Eyeworld

102 April 2016 EW REFRACTIVE SURGERY by Ellen Stodola EyeWorld Senior Staff Writer this is something that should be carried out by the physician, rather than delegated to support staff. This is an enormously powerful tool, he said. Finally, Samuel Masket, MD, Los Angeles, highlighted the man- agement of unhappy multifocal IOL patients. His first pearl was to avoid the "opathies." These could include keratopathy, optic neuropa- thy, zonulopathy, pupillopathy, and maculopathy. His second pearl was to manage expectations prior to surgery. Your patients may be expecting to "see like Superman," Dr. Masket said. They expect seamless vision, and both the patient and the surgeon need to understand multifocal optics. Next, Dr. Masket discussed the issue of consumerism and premium IOLs. Expectations change when people have to spend their own money for a device, he said. For his fourth pearl, he said to use custom laser enhancement when appropriate. Diffractive IOLs are highly sensitive to ametropia, he said. Additionally, aberrometry uncovers greater mixed astigmatism than clinical refraction methods. Custom LASIK/PRK photoablation may markedly improve vision, and LASIK/PRK could convert the unhap- py patient. Cleaning lens epithelial cells (LECs) aggressively at cataract surgery was his final pearl. This prac- tice can facilitate custom wavefront analysis and laser treatment and can make IOL exchange easier should it be needed. Surgeons working with multifocal IOLs should be able to remove and replace them as may occasionally be necessary. EW Editors' note: Drs. Beiko, Chayet, Hill, Ventura, and Yoo have no financial interests related to their comments. Dr. Masket has financial interests with Alcon (Fort Worth, Texas). Dr. Miller has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Alcon, and Calhoun Vision. Contact information Beiko: georgebeiko@hotmail.com Chayet: info@arisvision.com.mx Hill: k7wx@earthlink.net Masket: sammasket@aol.com Miller: kmiller@ucla.edu Ventura: brunaventuramd@gmail.com Yoo: syoo@med.miami.edu use of the light adjustable lens (Calhoun Vision, Pasadena, Cal- ifornia). Surgeons can do up to 3 adjustments, he said, and Dr. Chayet thinks it's the best case scenario to test monovision and determine patient adaptability, the amount of monovision and the amount of asphericity. There are a number of import- ant considerations when dealing with postoperative refractive en- hancement, which Sonia Yoo, MD, Miami, discussed. Her pearls were to check uncorrected distance and near vision preoperatively, to wait for stable refraction and topography, consider PRK, consider intraocular surgery, and to underpromise and overdeliver. Warren Hill, MD, Mesa, Arizona, gave attendees pearls for handling post-LASIK patients. It's important to select the appropriate type of IOL for patients with prior refractive surgery, he said. Also important are: obtaining a corneal aberration profile and using image simulation to demonstrate to the patient how contrast is reduced; and using the ASCRS online post-refrac- tive IOL power calculator, and look- ing to the Barrett True K formula for both myopic and hyperopic LASIK cases. One of the pearls that Dr. Hill stressed was setting aside time to show the patient what the issues are before surgery. He uses the combina- tion of a large LED screen and image simulation software to review with patients what their vision will be like following surgery. He said that Patient selection is critical when implanting a multifocal IOL. Bruna Ventura, MD, Recife, Brazil, offered her 5 pearls on this topic. Obtain accurate biometry and astigma- tism measurements, identify good candidates, exclude bad candidates (including those with ocular surface disease, zonular compromise, and macular alterations), understand the patient's emotional status, and analyze angle kappa, she said. Arturo Chayet, MD, Tijuana, Mexico, highlighted monovision in IOL surgery in his presentation. His first pearl was to have the right expectations. With monovision, 1 eye is dominant for distance with the other more for intermediate/ near. There is a noticeable difference between the eyes, he said, so this will involve some neuroadaptation. Patients may still need glasses and may need a postoperative refractive adjustment. He stressed choosing the dom- inant eye. If there is a cataract pres- ent, unknown BCVA may prevent the right choice of the dominant eye. Taking a visual history may help, Dr. Chayet said, adding that a light adjustable lens is ideal because dominance can be tested before adjustments. He said to choose the proper amount of monovision. IOL selection was the next pearl. "First of all, I want to minimize astigmatism," he said. Avoid a multi- focal IOL, Dr. Chayet recommended. Extended depth of focus IOLs may be a good option in the future. His final pearl focused on the Physicians share their top pearls for refractive surgery at the 2016 World Ophthalmology Congress D uring a session at the 2016 World Ophthalmology Congress (WOC) titled "Refractive Cataract/ IOL Surgery—My Top 5 Pearls," experts offered their top 5 pearls on a number of refractive topics. Kevin M. Miller, MD, Los Ange- les, discussed toric IOL challenges. If you've been waiting to start im- planting toric lenses, get over your inertia and do it, Dr. Miller said. Toric IOLs are here to stay, and phy- sicians have an ethical obligation to offer patients standard-of-care products or refer them to someone who will. The second pearl was to never promise spectacle independence. A realistic goal is to reduce spectacle dependence but not eliminate it, he said. It's not failure if the patient has to wear glasses some of the time, Dr. Miller stressed. All patients will wear sunglasses after surgery, and a small percentage will need glasses for driving. Take care when calculating the power and axis of a toric IOL, Dr. Miller said as his next pearl. He rec- ommended deciding which K value to use, looking at a corneal topogra- phy map, and being careful to avoid data entry mistakes when transfer- ring values to a toric calculator. Dr. Miller's fourth pearl was to be meticulous in the operating room. This includes marking your reference axis carefully, aligning the lens with the calculated steep corne- al meridian, and making sure all the OVD is out at the end. His final pearl was to be sure to have a plan for addressing postop power and alignment problems. George Beiko, MD, St. Catha- rines, Canada, spoke on astigmatic keratotomy. Physicians do not need to target zero cylinder, he said. Ad- ditionally, limbal relaxing incisions (LRIs) can be as effective as toric IOLs. His other tips were that expen- sive technology is not required for effective outcomes, to use and refine a chosen nomogram, and to deter- mine the amount of treatment using an astigmatism calculator. Refractive surgery tips Centering of a multifocal IOL is essential for good vision quality. Source: Samuel Masket, MD Presentation spotlight

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