EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW FEATURE 37 ments, I decide not to open the AK," he said, noting that sometimes the unopened limbal or AK incision is enough to reduce the patient's astigmatism. However, William F. Wiley, MD, assistant clinical professor of ophthalmology, University Hospital Medical Center, Cleveland, is not totally convinced. While he agrees that theoretically such titratability is possible, he thinks more study is needed. "In practice it's still early, we're still determining what effect an unopened incision has compared to an opened one," Dr. Wiley said. For those who rely heavily on intraoperative aberrometry in deter- mining needed treatment amounts, there may be practical difficulties in performing femtosecond AKs, he said. "The downside that I see with the current technology femtosecond lasers is the fact that you're making those [AK] treatments before you've started cataract surgery," Dr. Wiley said. He prefers to check the preop- erative measurements with aphakic intraoperative aberrometry to ensure this is accurate. However, creating a femtosecond AK at this point may be difficult in some practices be- cause the femtosecond laser may be located elsewhere, he explained. "The reality is doing a double dock with the current technology where often the cataracts are being done in a different room could present a hurdle that's not easily surmountable," Dr. Wiley said. Ideally, practitioners would want to take advantage of both the precision of the femtosecond AK incisions and intraoperative aber- rometry, he said. New femtosecond technology could make that possi- ble. For example, with the LDV 8 (Ziemer Ophthalmic Systems, Port, Switzerland) the delivery mecha- nism for the femtosecond laser is in a small handpiece that can be in- corporated into the operating room underneath the scope, he said. "You can, in theory, take advantage of the accuracy of the diagnosis of astigmatism with the intraoperative readings plus the accuracy of the femtosecond laser to make very precise aligned incisions based on that information," Dr. Wiley said. Toric considerations Practitioners must also wrestle with when to use AK incisions or when the use of toric IOLs may be prefer- able for correcting astigmatism. Dr. Thompson leans toward toric IOLs for more significant astigmatism. He views femtosecond AK as great for someone who has a very small amount of astigmatism. "When we have a patient who is going for quality uncorrected vision and has 0.5 D of astigmatism and we can take that patient from an OK 20/25 to a crisp 20/20, we like the idea of going after that astigma- tism," Dr. Thompson said. Meanwhile, Dr. Slade sees AK incisions with the femtosecond as a tool for an array of lower astigma- tism. While the toric IOL could be used for anyone, it is cheaper and faster to use AK for lesser astigma- tism amounts, he said, adding that in the U.S. there is no toric option for the multifocal ReSTOR lens (Alcon, Fort Worth, Texas). For those astigmatic patients who would like multifocality in an IOL, Dr. Slade will often use a traditional ReSTOR lens together with femtosecond AK. The AK is not necessarily as accurate for higher amounts, he said, so he limits this to approximately 2 D of astigmatism. Overall, Dr. Slade views the fem- tosecond AK as a wonderful option. "Some people say, 'The femtosecond laser hasn't proven itself to be better than manual cataract surgery'; I think it has in terms of precision and astigmatism outcomes," Dr. Slade said. "In our patients, laser is better than manual astigmatic keratotomy—it is more accurate and achieves better results." EW Editors' note: Dr. Donnenfeld has financial interests with Alcon, Abbott Medical Optics (Santa Ana, Calif.), and Bausch + Lomb (Bridgewater, N.J.). Dr. Slade has financial interests with Alcon, Bausch + Lomb, and Novartis (Basel, Switzerland). Dr. Thompson has financial interests with Abbott Medical Optics, Alcon, WaveTec Vision (Aliso Viejo, Calif.), and Carl Zeiss Meditec (Jena, Germany). Dr. Wiley has financial interests with Abbott Medical Optics and WaveTec Vision. Contact information Donnenfeld: ericdonnenfeld@gmail.com Slade: sgs@visiontexas.com Thompson: vance.thompson@vancethompsonvision.com Wiley: drwiley@clevelandeyeclinic.com June 2014 NEW Our Family of Pre-Loaded CTRs Has Expanded Malyugin/Cionni & Henderson Capsular Tension Rings Now Pre-Loaded in Morcher EyeJets Malyugin/Cionni CTR • Eyelet at curved end is sutured to sclera • Unique design facilitates smooth introduction into capsule • The only injectable Cionni type CTR Henderson CTR • Scalloped design facilitates cortical removal • Maintains the desired stretch of the capsular bag Standard CTRs • Stabilize the capsule during surgery • Available in three sizes to accommodate various capsule bags Henderson CTR TYPE 10C Standard CTRs TYPES 14, 14A, 14C Malyugin/Cionni CTR TYPE 10G 800.932.4202 Visit FCI-Ophthalmics.com to watch the EyeJet informational video. 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