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Staying retro: Cataract surgery with toric IOLs

This surgeon prefers to implant premium lenses without intraoperative aberrometry.

By Vanessa Caceres

Intraoperative aberrometry technology is intended to provide precise surgical results during premium IOL procedures, such as toric IOL implantation (See “When aberrometry comes in handy,” page 30). However, despite the clinical advantages, the technology can cost about $100,000, which is passed on to patients.

“There’s a limit to how many out-of-pocket expenses you can expect a patient to be willing to pay,” says Mark Kontos, MD, Empire Eye Physicians, Spokane Valley, Wash. Explaining to patients the various costs affiliated with premium surgery like intraoperative aberrometry and femtosecond laser use can overwhelm them and their wallets. “It can be a hard discussion to have with patients,” Dr. Kontos says.

Although Dr. Kontos appreciates the potential advantages of intraoperative aberrometry, he takes another approach to toric IOL implantation. By performing his surgeries systematically without the use of intraoperative aberrometry, he says he still is able to achieve similar clinical outcomes. Therefore, after Empire Eye Physicians invested in a femtosecond laser for refractive cataract surgery, he and the other doctors decided to hold off on investing in intraoperative aberrometry.

Clinical results

At last year’s Caribbean Eye meeting in Cancun, Mexico, Dr. Kontos presented five-year results involving 547 eyes that had toric IOL implantation at his practice. “What was reassuring was the vast majority of patients — 94% — did well with no need for additional intervention,” Dr. Kontos says. “If you’re meticulous, work on your technique, do accurate preoperative marking and use a systematic intraoperative technique, you can obtain great outcomes.”

Dr. Kontos found that 31 eyes needed an additional procedure after their first surgery. In his review, four eyes (<1%) were not at the target axis on day one, which intraoperative aberrometry can prevent. Thirteen eyes were on target for spherical equivalent and axis on day one but rotated later, a problem intraoperative aberrometry would not have prevented. “In our review, 17 eyes [3%] would have potentially benefited from having intraoperative aberrometry,” Dr. Kontos says.

Dr. Kontos’s review also showed that the patients most likely to rotate post-op tended to have longer eyes (24 mm or longer). “We always counsel that their eye anatomy is such that if we’re going to have an issue with lens rotation, it’ll be with an eye like theirs,” Dr. Kontos says. “As long as they know that ahead of time and understand, it’s never been an issue. We know we’re promising a more premium surgery, so it’s important to deliver premium results.”

Benefits

Along with avoiding financial barriers, toric IOL implantation without intraoperative aberrometry requires less of a learning curve than you might think, Dr. Kontos says. “Toric IOLs are actually the best ones to use if you’re getting started with premium IOLs,” he says. “The torics are perfect because when you do things correctly, you can have excellent results.”

Francis S. Mah, MD, director of cornea and external disease and co-director of refractive surgery at Scripps Clinic, La Jolla, Calif., supports the idea of delving into toric IOL implantation. “For patients who are being refracted, we correct significant astigmatism in glasses and contact lenses,” he says. “Since the report of the SRK formula in 1977, cataract surgeons have been correcting myopia and hyperopia during cataract surgery. With the advent of reliable toric implants, why wouldn’t we want to correct the astigmatism with cataract surgery?”

At this year’s Hawaiian Eye meeting in January, Drs. Kontos, Mah and other surgeons interviewed for this article took part in a forum on performing toric IOL implantations without expensive equipment.

According to John A. Vukich, MD, associate clinical professor at the University of Wisconsin-Madison Medical School, surgeons should experience very few barriers to entry with toric IOL implantation. “If we use reasonable care taking a few extra steps, we can do an excellent job. It makes no sense to say we don’t do toric IOLs until we have aberrometry.”

Sumit (Sam) Garg, MD, interim chair of clinical ophthalmology, and medical director, Gavin Herbert Eye Institute, University of California, Irvine, uses intraoperative aberrometry. However, he sees benefits in forgoing this technology. For example, Dr. Garg says refraining from intraoperative aberrometry can save time — about three to four minutes — in each case. Performing intraoperative aberrometry, on the other hand, could add anywhere from a few seconds to a few minutes, according to a survey conducted two years ago.¹

Surgical Pearls

To ensure success, those interviewed recommend the following:

Prioritize a clear capsule. Obtaining a clear capsule is even more important with toric IOL versus monofocal IOL implantation, Dr. Kontos cautions. “In the past, we’d do a conventional IOL surgery and there would be some cortex hard to get out, so we’d just leave it. You can’t do that with a toric. You have to get it all out, and the capsule has to be clear and clean.” Also, he adds, with toric IOLs, you need an intact capsular bag, and the anterior bag has to be circular and centered.

If possible, use a femtosecond laser, which Dr. Kontos credits with some of his toric IOL surgical success. “That allows us to make sure that we have a circular capsule, so there’s a lower chance of capsule problems.”

Preoperative markings. “You have to mark every patient at the slit lamp right before surgery and try to be as meticulous as possible about it,” he says.

Removal of viscoelastic material is also a crucial step for solid outcomes. “When the lens is in, you have to ensure that there’s no viscoelastic material anywhere. That’d make the lens easy to rotate. Removing the material also helps to reduce contraction of the capsule,” he says.

Toric IOL calculator. This will assist with IOL selection no matter how you approach toric IOL implantation, Dr. Garg says. Dr. Garg sees value in using measures like the Barrett calculator (http://www.ascrs.org/barrett-toric-calculator).

Markerless technology. This uses a reference image to avoid pre-operative cornea marking, Dr. Garg says. The pre-operative reference image allows for intraoperative markerless guidance for toric IOL orientation.

Mark patients while they are sitting up. Using traditional marking allows up to a 15-degree difference when a patient is lying down compared to a sitting-up position, Dr. Vukich says. Therefore, he takes patients to the slit lamp, instills a drop of pilocarpine and creates a micro-abrasion at the six and 12 o’clock limbus. This does not fade and it remains visible as a thin line. “It’s very easy to determine the top or bottom of an arc,” Dr. Vukich says. “You can accurately mark a reference point and then use a calibrated ring to mark the desired final axis.”

Additional pearls. Other key points to surgery include:

• Know the location of the active axis of astigmatism.

• Have a reliable topographer that measures the front and back surface of the cornea.

• Review the K readings.

“You have to look at all of this and try to come up with the power and axis that makes the most sense,” Dr. Kontos says.

Intraoperative aberrometry is a wonderful addition to assist with toric IOL implantation, unless it’s not readily available, Dr. Kontos says. Otherwise, you have other options. “You have to be careful with your biometry and how you measure the astigmatism,” Dr. Kontos says. “You have to have a system in place and be meticulous with your surgery. If you can do those things, there is no reason why you cannot achieve similar results.” OM

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