Eyeworld

R DECEMBER 2023 | EYEWORLD | 53 Even with perfect surgery, calculations, and placement, malpositioning still occurs. Intraoperatively, this is usually due to incorrect data acquisition (incorrect estimation of axis of astigmatism) or misjudged cyclorotation. Dagny Zhu, MD, said it can occur in the early postop days because the capsule hasn't contracted enough to hold the IOL in place. If rotation were to occur later, it is more likely due to trauma, Dr. Zhu said. Management When it comes to residual astigmatism, Dr. Lee said it's important to distinguish between incorrect axis due to the surgical plan vs. IOL rotation. Unreliable biometry and unrecognized corneal factors could mean the chosen toric power or axis were suboptimal, so treating the ocular surface and remeasuring may be helpful. Dr. Lee said there used to be a large difference in postoperative toric IOL stability among manufacturers, but this has significantly improved. Dr. Baartman said most cases of rotation occur early in the postop period, and it's often the patient notifying the surgeon that something seems off. "The earlier these patients are evaluated and refracted if UCVA does not meet expectations, the earlier you can identify malposition," he said. "For the sake of optimal patient satisfaction, I think it's best to identify and address the problem as early as possible." If unexpected residual refractive error is detected in toric IOL patients (whether it's a monofocal, EDOF, or multifocal), Dr. Baartman said the evaluation starts at the slit lamp. "Proper slit lamp measurement of the current rotation- al position is critical, and it's also important to ensure the lens implant is centered in the bag with proper anterior capsular overlap and that neither haptic has found its way into the sulcus," Dr. Baartman said. "If the intraoperative position was documented at the end of the case, you'll know which direction the lens needs to be rotated in and by how much. You can use an astigmatism calculator like astigmatismfix.com." If rotation is necessary, Dr. Baartman said he'll bring patients back within a week, reopen the primary incision, and insert just enough cohesive viscoelastic to free up and rotate the lens. If residual refractive error is recognized a month or more postop, Dr. Baartman said he'll usually use a laser refractive procedure to correct it. Dr. Lee recommended waiting about 2 weeks to allow the capsule to tighten before going back in to rotate. continued on page 54 A F R E S H P E R S P E C T I V E ™ 2500 Sandersville Rd ■ Lexington KY 40511 USA lacrivera.com ( 855 ) 857-0518 © 2023 Lacrivera, a division of Stephens Instruments. All rights reserved. Craig McCabe, MD, PhD, FACS McCabe Vision Center, Murfreesboro, TN White Paper: A Quick Way to Diagnose & Treat Dry Eye Disease Patients Prior to their Cataract Surgery Measurements A healthy ocular surface is most important in obtaining accurate topography measurements. While patient expectations of excellent vision have never been higher, the identification and treatment of DED before surgery may increase both patient and physician satisfaction. Learn how Dr. Craig McCabe achieves accurate preoperative measurements and excellent surgical outcomes through treatment of dry eye disease. A F R E S H P E R S P E C T I V E ™ Craig McCabe MD, PhD, FACS McCabe Vision Center, Murfreesboro, TN © 2023 Lacrivera, a division of Stephens Instruments. All rights reserved. lacrivera.com ( 855 ) 857-0518 2500 Sandersville Rd ■ Lexington KY 40511 USA A Quick Way to Diagnose and Treat Dry Eye Disease Patients Prior to their Cataract Surgery Measurements C ataract surgery stands as one of the most frequently performed major surgeries, with an estimated 4 million procedures expected to be performed this year. Patient expectations of excellent vision post-surgery are on the rise. It is important to note that one of the most common causes for patient dissatisfaction after uncomplicated cataract surgery is the presence of poor, uncorrected visual acuity arising from inaccuracies in preoperative measurements of corneal topography and axial length. 1 Among these measurements, keratometry is particularly susceptible to errors, most often due to a dry ocular surface. Erroneous topography data on individuals with dry eye disease (DED) can lead to incorrect selection of IOL spherical diopter power, as well as in IOL toric power and axis placement. This results in suboptimal uncorrected visual acuity for the postoperative cataract patient, 2 which disappoints both patients and physicians alike. Therefore, to increase patient and physician satisfaction and decrease enhancement rate, it's essential for the referring physician and/or surgeon to identify and address a patient's DED before conducting preoperative measurements for cataract surgery. The identification of DED patients before cataract surgery measurements involves three straightforward steps. First is obtaining a comprehensive history of ocular surface disease. This can be facilitated through a questionnaire that may trigger measurements of topography, tear osmolarity, or inflammatory markers. Second, during the slit lamp examination, signs of DED including corneal surface lustre, punctate epithelial erosions, tear meniscus height, conjunctival hyperemia, and meibomitis should be evaluated. To further confirm the diagnosis, additional assessments using common dyes for tear film breakup time and epithelial health, such as fluorescein, lissamine green, or rose bengal, may be performed. Challenges arise in diagnosing DED among pre-clinical DED patients who do not yet have symptoms and chronic mild DED patients who may have developed sympton tolerance or reduced corneal sensation. Nevertheless, the majority of DED patients tend to report symptoms of scratchy, red, or fatigued eyes, along with intermittent blurry vision—particularly while watching TV, reading, or using various digital displays after several minutes. Their topography placido images typically show imperfections in the reflected mires (Fig. 1), often one of the earliest associated signs of pre-clinical and mild dry eye disease. Notably, a majority of unsatified post-cataract surgery patients who subsequently experienced dry eye issues and resultant poor vision displayed slightly irregular mires in their initial corneal topography evaluation. Moderate blepharitis, conjunctivochalasis, eyelid malposition, and Demodex eyelash infestation appear more linked with moderate to severe chronic DED and may necessitate consideration if initial DED treatment proves inadequate. Figure 1. Placido disc image of patient with preclinical DED. Irregular mires indicated with yellow arrowheads. PDF Perspectives on improving patient outcomes Get the free PDF: lacrivera.com/McCabe

• Cover