Eyeworld

32 | EYEWORLD | SEPTEMBER 2023 ATARACT C Contact Rai: amandeep.rai@ mail.utoronto.ca Rubenstein: Jonathan_ Rubenstein@rush.edu Relevant disclosures Rai: Alcon, Bausch Health Rubenstein: Alcon family postop, namely because these patients are at increased risk for complications, such as high intraocular pressure in the first few hours postop, endophthalmitis in the days postop, and/or retinal tear/detachment, CME, or pseudophakic bullous keratopathy in the weeks postop. "They may also need further surgery for retained fragments. As such, patient education is important so they may seek immediate and appropriate care for any postoperative compli- cations. These patients should also be scheduled for close follow-up to monitor for complications and ensure a safe recovery," Dr. Rai said. Overall, Dr. Rai said that patients with astigmatism can benefit from a well-placed toric IOL, and even in the setting of some capsular complications, it is still possible, depending on a few factors, to deliver the best possible uncor- rected distance visual acuity to patients. "During placement, avoid further extension of the posterior capsule, using OVD to protect the capsular bag," he said. Dr. Rubenstein said if it's not advisable to place a toric IOL, you can still address astigma- tism in the OR. If you've planned for it or have a nomogram and the proper equipment available, you could perform limbal relaxing incisions (LRIs), he said. He added that he doesn't think many surgeons are comfortable or have the equipment/information available to them in the OR to perform this procedure, if they weren't already planning for it. Postop management of astigmatism, if a monofocal IOL was placed due to the compro- mised capsule, includes glasses, toric contact lenses, or a refractive procedure, such as corneal refractive surgery, LRIs, astigmatic keratectomy, and opposite clear corneal incision. Dr. Ruben- stein said these are options for patients who had a three-piece lens in the sulcus or placed with optic capture. He lets these patients stabilize for 3 months post-cataract surgery because "at that point, it's refractive astigmatism rather than astigmatism based on corneal measurement." The physicians also addressed the patient counseling aspect of this complication. "The discussion," Dr. Rubenstein said, "is: 'Our first priority is to get your cataract out safely and completely, which we were able to accomplish. … Second, we want to put a lens implant in your eye that is as close to the correct power and as stable as possible, and we were able to accomplish that. Third is to try to produce the lowest residual refractive error … as possible, and we're able to correct hopefully the spherical part of your refraction, but you still have astigmatism, which we were not able to correct in surgery, and we will offer you the opportunity to correct that later.' We'll say some- thing like, 'During surgery we assessed that your eye was not stable enough to support the type of lens implant that we originally had planned to correct astigmatism; we thought it was un- safe to use that kind of lens because we couldn't be assured it would stay in the position that was needed to fully correct your astigmatism, and therefore we put in a lens implant that does not correct astigmatism because it was the most sta- ble lens for your eye. We can always come back later and correct your astigmatism.'" Dr. Rai also said it's important to thoroughly discuss this situation with the patient and their continued from page 31 Is there still a place for AK and LRIs? Dr. Rubenstein said he has taught skills transfer labs for astigmatic keratectomy (AK) and limbal relaxing incisions (LRIs) at major medical meetings for many years, and every year, ahead of the lab, he would think, "This is dying." However, attendance would prove him wrong. "Every year there is still interest. People think this should still be in surgeons' toolbox," he said. It's good for very small amounts of astig- matism, Dr. Rubenstein continued, noting that in the U.S., toric IOLs correct 1–1.25 D of astigmatism minimum. LRIs, in contrast, can correct less than that. Another indica- tion, Dr. Rubenstein said, is higher amounts of astigmatism. LRIs can be performed in addition to a toric IOL to improve quality of vision. "I think there still is a place for this, and based on what happens at our meetings each year, there is still an interest in them," Dr. Rubenstein said, noting that his program trains residents to perform LRIs and AKs. "It's part of the surgical armamentarium we should know about."

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