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EW FEATURE 58 Controversies in ophthalmology • June 2016 lars in additional fees per eye," Dr. Devgan said. Dr. Hamilton prefers to make in- cisions with the laser for 3 reasons: He finds the laser is more predict- able and can treat higher levels of astigmatism more accurately than with a blade, he can titrate the effect by leaving the incisions closed and opening them after the postop refraction, and the laser does not create an epithelial defect like the diamond blade does, so there is min- imal postop discomfort, he said. Outcomes and cost to the patient Given all of these considerations, how do refractive outcomes compare between LRIs and toric IOLs? "I give torics the winning mark as the results will generally remain stable over time," Dr. Whitman said. "That is why knowing that your manual or femto incisions are deep enough is critical, as the result may lessen over time if the incisions are shallow." Dr. Devgan finds that at 1.25 D of astigmatism or less, the results for each procedure are essentially the same and patient satisfaction is equally high. At the 1 D range, the 2 tech- niques yield similar outcomes, according to Dr. Hamilton, but the outcomes depend on how regular the astigmatism is. Fortunately, as the amount of astigmatism increas- es, it typically becomes more regular, he said. "At 1 D, the astigmatism is often a bit irregular, which detracts from the toric [IOL] efficacy," he added. "When comparing efficacy at the 1 D level, this factor counterbalanc- es the lack of predictability of the [LRI]." Because neither treatment is covered by insurance, cost can be an issue for some patients. If a surgeon can treat the astigmatism and give the patient great vision without the need for glasses, the cost savings over a few years will certainly favor paying for the best surgical results, according to Dr. Devgan. "Patients will be seeing the world through our surgeries every waking moment for the rest of their lives," he said. "My goal is to give the very best to the patient and to place cost as a secondary consider- ation." For the few patients who don't heal as predicted and don't quite hit the intended refractive target, his practice offers a complimentary laser vision correction to give them the best possible outcome. EW Editors' note: Dr. Devgan has financial interests with Abbott Medical Optics and Bausch + Lomb. Dr. Hamilton and Dr. Whitman have no financial inter- ests related to their comments. Contact information Devgan: devgan@gmail.com Hamilton: hamilton@jsei.ucla.edu Whitman: whitman@keywhitman.com deep without risking perforation," Dr. Whitman said. The cost of the laser, however, must be factored in when making a surgical decision. "We must remem- ber that the femtosecond laser is very expensive to purchase and use: approximately $500,000 initial cost, then $50,000/year maintenance contract, and then hundreds of dol- Limbal continued from page 57 Are you a fan of EyeWorld? Follow us on Twitter at twitter.com/EWNews

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