MAR 2014

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 36 of 210

apparently she still is capable of doing this. Another likely possibility is that she had the entity "sagging eye syndrome." Finally, Dr. Liegner said: "This is a familiar story, as many in the pop- ulation and those MF IOL recipients often have an unrecognized mi- c rotropia. While she didn't have glasses (with prism) preoperatively, her right hypertropia was masked preoperatively by her monovision." "Because she had monovision in the past, we might have chosen a monovision solution with monofo- cal IOL OD and toric IOL OS; this still remains an option via IOL ex- c hange OS to the proper toric IOL, presumably for a near focus (–2.25 target). A toric IOL OS via exchange would give her binocular near per- formance in down gaze without diplopia, and once again mask the hypertropia in distance. This, of course, comes close to recreating her prior SCL experience, which i ncluded a multifocal SCL OD." "An alternative intervention would be to perform LASIK in the left eye to eliminate the corneal astigma- tism, with a mini-monovision target of –1.00 sphere, enhancing her midrange while reducing her diplopic symptoms. This could be easily demonstrated in this experienced contact lense wearer with a toric SCL, with some adjustments of SCL power until symptoms are suppressed." "I'm not concerned about the tight rhexis, which should still per- mit IOL extraction and replacement. There might be a place for enlarging the rhexis with a revision continu- ous tear rhexis." My thoughts on this case closely mirrored Dr. Liegner's. I felt that the answer regarding what to do for this patient lay in recreating what she had in the past, a multifocal in the OD and a toric for monovision in the OS. I decided to test this by trial framing her with astigmatic correc- tion OS but correcting her for near rather than distance leaving her –2.25 in this eye and Plano for dis- tance in the other eye. When I put this in front of her she immediately responded that this completely elim- inated her diplopia for distance and yet she was still able to fuse at near and read clearly. We trial framed this on three separate occasions and she assured me that she would be very happy with this outcome if I could achieve it surgically. I felt that an IOL exchange—removing the multi- focal and replacing with a toric in the OS—was the best approach here. My only concern was that the refrac- tive astigmatism, 1.75 D, was greater than the 1.0 D I measured with topography and keratometry. The question was whether to choose a toric based on her refraction or her keratometry/topography. I had a clue however from the other eye, which had 0.75 D of topographic astigmatism on the anterior cornea surface, but here it w as oblique/with-the-rule, whereas the other eye it was oblique/against- the-rule. Despite this, she still had about a 0.5 D of oblique/against-the- rule refractive astigmatism, suggesting that in both eyes the posterior cornea was contributing against-the-rule astigmatism to the refraction. Based on this, I decided to use a toric IOL p ower that would take this into ac- count and correct her based on her refraction rather than her Ks and to- pography. The surgery went unevent- fully, and the small rhexis did not turn out to create any particular difficulties. This worked out perfectly for her as she ended up with a –2.25 r efractive outcome and her problem was completely resolved. After doing this, I did a small LRI to tweak the OD and she was thrilled. This case highlights the fact that it is important to screen patients prior to placing presbyopia-correct- ing IOLs for strabismus and mi- crotropia prior to cataract surgery, especially if they have worn mono- vision for years previously. I have seen quite a few patients now un- happy with their outcomes from cataract surgery with multifocals and Crystalens (Bausch + Lomb) because it unmasked their inability to fuse without the aid of prism leading to symptomatic diplopia. This can be a very difficult problem to deal with, especially considering that most of these patients have paid extra with the belief that they will be able to function without glasses as a result. Some of these patients have prism in their glasses already, which provides a strong hint of problems that may come after surgery. In this case, however, the problem was not obvious to the operating surgeon because it was masked (and possibly contributed to) by the patient's history of years of wearing monovision in contact lenses. It highlights the importance of considering the patient's refrac- tive and strabismic state prior to cataract surgery in designing the postoperative outcome. EW Contact information Horn: jeff.horn@bestvisionforlife.com Kim: kim@professionaleye.com Liegner: liegner@embarqmail.com Safran: safran12@comcast.net Waltz: kwaltz56@gmail.com T. 800.461.1200 | www.innovativexcimer.com Improved Clinical Outcomes of CXL and PRK with Amoils Epithelial Scrubber Epithelial Removal Has Never Been Easier Corneal Xlinking, PRK & Advanced Surface Ablation E^YV_b]U`YdXU\Ye]bU]_fQ\Y^ only 5 - 7 seconds 1f_YTQ\S_X_\TQ]QWUd_ surrounding tissue =Y^Y]YjUd_dQ\`b_SUTebUdY]U >_^UUTV_bceRcUaeU^dcSbQ`Y^W Visit us at the ASCRS Booth 2032 Epithelial Removal Has Never Been Easier Visit us at the ASCRS Booth 2032 Epithelial Removal Has Never Been Easier Visit us at the ASCRS Booth 2032 Epithelial Removal Has Never Been Easier Visit us at the ASCRS Booth 2032 Visit us at the ASCRS Booth 2032 Cor PRK & Advanced Sur Visit us at the ASCRS Booth 2032 neal Cor Xlinking, PRK & Advanced face Ablation Sur Visit us at the ASCRS Booth 2032 Xlinking, PRK & Advanced face Ablation oved Clinical Outcomes of CXL and Impr PRK with Amoils Epithelial Scrubber oved Clinical Outcomes of CXL and PRK with Amoils Epithelial Scrubber oved Clinical Outcomes of CXL and PRK with Amoils Epithelial Scrubber _ V Y ^ E only 5 - 7 seconds Y _ f 1f ounding tissue surr ] Y ^ Y = U b ] e Y \ U X d Y ` U ] b _ only 5 - 7 seconds Q ] Q T \ _ X _ S \ Q T ounding tissue T U S _ b ` \ Q d _ d U j Y ] ^ Y \ Q f _ ] U _ d U W U ] Y d U b e T ^ _ > e a U c R e c b _ V T U U ^ W ^ Y ` Q b S c d ^ U e . 800.461.1200 | www.innovativexcimer T . 800.461.1200 | www.innovativexcimer .com . 800.461.1200 | www.innovativexcimer Double continued from page 30 18-47 News_EW March 2014-DL2 copy_Layout 1 3/6/14 2:46 PM Page 34

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