LIMBAL RELAXING INCISIONS (LRI)

Pembimbing:

dr. Henry A Wibowo, Sp.M (K)

Disusun oleh :

Aswan Bagastoro (1102014045)

KEPANITERAAN KLINIK ILMU MATA

FAKULTAS KEDOKTERAN UNIVERSITAS YARSI

RUMAH SAKIT BHAYANGKARA TK. I R. SAID SUKANTO

PERIODE 8 APRIL 2019 – 11 MEI 2019

 Introduction

Astigmatism is an optical defect in which vision is blurred due to the inability of the
optics of the eye to focus a point object into a sharp focused image on the retina.1 Astigmatism
decreases visual acuity through meridional blur; one axis of the cornea is steeper than the other,
causing the cornea to distort image.2 Astigmatism can be reduced or eliminated by a variety of
surgical techniques, including selective positioning of the phacoemulsification incisions,
corneal relaxing incisions (CRI s), limbal relaxing incisions (LRIs), excimer laser keratectomy,
and toric intraocular lens (IOL) implantation.1,2

Limbal relaxing incisions (LRIs), whether performed as standalone procedures or

during cataract surgery, provide the surgeon with a tool to improve patients’ quality of vision,
quality of life, and satisfaction with their cataract surgery.3 .The limbal relaxing incisions
(LRIs) technique involves the placement of incisions corresponding to the steep meridian,
resulting in corneal flattening and the reduction of astigmatic power. 4

LRIs are one of the most commonly performed adjunctive procedures with
phacoemulsification to correct preexisting astigmatism, primarily because of the cost
effectiveness and the predictable surgical profile. 1 Furthermore, reducing corneal astigmatism
with LRIs is more cost effective and convenient than other techniques.1,2

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Definition
Limbal relaxing incisions (LRIs) are partial-thickness corneal incisions placed adjacent
to the limbus along the steep meridian to correct minor astigmatism in the eye. Incisions are
made at the opposite edges of the cornea, following the curve of the iris, causing a slight
flattening in that direction. Because the incisions are outside of the field of view, they do not
cause glare and other visual effects that result from other corneal surgeries like Radial
Keratotomy. LRIs, whether performed as standalone procedures or during cataract surgery,
provide the surgeon with a tool to improve patients’ quality of vision, quality of life, and
satisfaction with their cataract surgery. 1,2

History
The ideal refractive surgical procedure is simple to perform, inexpensive, and
applicable to a wide range of ametropias. Astigmatic keratotomy (AK) is one such procedure.
Astigmatic keratotomy is used to treat numerous refractive disorders, including congenital
astigmatism, residual corneal astigmatism at the time of or following cataract surgery, post-
traumatic astigmatism, and astigmatism after corneal transplantation.5

Even with the extensive use of excimer laser vision correction platforms to treat
refractive error (eg, photorefractive keratoplasty [PRK], LASIK), astigmatic keratotomy
continues to be a valuable and versatile tool for the treatment of many eyes. Early investigative
surgeons of astigmatic keratotomy, Thornton, Buzard, Price, Grene, Nordan, and Lindstrom,
demonstrated the efficacy, safety and reproducibility of refractive outcomes, and led, albeit
over more than a decade, to the adoption of the procedure by the broader ophthalmological
community.5

Within the past few years, much consideration has been given to an evolutionary variant
of the procedure, the limbal relaxing incision (LRI). By moving the incision farther to the
periphery, cataract surgeons can safely and predictably remediate mild to moderate amounts of
regular astigmatism at the time of cataract surgery by performing this incisional technique,
either by hand or by application of femtosecond laser technology. Glare from spread of the
incisional scar toward the pupil is a potential problem for the cataract surgical patient, for whom
postoperative quality of vision is paramount. Any infection near the center of the cornea has
serious consequences. For these reasons, AK has largely been supplanted by limbal relaxing
incisions. 5
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Nomograms
Notable surgeons such as Louis “Skip” D. Nichamin, MD4; Douglas Koch, MD5; and
James Gills, MD,6 have proposed different nomograms for correcting small amounts of
cylinder with LRIs. Although these formulae are meant to simplify the placement of the
incisions, their specific adjustments for age and axis cylinder can give the impression that the
procedure is overly complex, precise, and unforgiving. In general, surgeons should practice the
basic techniques for placing LRIs and eventually develop their own nomograms to achieve
consistent results.6

(Figure 1. The Donnenfeld Nomogram For LRIs)6

(Figure 2. Modified Gills Nomogram For LRIs)7

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 Several nomograms have been proposed for determining AK and LRI positioning and
length. Most nomograms are adjusted for age, sex, and cylinder axis, making them detailed and
complex, and this may give the impression that these procedures are extremely precise and
unforgiving. Placement of astigmatic incisions, especially manual ones, remains as much an
art as it is a science. 2,6

For novice surgeons, a simple nomogram may be favored, such as the Donnenfeld
nomogram, which works extremely well for this purpose (Figure 1). The online calculator
employs vector analysis to calculate incision parameters based on preoperative patient
keratometry, surgically induced astigmatism, and the location of a planned primary cataract
incision. If the Donnenfeld or Nichamin nomogram is used, a visual map showing the axis and
lengths of incisions will be provided, and a printout of the LRI calculator can be brought to the
OR and used as a guide when marking the cornea and performing the LRIs. In general, it is
best for surgeons to practice the techniques of LRIs and develop their own nomogram to
achieve consistent results. A very useful resource is the website www.lricalculator.com. It
provides a vector analysis of the cataract incision to fine-tune astigmatic results and an image
that can be brought to the OR. The website uses both the Donnenfeld and Nichamin
nomograms. 2,6

(Figure 3 . The Donnenfeld nomogram (LRIcalculator.com))3

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Indications
LRI procedures can remediate or lessen astigmatism in numerous refractive
presentations as either a stand-alone procedure or one that can be easily combined with other
forms of surgery. This versatility, the simple surgical setup, and the production of predictable
outcomes make this procedure a useful tool for all refractive surgeons, even with the
advancement of laser surgery. 5

LRI surgery combined with or following cataract surgery is frequently used as an

ancillary refractive procedure in patients presenting with topographical regular astigmatism at
the time of cataract surgery. The addition of an arcuate incision or incisions when the patient
exhibits 0.75-2.75 D of regular astigmatism improves the likelihood of attaining excellent
uncorrected vision postoperatively. 5

LRI procedure becomes even more important when multifocal IOLs are chosen
because satisfactory simultaneous uncorrected vision at distance and near can be obtained only
with a nearly spherical cornea. At the time of this writing, toric multifocal IOLs are not
available in the United States, so the need for concurrent astigmatic correction must rely on
either manual or laser-assisted incisional placement to mitigate mild to moderate amounts of
astigmatism. 5

A more traditional keratorefractive approach outside of cataract surgery involves

using astigmatic keratotomy/LRI surgery in patients who exhibit mixed astigmatism. When a
patient requests vision correction surgery and has a refractive error with a spherical equivalent
approaching zero (eg, -1.00 + 2.00 X [any axis]), PRK or LASIK may not be necessary. 5

While an astigmatic keratotomy procedure may appear redundant to PRK or LASIK

treatment before or after refractive surgery, synergy between the techniques may benefit some
patients. For instance, patients who present with high astigmatism may find that the combined
treatment of PRK/LASIK with astigmatic keratotomy may provide a more satisfactory visual
result than PRK or LASIK alone. By first reducing high amounts of cylinder by 2-3 D with an
LRI, lesser amounts of astigmatic laser correction are needed, allowing for the use of larger
optical zone sizes, which ultimately provides for a smoother optical zone transition. This
enhanced transition lessens the degree of nighttime glare and ghosting and provides for overall
better vision quality. With regard to post-LASIK astigmatic keratotomy surgical interventions,
performing an astigmatic keratotomy may be preferable to lifting a well-healed LASIK flap in
patients who go on to develop significant astigmatism. 5

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Contraindications
All surgical procedures may provide suboptimal outcomes. While the LRI
procedure is thought to create less glare and optical artifacts than its predecessor, astigmatic
keratotomy, the most common side effects remain overcorrection and undercorrection of
astigmatism. Infection, corneal perforation, and decreased corneal sensation are possible
sequelae. 5

Patients with high astigmatism due to Terrien degeneration, Mooren ulcer, or any
disease or dystrophy that produces peripheral corneal thinning should not undergo astigmatic
keratotomy/LRI incisions owing to the progressive risk of corneal thinning and evolving
astigmatism, potentially leading to perforation. 5

Patients with chronic diabetes, chemical burn, or other causes of ocular surface
disease should be approached with increased caution, as re-epithelialization problems after
corneal surgery may ensue. 5

Caution should be exercised when considering an astigmatic keratotomy/LRI

procedure in patients with connective-tissue diseases (eg, rheumatoid arthritis). Patients with
extreme dry eye, whether related to rheumatoid arthritis or not , require close follow-up care if
undergoing this procedure, as they are more prone to ocular discomfort, dryness, poor healing
and potential thinning due to corneal melting. 5

Patients with astigmatism who previously underwent radial keratotomy may later
present for astigmatic "enhancement." LRI surgery is a reasonable option in these patients, but
the surgeon should take care when orienting the new incisions. The crossing of a radial incision
with a transverse incision, even years after the initial procedure, may produce excessive and
unwanted overcorrection. It is recommended to preoperatively map the faded RK incisions,
identifying their location with useful landmarks. Since most RK incisions approach the limbus,
surgeons should avoid crossing the RK incision with a long, uninterrupted LRI incision.
Instead, they should use multiple smaller LRI incisions straddling the RK incisions to obtain
the desired effect. As can be imagined, it is especially difficult to perform astigmatic correction
through LRI incisions in a patient who has undergone a 16-incision RK. 5

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The Role of LRIs
For many ophthalmologists, the management of astigmatism is one of the most common
rate-limiting steps that prevents patients from achieving optimal quality of vision and
satisfaction after refractive cataract surgery. If we want to provide our refractive IOL patients
with successful surgical outcomes, we need to treat their residual postoperative astigmatism.
Although ophthalmologists can accomplish this goal with excimer photoablation and
conductive keratoplasty, they should not dismiss LRIs as a valid alternative. LRIs are a valid
alternative or adjunctive therapy, Although the use of manual LRIs has been an art form with
inherent surgeon variability and predictability and although LRIs require expertise, there is
enormous value to using this technique for today’s cataract surgery patients. 2,6

Cost-Effective Alternative for Small Refractive Errors

Most patients tolerate postoperative astigmatism of 0.50 D or less. New incisional
technologies such as the femtosecond laser offer greater predictability and a repeatable incision
depth, and laser arcs can be more centrally located compared to LRIs3; however, patients and
surgeons should evaluate the cost-effectiveness of a manual LRI, which is certainly a better
alternative to no treatmentat all. There is a myth in the refractive surgery world that IOL
patients will tolerate small refractive errors. Nothing could be further from the truth. All
cataract surgery patients particularly those receiving presbyopia-correcting IOLs are incredibly
sensitive to even minor cylindrical errors. Refractive IOL surgeons must be willing and able to
treat postoperative astigmatism to achieve happy postoperative patients.6

Zero Tolerance Policy

A common belief about refractive surgery is that patients who receive presbyopia-
correcting IOLs willingly tolerate small refractive errors after cataract surgery. In fact, nothing
could be further from the truth. These individuals are incredibly sensitive to even minor
refractive errors, including astigmatism. Found that most patients can tolerate postoperative
astigmatism of 0.50 D or less. 2

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Nomograms Are Too Complex

Notable surgeons such as Louis “Skip” D. Nichamin, MD1; Douglas Koch, MD2; and
James Gills, MD,3 have proposed different nomograms for correcting small amounts of
cylinder with LRIs. Although these formulae are meant to simplify the placement of the
incisions, their specific adjustments for age and cylinder can give the impression that the
procedure is overly complex, precise, and unforgiving. Instead, believe that LRIs are as much
an art as a science. In general, it is best for surgeons to practice the basic techniques for placing
LRIs and eventually develop their own nomograms to achieve consistent results. 2,6

Inadequate Equipment
Another inaccurate assumption about why surgeons hesitate to perform LRIs is that
they are not comfortable with this technique. Instead, surgeons do not perform LRIs as often
as they could because they do not have access to operating microscopes in their offices. A
simple solution in this situation is to perform LRIs at the slit lamp (Figure 3). Prepare patients
for in-office LRIs by anesthetizing their eye with lidocaine gel. When satisfied that the patient’s
head is positioned correctly on the chin rest, look at his eye through the phoropter and use a
diamond blade to create a small LRI, just as it would under an operating microscope. One small
incision will correct 0.50 to 0.75 D of cylinder. The whole procedure takes approximately 30
seconds, and the patient’s vision improves immediately. To prevent postoperative
inflammation and infection, prescribe prednisolone acetate 1% and gatifloxacin 0.3% q.i.d. for
5 days. 2

(Figure 4. Performed LRI at Slit Lamp)2

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Pros and Cons
1) LRI or Toric IOL
In 1995, the use of foldable lenses allowed reduction of the width of the incision, first
to 3.2 mm and then to 2.2 mm. Dr. Ligabue also started to perform corneal limbal relaxing
incisions (LRIs) using the nomogram developed by Louis D. “Skip” Nichamin, MD.1 The
technique was attractive given that, apart from corneal surgery with the excimer laser, there
were no real alternative techniques for astigmatism reduction until the introduction of toric
IOLs in 2004. 8

Insight and Advantages:

Preoperative examination
In the routine preoperative examination of toric IOL candidates, careful evaluation of
corneal topography and astigmatism is required. These measurements must be as accurate as
possible in order to precisely determine the positioning axis. It is advisable to perform
Scheimpflug corneal tomography, which allows assessment of the posterior surface of the
cornea. Proper evaluation of the tear film and assessment for the presence of contact lens
warpage are key in order to avoid artifacts and unreliable data collection.8

Marking
Marking is crucial for both LRI positioning and toric IOL alignment. Our routine
marking system is to identify the axis 0° to 180° at a slit lamp with a chin rest, using a marker
with bubble horizontal reference (E. Janach; axial marker JSL9000) before treatment with the
femtosecond laser. The axis of alignment is then marked intraoperatively using a modified
Mendez ring Calculations. For LRIs, the nomogram used is always approximate, and it is
impossible to take into account all of the variables involved, such as corneal response, actual
cutting depth, distance of the corneal incisions from the center, etc.
For toric IOLs, use the online calculator provided by the relevant lens manufacturer.
Estimate only the keratometry reading of the anterior surface of the cornea because the
posterior cornea has little influence on outcomes. In reality, they still do not have a reliable
calculation formula that also takes into account the posterior cornea. The available calculators
are accurate if the refractive target is emmetropia; however, if the target is myopia, the
calculation will result in an undercorrection of about 0.50 D or more. Correction. Toric IOLs
allow correction of 0.75 D to 10.00 D of astigmatism, depending on the lens and manufacturer.

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LRIs produce good results up to about 2.00 D of astigmatism. Beyond this value, the correction
is variable, and it is difficult to exceed 3.00 D. 8

Reliability
In terms of reliability, accuracy, and confidence in results, toric IOLs are, superior to
LRIs because they require less approximation and craftsmanship of execution to achieve good
results. In regard to long-term stability, toric IOLs are also in the lead. In fact, the rotational
stability of these IOLs in the capsular bag is maintained even after 5 years. 8

Cost
From a cost perspective, LRIs are less expensive than toric IOLs, but a high level of
surgeon experience is required to achieve acceptable results. In contrast, toric IOLs are more
expensive, but they can be used successfully by any ophthalmic surgeon.8

Enhancements
In the event of an unsatisfactory result, LRIs can be extended in the case of an
undercorrection; nothing can be done to fix an overcorrection. Toric IOLs can be repositioned
in the event of a misalignment. If an enhancement is necessary, evaluation with an aberrometer
such as the OPD Scan III (Nidek) is useful, as this can indicate exactly how many degrees the
IOL is out of alignment6 (Figure 4). 8

(Figure 5. Evaluation of Alignment and of Capsulotomy Centration)8

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 (Figure 6. Comparison of LRIs and Toric IOLs)8

Conclusion Between RLIs and Toric IOL

Based on research performed by Batra, 2015 Both limbal relaxing incisions/laser
arcuate incisions and toric lenses can be used to successfully treat 1.00 D of cornea
lastigmatism. The keys are verifying the axis of astigmatism, checking the refraction in
comparison to the topographic astigmatism, accounting for posterior corneal cylinder, and then
planning the astigmatic correction. Once the plan is created, I find it is important to adjust for
cyclotorison and to use intraoperative aberrrometry to refine the astigmatic correction. cataract
surgery requires superior refractive outcomes in the correction of astigmatism, and, in our
opinion, only toric IOLs can guarantee these results. However, in order to achieve success with
toric IOLs, it is imperative that all of the necessary precautions be followed before and during
implantation. Each measurement and each step can generate a small percentage of error. If all
steps of the evaluation, calculation, and surgery are optimized, great results can be achieved
every time.8,9

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2) RLIs or Femtosecond Laser Arcuate Keratotoymy

Limbal relaxing incisions or femtosecond arcuate keratotomies have been found to be

efficacious in the management of low to moderate astigmatism (2.5 to 3.0 D) but are less
suitable for moderate to high astigmatism, which requires toric IOLs or bioptics.10
The femtosecond laser can perform, with reliability and reproducibility, several steps
of cataract surgery. These include the creation of arcuate keratotomies, which are performed to
reduce corneal astigmatism at the time of surgery. Based on research performed by Roberts
HW et al, 2018 said that Both techniques have been shown to be efficacious at reducing corneal
astigmatism but have not yet been directly compared. They used the femtosecond arcuate
keratotomy nomogram originally described by Day et al. notwithstanding 2 important
differences. First, we used a different femtosecond laser platform and second, unlike the study
of Day’s group, in which the main incisions were consistently temporal, they elected to perform
our main incisions on axis when possible (eg, accounting for surgical access). In summary, we
found that both manual LRIs and femtosecond laser intrastromal arcuate keratotomies were
safe and easy to perform, with both achieving a meaningful reduction in corneal astigmatism.
However, the laser group achieved a correction of greater magnitude than the LRI cohort 4
weeks after surgery. 10
The use of the femtosecond laser to perform corneal incisions, capsulotomy, and lens
fragmentation undoubtedly offers many advantages, including the following:8
 Perfect incisions with standardized surgically induced astigmatism;
 A centered and perfectly circular capsulotomy;
 Stable and well-centered IOL positioning without lens tilt (Figure 6);
 Superior rotational stability in the capsular bag; and
 Excellent refractive predictability.

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 (Figure 7. An enVista Toric IOL behind a femtosecond laser created capsulotomy)10

Step by Step

The OR is the best place to start performing astigmatic incisions, which are often
combined with routine cataract surgery. When cataract surgery is planned, it is important to
account for astigmatism, whether preexisting or surgically induced. Residual astigmatism of
0.50 D or even less can result in glare, symptomatic blur, ghosting, and halos. The reduced
quality of vision associated with residual astigmatism after cataract surgery is magnified in
patients with multifocal IOLs. As a result, in recent years, increased emphasis has been placed
on treating corneal astigmatism at the time of cataract surgery.3
For surgeons beginning to add LRIs to their skill set, it may be preferable to start with
peribulbar anesthesia and conventional monofocal IOLs, as patients implanted with
presbyopia-correcting IOLs are significantly more sensitive to even minor refractive errors.
The astigmatic incisions should be performed at the start of the case, while the eye is firm,
before any manipulation takes place or dehydration of the cornea occurs due to instrumentation
or the operating microscope. 3
It is a good idea to mark the cornea, especially for large cylindrical errors. To create an
incision, the episclera is grasped at the limbus with 0.12-mm forceps approximately 180º away

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from the intended incision site. Approaching perpendicular to the cornea, a diamond knife with
a preset depth guard is advanced into the cornea 0.5 mm central to the limbus, centered on the
axis as determined by vector analysis of residual cylinder. Multiple companies manufacture a
variety of preset diamond knives. My preference is for a 0.6-mm preset depth. 3
After it is advanced to the desired depth, the knife is held in position for 1 full second
to ensure that the full depth of the blade is achieved Creation of a shallow, ineffective incision
is one of the most common mistakes for novice surgeons. The incision is then extended to its
desired length. For control purposes, it is always preferable to cut toward oneself.
After the surgeon becomes comfortable with the technique, astigmatic incisions can be
employed on any patient undergoing cataract surgery, especially those who are likely to end
up with 0.50 D or more of residual cylinder. 3

The effectiveness of LRI was evaluated by comparing pre- and postoperative

topographic astigmatism.16 Effectiveness was analyzed using the mean and standard deviation
of the postoperative topographic astigmatism at months 2 and 6 after surgery. The vector
analysis method was used to evaluate the efficacy of astigmatic correction (method of Kaye
and Patterson).17 The safety of the LRI procedure was evaluated by recording of the intra
operative and postoperative complications and subjective symptoms. Stability of procedure
was evaluated by the variability of the mean topographic astigmatism through 2nd and 6 th
months postoperative follow-up examinations.8

At the Slit Lamp

Alternatively, experienced surgeons may elect to perform LRIs as an in-office,

standalone procedure under the microscope or at the slit lamp. Slit-lamp LRIs are a 30-second
procedure, and typically patients walk out of the room seeing better than they did entering. 3
To perform LRIs at the slit lamp, the phoropter is used to locate the incision axis and then
placed adjacent to the patient’s eye with the cylinder stripe aligned on the steep axis of
astigmatism. Lidocaine gel is administered into the operative eye, and the patient should be
comfortable with his or her head placed forward against that slit lamp’s headband. With an
angled preset diamond knife coming from the side, the surgeon performs the procedure as
previously described (Figure 3). Postoperatively, a regimen of topical antibiotics and
antiinflammatory drops four times daily for 5 days is recommended. 3

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 (Figure 8. LRIs Procedure)7

(Figure 9. Preoperative and six months postoperative topography)7

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Complications

As with any surgical procedure, there are potential complications associated with
astigmatic incisions, but most are temporary or correctable.Complications associated with LRIs
have been reported. Possible complications include overcorrection, undercorrection,
perforation of the LRI incision, gaping of the LRI incision, glare, mild to severe dry eyes,
itching, and discomfort. 3,11
For both under- and overcorrection, it has been suggest to wait for the refraction to
stabilize. A waiting period of 1 to 2 months is typically adequate; however, this is highly
surgeon-dependent. In patients with significant remaining astigmatism, it may be necessary to
retreat by deepening or enlarging the original incision. For over-corrected patients, the original
incision should be cleaned with the assistance of a Sinskey hook and then partially sutured
closed with 10-0 nylon or polypropylene suture.3,11

Conclusion

Astigmatic corneal surgery with a diamond knife can dramatically improve the
refractive results of cataract surgery. Astigmatic corneal surgery can be performed
intraoperatively or postoperatively in order to titrate residual corneal cylinder. The most
common rate-limiting factor for refractive results after cataract surgery is residual astigmatism,
and astigmatic incisional corneal surgery is often the best solution to improve patients’
refractive results and overall satisfaction. LRI is effective in correcting corneal astigmatism
during ICL surgery and phacoemulsification it appears to be safe and fairly effective to correct
mild to moderate amounts of corneal astigmatism, while it tends to undercorrect
astigmatism.3,4,7

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Referrences

1. Lončar VL, Vicković IP, Iveković R, Mandić Z. Limbal relaxing incision during cataract
surgery. Acta Clin Croat 2012; 1(51): .
2. Donnenfeld ED. The Importance of LRIs. Catarat & Refractive Surgery Today 2008; 1(1):
3. Donnenfeld ED. LRI Basics. Catarct & Refractive Surgery Today Europe 2019; 1(2): .
4. Li Z, Han Y, Hu B, Du H, Hao G, Chen X. Effect of Limbal relaxing incisions during
implantable collamer lens surgery. BMC Ophthalmology 2017; 17(63): .
5. Hays J. Astigmatic Keratotomy for the Correction of Astigmatism.
https://emedicine.medscape.com/article/1220380-overview#a6 (accessed 4 May 2019).
6. Donnenfeld ED. The Role of Manual LRIs In Today's World. Catarat & Refractive
Surgery Today 2015; 1(1): .
7. Zare MA, Tehrani MH, Gohari M. Management of Corneal Astigmatism by Limbal
Relaxing Incisions during Cataract Surgery. Iranian Society of Ophthalmology 2010; 22(1): .
8. Ligabue E, Giordano C, Gangwani V. Toric IOL or LRI?. Catarat & Refractive Surgery
Today Europe 2016; 1(1): .
9. Batra N. Toric IOL or LRI?. Catarat & Refractive Surgery Today 2015; 1(1): .
10. Roberts HW, Wagh VK, Sullivan DL, Archer TJ, O’Brart DPS. Refractive outcomes after
limbal relaxing incisions or femtosecond laser arcuate keratotomy to manage corneal
astigmatism at the time of cataract surgery. ASCRS and ESCRS 2018; 1(1): .
11. Lim R, Borasio E, Ilari L. Long-term stability of keratometric astigmatism after limbal
relaxing incisions. ASCRS and ESCRS 2014; 1(1): .

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