Eyeworld

I INNOVATIONS IN LENSES N FOCUS 104 | EYEWORLD | APRIL 2019 Contact information Rubenstein: Jonathan_Rubenstein@rush.edu Waring: gwaring@waringvision.com the option to function without glasses for the first time in their life, Dr. Rubenstein said. However, he noted that you still need to determine the true axis of astigmatism to place the toric IOL. "You've got to be sure that the astigmatism is regular enough to determine the true axis," he said. To know this, Dr. Rubenstein advocated for using corneal maps, optical biome- try, elevation maps, manual Ks, and "as much data as you can possibly get." Dr. Waring said that in post-penetrating ker- atoplasty (PK) patients, there may be high levels of astigmatism. This might require a bioptics approach, like a combined toric and femtosecond LRI procedure. Pseudophakic patients who are not catarac- tous post-transplant can undergo femtosecond laser-assisted astigmatic keratotomy, he said. Advanced technology options for post-LASIK or PRK patients Dr. Rubenstein said that these patients can be tricky, particularly because this is a patient popu- lation who paid out of pocket for a procedure to see without glasses, so they want to see without glasses after cataract surgery as well. It's important to get a corneal topography, he added, and this has to show both a centered and symmetric ablation on the PRK or LASIK. If the ablation is decentered or quite asym- metric in the healing pattern, you should avoid any presbyopia-correcting IOL, Dr. Rubenstein said. Meanwhile, if the patients has a well-cen- tered and symmetric ablation, you could consider some of the presbyopia-correcting IOLs. He added that some LASIK patients may also have dry eye issues, so you have to be sure that they have a good ocular surface. If the patient has irregular astigmatism, they won't do well with a premium IOL, Dr. Ruben- stein said. Considerations for patients with dry eye disease Dr. Waring said that care should be taken with LRIs in severe dry eye patients, but there could be a role for intrastromal LRIs with a femtosecond laser. He added that AKs and presbyopia-cor- recting IOLs can be an option in patients with moderate dry eye, if preoperatively and postoper- atively managed aggressively. It's important to watch out for dry eye disease because it can produce an irregular surface and fluctuating vision, Dr. Rubenstein said. If the ocular surface is degrading the quality of vision, there may be an exaggerated negative response to presbyopia-correcting lenses vs. standard lenses. Dr. Rubenstein said to be sure there is no staining of the cornea, and he emphasized that corneal topography is necessary. AKs can be used, depending on the level of dryness, but only in mild dry eyes without corneal staining. IOL options for post-RK patients The post-RK patient can also be tricky. In general, Dr. Rubenstein said these patients have a higher degree of irregular astigmatism, depending on how many incisions they had, how central they are, and how they were performed. Irregular astig- matism can affect the choice of lens, he said. Another problem is that these patients can have fluctuating vision. Because the procedure causes weakening of the mid-peripheral cornea, the corneal shape can fluctuate throughout the day. Dr. Rubenstein said that determining the correct IOL power is tricky because the corneal shape can be hard to assess. Topography and bi- ometry often cannot figure out the correct corne- al power, he said, adding that ORA intraoperative aberrometry (Alcon) may be helpful. The physician should warn these patients that their vision can fluctuate, he said, and that they may not be a candidate for a presbyopia-correct- ing or toric lens. continued from page 103 Financial interests Rubenstein: Alcon, Shire Waring: None

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