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EW SHOW DAILY 46 ASCRS Symposia Monday, May 8, 2017 by Lauren Lipuma EyeWorld Contributing Writer E xperts in Sunday after- noon's symposium dis- cussed how best to measure and treat astigmatism during cataract surgery. Rosa Braga-Mele, MD, Toronto, kicked off the discussion by high- lighting the importance of astig- matism correction at the time of surgery. "We wouldn't leave astigma- tism out of glasses that we prescribe for patients, so we have to start thinking that way and knowing we should be treating astigmatism at the time of surgery to optimize our patients' vision," she said. Dr. Braga-Mele compared the merits of manual limbal relaxing incisions (LRIs) to femtosecond laser astigmatic keratotomies (AKs). While toric lenses are her go-to for treat- ing astigmatism, if you're using a combination lens, femtosecond laser arcuate incisions or manual LRIs are a viable option, she said. Three things determine success when performing astigmatic corneal surgery, Dr. Braga-Mele said: efficacy, safety, and economics. LRIs are more of an art than a science, so they may not be best in terms of efficacy, she said. Incisions are variable and imprecise with respect to incision depth, length, angulation, and position. Femtosecond arcuate incisions, on the other hand, are more con- sistent and predictable compared to manual LRIs. They are fully cus- tomizable and adjustable and are a science, not an art, Dr. Braga-Mele said. Femtosecond intrastromal ablations are also an option: They are less effective than full-thickness incisions but leave Bowman's layer intact, resulting in less dry eye and pain, greater wound stability, and no need for antibiotics, she said. Pearls for inserting toric IOLs Richard Tipperman, MD, Philadel- phia, shared pearls for implanting toric IOLs for those surgeons who are new to the procedure or consid- ering adding it to their practice. The first piece of advice Dr. Tipperman shared was to get com- fortable with marking before you start implanting torics. He suggested marking all routine cataract patients in the preop area as you would for a toric to get accustomed to the procedure and learn which marking system works best for you. One of the challenges for sur- geons beginning to implant torics is getting comfortable rotating the lens to the appropriate axis. Dr. Tipper- man recommended practicing this maneuver during routine surgeries with monofocal IOLs and leaving the haptic-optic junction at a prede- termined axis. It's easiest to rotate the IOL with the capsular bag fully inflated, he continued. By placing the I/A tip at the haptic-optic junction, surgeons can easily get comfortable rotating the lens all 360 degrees, he said. It's also important to make sure all the viscoelastic is removed when implanting toric IOLs. One of the issues that can relate to spontaneous lens rotation is if the surgeon leaves too much viscoelastic in the eye. Dr. Tipperman recommended looking for the "jiggle" of the lens—that's when you now all the viscoelastic is out, he said. One strategy that's especially good for treating against-the-rule (ATR) astigmatism is what Dr. Tipperman called "turn back the clock." When inserting a toric for ATR astigmatism through a temporal incision, if the lens rotates a bit as it's unfolding, it will be past where the marks are, meaning you'll have to rotate the lens at least 180 degrees to get it to the correct position. But if you try to rotate or nudge the lens counterclockwise as it's being inserted, the lens will unfold with the toric marks before the steep meridian rather than after it, so you'll only need to rotate it a clock hour or two, he said. Surgeons often wonder what to do with small pupils, Dr. Tip- perman said, especially when the pupil constricts enough that the toric marks are no longer visible. He recommended shifting the optic in the axis of the toric marks to be able to visualize them as the lens is being positioned. This is one of the advantages of rotating the lens with the I/A handpiece, he added. Placing an iris retractor at the intended axis will also make it easier to view the marks, he said. EW Editors' note: Drs. Braga-Mele and Tipperman have no financial interests related to their comments. Nailing astigmatism correction during cataract surgery Dr. Tipperman shares pearls for inserting toric IOLs for surgeons just starting out. that for me is the crossroads," Dr. Kanellopoulos said. Another issue that arises with monovision is the finding of a re- duction in stereopsis. "It can become—even at 1.5 D of monovision—quite significant for some folks," Dr. Thompson said. A common finding of surgeons is that female patients appear to adapt to monovision better than male patients. Other monofocal challeng- es have included the loss of any remaining accommodative ability if the implant takes them to plano vision. "When I take them to plano with a monofocal implant, unless they have spherical aberration, small pupils or something on their cornea helping them with depth of focus, I'm thinking about absolute pres- byopia at plano with a monofocal implant," Dr. Thompson said. Among the data that moved Dr. Thompson toward multifocals in such patients was a recent literature review in Seminars in Ophthalmology of previous research comparing pres- byopia treatments with multifocal IOL implantation or pseudophakic monovision. The review found, generally, near vision was better with multifo- cal IOLs, and more patients reported complete spectacle independence with multifocal IOLs. The downsides of multifocals included more glare and haloes and worse intermediate vision than monofocals achieved. "If you want to talk about mod- ern day technology, I sure can, but we need to do an attitude adjust- ment with regard to near-sighted near," said Dr. Thompson, who never promises patients they won't need glasses. The results of the literature review could have underestimated the benefits of multifocals because they did not examine the benefits of modern low-add multifocal IOLs. EW Editors' note: Dr. Dell has financial interests with Johnson & Johnson Vi- sion (Santa Ana, California) and other companies. Dr. Thompson has financial interests with Avedro (Waltham, Mas- sachusetts) and other companies. Dr. Kanellopoulos has financial interests with Alcon (Fort Worth, Texas) and other companies. When and how continued from page 44

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