Out With the Old, in With the New: The Best of AAO 2013

American Academy of Ophthalmology 2013

Roger F. Steinert, MD; Eric D. Donnenfeld, MD; Richard A. Lewis, MD


November 25, 2013

In This Article

Better Refractive Results With Intraoperative Aberrometry

Dr. Steinert: We would be remiss if we didn't take the last couple of minutes to talk about the one other big elephant at the meeting: the whole issue of trying to make our power predictions better and our astigmatism corrections better with intraoperative technology and new lenses. Eric, give us a summary of this.

Dr. Donnenfeld: We have been looking at astigmatism management and improving our postoperative refractive error so that we can get LASIK-like results with cataract surgery. Intraoperative aberrometry has come of age. At this meeting, we have come to the realization that this is a technology that's here to stay. It is imperative to understand that you can do things with intraoperative aberrometry that you can't do with anything else. Not only can you get the corneal curvature, but you get the posterior corneal curvature as well, which affects astigmatism. You get the astigmatism that is induced by your cataract incision. It will account for rotation of the IOL as well.

So we have much less refractive error. It's especially good after LASIK or photorefractive keratectomy, which have traditionally been the most difficult cases to calculate. It's great for toric IOLs, and it's especially good for high myopes and hyperopes. These are the places where the IOL formulas break down. We're now able to get very good refractive errors. About 85% of our patients now, with this technology, are within a half a diopter of emmetropia.

A major study by Doug Koch[4] that was presented a year ago and highlighted again at this meeting shows that one of the reasons why we are not getting the astigmatic results we want with cataract surgery all the time is that it is not just the anterior surface of the cornea that has an impact on astigmatism; it's also the posterior cornea. We now know that with with-the-rule astigmatism, you have less of an effect, and with against-the-rule astigmatism, you have more of an effect from the posterior corneal astigmatism. So you want to undercorrect with-the-rule and overcorrect against-the-rule when you are putting in toric lenses and doing limbal relaxing incisions. This has allowed us to titrate our cylinder and achieve better refractive results.

Dr. Steinert: Using the WaveTec ORA®, for example, I saw some results that were just breathtaking. Using the new AMO toric lens, for example, they were saying that two thirds of the patients who had been measured intraoperatively with the ORA ended up within a quarter of a diopter or less of astigmatism, and 90% were within a half diopter or less. Those are enormous numbers. We never used to do that well. It is stunning to see this all happen.

Dr. Donnenfeld: It is spectacular. It is also great for the ophthalmologists and for the patients that 4 different toric lenses are now available to us. All these different IOLs have different advantages and disadvantages, but we can now use these different lenses to treat astigmatism.

Many ophthalmologists don't feel comfortable with an accommodating [lens] or a multifocal lens; I understand that. But toric lenses should be embraced by everyone. There is really no downside to using a toric lens. Astigmatism is the lynchpin for most ophthalmologists to achieve refractive results.

Dr. Steinert: I would like to thank you both, Dr. Rick Lewis and Dr. Eric Donnenfeld. This has been a terrific opportunity to chat, and you have been educating me, so I appreciate that very much. On behalf of Drs. Donnenfeld and Lewis, I'm Dr. Roger Steinert for Medscape Ophthalmology Insights.


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