Eyeworld

MARCH 2021 | EYEWORLD | 71 R Contact Donnenfeld: ericdonnenfeld@gmail.com Weinstock: rjweinstock@yahoo.com Relevant disclosures Donnenfeld: Johnson & Johnson Vision Weinstock: Alcon, Bausch + Lomb, Johnson & Johnson Vision, LENSAR be at, and how long the arc would be and how deep the cut would be in the cornea depending on the localized pachymetry of the cornea. The longer arc length, the more astigmatism was being corrected. "If you don't have access to a femtosecond laser, [you can fall] back on the Donnenfeld or Nichamin nomogram with a diamond blade during surgery at the beginning or end of the case," Dr. Weinstock said. Dr. Donnenfeld said he uses the Donnen- feld nomogram and that this is available on the CATALYS femtosecond laser platform (Johnson & Johnson Vision). Dr. Donnenfeld also said a good place to learn about limbal relaxing incisions is www. lricalculator.com, which he designed about 10 years ago. It gives doctors the nomogram and allows them to populate their patients' treat- ments, so they know where to place the inci- sions, he said. Dr. Donnenfeld stressed that LRIs are tools to take patients' results from good to great. "I often will offer patients LRIs for even small amounts of astigmatism," he said. "My goal for refractive cataract surgery is not to make people happy but to exceed their expectations, and limbal relaxing incisions are one of the most important ways that I can exceed patients' expectations by reducing astigmatism to lower levels." When the femtosecond laser came along, it became more accurate to use it to make these incisions to correct astigmatism, Dr. Weinstock said, adding that many surgeons use the femto- second laser for the bulk of their patients. It's important to have AKs/LRIs at the right axis, Dr. Weinstock said, and many laser compa- nies are including features to help with this. He added that ORA (Alcon) and Callisto eye (Carl Zeiss Meditec) can be used during surgery for placement at the right axis (or a marking pen can be used preoperatively). Some surgeons prefer to open the incisions up at the time of surgery to give them more effect, he said, while others like to open up af- terward, depending on how the patient is doing. "Sometimes the arcuate incision alone does the correction and you don't have to open them," Dr. Weinstock said. "But sometimes you need to open them." He prefers to not open the incisions during surgery but waits to see the patient in a month. "If the astigmatism is not gone, I'll open the incision up at the slit lamp and check them," he said. "Sometimes I'll even augment it manually at the slit lamp with a diamond blade and either extend the incision or make another incision." If patients are signing up for premium cata- ract surgery, it's the responsibility of the surgeon to not just do great surgery but also to follow them postop and do the enhancement that may be needed, Dr. Weinstock said. He mentioned that sometimes there may be a break in suction or another situation where a femtosecond laser can't be used. In these cases, he will use a manual technique. If a surgeon doesn't have access to a femto- second laser, they can easily practice on pig eyes or artificial eyes and incorporate manual LRIs into their surgical routine, Dr. Weinstock said, adding that the technique for doing manual incisions is not difficult. Nomograms Going back 30 years, Dr. Weinstock said that Dr. Donnenfeld, Louis Nichamin, MD, and Richard Lindstrom, MD, were among those doing AKs using a diamond blade. They developed nomo- grams depending on how much astigmatism there was and what optical zone the arc would Femtosecond LRI Source (all): Eric Donnenfeld, MD

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