Preparing the Ocular Surface for Cataract Surgery: Q&A with Niraj Desai, MD

With the high prevalence of ocular surface disease and its affect on cataract surgery outcomes, ensuring a healthy ocular surface prior to and post cataract surgery is very important. Bio-Tissue recently spoke with Niraj Desai, MD, about his experience with preparing the ocular surface for cataract surgery.

Optimizing the Ocular Surface Prior to Surgery: Why I Added Prokera to My Refractive Cataract Pre-Surgical Regimen

Refractive cataract surgery requires a high level of attention to the ocular surface. Patients expect perfect outcomes, and any compromise of the ocular surface interferes with preoperative measurements and proper IOL selection. To ensure we don’t end up with a postoperative refractive surprise, we need to be on alert for ocular surface disease and get it under control before proceeding with surgery.

Be Proactive

Our typical cataract surgery patients have all the risk factors for ocular surface problems. They have chronic disease comorbidities, they’re using multiple medications, and so forth. Many are neurotrophic to some degree; therefore, we can’t rely on them to report symptoms. We must proactively look for dry eye as well as epithelial-based diseases, such as Salzmann’s nodular degeneration (SND) and epithelial basement membrane dystrophy (EBMD). EBMD not only leads to irregularities in preoperative measurements and outcomes but also puts patients at risk for epithelial sloughing during surgery and poor wound healing postoperatively.

The Economic Benefits of PROKERA®

It’s not a simple cliché or abstraction to state, for the record, that the best, most profitable, and most enduring business plan is simply, and above all else, doing the best for the patient. Hence, when considering the economics of PROKERA® use in practice, we must ensure that we are making calculations based on the appropriate metrics. Are we considering only the myopic calculation of price and profit-margin; erroneously rationalizing that an amniotic membrane is an amniotic membrane?

Or, are we, our patients, and our long-term practice prospects, better off, by focusing on endpoints like quality of healing, speed of healing, and the other metrics of efficiency, time, and profitability that they directly and indirectly impact? In this blog, I will address the rationale (both economic and medical) behind our decision to use the PROKERA-line in my Cornea, Cataract, and Refractive practice.

The Importance of EBMD Prior to Cataract Surgery

A 73-year-old nun presented in my office complaining of severe blurred vision in the left eye that was slowly getting worse. She stated that she had seen prior eye doctors that recommended cataract surgery, however she was quite hesitant and had a lot of anxiety about surgery so wanted a second opinion.

Quality Healing in Chronic Dry Eye Patients

The majority of patients I see in my anterior segment-focused practice who have Dry Eye are either referred for cataract surgery or are patients who have sought treatment elsewhere without success. When these patients present with dryness-related keratitis, such as superficial punctate keratopathy (SPK) that doesn’t respond to initial therapies, I turn to PROKERA®, a biologic corneal bandage composed of a cryopreserved amniotic membrane. Its natural therapeutic effects reduce inflammation, promote healing and minimize the risk of scarring, all of which are necessary to alleviate symptoms, return the ocular surface to a normal state and optimize cataract surgery (and LASIK) outcomes.

Preparing the Ocular Surface for Cataract Surgery

The condition of a patient’s ocular surface prior to cataract surgery, particularly refractive cataract surgery, can greatly impact the outcome. This is especially true for patients with dry eye and/or mild or severe epithelial basement membrane dystrophy (EBMD). Both of these conditions are so prevalent, they can be easy to overlook. I was taught in residency, 10% of the population, but if you look at the studies, it's widely variable. Some studies are upwards of 30 to 40% of the population.