EyeWorld Asia-Pacific September 2015 Issue

16 September 2015 EWAP FEATURE on,” he continued. “With the lower powers, it’s harder to get spot on, but it’s more forgiving if you’re slightly off.” Looking at the big picture Astigmatism correction is quickly becoming the standard of care in ophthalmology, but toric IOLs are considered premium products, so they may not become the standard option for cataract patients just yet. “I think it is the standard of care to discuss astigmatism correction options with any patient considering surgery,” Dr. Kontos said. “But because it is a non-covered service, it will be a significant part of cataract surgery, more than a niche, but not a standard procedure.” By consistently achieving accurate alignment and delivering great refractive results, surgeons can help unlock the benefits of this technology and possibly make it the standard of care in the future. EWAP Reference Zhang L, Sy ME, Mai H, Yu F, Hamilton DR. Effect of posterior corneal astigmatism on refractive outcomes after toric intraocular lens implantation. J Cataract Refract Surg. 2015 Jan; 41(1):84–9. Editors’ note: Dr. Kontos has financial interests with Abbott Medical Optics and Allergan (Irvine, Calif.). Dr. Rubenstein has financial interests with Alcon. Dr. Hamilton has no financial interests related to this article. Contact information Kontos : mark.kontos@empireeye.com Hamilton : hamilton@jsei.ucla.edu Rubenstein : Jonathan_Rubenstein@rush.edu price, Dr. Braga-Mele favors honesty. “I briefly talk about the cost of preop testing and the cost of the lens. I give them a ballpark figure and see if they’re comfortable,” she said. Her assistants will go over the costs more closely, and she emphasizes that patients are welcome to come back for another appointment before surgery or they can call her with a quick question. “We need to remember that patients get overloaded with a lot of information, and they may have questions later on,” she said. Dr. Wortz lets patients know they can pay by credit card or use financing options. He also thinks it is better to charge the patient for a more all-inclusive refractive package that will cover any possible need for enhancements. This seems to work better than patients being told after surgery that they need to pay more. “That becomes an awkward conversation,” he said. “It’s also important to tell the patient that just like regular cataract patients, we’re good at hitting our target, but we don’t always make it. If we need to do something else to enhance their vision, we’ll do it.” EWAP Editors’ note: Dr. Braga-Mele has financial interests with Alcon (Fort Worth, Texas) and Allergan (Irvine, Calif.). Dr. Wortz has financial interests with Alcon, Allergan, Abbott Medical Optics (Abbott Park, Ill.), Bio-Tissue (Doral, Fla.), Carl Zeiss Meditec, Omega Ophthalmics (Lexington, Ky.), and Topcon (Tokyo). Drs. Hardten and Waring have no financial interests related to their comments. Contact information Braga-Mele: rbragamele@rogers.com Hardten: drhardten@mneye.com Waring: georgewaring@me.com Wortz: 2020md@gmail.com How to get - from page 8 Intraoperative pearls - from page 15 after all of the viscoelastic is removed and after the incisions are stromally hydrated,” Dr. Rubenstein said. “If minor adjustments are needed, they can be done with a long-tipped 27-gauge balanced salt solution cannula. I always tap on the lens with the cannula through the paracentesis port to make sure that the IOL is firmly against the posterior capsule.” Use intraoperative aberrometry (or don’t) When it comes to the question of using intraoperative aberrometry for implanting toric IOLs, physicians are split. Dr. Hamilton has had success using the ORA system with VerifEye (Alcon, Fort Worth, Texas), which provides real- time feedback of where the residual astigmatism is as the lens is being rotated. “I also think that using the ORA aberrometer is useful in checking the toric IOL alignment after the lens is in place and the eye is still filled with viscoelastic,” Dr. Rubenstein said. “Although the spherical readings are not very accurate after IOL placement, the toric axis readings are helpful in determining correct axis placement and showing maximal reduction of cylinder.” According to Dr. Kontos, if you are consistent with your surgical technique and meticulous with determining the axis of orientation, intraoperative aberrometry isn’t necessary. “You have to have a good way to measure the axis and magnitude of the astigmatism, and make sure you’re uncompromising in the way you do your surgery,” he said. “Then you can get good results with toric lenses and not need to have that technology.” Be consistent Drs. Kontos and Hamilton agreed that consistency in every step of the procedure is the key for success with toric IOLs. Using the same technique with every toric IOL patient will ensure consistency in the effective lens position and help prevent postop rotation of the lens. Dr. Kontos performs femtosecond laser-assisted surgery with the Catalys laser for all of his toric IOL patients to ensure that the capsulotomy is perfectly circular and well centered. “I think it is critical that the capsule is intact,” Dr. Kontos said. “The anterior capsulorhexis needs to be circular and continuous, and it needs to be well centered. All of those things are important for the alignment of the lens.” Consistency is also important when it comes to tapping the lens against the posterior capsule. “I think you need to be very consistent with that because if you do it in some cases and not in others, you can get variability in your effective lens position,” Dr. Hamilton said. “I’m not a big anterior capsule polisher; I think again you need to be consistent, either do it or don’t do it. “Fortunately, with higher levels of astigmatism, you need to be closer to spot on, but those are the ones that are easier to get spot