CATARACT 12 EWAP DECEMBER 2022 have a partial thickness hole, which doesn’t affect vision much, but sometimes they have a full thickness hole that severely degrades vision and may benefit from surgical repair by a retina colleague, usually after cataract surgery,” she said. Dr. Zhu said she doesn’t typically get an OCT of the optic nerve as she relies more on biomicroscopy to examine the neuroretinal rim. If the patient has a large cup-to-disc ratio, she will get an OCT of the optic nerve head and a visual field to assess for glaucomatous changes. “OCT helps you differentiate between a glaucoma suspect and a patient who truly has glaucoma, or at least it helps you decide whether you need to refer to a glaucoma specialist to make that ultimate decision,” she said. “That diagnosis will affect your discussion on IOL selection with the patient.” EWAP Editors’ note: Dr. Charles practices at Charles Retina Institute Germantown, Tennessee. Dr. Zhu practices at NVISION Eye Centers Rowland Heights, California. Factoring astigmatism - from page 9 approval for toric IOLs for low levels of astigmatism. Whether it’s addressing the astigmatism on the cornea/limbus (incisional techniques, laser vision correction, or other methods) or with a toric IOL, Dr. Schallhorn said it’s important to improve the accuracy and predictability of correcting astigmatism. Dr. McCabe agreed with the results of this study and said in her own experience, small amounts of residual astigmatism can impact quality of vision, especially when using more sophisticated optics that split light. “I’ve been treating those low levels of astigmatism with my own nomogram until recently when we had more validated nomograms,” she said. “I know low levels of astigmatism will decrease the quality of distance vision with a diffractive optic. If I think it’s universally important to treat in the setting of diffractive optics, then I also think it’s important to address all levels of astigmatism to improve quality of vision at distance with all lenses. Therefore, I treat all low levels of astigmatism when I’m trying to reach a refractive target that allows for independence from glasses. I think that does provide better outcomes than we would get if we were not so focused on reducing residual astigmatism.” At this point in the evolution of delivering excellent outcomes with cataract surgery, it’s not reasonable to ignore astigmatism, Dr. McCabe said. “It’s a fundamental part of how we can improve the visual function and quality of vision for our patients.” EWAP Reference 1. Schallhorn SC, et al. Effect of residual astigmatism on uncorrected visual acuity and patient satisfaction in pseudophakic patients. J Cataract Refract Surg. 2021;47:991–998 Editors’ note: Dr. McCabe is Medical Director, The Eye Associates, Bradenton, Florida, and disclosed interests with Alcon, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision, LENSAR, and Rayner. Dr. Schallhorn is Professor of Ophthalmology, University of California San Francisco, San Francisco, California, and disclosed no relevant financial interests. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. A ur rising, incidental finding from Dr. Schallhorn’s study was that leaving patients slightly hyperopic led to slightly better outcomes and patient satisfaction. “What it showed, which needs to be studied in greater detail, was that a low level of hyperopia resulted in better uncorrected vision and happier patients than if you leave those patients slightly myopic,” Dr. Schallhorn said. The important caveat is that it was in patients who wanted good distance vision in that eye; of course, this is not for patients in whom you’re targeting myopia. In those patients where the physician wants to hit zero refractive error and give the best uncorrected distance vision, the findings from the study suggested that leaving patients slightly hyperopic is better than leaving them slightly myopic, he said, further clarifying that this is in reference to when the surgeon is deciding between lens power options with half diopter increments in which the estimated postop refraction straddles emmetropia. Previously, he would default to leaving the patient slightly myopic. He reiterated that this needs to be investigated further to understand in greater detail what it means and how should it drive practice. The size of the study was its strength, Dr. Schallhorn said. It requires large sets of data to accurately assess patient satisfaction and patient-reported outcomes because of the inherent variability in patient responses. Dr. McCabe said that she usually aims for as close to plano as possible. “I’ve found that allows the patient to have the best quality of vision,” she said. “Unfortunately, right now, we don’t have a way of targeting in less than half diopter increments of power.” Dr. McCabe said that when it’s within a half diopter, she generally will target closest to plano or a little on the myopic side, but she added that there are certain optics that work better with a little residual hyperopia, like the Synergy (Johnson & Johnson Vision).
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