Innovations in Cornea: Managing Low Astigmatism

I. Paul Singh, MD; and Gary Wörtz, MD

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As patients increasingly think about cataract surgery as a refractive procedure, the need to fine-tune the outcomes becomes increasingly important. In this episode, Gary Wörtz, MD, joins I. Paul Singh, MD, to discuss one area where surgeons can help patients achieve the best quality vision possible: management of astigmatism below 1.0 D.

Posted: 3/01/2024

Keywords:

Astigmatism

•

Corneal Astigmatism

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Name: Innovations in Cornea: Managing Low Astigmatism
Uploaded: 2024-03-01T22:05:30+00:00
Description: As patients increasingly think about cataract surgery as a refractive procedure, the need to fine-tune the outcomes becomes increasingly important. In this episode, Gary Wörtz, MD, joins I. Paul Singh, MD, to discuss one area where surgeons can help patients achieve the best quality vision possible: management of astigmatism below 1.0 D.

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Back to All Videos

Innovations in Cornea: Managing Low Astigmatism

I. Paul Singh, MD; and Gary Wörtz, MD

Posted: 3/01/2024

Keywords:

Astigmatism

•

Corneal Astigmatism

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Comments

lawrence tenkman

1 year ago

There's another very easy way to treat low corneal cyl: EXTRA KERATOME INCISIONS! McKool and I both independently developed on-axis keratome incisions at case end to reliably treat cyl. Single keratome incisions treat 0.2 if starting near limbus and 0.3 or so if started just a touch centrally (0.5 mL). Paired incisions 180 degrees apart treat 0.4 and 0.6 or even 0.7 depending how far in you start. Don't put extra incisions in until the end so they don't leak during the case. Because no instruments go through them, they almost never leak. But always check and hydrate PRN. If ergonomics prohibit you from operating on steep axis, you can use a separate surgical incision that is astigmatically neutral (by starting in limbal sclera, and knick the conj there to prevent exiting fluid from causing chemosis). I agree, Toric IOLs are far more accurate than incisions. So my plan is: 1. MILD cyl (0.7 and under): single or paired keratome incisions. 2. MODERATE TO HIGH cyl (0.8 to 4.6) - Toric IOL with subtractive (90 degrees away) or additive (on axis) keratome incisions. 3. SEVERE cyl (near 5.0 or greater) - Add an LRI instead of just extra keratomes to a full power toric IOL. So in this plan, LRIs (and their risk of neurotrophic keratitis or tissue instability) are only used in the most severe astigmatism cases. Just a few a year. Always base the treatment on a nomogram that assumes some posterior corneal astigmatism (Barrett). Don't just treat off of topography. I usually use the Alcon Toric Calculator, even if I know the cyl is too low for a toric IOL. I plan my keratomes off that. Our businesses do better when patients select upgrades, and it seems laser programs earn more upgrades. I think this is because of two things. One is promise of vision. Many surgeons link their astigmatism treatment & promise glasses freedom to the laser. Two is safety. Many of the videos that advertise laser cataract suggest that a surgeon doing the rhexis by hand is scary (and show an image of a shaky rhexis line then a dissheveled tilted IOL in the bag). If you count the "fear", I think it doubles the number of upgrades. In reality, I've found the manual rhexis to be far safer because it is stronger (not a micro-canopener saw tooth pattern). A surgeon doesn't have treat it with kid gloves or worry about radial extension of the rhexis from hydrodissection... the manual rhexis is strong and will almost never have such extension. So, there really are great ways to treat low astigmatism without LRIs (laser or manual). As time goes on, I think upgrades are becoming more and more about the IOL anyway.