Eyeworld

78 | EYEWORLD | MARCH 2021 R EFRACTIVE by Ellen Stodola Editorial Co-Director About the physicians Neda Nikpoor, MD Aloha Laser Vision Honolulu, Hawaii Keith Walter, MD Wake Forest Baptist Health Winston-Salem, North Carolina Blake Williamson, MD Williamson Eye Center Baton Rouge, Louisiana W hen it comes to premium lenses, patients have high expectations for great outcomes. Neda Nikpoor, MD, Keith Walter, MD, and Blake Williamson, MD, discussed some of the technologies that they use preoperatively, intraoperatively, and postopera- tively to help achieve excellent outcomes. Preoperative technologies and testing Dr. Nikpoor said that every patient who comes into her office for a refractive lens exchange (RLE) or cataract evaluation gets the same testing. This includes a preoperative macular OCT, topography, RNFL analysis, and aberrom- etry. She will also use the HD Analyzer (Keeler) on every patient, which she said helps by giving an objective assessment of the tear film. "Com- paring this index with the iTrace Dysfunctional Lens Index [Tracey Technologies] helps me grade the impact of very early lens changes," she said. She noted that having a high-quality biom- eter is helpful for measuring posterior astigma- tism; she uses the IOLMaster 700 (Carl Zeiss Meditec). She will also obtain a LipiScan (Johnson & Johnson Vision) on every patient and likes to use epithelial mapping. "We don't use it on everyone, but we'll use it if someone is post-refractive or if we think they have OSD or early keratoconus," Dr. Nikpoor said. This preoperative plan, Dr. Nikpoor said, is used for all cataract patients, even those getting standard IOLs. Additionally, for cataract patients getting premium lenses, she performs a stan- dard OSD optimization protocol that includes warm compresses, lid scrubs, and artificial tears. She will add in more treatments as needed, including LipiFlow (Johnson & Johnson Vision) and/or pharmaceutical dry eye treatments. Dr. Nikpoor said measurements used for the IOL calculation—topography, aberrometry, and IOLMaster—are repeated so there are two sets. All of this information is consolidated into a grid with the astigmatism measurements. Dr. Nikpoor said she uses VERACITY (Carl Zeiss Meditec) for all IOL calculations to help with IOL selection and finds it particularly useful for toric lenses because she can toggle between different measurements, toric calcula- tors, and other data. She added that VERACITY is helpful for post-refractive cases, as it has a built-in calculator for that. She described it as a useful tool that moves everything from the EHR to the VERACITY system. Dr. Williamson stressed the importance of having a healthy eye for advanced IOLs. He said the physician has to make sure they have all the testing in place to confirm it's a pristine eye because these implants are very sensitive to any type of comorbidity or aberration. He examines the ocular surface and may use point-of-care testing, such as the Inflam- maDry (Quidel) and TearLab Osmolarity Test (TearLab). He also mentioned doing meibogra- phy on the Keratograph (Oculus) if the meibo- mian glands are a concern. "Everyone is going to get topography and tomography," Dr. Williamson said. He also likes to get an OCT of the macula on every patient, regardless of what lens is being putting in. Dr. Williamson will sometimes use the HD Analyzer preoperatively in less dense cataracts, which he said will give him an idea of the oc- ular scatter index when symptoms and com- plaints seem to outweigh the clinical exam. This device will also offer objective data on dry eye. Dr. Walter said that he always uses the IOLMaster or LENSTAR (Haag-Streit) to get accurate measurements and calculations. "I only use the Barrett formulas, as they are the most accurate," he added. Dr. Walter will use macular OCT to look for any potential problems that might render the patient a non-candidate for a premium lens. "Corneal topography is also important especial- ly with prior LASIK and to rule out bad ocular surfaces or other cornea disorders," he said. He added that he thinks that all of these technologies are "absolutely necessary, unless you have a patient with low cylinder, a great ocular surface, and no history of LASIK; then maybe you could skip the topography and just use the biometry to guide you," he said. Technologies for achieving better outcomes

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