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EW SHOW DAILY 36 ASCRS Symposia by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer implanted with toric IOLs with an average of 6.67 degrees of misalign- ment seen at the end of 1 year after surgery, 1.87 degrees (28%) was actually surgical misalignment, 4.09 degrees (61%) occurred in the first hour, and only 0.71 degrees (11%) of actual rotation occurred between postop hour 1 and postop year 1. In the context of this data, Dr. Chang shared six pearls to avoid to- ric misalignment: 1) use non-disper- sive OVD; 2) remove OVD behind the IOL, ensuring full IOL/posterior capsule contact; 3) use a digital alignment guide; 4) use nasal place- ment; 5) leave a soft eye, with the anterior chamber formed and bag collapse; and 6) minimize activity immediately after the operation. EW Editors' note: Dr. Donnenfeld has financial interests with various compa- nies, including Alcon (Fort Worth, Tex- as), Bausch + Lomb (Bridgewater, New Jersey), and Johnson & Johnson Vision (Santa Ana, California). Dr. Raviv has financial interests with Bausch + Lomb and Johnson & Johnson Vision. Drs. Shorstein and Chang have no financial interests related to their comments. spot separation, energy level, and angulation of incision. Dr. Donnenfeld considers femtosecond astigmatic incisions superior to manual LRIs. Apart from increasing surgeon and patient ac- ceptance, they have increased safety and accuracy, with incisions that are customizable, adjustable, and repeatable, with a reduced risk of flipped axis. The femtosecond laser also makes it possible to create intrastro- mal incisions for astigmatism which, while less effective than full-thick- ness incisions, leave the Bowman's membrane intact, leading to less pain, reduced loss of corneal sen- sation, less dry eye, greater wound stability, and no risk of infection. As to the question of whether to do astigmatic incisions or implant toric IOLs, Tal Raviv, MD, New York, recommended using torics for with-the-rule astigmatism of greater than 1.5 D and against-the-rule astigmatism of greater than 0.4 D; for everything else, use LRIs. At the same symposium, David Chang, MD, Los Altos, California, noted that what is typically inter- preted as toric IOL rotation is more likely toric misalignment. He cited a study that found that in 72 eyes dure that can be performed at the slit lamp. Refractive outcome is, admittedly, a bit less accurate than toric, but remains stable for at least 3 years. The question, according to Eric Donnenfeld, MD, Rockville Centre, New York, is not whether LRIs work; it's if surgeons are performing them. He cited a study that found that 52% of residents and newly trained ophthalmologists have no experi- ence performing LRIs. The use of femtosecond lasers in cataract surgery provides an oppor- tunity for surgeons to get back to using LRIs to correct astigmatism. Moreover, femtosecond laser LRIs have the advantage of being fully customizable and adjustable; these incisions, Dr. Donnenfeld said, are no longer an art form, but a science. Incisions can be made to an exact size, with exact placement, at an exact depth. But the best thing about fem- tosecond laser LRIs in Dr. Donnen- feld's view is that the full effect is not achieved until the incision is manually opened, which may be done either intraoperatively or post- operatively. In addition, the surgeon has the ability to titrate the response to the laser by adjusting line and N eal Shorstein, MD, Walnut Creek, Califor- nia, described himself as a femto-poor, manual rich surgeon, so who better to lay down the essentials of manual limbal and corneal relaxing incisions? Dr. Shorstein kicked off the symposium on "Astigmatism Management at the Time of Cataract Surgery" Sunday afternoon. According to Dr. Shorstein, 20– 30% of cataract patients have greater than 1.0 D of astigmatism. More- over, astigmatism of more than 0.50 D may cause glare, blur, ghosting, and halos. These facts suggest that astigmatism correction should be an essential part of cataract surgery. LRIs, Dr. Shorstein said, are useful for correcting regular astigmatism. Astigmatism should be mea- sured with an autokeratometer and confirmed with a topographer and/ or biometry Ks; consider aban- doning LRIs if there are significant differences between tests. Describing his LRI technique, Dr. Shorstein said he marks the eye with the patient sitting. He aligns the marker under the scope. He makes the incision prior to phaco. He incises slowly and firmly, at depth, holding the diamond blade toward himself. Viscoelastic or balanced salt solution on the surface helps guide the incision, and it is made with the blade perpendicu- lar to the corneal plane—not the ground. He also makes the incision in the clear cornea, about 0.5 mm from the limbus. Postoperatively, patients can be given a topical antibiotic oint- ment or drops and NSAIDs may be beneficial. Refraction stabilizes at 2–3 months, at which point the amount of correction can be assessed. For un- dercorrections, Dr. Shorstein said the surgeon should lengthen or deepen the wounds, taking care not to perfo- rate the cornea. For overcorrections detected early, the surgeon can place sutures; for late overcorrections, surgeons can open the wound with a Sinskey hook and place 10-0 nylon sutures. Dr. Shorstein said additional LRIs should not be placed 90 degrees from the original incisions. In summary, he said, manual LRI is a low cost, reversible proce- Monday, April 16, 2018 Astigmatism management at the time of cataract surgery Dr. Donnenfeld discusses the use of femtosecond lasers to create LRIs.

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