JAN 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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10 EW NEWS & OPINION January 2013 Anterior segment grand rounds Taking the spin out of toric rotation: Part 2 by Steven G. Safran, M.D. T his is the second case in a two-part series looking at the subject of toric rotation and how to manage it. This is a young, male, high myope (53 years old) with a history of macula-off retinal detachment (RD) repair in the right eye who presented with rather impressive cataracts in both eyes. I did cataract surgery in the left eye first with a standard monofocal IOL, and the patient did very well with a 20/20 uncorrected outcome. The OD had 1.75 diopters of cornea astigmatism with the steep axis at 100 degrees and is 27.35 mm so an 11 diopter T4 was chosen with a surprisingly good post-op day 1 visual outcome—20/40+ uncorrected. This is a bit better than expected because of the history of a macula-off detachment. At one week post-op, however, he noticed that his vision had dropped, and he presented with uncorrected 20/100-1. The axis of the lens has rotated from 100 degrees as planned to 67 degrees. He refracts to about 20/30 with an Rx that includes about 1.5 D of astigmatism. The other eye is plano = 20/20. He is an avid golfer and sportsman and would like to avoid glasses for distance. What would you do? He's one week post-op, and the IOL has rotated 33 degrees off axis, completely negating the astigmatic benefit of the toric lens. Figure 1 is his post-op photo at one week showing the lens at 67 degrees when it should be at 100 degrees. Steven G. Safran, M.D., ASGR editor Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) M ichael Wong, M.D., Princeton Eye Group, Princeton, N.J., commented, "Toric IOL rotational stability derives from at least five factors: rotational friction of the haptics at the equator of the capsular bag, the square edge of the profile of the IOL, the tackiness of the acrylic material, the adhesiveness of fibronectin between the IOL and bag, and later the fibrosis of the capsular leaves around the haptics. "Conversely, post-operative rotation of the IOL can occur if the diameter of the bag is larger than the 13.0 mm haptic diameter (such as with a high myope), if there has been a disruption of the zonular apparatus so that the bag is not round (the IOL will tend to drift toward the greatest diameter), lack of evacuation of the VED (countering the effect of the tackiness of the acrylic material or laying down of fibronectin), or zonular variation or anterior capsular fibrosis that diminishes the fibrosis or 'shrink wrapping' of the capsular leaves (a case for not vacuuming all of the subanterior capsular cells). "This case is a high myope, but in addition, he had a vitrectomy. This surgery increases the risk of zonular disruption, making the bag irregular. In this case, insertion of a CTR makes sense. "In my experience, sometimes practice does not follow theory. There are unexplained rotations and inexplicable refractive surprises. I then turn to corneal laser vision correction to erase the residual refractive error when not contraindicated." Lisa Arbisser, M.D., adjunct clinical associate professor, John A. Moran Eye Center, University of Utah, Salt Lake City, and in private practice, Eye Surgeons Associates, Iowa and Illinois Quad Cities, would also implant a CTR here. "Since the CCC is on the optic, you can open the bag and insert a CTR and rotate the lens." Jeff Horn, M.D., Vision for Life, Nashville, Tenn., on the other hand, would simply wait a bit, rotate and only use a CTR to facilitate rotation if it were proving to be difficult otherwise. "In this patient whose lens has rotated, I would wait at least three more weeks for the capsule to Figure 1: Post-op at one week shows the lens at 67 degrees. begin to contract. There is no rush. I would then return to the OR, viscodissect the lens with a dispersive OVD, and rotate it to the proper axis. If there were any difficulty in rotating it, I would implant a CTR, and then rotation will be easy." Stephen Lane, M.D., medical director, Associated Eye Care, St. Paul, Minn., and adjunct professor of ophthalmology, University of Minnesota, would choose the option of anterior optic capture to "lock" the lens in place. "While keratorefractive procedures could be considered, they do not solve the basic problem of the lens being out of position, and the lens may continue to be unstable and rotate down the line. The photograph shows a wellpositioned toric IOL in the bag with good overlap of the anterior capsule over the optic (at least for the 270 degrees or so that I can see). After viscodissecting the IOL free, I would prolapse the optic in front of the rhexis (reverse capsule capture) and rotate it to the proper position on the steep axis. This can be done quite atraumatically with minimal risk." Because I have no personal experience with anterior optic capture, I was a bit uncomfortable with the idea of purposefully putting part of a single-piece AcrySof implant (Alcon, Fort Worth, Texas) anterior the rhexis where it could potentially contact the iris. I asked about experience with reverse optic capture (ROC) using the single-piece AcrySof platform on the ASCRS chat board and got this response from Jason Jones, M.D., medical director, Jones Eye Clinic, Sioux City, Iowa. "ROC is a capsule fixation technique where the haptics of the IOL are posterior to the anterior capsule and the optic is brought forward (captured) by the intact CCC. Several anatomic elements must be respected here. The CCC must be intact, smaller than the optic, and well centered. The zonules must be stable. And the CCC must be free of any vitreous (if the PC has been breached). Ideally the configuration of the iris relative to the capsule should be assessed; I don't have any numbers to recommend here, but there should be good clearance to avoid iris-optic contact. Given that the cataract has been removed and the IOL occupies much less space, I feel it is reasonable to assume most (not all) eyes will avoid such contact. In the case of repositioning a toric with ROC, this can and should be considered. Once the lens is rotated into position then the optic can be brought forward to obtain capture. … Now, I have not had an opportunity to use ROC for a misbehaving toric lens. But I have implanted a series of AcrySof singlepiece acrylic IOLs using ROC. In these cases the PC was damaged during primary surgery, and I elected to use this technique. All of my patients have done very well with clear visual pathways, no UGH syndrome, no RD, no decentration, and with up to four years or more follow-up in select cases. This is not sulcus fixation, and the issues that AcrySof SPA IOLs in the sulcus have encountered should not be conflated with ROC." Dr. Jones' experience with this technique should be comforting to those who may consider it. In a fol-

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