Eyeworld

SPRING 2026 | EYEWORLD | 69 R Contact Fram: nicfram@yahoo.com Koch: dkoch@bcm.edu Relevant disclosures Fram: Zeiss Koch: Johnson & Johnson Vision, Zeiss or blepharitis; even sitting in front of the device unblinking for too long can affect tear film qual- ity. If the tear film quality is not the cause, the patient could have epithelial basement mem- brane disease (EBMD) or subepithelial scarring. Dr. Fram said she needs about 20% of her patients to come back for repeat biome- try because she's not happy with their initial measurements, most commonly due to dry eye and ocular surface issues. In most of these cases (about 80%), she said, a mild steroid like a loteprednol pulse and cyclosporine or lifitegrast can get them on track for surgery. Dr. Fram said she is also looking for and treating Demodex blepharitis to improve the ocular surface for quality measurements as well. "It's not enough, however, to say we've got you optimized for surgery. We need to keep them optimized after surgery," Dr. Fram said. "You have to have a system of how to maintain the ocular surface or else you're not going to have a good outcome." For patients who don't want a superficial keratectomy to treat EBMD or who have condi- tions that will always cause fluctuations of their ocular surface, Dr. Fram said a monofocal IOL is the best choice, but another creative option to mask up to 1.5 D of astigmatism could be the IC-8 Apthera IOL (Bausch + Lomb). "It's an interesting option for the non-dominant eye in those patients where you can't, no matter how many measurements you get, no matter how many times you try and optimize their surface, get them to where they need to be," she said. Case example Dr. Koch described a patient with diffuse punc- tate corneal erosions who was treated for dry eye preoperatively for 6 months, but her ocular surface never fully recovered even with plasma tears. Dr. Koch said they went forward with a standard surgery at that point because she had narrow angles and her cataract was significant. "She had a good result of about 20/25 and was very happy. She was certainly not a candi- date you would entertain for something like a diffractive or other form of simultaneous vision IOL, either EDOF or trifocal," he said. "In those cases, I would look at what the refraction was because the refraction often indicates how the patient's corneal astigmatism contributes to the vision. In this patient, repeated preop refrac- tions were consistent with K readings." Take-home messages Dr. Koch's take-home message is to avoid trifocal IOLs if you can't get consistent surface measurements due to severe dry eye. "The dry eye will come back to haunt you postoperatively and impair quality of vision," he said. He also advised against a trifocal in patients who have anterior basement membrane dys- trophy and who refuse to have it treated before surgery. "You have to treat it and get rid of it in order to have accurate measurements and the best quality of vision," he said. If the mires are poor, Dr. Koch would also not implant a toric IOL. "I tell patients they're better off wearing glasses for astigmatism be- cause you can always adjust glasses." One of Dr. Fram's take-home messages is to avoid under-treating against-the-rule astigma- tism. "These are some of my most unhappy pa- tients," she said. "It used to be that we would say, 'They have to have a diopter or more or else I'm not going to use a toric lens.' I think more and more … we are treating against-the-rule astig- matism at the 0.6 D level." Dr. Fram said that because the total K is verified with the IOLMaster 700 and Pentacam to include the contributions of the posterior cornea, she thinks measurements are becoming more sophisticated and accurate, rather than relying on a nomogram. Dr. Fram also said that using language in preoperative visits like "we're going to reduce your astigmatism" instead of "we're going to correct all of your astigmatism" can be helpful in setting patient expectations. She tells patients that astigmatism can be further fine-tuned, if needed, postoperatively with limbal relaxing incisions or laser refractive surgery. There are surgical tips to help avoid toric IOL rotation (like making sure all the viscoelas- tic is removed behind the lens and confirming its removal/lens stability with a balanced salt solution pulse at the end of the case), but Dr. Fram said starting with quality preoperative measurements—knowing what's reliable and what's not and what to do to increase accura- cy—is most important for gaining confidence with astigmatic correction.

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