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EW FEATURE 100 procedure can't be controlled, he said, so sometimes surgeons get exact corrections and other times they get undercorrections. Rarely do they get overcorrections, he said. In addition, the surgeon can create ep- ithelial defects with LRIs and in- crease post-op dry eye. "Because toric lenses have great efficacy and minimal complications, they are the new dominant proce- dure to manage astigmatism," Dr. Holland said. Unlike most doctors, however, Dr. Nichamin said he prefers the LRI to toric lenses. He's very comfortable with the technique, as he has per- formed incisional keratotomy since the late 80s, he explained. He transi- tioned from what used to be called astigmatic keratotomy or AK2 in the early and mid-90s. "Some doctors don't believe in LRIs because they think that they regress and are unpredictable, but they're not. We have 10- to 15-year data that shows how well these work, but it is a specific surgical technique that one cannot take lightly. It has to be done properly," Dr. Nichamin said. In addition, in the United States, without any toric premium or presbyopia-correcting IOL options, surgeons are limited to one toric IOL, he said. "As such, I continue to use a lot of LRIs, at least to debulk if not to completely eliminate the astigma- tism. If it remains after the LRI, then we turn to the excimer laser to fur- ther enhance the result," he said. Even with most doctors prefer- ring the toric lens to the LRI to cor- rect astigmatism, the incisional technique has not been completely replaced. When implanting a patient with a multifocal lens, for instance, surgeons manage the astigmatism with LRIs, Dr. Holland said. Addi- tionally, in cases of high astigma- tism where a patient's astigmatism exceeds the power of the toric lens, LRI is combined with toric lens im- plantation, he said. The technique Combining phacoemulsification with an LRI is a routine, well-appre- ciated approach, Dr. Nichamin said. The LRI is typically performed at the beginning of surgery prior to pha- coemulsification and IOL implanta- tion, except in one situation where the phaco incision is superimposed with the LRI, he said. In that situa- tion, he doesn't create a long LRI, just a short initial one, and then he extends it at the end of surgery to prevent wound gape. Dr. Nichamin said his technique is more detailed than others who might take a low-down and simple approach. He measures at the limbus and uses an adjustable, high-quality Fixing continued from page 99 San Diego Facts February 2011 COMBINED SURGERY March 2011 Anthropologists believe humans first settled in the San Diego area as early as 20,000 years ago along the coast and 12,000 years ago in the desert Source: City of San Dieg

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