FEATURE 10 EWAP DECEMBER 2023 priority is to get your cataract out safely and completely, which we were able to accomplish. … Second, we want to put a lens implant in your eye that is as Presbyopia eye drops in development Dr. Rubenstein said he has taught skills transfer labs for astigmatic keratectomy (AK) and limbal relaxing incisions (LRIs) at major medical meetings for many years, and every year, ahead of the lab, he would think, “This is dying.” However, attendance would prove him wrong. “Every year there is still interest. People think this should still be in surgeons’ toolbox,” he said. It’s good for very small amounts of astigmatism, Dr. Rubenstein continued, noting that in the U.S., toric IOLs correct 1–1.25 D of astigmatism minimum. LRIs, in contrast, can correct less than that. Another indication, Dr. Rubenstein said, is higher amounts of astigmatism. LRIs can be performed in addition to a toric IOL to improve quality of vision. “I think there still is a place for this, and based on what happens at our meetings each year, there is still an interest in them,” Dr. Rubenstein said, noting that his program trains residents to perform LRIs and AKs. “It’s part of the surgical armamentarium we should know about.” Is there still a place for AK and LRIs? Drs. Rai and Rubenstein discuss many possible scenarios when the lens capsule is compromised and a toric IOL is planned. This clinical situation is not uncommon given the inexorable trend towards correcting all amounts of corneal cylinder with the better formulae and IOLs available today. Of course, if a toric multifocal IOL is planned in a second eye, the imperative to implant the lens is even greater! As elegantly discussed, the size, location and morphology of the capsular tear is important in deciding how to achieve the desired toric correction. Capsular complications include anterior radial tears, posterior capsule ruptures (PCRs) and zonular dehiscences which can exist in isolation or in combination. In most cases of anterior radial tears without posterior extension, it is possible to place a single-piece IOL in the bag securely, the critical point being to ensure that the haptic does not protrude through the radial tear into the sulcus. PCRs when small, rounded, and clearly defined are compatible with in-the-bag IOL placement and, as mentioned, anterior optic capture is an excellent maneuver that stabilizes the IOL very nicely. Single-piece IOLs whether toric or not should not be placed in the sulcus. Finally, there are times when the zonular ligaments are compromised and the placement of a single-piece toric implant challenging. These cases can still benefit from a single-piece toric lens if the vitrectomy using triamcinolone is carefully done and then capsular tension segments or capsular tension rings with eyelets can be sutured in place to stabilize the bag. The single-piece toric IOL can then easily be placed with good results. The modern refractive cataract surgeons needs to have all these techniques at his disposal to achieve optimal outcomes for his patients. Editors’ note: Dr. Yeoh has no relevant financial interests. Ronald Yeoh, FRCS, FRCOphth, DO, FAMS Consultant Eye Surgeon & Medical Director, Eye & Retina Surgeons Clinical Associate Professor Duke-NUS Grad Med School, Singapore National Eye Centre ry@ers.clinic ASIA-PACIFIC PERSPECTIVES close to the correct power and as stable as possible, and we were able to accomplish that. Third is to try to produce the lowest residual refractive error … as possible, and we’re able to correct hopefully the spherical part of your refraction, but you still have astigmatism, which we were not able to correct in surgery, and we will offer you the opportunity to correct that later.’ We’ll say something like, ‘During surgery we assessed that your eye was not stable enough to support the type of lens implant that we originally had planned to correct astigmatism; we thought it was unsafe to use that kind of lens because we couldn’t be assured it would stay in the position that was needed to fully correct your astigmatism, and therefore we put in a lens implant that does not correct astigmatism because it was the most stable lens for your eye. We can always come back later and correct your astigmatism.’” Dr. Rai also said it’s important to thoroughly discuss this situation with the patient and their family postop, namely because these patients are at increased risk for complications, such as high intraocular pressure in the first few hours postop, endophthalmitis in the days postop, and/ or retinal tear/detachment, CME, or pseudophakic bullous keratopathy in the weeks postop. continued on page 15
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