Eyeworld

129 October 2017 EW MEETING REPORTER Dr. Goyal noted that there may be complications with LRIs, as well as the possibility of overcorrection or undercorrection. However, she noted that the majority of patients do very well. Editors' note: Dr. Goyal has no finan- cial interests related to her comments. Piggyback lenses During a discussion on refractive enhancements after cataract surgery, Farrell "Toby" Tyson, MD, Cape Coral, Florida, highlighted piggy- back lenses. The benefits of a piggyback IOL include known implantation power; it doesn't affect the ocular surface; it's closer to the optical nodal point; there is reduction of glare; there is reduction of dysphotopsias; it's a simple procedure; and there are reduced costs, he said. When choosing an IOL for a piggyback, Dr. Tyson offered several tips. He said you would preferably use a three-piece silicone IOL. A large overlapping optic is also a metal-guarded LRI blades available. There are 450–650 micron blades available, she said, with the 600 micron ones being the most com- monly used. The arc-shaped incision is made 1 mm inside the limbus. She recommended grasping the episclera with 0.12 forceps and drawing the blade toward you for best control. For femtosecond LRIs, Dr. Goyal said you can use the same nomo- grams, but you should decrease the arc length to 70% of the manual technique. Print out in superior view, she said. The OCT will auto- matically measure 90% depth for the LRI. The patient's cornea still needs to be marked in an upright position, Dr. Goyal said, unless axis alignment software is used. She said to open the laser incision with a Sin- skey hook prior to or after cataract surgery. Postoperative follow-up should be routine for cataract surgery. Manifest refractions should be per- formed as needed, and postoperative corneal topography and keratometry readings are helpful to identify treat- ment effect. As for treatment, Dr. Gupta said she'll recommend topical prescrip- tion medications for these patients sooner, and she finds "disease-mod- ifying procedures" such as thermal pulsation and intense light therapy useful for getting to the root of meibomian gland dysfunction. "It's important to not hold these treat- ments until patients are end stage," Dr. Gupta said, explaining that they work better on patients who have mild to moderate disease. Editors' note: Drs. Solomon and Starr have financial interests related to their comments. Drs. Gupta and Zavodni have no financial interests related to their comments. Clinical pearls for corneal relaxing incisions Himani Goyal, MD, New York, shared some of her pearls for corneal relaxing incisions, highlighting both manual and femto-assisted incisions. Once you determine the amount of astigmatism, you want to figure out if LRIs are the best method to correct, Dr. Goyal said. Astigmatism of about 1.0 D can be treated with LRIs. Astigmatism ranging from 1.0 D to 3.0 D can be corrected with a toric IOL or LRIs, she said, noting that toric IOLs are regarded as giving more reliable results. If there is astig- matism greater than 3.0 D, this can be corrected with a combination of toric IOL, LRIs, and/or strategic cata- ract incision placement, she said. Dr. Goyal also highlighted surgical plan- ning for LRIs, emphasizing some of the available nomograms. She spoke about the techniques for manual LRIs and femtosecond LRIs. For a manual LRI, it's easiest to begin in the OR in conjunction with cataract surgery. For corneal marking, Dr. Goyal noted that it's key to sit the patient upright prior to draping and to mark at 12 o'clock and 6 o'clock. There are disposable Dr. Starr gave a brief overview of the recently released Tear Film and Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II), highlighting the report's new defi- nition, which leads to an expanded understanding of dry eye, and the new two-layer tear film mode (a lipid layer and mucoaqueous layer), now preferred over the previous three-layer model. While the TFOS DEWS II diagnostic schematic focuses on symptoms, for refractive cataract surgery, Dr. Starr said he thinks the symptoms are less important, espe- cially with studies showing a high prevalence of undiagnosed dry eye disease. "I think you should screen every patient who is paying out of pocket for refractive surgery for dry eye and ocular surface disease," Dr. Starr said, specifically mentioning osmolarity and MMP-9 testing. He said that the TFOS DEWS II does not necessarily focus on visual quality testing, such as ocular scatter index, topography, aberrometry, and non-invasive tear breakup time, but he thinks those seeking refractive outcomes should consider these. Dr. Starr also said surgeons should take a multipronged approach to treatment from the start, not proceeding with final measurements or surgery until the patient is optimized. What's more, the patient should be coun- seled that dry eye treatment will continue in the postop period. While there are many algo- rithms, criteria, and subsets of dry eye, Dr. Gupta offered a couple of the things she does for fast diag- nosis. She'll always look at meibo- mian glands and will rely on her technicians to conduct osmolarity, non-contact tear breakup time, and MMP-9 testing and meibography. One does not, however, need to have all of these testing options, Dr. Gupta said. "When you are just get- ting started, pick one," she said. continued on page 130 View videos from YES ACT 2017: EWrePlay.org Elizabeth Yeu, MD, shares insights on how to approach dissatisfied postop patients.

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