Eyeworld

76 | EYEWORLD | DECEMBER 2020 R EFRACTIVE know what we're treating at the time of cataract surgery. If their goal is more of a basic cataract surgery, maybe I'll hold off on the PTK," he said, explaining that the procedure could be done later to regularize the basement membrane disorder, if needed. "Consider what's important to the patient. Sometimes the patient is not motivated to treat their astigmatism. If that's the case, we make note of it and go with the basic cataract surgery. But if they're motivated, we want to make sure we're measuring properly and make sure we're not measuring something that's a dynamic process. … We want to make sure their dry eye disease is stable before we do a treatment plan." Treating regular astigmatism Toric IOLs are an obvious choice for regular astigmatism, but Dr. Swan pointed out that, at least in the U.S., low-add toric powers are not available. "Below a diopter becomes hard," he said. For astigmatism that is less than a diopter, he said he'll occasionally use an LRI, but over LRIs and torics, Dr. Swan is turning more to the Light Adjustable Lens (RxSight). "In a patient with regular astigmatism, the results when you look at the FDA trial for the Light Adjustable Lens vs. the FDA trials for many of the other standard toric lenses that we use, the percentage of patients who got to 20/20 with the Light Adjustable Lens is almost twice as high as the PMMA studies looking at the other lenses. I think the accuracy of the Light Adjustable Lens is fantastic. For post-re- fractive it is a wonderful technology … but even for a primary astigmatic patient with a naive cornea, it is still a nice option." If the patient is contraindicated for the Light Adjustable Lens—if they have poor dila- tion, concerns with compliance of the UV block- ing glasses required until treatment is locked in, etc.—toric lenses remain a fantastic option, Dr. Swan said. Dr. Lee said he's had good results with toric lenses in patients with prior laser vision correc- tion, even if their cornea isn't completely regu- lar. However, he mentions preoperatively that toric IOLs are not labeled to correct irregular astigmatism. "[I]deal astigmatism correction will address those underlying conditions before phaco. If the irregularity is mild or peripheral, I tell [patients] they can proceed without superficial keratec- tomy or PTK if they are willing to make that compromise," he said. Dr. Wiley takes the patient's outcome goals into consideration at this point. "If their goals are to see without glasses and have their astigmatism corrected, I urge them to get PTK first to regularize the cornea so we continued on page 78 continued from page 74 A recent patient of Dr. Ristvedt's presented for cataract evaluation wanting a trifocal IOL. Blurred Placido images indicated dryness, which was then treated before she returned for repeat measure- ments. The power and orientation of the patient's astigmatism changed after treating the dry eye. Source: Deborah Ristvedt, DO

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