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EW NEWS & OPINION May 2016 19 depth, only opening them postoper- atively at a slit lamp if needed. Dr. Garg said he will leave a little with-the-rule astigmatism, un- dercorrecting for with-the-rule and overcorrecting for against-the-rule. Dr. Burger more specifically said she tries to leave about 0.25 D with-the- rule cylinder because it can increase depth perception and should shift as the against-the-rule cylinder of the cornea increases over time. Overall takeaway Both Dr. Koch and Dr. Garg said their biggest piece of advice is for younger eye surgeons to take the time to get comfortable. Get com- fortable with your measuring de- vices, with your preferred toric IOL, and with your nomogram of choice. Dr. Koch also advised surgeons to be open with patients about the uncertainty that comes with this correction. "Sometimes additional touch- ups are required," he said. "You're doing your best job with the measurements and the correction, but there are things called variable wound healing and patient re- sponse, and those could potentially factor into the results." Another pearl, Dr. Koch said, is to be conservative. "It's easier to add correction rather than compensate for overcor- rection," he said. Dr. Garg's final words: "Make sure the astigmatism is regular and that the numbers are reproducible. If there is variability, take the time to address the ocular surface prior to proceeding with surgery. Also, start with 'easy' eyes—avoid post-re- fractive, RK, K scarring cases to start with. [Then] make sure you are com- fortable with the technology prior to tackling more difficult cases." EW Editors' note: Dr. Garg has no financial interests related to his comments. Dr. Koch has financial interests with Alcon (Fort Worth, Texas), Abbott Medical Optics (Abbott Park, Illinois), Bausch + Lomb (Bridgewater, New Jersey), i-Optics, and Ziemer. Dr. Burger has financial interests with Alcon. Contact information Burger: Berdine.Burger@carolinaeyecare.com Garg: gargs@uci.edu Koch: dkoch@bcm.edu topography and its refractive effect on light entering the eye." If 1 or more of these measure- ments conflict, Dr. Koch said he will try to repeat them or use another device. If there still is not harmony among the measurements, that's where intraoperative aberrometry could come into play. But in the end, he might avoid astigmatism correction at the time of cataract surgery, Dr. Koch said. It can always be corrected postop if needed, he said. Dr. Garg doesn't necessarily give more weight to 1 measurement over another, but noted that he does find intraoperative aberrometry help- ful in cases of discordance among measurements or devices. If there is a discrepancy, he said an unhealthy ocular surface is often behind it. While devices might produce slightly different numbers, they should at least show consistency, Dr. Burger said. "You are treating a real, refrac- tive cornea, not arbitrary keratom- etry values," she said. "If there is significant discordance, surgery should not proceed until the pa- tient's ocular surface is treated to the degree that accurate and consistent measurements can be obtained." As a whole, Dr. Burger pre- fers the centrality of the LENSTAR keratometry values because they "seem to most accurately measure the astigmatic effect at the patient's visual axis." Provided there are no red flags with the measurements, Dr. Koch then decides what course of astigma- tism correction to take. He said he will make intrastromal relaxing in- cisions with a femtosecond laser for correction of 0.5 D, but he'll make penetrating relaxing incisions for up to a diopter. If the astigmatism is more than a diopter, he'd use a toric IOL rather than making an incision. If he were inserting a multifocal IOL, however, Dr. Koch said he would treat a patient's astigmatism up to a diopter and a half, but not much more, wanting to preserve good corneal optical quality. Dr. Burger said she will always try to use a toric IOL versus an LRI, unless it would overcorrect a pa- tient's astigmatism. In that case, Dr. Burger said she would use a femto- second laser to make LRIs at an 80% Nasal & Temporal Speculums 3360 Scherer Drive, Suite B, St. Petersburg, FL 33716 800-637-4346 • Tel: 727-209-2244 • Fax: 727-341-8123 Email: Info@RheinMedical.com • Website: www.RheinMedical.com *Developed In Coordination with Reay H. Brown, M.D. ** Developed In Coordination With Roger F. Steinert, M.D. Leonardo Da Vinci, Unnamed ADBC 1339 Rev.A Call 727-209-2244 For More Information. 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