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What will be the role of toric IOLs if femtosecond laser-assisted cataract surgery becomes commonplace?
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Femtosecond methods may reduce role of toric IOLs
 John A. Hovanesian |
There are two reasons why I suspect that the use of toric IOLs will diminish as femtosecond lasers become more prevalent. The first is that the precision offered by toric lenses can be offered as part of the laser procedure that the patient is already paying for. The second follows from the first, and it is cost. There is no reason for a patient to invest in a toric IOL if he or she can get adequate astigmatism control from incisions made with a laser. If a surgeon can achieve good astigmatism control with an incisional procedure, whether it is an LRI made by hand or with a femtosecond laser, he then has the opportunity to use a presbyopia-correcting lens and give the patient more value.
There is room for improvement in LRIs. The most prominent reason that surgeons will want to use femtosecond lasers is to improve the precision of cataract surgery. The improved precision in astigmatism correction over hand-cut LRIs is not to be underestimated. Most surgeons who perform a large number of LRIs and carefully track both their technique and their results report very consistent outcomes with these procedures. Their consistency will only be improved through the automation of these steps with the laser.
John A. Hovanesian, MD, FACS, is an OSN Cornea/External Disease Board Member and practices at Harvard Eye Associates in Laguna Hills, Calif. Disclosure: Dr. Hovanesian is a consultant for Abbott Medical Optics and Bausch + Lomb.
Femtosecond LRIs may complement toric lenses
 Jay S. Pepose |
Time will tell whether the emergence of femtosecond cataract surgery will represent a complementary technology that facilitates and advances the use of toric IOLs. Prospective studies will be required to determine whether the greater uniformity of femtosecond corneal incisions and capsulorrhexis will improve the outcomes of toric IOL implantation, which will also become more refined by other advancing technologies. For example, the accuracy of toric IOLs will likely benefit from progress in intraoperative wavefront aberrometry, particularly new sequential scanning wavefront techniques capable of high-speed, high-resolution measurement and simultaneous display of real-time refractive data throughout the operation. If prospective studies show that femtosecond cataract surgery further standardizes the estimation of the effective lens position, this could further enhance the defocus outcomes of toric lenses, which are recently available in a wider range of toricity.
The use of toric IOLs will likely continue to grow given greater choices of toric powers, along with a number of toric presbyopia-correcting IOLs under investigation progressing through the regulatory pathway. Prospective studies will be required to show whether femtosecond laser LRIs are more predictable than standard LRIs or toric IOLs. While femtosecond LRIs are more likely to be of more uniform depth and placement, all forms of incisional surgery are still likely to be subject to the vagaries of variable wound healing and biomechanical impact. Comparative studies will bear out whether toric IOLs or femto-assisted LRIs are more predictable for each range of pre-existing keratometric astigmatism. Each technique may have some advantages in different circumstances. For example, the LRI may be a bit more regionally titratable than torics in cases of asymmetric topographic corneal astigmatism. In summary, I view the femtosecond laser LRI and toric options as being complementary and even potentially additive in some situations.
Jay S. Pepose, MD, PhD, is director and founder of Pepose Vision Institute and professor of clinical ophthalmology at Washington University School of Medicine in St. Louis. Disclosure: Dr. Pepose is a consultant to Abbott Medical Optics and Bausch + Lomb.