Eyeworld

40 Surgery often depends on patient's health, pocketbook D epending on the IOL sur- gery patient and his or her history, there are sev- eral ways surgeons can treat corneal astigmatism, including limbal relaxing incisions, double penetrating incisions, or toric lenses. The surgeons inter- viewed here discussed those options and how they arrive at their decision to treat the astigmatism. The patient decides Y. Ralph Chu, M.D., Edina, Minn., believes in educating his patients and letting them decide on the course of action. "In my IOL patients, if they have 1 D or more of astigmatism pre-operatively, I do a topography and we have a discussion about their choices," Dr. Chu said. "Then they can choose whether they want a corneal-based procedure like a lim- bal relaxing incision at the time of surgery or if they want a toric lens." Toric IOL is favored All patients who have pre-existing astigmatism when they come to Robert J. Cionni, M.D., Salt Lake City, are offered the choice of astig- matic reduction surgery if they indi- cate a desire to see without glasses. Dr. Cionni said he appreciates the preciseness of the toric lens. "As far as modality of astigmatic correction, nothing has been as pre- cise as toric IOL implantation in my hands," Dr. Cionni said. Patients are required to pay out of pocket for an astigmatic reduction procedure using a limbal relaxing in- cision, which is now performed with the LenSx Femtosecond Laser (Alcon, Fort Worth, Texas) in Dr. Cionni's office. "For patients receiving a multi- focal IOL, I do perform astigmatic relaxing incisions. Prior to incorpo- rating the [femtosecond laser] into our facility, this was performed with LRIs using the Donnenfeld nomogram, available at www. lricalculator.com," he said. "Now patients are offered femtosecond ar- cuate incisions, which achieve a pre- cise depth of 80% at a 9 mm optical zone." Dr. Cionni said patients differ on the amount of cylinder needed to justify the effort, cost, and risk of the procedure. "I have seen patients tolerate more than 1 D of astigmatism easily, while others are overwhelmed with the improvement they perceive when we relieve a mere 0.5 D of residual cylinder," Dr. Cionni said. "My rule of thumb is 0.5 D with-the- rule or 0.75 D against-the-rule cylin- der. Those with greater than 1 D of astigmatism are more likely to be ex- cited about astigmatic reduction." Depends on the diopters For Bradley C. Black, M.D., Jeffersonville, Ind., the decision of astigmatic reduction depends on the patient's cylinder. Dr. Black said he does limbal re- laxing incisions for monofocal IOLs with .75 D of cylinder or less. If there is .75 D of cylinder or more present, Dr. Black offers toric lenses because he believes them to be opti- cally superior in those cases. "I do, however, perform either single or paired PLRIs for residual post-incisional cylinder of 0.5-1.5 D EW REFRACTIVE SURGERY 40 July 2011 by Jena Passut EyeWorld Staff Writer Treating corneal astigmatism W elcome to the second edition of the "Refractive corner of the world." These are interesting times for the refractive cataract surgeon. It wasn't that long ago that astigmatism was not readily treated with cataract surgery. In fact, it was ignored al- most completely. Patients had their surgery performed, an intraocular lens was placed in the eye, and glasses or contacts were prescribed when things were stable, typi- cally 4-6 weeks. Fast forward to the present day. I was recently very surprised to dis- cover that 50-75% of today's refractive cataract surgeons do not address pre-exist- ing astigmatism. Patient satisfaction is one of the more important issues with refractive cataract surgery. As our corneal refractive colleagues have discovered, the happiest LASIK or PRK patients are those whose re- fraction is close to plano. For this to be achieved, we must address astigmatism, in addition to the spherical component of the refraction. Today's refractive cataract surgeon must be aware of astigmatism and reduce it to 0.5 diopters or less. The good news is that today's surgeons have many options to choose from and several tech- nologies to offer their patients. I'd like to thank Drs. Black, Chu, Cionni, and Dell for sharing their strategies for treating astig- matism at the time of cataract surgery. Here's to experiencing happy, satisfied refractive cataract patients! Kerry Solomon, M.D., refractive editor Refractive editor's corner of the world continued on page 41

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