EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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44 EW FEATURE A toric continued from page 43 tion to the true axis of cylinder, taking into account supine cyclotor- sion, SIA, and other easily over- looked factors like mild lens tilt. Dr. Berdahl: My next step would be a careful slit lamp evalua- tion looking specifically for ocular surface disease and subtle ABMD. Provided OSD was minimal and there was no ABMD, I would then visit astigmatismfix.com (soon to be on the ASCRS IOL calculation site) to determine if the toric IOL was not placed in the ideal axis. The ideal Ophthalmology Business: August 2012 eZine Feature: Preparing for trial Experts weigh in on how to evaluate claims in cases where you're asked to be an expert witness If you build it, they will come The importance of creating a solid online presence for your practice Why simulators help pilots and surgeons alike Simulators are often mandatory for pilots; should they be for surgeons? Retirement done right part 3: Setting the date The team at Oregon Eye Associates participated in a panel discussion with topics including building a practice before leaving it, reducing responsibilities, and selling a practice. In this article, the team discusses setting a date for retirement Employee to manager: Making the transition Ophthalmology Business examines a few of the reasons employees may be considered for management and why not all are a valid indication of a good manager axis is not always the same as the in- tended axis. Based on Dr. Solomon's manual keratometry and toric IOL calculation from the Alcon AcrySof Toric calculation site, the IOL was placed in the intended axis, but factors like posterior corneal curva- ture and unanticipated surgically induced astigmatism can cause the ideal axis and intended axis to be different. After entering the manifest refraction and current location and power of the toric IOL, the website will calculate the amount of IOL rotation and the anticipated residual astigmatism. If the residual astigma- tism after IOL rotation is significant, either an IOL exchange or an excimer photoablation would be more appropriate. In this case, the expected post-rotation refraction would be –0.54 +0.82 x 163, which would decrease the astigmatism by about 0.5 D but would leave over 0.75 D of astigmatism. Given the difficulty this patient is having, I suspect he would not be satisfied with >0.75 D residual astigmatism, and I would lean toward an excimer laser photoablation. What are some of the biggest challenges in treating a case like this? Dr. Desai: Post-operative manage- ment of this patient is just as chal- lenging as identifying the source of the refractive surprise itself. With the option of referring such patients to the expert hands of Dr. Solomon not always available to me, I might consider the option of performing an early IOL exchange with ORA confirmation versus laser vision cor- rection with LASIK or PRK. Despite the widespread, and often justified, reluctance to perform an IOL ex- change, I believe we should not take this option off the table if it is the most likely to address the problem where it exists. For those uncomfort- able with the possibility of opening a Pandora's box of new problems via attempted IOL exchange, PRK enhancement might offer the safest and easiest route to 20/happy. I gen- erally prefer PRK enhancement over LASIK in post-cataract cases because of this patient population's propen- sity for dry eye syndrome, basement membrane dystrophy, and other disorders that may complicate LASIK flap healing. Dr. Berdahl: One challenge is to match the intended axis with the ideal axis. Recently Doug Koch, M.D., has taught us that the against- the-rule astigmatism increases as pa- tients age because of changes to the posterior corneal curvature. Impor- tantly, posterior corneal curvature is not measured in keratometry meas- urements. This phenomenon will generally lead to an undercorrection of against-the-rule astigmatism (which happened in this case) or an overcorrection of with-the-rule astigmatism. Can you offer pearls for similar cases? Dr. Desai: • Recognize irregular astigmatism in pre-operative biometry. • Identify the source of irregularity (e.g., bad scan, ocular surface disease) and treat it appropriately before repeating biometry or performing cataract surgery. Monthly Pulse Keeping a Pulse on Ophthalmology P ost-keratoplasty refractive errors are one of the most challenging corrections for the refractive surgeon. For spherical refractive errors, PRK with MMC was the most common choice as it is relatively simple to perform and minimizes the risk of epithelial ingrowth. For pure astigmatic corrections, AK was also a common choice, as many of these eyes will have mixed astigmatism. Interestingly, some surgeons would prefer not to personally perform these corrections at all, which reflects the difficulty in achieving a predictable outcome and a satisfied patient in this unique subset. While dry eyes and night vision symptoms are often cited as the most common post-op refractive complaints, the survey shows that in the era of advanced corrections these problems are actually relatively rare, while achieving full refractive correction and meeting the patients' expectations are the cornerstone of successful refractive surgery. Lou Probst, M.D., refractive editorial board member February 2011 Refractive challenges and innovations August 2012 USING PATIENT SURVEYS EFFECTIVELY P.20 HELP PATIENTS NAVIGATE EYE HEALTH INFORMATION ONLINE P.22 TM March 2012 www.OphthalmologyBusiness.org P.14 Surviving office renovations: Making it easier on you and your patients P.11 CR Pb FIVE SOCIAL NETWORKING MISTAKES TO AVOID pg. 12 ADOPTING LASER CATARACT SURGERY IN YOUR PRACTICE pg. 24 MANAGING REFRACTIVE PATIENT EXPECTATIONS pg. 22 TM APRIL 2011 www.OphthalmologyBusiness.org pg. 14 Non-covered services associated with cataract surgery pg. 6