In these cases, the lens status is an important consideration. If cataract surgery is in the near future, then ocular surface irregularities that may affect the corneal curvature (and, therefore, intraocular lens calculations) should be addressed first. In the case of pterygium, some studies have attempted to determine the predictability of its impact on K measurements and use this information for combined pterygium and cataract removal [15]. At this time, there appears to be less than optimal predictability based on available regression formulas, particularly for larger lesions. We take into consideration clinical examination findings, refraction, and corneal topography in determining whether a pterygium is visually significant and warrants excision prior to cataract surgery. The same principles apply for Salzmann nodular degeneration. Typically, we will obtain measurements for cataract surgery no sooner than 4–6 weeks after surgery for pterygium or Salzmann nodular degeneration.

If the patient does not have a visually significant cataract, then there may be more time to observe or pursue medical treatments, unless the patient is symptomatic or has disease that threatens involvement of the visual axis. For Salzmann nodular degeneration, any associated underlying conditions (e.g., blepharitis, ocular surface disease, interstitial keratitis) are treated aggressively, often with some form of local immunosuppression such as a topical steroid or cyclosporine. In patients with visual impairment and a lack of improvement with conservative treatments, surgical intervention is then recommended.

For pterygium excision, a conjunctival autograft is often a reasonable consideration, provided that the ocular surface is otherwise healthy and there are no signs of limbal stem cell deficiency. However, in the presence of ocular surface disease, conjunctival scarring or a double-headed pterygium, we prefer amniotic membrane transplantation over the area of excised conjunctiva. The graft may be secured in placed with fibrin glue, sutures, or both. We typically reserve the use of mitomycin C for recurrences or cases that are at high risk for recurrence (e.g., younger age). A recent study found that mitomycin C in conjunction with either AMT or conjunctival autograft resulted in a similar rate of success [16]. In the case of Salzmann nodular degeneration, the role of amniotic membrane is dependent on the extent of involvement; if a large superficial keratectomy is required, then an amniotic membrane graft over the area of excision can reduce the risk of recurrence while improving the rate of epithelial healing [17]. The patient should be made aware that the amniotic membrane graft will cause visual blurring if placed over the visual axis.

This patient had a visually significant cataract OD greater than OS, and therefore we recommended surgical intervention for the right eye. Intraoperatively, the nasal and temporal pterygia were excised and a superficial keratectomy was performed using a 57 blade and non-toothed forceps. A larger conjunctival excision was performed nasally than temporally, and eraser tip cautery was used to achieve hemostasis. The nasal and temporal amniotic membrane grafts were sequentially secured in place with fibrin glue as well as 9-0 vicryl sutures on the limbal side and 8-0 vicryl sutures on the conjunctival side. Postoperatively, the patient was treated with prednisolone acetate 1% and ofloxacin 0.3% drops, both QID. She initially noted foreign body sensation and photophobia with a drop in visual acuity to 20/500 on postoperative day one; however, these symptoms improved significantly over the first week with vision returning to baseline. The ocular surface was noted to heal well, and there was a small amount of residual anterior stromal scarring nasally ( Fig. 18.3 ).

In this particular case, there was both a nasal and temporal conjunctival excision as well as a superficial keratectomy performed. Given the location and extent of involvement, neither a dry amniotic membrane disc nor a ProKera would have provided adequate coverage. Therefore, we used two sheets of amniotic membrane (AmnioGraft) over the involved areas, which we secured in place with both glue and sutures. Although it requires more delicate handling than the other two products, the AmnioGraft can be cut to the appropriate size and shape based on anatomical considerations.

In this case, the diagnosis of ocular rosacea was straightforward. The patient had numerous facial telangiectasias, skin papules, rhinophyma, and the ocular findings described above (Fig. 18.4). The findings in ocular rosacea can range from only mild meibomian gland dysfunction and vascular telangiectasias at the eyelid margin to severe ocular surface disease with chronic conjunctival injection, symblepharon formation, corneal neovascularization, and corneal melt. The diagnosis may be challenging when facial skin changes are subtle or when ocular rosacea precedes extraocular changes; the symptoms of ocular rosacea (e.g., redness, irritation, foreign body sensation) are also relatively nonspecific [18]. Some patients with ocular rosacea have chronic blepharitis and ocular surface disease, whereas others have more of a relapsing remitting course. The differential diagnosis in severe cases includes graft versus host disease, atopic keratoconjunctivitis, ocular cicatricial pemphigoid, Stevens-Johnson syndrome, and chemical burn. In the absence of characteristic clinical features of rosacea, a thorough history and potentially a conjunctival biopsy may be indicated.