The importance of treating EBMD before cataract surgery

Many patients who receive cataract surgery today are seeking a premium IOL and, in turn, expect a premium experience. To successfully treat these patients and deliver the outcomes patients expect, ophthalmologists need to enter surgery with the most accurate possible measurements. Unaddressed corneal conditions can introduce inherent measurement inaccuracies and result in postoperative complications, refractive surprises, and significant patient dissatisfaction, especially with premium IOLs.

In my experience, one of the most frequently underdiagnosed and overlooked conditions that can lead to patient dissatisfaction with cataract surgery is epithelial basement membrane dystrophy (EBMD).

Defining and diagnosing EBMD

EBMD is the most common form of anterior dystrophy and is characterized by an abnormal basement membrane that can cause defective adhesions and result in epithelial breakdowns.¹ Although EBMD has been estimated to affect 2% to 6% of the general population,² it is more common in older adults and has been reported in 7.5% of patients presenting for cataract surgery.³

EBMD can be challenging to identify because it is often asymptomatic, and when patients do present with symptoms, they may mirror those of dry eye disease, such as fluctuating vision, foreign body sensation, irritation, and dry eyes. As such, EBMD is frequently misdiagnosed.⁴ Obtaining a diagnosis of EBMD therefore relies heavily on the clinical exam, with fluorescein staining being particularly vital.

The hallmark of EBMD is unilateral or bilateral, often asymmetric, negative staining patterns that resemble “map-dot-fingerprints.” The maps appear as irregular, thickened grayish islands, the dots appear as irregular, putty-gray intraepithelial opacities, and the fingerprints appear as small clusters of curved, parallel lines.⁵ When these patterns appear, identifying and documenting whether they are central or peripheral and diffuse or focal is important, as these factors will impact the appropriate management strategy. If topography or tomography reveals significant corneal surface irregularity without a specific evaluation for EBMD, I would encourage reevaluation with fluorescein staining to look for these characteristic signs.

Preparing patients with EBMD for cataract surgery

Most patients I see with EBMD have mild peripheral or paracentral disease that does not particularly impact their topography, tomography, or IOL measurements. For these patients, treatment is not strictly necessary, so I typically provide conservative options such as preservative-free lubricating drops (Systane Pro PF; Alcon) or hypertonic saline ointment (Muro 128; Bausch + Lomb) and monitor them to ensure their disease does not progress.

However, if a patient has central or diffuse staining patterns, this is indicative of more significant disease, even in the absence of symptoms. In these patients, EBMD can induce astigmatic changes on the corneal surface, resulting in irregular topography or tomography. I would recommend performing a superficial keratectomy in these patients prior to cataract surgery to normalize the ocular surface and determine the true astigmatism of their cornea. Superficial keratectomy has been used for decades to treat EBMD and other ocular surface pathologies and has been shown to improve visual acuity, reduce corneal astigmatism, and alleviate symptoms in these patients.⁶^,⁷

For patients with more severe disease, such as those with symptoms that do not respond to conservative therapies, I would consider performing phototherapeutic keratectomy (PTK) rather than superficial keratectomy. PTK uses a laser to remove abnormal tissue and smooth the corneal surface. I consider PTK an especially good option for patients with recurrent corneal erosions, which can occur in patients with EBMD because their superficial cells have difficulty adhering to the basement membrane, causing them to easily slough off. This can be extremely painful, as even the mechanical act of opening their eyelids can cause abrasions in these patients. One study on the use of PTK in patients with EBMD found that 83% of treated patients were recurrence-free for visual disturbances and 88% were recurrence-free for corneal erosions after 5 years postoperatively.⁸ However, it should be noted that PTK carries the potential for inducing both corneal haze and hyperopic shift.⁹

The role of cryopreserved amniotic membrane

Although not strictly necessary for all patients with EBMD, I consider the use of a cryopreserved amniotic membrane (CAM), regardless of whether I am performing a superficial keratectomy or a PTK. CAM can be highly beneficial for these patients due to its ability to provide regenerative ocular wound healing and its anti-inflammatory, antiscarring, and antiangiogenic properties.¹⁰ In one retrospective study, the use of CAM in patients with EBMD who underwent superficial keratectomy led to complete reepithelialization in more than 96% of cases within 10 days, with significant improvements in higher-order aberrations, cylinder power, and IOL spherical equivalent.¹¹

Whether a patient with EBMD requires CAM largely relies on the extent and location of their disease, as well as the presence of any patient factors or systemic conditions that could inhibit their healing. I typically prioritize placing CAMs in patients with extensive, central EBMD or those with conditions that predispose them to poor healing, like diabetes or Sjögren syndrome. I would also place one in any patient with a history of herpes keratitis, as well as in patients with larger epithelial defects.

CAM can be placed on the day of the superficial keratectomy or PTK. However, it is important to be mindful of coding guidelines and payer requirements. Alternatively, the patient can be followed closely, and if the epithelium is not healing quickly, the CAM can be placed at a subsequent visit. I typically leave it in for 2 to 5 days, depending on the size of the epithelial defect.

The 2 CAM products I use are Prokera and CAM360 AmnioGraft (CAM360 AG) (BioTissue). My choice depends on the patient’s disease severity and the depth and extent of their epithelial defect. In defects smaller than 4 mm, I usually opt for CAM360 AG, as it is a ringless product that is more comfortable for patients. In defects 4 mm or larger, I usually opt for Prokera to regularize the epithelium as quickly as possible.

Conclusion

Prevention is the most important treatment, so identifying EBMD prior to cataract surgery may reduce the risk of patient dissatisfaction. Every patient considering this procedure should have fluorescein staining done at the consultation. This can also help identify EBMD and other ocular surface diseases, which have been reported at rates as high as 80% in this population.³ Treating and optimizing ocular surface diseases prior to moving forward with any ocular surgery will ultimately lead to higher rates of patient and surgeon satisfaction.

Ashraf F. Ahmad, MD

E: [email protected]

Ahmad is a board-certified, fellowship-trained ophthalmologist practicing at Harvard Eye Associates in Laguna Hills, California, as well as a member of both the American Academy of Ophthalmology and the Orange County Society of Ophthalmology. Ahmad specializes in cornea, cataract, and refractive surgery. Ahmad reports an affiliation with BioTissue.

References

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3. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018;44(9):1090-1096. doi:10.1016/j.jcrs.2018.06.026

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8. Lee WS, Lam CK, Manche EE. Phototherapeutic keratectomy for epithelial basement membrane dystrophy. Clin Ophthalmol. 2016;11:15-22. doi:10.2147/OPTH.S122870

9. Hayakawa H, Kamiya K, Tsujisawa T, Takahashi M, Shoji N. Hyperopia-correcting phototherapeutic keratectomy and its comparison with conventional phototherapeutic keratectomy. Front Med (Lausanne). 2022;9:708188. doi:10.3389/fmed.2022.708188

10. Zhang Y, Helman A, Mead OG, et al. Processing methods affect biological properties of amniotic membrane sheet products. Cornea. 2025;44(6):671-678. doi:10.1097/ICO.0000000000003849

11. Kimmell SW. Superficial keratectomy with cryopreserved amniotic membrane for ocular surface optimization in patients with epithelial basement membrane dystrophy. Clin Optom (Auckl). 2026;18:588116. doi:10.2147/OPTO.S588116