published on December 10, 2015 by
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.
On initial examination the BCVA in the right eye was 20/25 and in the left eye was 20/60. There was dense epithelial basement membrane dystrophy in the visual axis of the left eye. Additionally the patient had 1-2+ nuclear sclerosis in both eyes. The symmetry of the nuclear sclerosis and the asymmetry of the Epithelial Basement Membrane Dystrophy (EBMD) were highly suggestive that the EBMD was the root cause of her visual difficulties in the left eye. This type of asymmetry, where the visual acuity does not match the cataract findings, is often overlooked, and frequently results in patients undergoing cataract surgery with unsatisfactory results that are frustrating for the patient and physician alike.
I explained to the patient the findings and my recommendation for a superficial keratectomy with 20% ETOH followed by an amniotic membrane graft “contact lens” (PROKERA®) placed on the eye or a bandage contact lens. She stated, despite significant education in the office about PROKERA, due to religious reasons she was hesitant to use amniotic membrane. The patient, following informed consent, chose to proceed with the superficial keratectomy of the left eye with a bandage contact lens instead.
The procedure was performed without complications on the left eye. Post operatively, after a bandage contact lens was in place for two weeks, the lens was removed and there were persistent epithelial irregularities in the visual axis, which resulted in some discomfort and a visual acuity of 20/40. At this point the risks, benefits and alternatives to PROKERA were discussed with the patient again and the patient stated after doing significant research on the Bio-Tissue website, which she found extremely helpful, she was now agreeable to proceed with PROKERA in the left eye.
PROKERA Slim was placed without complications and removed in one week after dissolving. The patient noted immediate improved vision and no discomfort. The vision on the day of removal was 20/25. The vision 3 months post-PROKERA was 20/20. The patient opted to defer cataract extraction for now.
This case highlights the importance of addressing EBMD prior to cataract extraction, the importance of recognizing EBMD prior to cataract extraction specifically in those cases with asymmetry of vision but with symmetry of nuclear sclerosis, the superiority of PROKERA to bandage contact lens and the significant visual effect that EBMD has on our vision. The importance of educating the patient so they feel comfortable with the use of PROKERA is also highlighted.
Daniel C. Brocks, M.D. is a board certified comprehensive ophthalmologist with a specialization in the medical and surgical treatment of the cornea. He is in practice at Hudson Valley Eye Surgeons in Fishkill, NY where he founded The Dry Eye Center, and is also Director, Department of Ophthalmology at Vassar Brothers Medical Center.