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    Aspiring for zero tolerance of residual astigmatism

    Case examples highlight tools, techniques toward quest for excellent visual endpoint

    When considering premium surgeries and high expectations from patients along with an unrelenting quest for vision exceeding 20/20, the tolerance of residual astigmatism must be zero.

    Like bespoke tailors, ophthalmologists need to be bespoke surgeons who tailor vision in each eye to the highest level possible. We cannot claim to design the best suit using the best technology and tailoring materials, and yet, in our minds, find it “acceptable” to have the suit length within a half-inch to three-quarters of an inch too short or wide.

    In my practice—in which I see numerous patients from all over the world who are seeking second opinions and correction of complications—it is common to see patients who express dissatisfaction with their eye surgeons. These surgeons in many cases might have performed good surgeries, but after using expensive technologies (including premium IOL implants), they left their patients with residual astigmatism that was considered to be within an acceptable range (for that surgeon).

    I corrected many of these patients using laser Corneoplastique techniques even up to as low as 0.4 D of astigmatism that resulted in a night-and-day difference (for the patient). This turned distressed patients into those who were very happy with outcomes, which emphasizes my zero tolerance of astigmatism.

    Figure 1 demonstrates the preoperative status of many of my patients who have had premium cataract surgery with their surgeons, which, despite having undergone well-performed surgeries, resulted in half-done outcomes with residual astigmatism that could have been corrected easily.

    Residual astigmatism is the common culprit in most of these cases.

    Astigmatic correction can range from techniques using corneal relaxing incisions created using diamond knives to femtosecond laser correction performed conveniently in the office at intraoperative and postoperative settings, including intraocular scenarios that include the use of toric implants (monofocal/multifocal), and finally laser corneal surgery to correct planned or residual astigmatism to bring every patient to their visual end zone.

    In certain cases, astigmatism also can be used to our advantage as in the cases of patients who have a corneal scar that I approach using Corneoplastique principles. In these cases, I flip the axis of the corneal astigmatism by implanting a toric IOL during cataract surgery in such a way that the axis comes to lie in the direction of the corneal scar.

    I then treat them with laser to both bring the vision to 20/20 and achieve a clear central cornea.

    Astigmatism also can be useful in some cases to help reading vision (as in our experience with monofocal IOLs), while in some cases it can be used to our advantage to help cope with the delicate balance between visual improvement and visual distortion (irregular to regular astigmatism in an advantageous position for vision).

    Arun C. Gulani, MD
    Dr. Gulani is director of refractive surgery and chief, cornea & external disease, as well as assistant professor, department of ...

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