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10 | EYEWORLD DAILY NEWS | MAY 18, 2020 DAILY NEWS ASCRS VIRTUAL ANNUAL MEETING myopes, high hyperopes, and those with previous refractive surgery can be more likely to experience a refractive sur- prise. In some cases of refrac- tive surprise, medical options can be helpful. Dr. Hatch mentioned omega-3s, hot compresses, artificial tears, lid scrubs, oral tetracyclines, topical steroids and/or cyc- losporine, thermal, in-office procedures, and plugs. Ocular pathology identified as the cause of refractive surprise postop should be treated. ABMD may need a superficial keratectomy, and PCO could be treated with a YAG capsu- lotomy, for example. For other situations, after allowing time for neuroadaptation, reim- age and refract patients and perform an enhancement. Dr. Hatch also presented that it is sometimes beneficial to treat the fellow eye then reassess the first. Surgical options for re- fractive surprise could include laser vision correction, AK/ LRI, piggyback IOL, or IOL exchange. She advised doing a contact lens trial, if possible, before surgical enhancement. Bring it home Finally, to bring that run home, William Wiley, MD, Cleveland, Ohio, discussed the financial considerations in using this technology and the importance of investing in better outcomes. View the full symposium in SYM-5. Editors' note: Dr. Hatch has finan- cial interests with Avedro/Glau- kos, Johnson & Johnson Vision, Carl Zeiss Meditec, Eyevance, and EyePoint. Dr. Chang has financial interests with a number of ophthal- mic companies. Drs. Ciralsky and Nehls have no financial interests related to their presentations. "I think this is the most important part of the examina- tion, because even if you have this perfect candidate … if you tell them they will never need glasses again with this lens and they go on to need glasses 10% of the time, their expectations were not met and they will be unhappy," Dr. Ciralsky said. In setting realistic expec- tations, Dr. Ciralsky advised a discussion on "optical com- promise." Patients have to compromise something with every lens, so ask them in which scenarios might they be willing to wear glasses (and vice versa). From a personality standpoint, she said she would avoid presbyopia-correcting IOLs in the "type A" (competi- tive, controlling, perfectionist) patient, as well as those with obsessive-compulsive personal- ities and those with unrealistic expectations. She also considers the pa- tient's profession and lifestyle. "I avoid pilots and driv- ers because they often have to drive at night," she said, explaining that they might ex- perience glare. She also avoids engineers due to the perfec- tionist personality type. Objective screening factors are equally important: • Refractive: Dr. Ciralsky said to be careful with the low myope (–2 D). "They're never going to be happy with the reading vision you give them through a multifocal—they love reading without glass- es," she said. Post-refractive patients should also be ap- proached with caution. • Anterior pathology: Many times, anterior pathology is subtle, and if you have ocular surface abnormalities it can cause light scatter, increase higher order aberrations, and decrease image quality. Anterior pathology includes dry eye, corneal pathology, and types of ectasia. • Cataract type: Avoid or be cautious with presbyopia-correcting IOLs in patients with zonular insta- bility, those with high risk of capsular tear, and those with dense cataracts. • Posterior pathology: Avoid those with decreased contrast sensitivity. Sarah Nehls, MD, Madison, Wisconsin, presented on the refractive cataract workup. She said the principles of "measure twice, cut once" can be applied to refractive cataract surgery. "You want reproducibility of your measurements," she said, adding that address- ing and optimizing dry eye or blepharitis before taking measurements can enhance accuracy. Optical biometry accu- racy can be enhanced with newer technology, such as swept-source OCT, Dr. Ne- hls said. Corneal topography and tomography provide a "big-picture overview" of the ocular surface, and irregular topography patterns (or lack of correlation with biome- try) need to be identified and addressed preoperatively, if possible. OCT of the macula is important to confirm normal macular health before using presbyopia-correcting lenses, but Dr. Nehls noted that toric lenses can be beneficial in eyes with macular pathology. Ocular dominance is also important when considering monovision as an option in refractive cataract surgery, Dr. Nehls continued. In con- ventional monovision, the dominant eye is set for distance and nondominant eye is set for near. In crossed monovision, it's the reverse. Crossed mono- vision, Dr. Nehls explained, has a good history in being suc- cessful in patient results and satisfaction. "If a patient liked monovi- sion in their contact lenses, it will be a success in their cata- ract surgery," Dr. Nehls said. Swing for the fences Once you're at the plate (in the OR), you've got to be prepared to "swing for the fences" to achieve that home run. Pre- sentations to enhance this capability covered centration and astigmatic correction and the use of adjunct technology, such as femtosecond laser and intraoperative aberrometry. Run the bases Once you've performed the surgery, you have to "run the bases" of postoperative man- agement, which might include management of an unhappy patient, fixing problems, and performing enhancements. Kathryn Hatch, MD, Waltham, Massachusetts, dis- cussed what to do when faced with an unhappy patient who received an advanced technol- ogy IOL. The first thing to do is don't panic, be positive. The patient should be embraced and their concerns listened to and addressed. Some pa- tients, Dr. Hatch noted in her presentation, might not need correction for a refractive sur- prise; they might be 20/happy. Determine the cause of the refractive surprise and allow ample time for neuroaccomo- dation before recommending a correction. Patients should be pre- pared during preop counseling for the potential of postop procedures to achieve intend- ed results. If they're not, they might be disappointed in their initial outcome. It's important to document this preoperative conversation with the patient so it can be referred back to later, if needed, Dr. Hatch noted. Most refractive surprise errors relate to errors in biom- etry, Dr. Hatch said. An axial length error of 1 mm can result in a 3 D postop error, and a 1 D error in average K can equal 1 D in postop refractive error. She also noted that high continued from page 8

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