Case 6 was my own patient who sought my services for cataracts associated with bitemporal, elevated scars on her corneas with high irregular astigmatism of nearly 5.8 diopters and topographic distortion. Contact lenses were not possible because of patient discomfort and the irregular corneal shape.
I usually always work on such a cornea first to make it measureable and then proceed with cataract surgery, but she was a young school teacher and could not take that much time off work (four elevated scar-pterygium complexes/lesions, one on each side of her corneas) and so I relented and proceeded with refraction like I always do and for some reason (also because the IOLMaster (Zeiss) could not measure her axial length/Ks or IOL powers) in this case I did not believe her astigmatism and its high correlate given her improving to 20/70- with my refraction, my plan therefore being to perform laser ASA as a staged procedure to get her to emmetropia after cataract surgery.
On performing her cataract surgery, I came to my end zone of plano spherical error despite poor reliability of her automated calculations but when I saw her astigmatism to actually be the nearly 6 diopters that was measured by me at all levels (though inconsistent) preoperatively, I could improve her vision even more. Now, I could certainly do her laser ASA but instead I could save her the cost of laser correction and healing and instead max out the toric IOL (SN6AT9, Alcon) and exchanged her toric IOL for the highest toric IOL available. She was extremely pleased with her unaided vision. She did not proceed with planned laser stage as she is very happy with her unaided vision for the first time in her life.
This is an example of maxing out on available technology using the 5S system and also getting personal with the decision to help patients to their end zone once the direction of that end zone was confirmed immediate postoperatively.