EyeWorld Asia-Pacific September 2015 Issue

8 September 2015 EWAP FEATURE “the ability to place the IOL in the proper orientation is still lacking with the typical techniques, and there is mounting clarity that improved registration of the IOL to the preexisting corneal astigmatism may improve results,” Dr. Hardten said. Another key part of toric IOL use is identifying who is and who is not a suitable candidate. One part of this is analyzing ocular surface health via topography and confirming findings via a clinical exam, Dr. Waring said. It is also important to look out preoperatively for corneal abnormalities like keratoconus or map dot fingerprint dystrophy; it is best to avoid toric IOLs in these patients, Dr. Braga-Mele cautioned. Patients with skewed central radial axes or non-descriptive astigmatism patterns may not be ideal candidates for toric IOLs, Dr. Waring said. Another group to avoid at least initially is very high myopes, as they have more of a tendency to rotate postoperatively, Dr. Wortz said. Above all, aim for precision, Dr. Braga-Mele advised. “You’ll be happiest with this lens if you have the right tools to measure astigmatism and are precise in your marking and alignment of the lens. If you do all of that, your retreatment rate will be low,” she said. Presenting toric IOLs to staff and patients Everyone from the front office to back office staff needs to know what toric IOLs can offer before you can confidently discuss them with patients, Dr. Wortz said. “There needs to be comprehensive staff-wide education to talk about the message that’s delivered if patients call and need cataract surgery,” he said. When a cataract patient has astigmatism and may be a toric IOL candidate, Dr. Wortz likes to discuss the positive changes that accompany life without glasses. He usually finds one of three responses. In one group, patients say they will always wear their glasses—perhaps for cosmetic reasons, such as to help cover bags under their eyes. In this group, Dr. Wortz typically drops the subject. In the next group, patients say they want to learn more. In the Views from Asia-Pacific Ronald YEOH, FRCS, FRCOphth, DO, FAMS Consultant Eye Surgeon & Medical Director Adj. Asst. Professor Duke-NUS Grad Med School Eye & Retina Surgeons Singapore National Eye Centre #13-03 Camden Medical Centre One Orchard Boulevard Singapore 248649 Tel. no. +65-67382000 Fax no. +65-67382111 I t is now accepted by most cataract surgeons all over the world that toric IOLs are an appropriate choice for correcting post-cataract surgery corneal astigmatism. After all, we would correct astigmatism with spectacles in the non-surgical eye, so why wouldn’t we do so with an intraocular lens at the time of cataract surgery? However, despite this general acceptance, there are still surgeons who are reluctant to embrace this IOL advancement. There are many reasons for this: more preoperative assessments, extra work in making reference and axis markings, anxiety about IOL rotation postoperatively and finally of course the greater cost. The doctors quoted in this article rightly stress the importance of starting toric implantation properly. A great piece of advice is to measure the keratometry with more than one device; consistent readings among the two or three different devices (usually an IOLMaster or Lenstar, aberrometer or other keratometer) generates confidence in toric IOL implantation. Widely differing readings should be viewed with caution and it may not be wise to implant a toric lens in these cases. Irregular corneal astigmatism is also not precisely corrected by toric IOLs. Of late, it is widely accepted that one of the most accurate formulae to use in toric lens calculations is the Barrett Toric Calculator, available on the ASCRS website or the APACRS website (http://www.apacrs.org/). Once the correct toric IOL strength and axis is determined, the challenge is to transfer the preoperative assessment data to the supine patient on the operating table and factor in cyclotorsion. Hence the plethora of methods devised to make reference and axis marks. These range from simple free-hand marking using spirit levels, mobile phone accelerometers, and slit lamps, to expensive preoperative scanning and subsequent registration on the operating table. Whichever method a surgeon chooses, it is important to be consistent. For instance, use the same temporal clear corneal incision in each case. Editors’ note: Dr. Yeoh is on the Alcon (Fort Worth, Texas/Hünenberg, Switzerland) and Abbott Medical Optics (Santa Ana, Calif.) speaker panels but has no financial interests related to his comments. third and most common group, patients say the possibility sounds nice but it depends on the cost. “You don’t have to deliver a sales pitch. You just need to tell patients this is available and if they are interested, this is what it would be like,” Dr. Wortz said. Dr. Braga-Mele likes to use visual aids to give patients a sense of what astigmatism is and why they might continue to need glasses if astigmatism is not corrected. In the discussion with patients, Dr. Wortz likes to emphasize a teamwork approach, saying he will do everything he can to get patients out of glasses, even if that means retreatment. Broaching price When it comes to discussing continued on page 16 How to get - continued from page 7