
Although some patients can get by without PTK, Dr. Afshari tends to be
more conservative with her approach in patients who want a premium IOL.
Perfection is the goal, especially with those patients, she said.
Dr. Safran tries to limit scraping to before surgery as he finds that scraping
after cataract surgery can induce a change in refraction. However, Dr. Henderson
prefers not to scrape the cornea before surgery in mild ABMD cases. She instead
discusses with patient the associated potential risks for pain and blurred vision,
which might cause the need for scraping after surgery. She also discusses the
possibility of a refractive surprise caused by the difficulty in measuring
keratometry values.
Scraping before surgery is a reasonable approach. However, I have found
that the majority of patients who have ABMD do not develop postoperative
issues and have accurate K measurement, Dr. Henderson said.
However, if K measurements are inconsistent pre-op, Dr. Henderson will go
ahead and scrape the cornea to obtain reproducible and accurate
measurements. Also, if a pre-operative topography shows a significant irregular
surface, then the patient may benefit from scraping, she said.
Dr. Henderson finds it useful to perform the K readings for these patients
in up to four different methodsmanual, auto, noncontact biometry, and
topographyto compare their values and obtain cconsistency. If the values
differ even after repeated measurements, then I do not implant a toric or
presbyopia correcting IOL, she said.
Post-treatment considerations

Once the ABMD is treated, the surgeon can ussualy proceed with premium
IOL implantation. Once its stabilized, you can do what you want, Dr. Safran
said. Still, these patients require some extra monitoring during and after suregry.
Dr. Verdier is cautious about recommending multifocal lens implants for
ABMD patients, as the issues of contrast sensitivity loss and increased glare can
further compromise optical aberrations associated with ABMD. Some premium
lenses, including toric lenses and the Crystalens (Bausch + Lomb, Rochester, NY,
USA), are not associated with contrast sensitivity loss or increased glare. I do
not find them contraindicated for ABMD, Dr. Verdier said. My primary goal is to
maximize the patients quality of vision and in doing so preserve the patients
ability to drive safely and maintain his or her independence. This is more
important than spectacle independence, thus my reluctance to recommend
multifocal intraoculer lens implants.
Dr. Henderson will be careful during cataract surgery with patients who
have mild ABMD to avoid trauma to the epithelium and keep the epithelium well
lubricated. She uses a dispersive viscoelastic to help avoid damage from
excessive phaco energy. Advanced phaco technology such as torsional
ultrasound, burst, and pulse modes can decrease the total amount of energy
delivered inside the eye, she said.