Eyeworld

70 | EYEWORLD | MARCH 2021 R EFRACTIVE by Ellen Stodola Editorial Co-Director About the physicians Eric Donnenfeld, MD Ophthalmic Consultants of Long Island Garden City, New York Robert Weinstock, MD Weinstock Laser Eye Center Largo, Florida W ith many new premium lens technologies and increased patient expectations, astigmatic keratotomy (AK) and limbal re- laxing incisions (LRIs) are tools that can be used by surgeons to help correct low levels of astigmatism. Eric Donnenfeld, MD, and Robert Weinstock, MD, discussed how they use these to improve outcomes. LRIs are made to widen the cornea in certain areas to reduce astigmatism, Dr. Don- nenfeld said. The purpose is to reduce astigma- tism by flattening the steep axis of the cornea. "The analogy I make to patients is it's similar to cutting the laces on a football," he said. "If you do that, it would round out to become more basketball shaped, which is similar to what you want to do to reduce astigmatism." Dr. Donnenfeld that he's using LRIs more than ever in his practice because patients have higher expectations. "They expect better uncor- rected vision after LASIK and cataract surgery." Dr. Donnenfeld said that over the last several years, his use has shifted. Previously, these incisions could be used for higher levels of astigmatism. Now, there are specific technolo- gies, like toric IOLs, that can be used to correct higher levels of astigmatism. However, he noted that LRIs are still valuable to correct astigma- tism from 0.5 D up to 1–1.25 D. "I use them in patients who've had LASIK who have a spherical equivalent close to plano but have astigma- tism," he said, adding that he also uses them for patients who had cataract surgery and have astigmatism after. "It's a simple procedure, and you get an almost instantaneous response." According to Dr. Weinstock, astigmatism management has become one of the hottest top- ics in cataract and refractive surgery. As cataract technology has improved, IOL implants have improved, as well as biometry, he said, adding that it's approaching standard of care to address astigmatism at the time of cataract surgery. "Typically, a single arc, pair of arcs, or even double pair of arcs were used to correct with a diamond blade," he said. This was before toric IOLs were released. Dr. Weinstock noted that to- ric IOLs can be used to correct higher amounts of astigmatism, but he said that most patients tend to have lower amounts of astigmatism. Manual vs. femtosecond laser technique Dr. Donnenfeld said surgeons can employ a manual technique or use a femtosecond laser for LRIs/AKs. Both of these options may still be needed. The femtosecond laser gives access to a technology that allows surgeons to perform a surgery as efficaciously, as accurately, and as safely as they can, he said. Femtosecond lasers can do something that manual LRIs can't do in that you can do intras- tromal incisions with the femtosecond laser, Dr. Donnenfeld said. The incision is made in the stroma, and there is no pain, no disruption of the epithelium, no gaping wound, and it doesn't cut the cornea nerve. There is also no need for topical antibiotics. However, Dr. Donnenfeld said he would use a manual technique for patients having cataract surgery who aren't financially comfortable get- ting a premium IOL. For these patients, adding a manual LRI to surgery is an added value, he said. Dr. Donnenfeld said he will also use a man- ual technique for patients who've had LASIK or cataract surgery, and he will use a diamond knife at the slit lamp. "It's a simple, 1-minute procedure," he said. "The patient leaves the office seeing better almost immediately." If you don't have a femtosecond laser, a manual LRI is very reasonable to do, Dr. Don- nenfeld said, as long as you understand the limitations of an LRI. These are wonderful for low levels of astigmatism, but for higher levels, there are other things that are better, he said. Using AK/LRIs to correct astigmatism Manual LRI performed at the slit lamp

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