Irregular Astigmatism & honing your K incision Uday Devgan MD Private Practice, Devgan Eye Surgery, Los Angeles
Uday Devgan MD Current Disclosures: Aaren Scientific: consultant Accutome Inc: royalties Alcon Laboratories: consultant Bausch + Lomb: consultant Gerson Lehman Group: consultant LensGen: consultant, stockholder Omeros: consultant Optimedica: consultant Slack / OSN: speaker Specialty Surgical: stockholder Former Relationships: AMO / Abbott: consultant, speaker Allergan: consultant, speaker Eyeonics: consultant, stockholder Haag-Streit: speaker Hoya Surgical Optics: consultant Ista Pharma: consultant itherapeutix: trial, travel support Optos: speaker Staar Surgical: consultant,speaker Zeiss / Carl Zeiss: speaker My presentation may include OFF-LABEL use of devices and/or medications. This talk represents my personal opinion as a surgeon.
Even 1D of Astigmatism degrades image quality
Irregular Astigmatism Can I fix it during cataract surgery?
Fix the irreg. astig. BEFORE cataract surgery
Remove Pterygium months BEFORE Cataract Surgery
9 Diopters of Induced Irregular Astigmatism from the Pterygium!
EBMD / Map-Dot-Fingerprint Scrape Epithelium and wait! Scrape Epithelium Wait for K to stabilize (months) Now plan Cataract Surgery
Epithelial Ingrowth after LASIK poor vision: 90% ingrowth + 10% cataract Lift LASIK flap + remove cells Suture flap and wait and wait
Dry Eye Syndrome Punctate Keratitis causes irregular topography!
Address irreg. astig. AFTER cataract surgery
Do NOT touch the cornea during phaco Consider scleral tunnel phaco incision Keratoconus with dense cataract Address KC with RGP CL, CXL. or Surgery later
Traumatic Corneal Injury + Cataract Fix the cataract first, address corneal issues later Consider scleral tunnel phaco incision Seidel check the cornea after phaco
Old Corneal Scar cataract surgery alone may be enough
Highly Irregular (K 72 x 42)
You re not going to be able to fix this RGP contact lenses may be helpful 32 cut RK too irregular, too unstable
You re not going to be able to fix this RGP contact lenses may be helpful 32 cut RK too irregular, too unstable
Decentered LASIK ablation Now with PSC cataract No way to fix this with an IOL
Do NOT attempt to fix astigmatism if it s: Very Irregular Centrally Asymmetric Unstable Pellucid Marginal Degeneration
Sometimes the best surgery is no surgery at all.
Fix the irreg. astig. AT TIME OF cataract surgery
Regular, Symmetric Astigmatism is easily treated during cataract surgery Symmetric Regular Stable
LRI to treat regular, symmetric astig.
Toric IOL for regular, symmetric astig.
Look at the central cornea
If the central cornea is relatively symmetric, then a toric IOL can be reasonable
Look at Central K on topo Some K irregularity But regular within pupil zone
Central K: regular Peripheral K: irregular Prior CK
Case Example 1 FFKC Forme Fruste Keratoconus
Referring Doc s Mom / FFKC Hx of monovision in soft toric contact lenses (was doing goal of plano OD and -2.00 OS) -6.00+1.50x090-4.50+1.50x090 20/60 BCVA 20/70 BCVA (20/20 BCVA 10 yr old records 20/25- BCVA)
1.5 D K cyl OU / some irreg OS Screening test shows inferior steepening OS
OD looks good => use Toric IOL 1.5 D of WTR K cyl OD Regular, symmetric
OS has inferior steepening but is reasonable in pupil zone 1.5 D of WTR cyl OS Inferior Steepening OS
Asymmetric K Astigmatism / FFKC K 46.50 x 90 / 45.00 OD (clean mires) K 47.25 x 100 / 45.25 OS (slight inferior distortion of mires) Keep same monovision arrangement Use Toric IOLs to address astigmatism
Asymmetric K Astigmatism / FFKC OD: Rx of plano achieved = 20/20- sc -0.25+0.25x090 = 20/20 OS: Rx of -1.50 achieved = J1 sc -1.75+0.50x100 = 20/25
Case Example 2 Prior RK 8-cut radial keratotomy
Prior 8-cut RK, now cataracts
Prior 8-cut RK, now cataracts
Prior 8-cut RK, look at topo Look at central K on topo
Reasonable Symmetry in Pupil Zone
Reasonable Symmetry in Pupil Zone
Toric IOL Calcs
Phaco incision between RK cuts
POD 1: looks great
After 1 week 20/25 UCVA
After 1 month MRx -0.50 sph
If you remember just ONE thing
Look at the K topo in the pupil zone If treatable pre-op condition, address it first If K is highly irregular or unstable, don t touch it If central K zone is ok, toric IOL is reasonable
Thank you