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4 4 What does the data say? Safety, efficacy, and clinical outcomes of laser-assisted cataract surgery by Robert Weinstock, MD Arcuate incisions: Using laser-assisted cataract surgery to improve refractive outcomes and reduce complications than 1.0 D of residual astigma- tism and we can obtain consistent measurements, we can use the femtosecond laser to perform LRIs with the patient in the pseudopha- kic state. Conclusion Surgeons should feel confident using the femtosecond laser to correct low to moderate amounts of astigmatism. This technology is a necessary part of their armamen- tarium if their goal is to achieve uncorrected visual acuity of 20/20 in more of their patients. References 1. Yoo A, et al. Femtosecond laser-assisted arcuate keratotomy versus toric IOL implan- tation for correcting astigmatism. J Refract Surg. 2015;31:574–578. 2. Chan TC, et al. Vector analysis of corneal astigmatism after combined femtosec- ond-assisted phacoemulsification and arcuate keratotomy. Am J Ophthalmol. 2015;160:250–255. 3. Day AC, et al. Predictors of femtosecond laser intrastromal astigmatic keratotomy efficacy for astigmatism management in cataract surgery. J Cataract Refract Surg. 2016;42:251–257. Dr. Weinstock is in private practice at the Eye Institute of West Florida, Largo. He can be contacted at rjwein- stock@yahoo.com. blade. When we objectively exam- ine the data and technology, fem- tosecond laser arcuate incisions are more precise and controlled. The femtosecond laser offers surgeons who perform peripheral corneal relaxing incisions a more precise and accurate technology (Figure 1). Surgeons who have not used the femtosecond laser previous- ly should choose a nomogram, continue using it, and track their data and results. Based on those outcomes, they should modify the nomogram. Surgeons can determine whether it is better for them to open the laser-created LRI during surgery and titrate it using intraoperative aberrometry, open it in all cases, or refract patients after surgery and open incisions later if needed. Astigmatism treatment may not be wise if the patient has variable amounts of astigmatism or it is difficult to identify the true axis during preoperative testing. In such cases, we sometimes use av- erage keratometric values to select a non-toric IOL. After the patient has healed, we can perform serial refractions and topography. If readings are stable, we may be able to use the femtosecond laser to perform LRIs. If the patient has a spherical equivalent close to zero and less Another study by Chan et al. demonstrated that femtosecond laser arcuate keratotomy combined with cataract surgery is an easy and safe means to manage a low to moderate amount of corneal astigmatism. 2 Day et al. showed that corneal biomechanical parameters and astigmatism meridians predicted the efficacy of intrastromal astig- matic keratotomy created with the femtosecond laser. 3 Experience from surgeons and a growing body of literature are validating that the femtosecond la- ser is a useful and safe technology to manage astigmatism, particular- ly in patients with regular low to moderate astigmatism (less than 1.25 D is ideal). Most patients who we see for cataract surgery have low to moderate amounts of astig- matism, so they fit the ideal profile for the femtosecond laser. Optimizing astigmatic incisions Results from the 2015 ASCRS Clin- ical Survey showed that surgeons still prefer manual methods com- pared with the femtosecond laser when performing limbal relaxing incisions (LRIs) or astigmatic keratotomy. In my experience, however, I consider the femtosecond laser far superior in performing an arcuate incision compared with a diamond Research demonstrates the advantages of using the femtosecond laser in treating astigmatism R esearchers continue to study the safety and efficacy of laser-assisted cataract surgery (LACS) in creating arcuate inci- sions to correct astigmatism. Ongoing research In a retrospective chart review of patients who had cataracts with corneal astigmatism, Yoo et al. reported that astigmatic keratoto- my performed with the femtosec- ond laser is precise, customizable, adjustable, and safe in reducing refractive errors in patients with residual astigmatism after cataract surgery. 1 " Surgeons should feel confident using the femtosecond laser to correct low to moderate amounts of astigmatism. " –Robert Weinstock, MD Robert Weinstock, MD • High amount of accuracy • Many barriers no longer relevant: • Reproducibility • Precision • Overall learning curve • Safety and efficacy • Body of literature growing to support outcomes to treat low amounts of astigmatism Figure 1. Femtosecond laser arcuate incisions

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