MAY 2013

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

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6 Supplement to EyeWorld May 2013 Building a successful toric IOL practice by John Vukich, MD Adding toric IOLs to your armamentarium is quick and easy John Vukich, MD " The steps that surgeons need to take to be successful with toric IOLs are common sense, and they are things that most of us are already doing routinely. " A s you know, cataract surgery has now become refractive surgery. The quality of your work as a cataract surgeon is largely determined by how close your refractive outcome is to your targeted outcome. For patients with astigmatism, toric IOLs can be an attractive alternative, and adding them to your practice can be easy and beneficial. If the astigmatic component is not corrected, the patient will be left with a residual refractive error and a less-than-optimal outcome. To correct astigmatism, we can do limbal relaxing incisions and on-axis incisions for a limited amount of correction. Unfortunately, limbal relaxing incisions are not accurate enough to provide a consistent, desirable result. The best way to approach astigmatism correction in these patients is by implanting toric IOLs. Toric IOLs have been around for more than a decade, starting with the introduction of the STAAR (Monrovia, Calif.) toric IOL, followed by the Alcon (Fort Worth, Texas) toric lens, and most recently by the arrival of the Tecnis toric IOL (Abbott Medical Optics, Santa Ana, Calif.). These lenses have given us the ability to, in a single procedure, treat not only the refractive spherical equivalent but the astigmatic correction. However, to achieve the best possible outcomes with toric IOLs, there are certain preconditions. For example, we must be able to get the axial length and the main keratome- tries correct, and we have to have a good power selection. Beyond that, we also have to place the implant into a very specific axis. Minimal barriers to entry The good news is that this can be easily done by any surgeon who is comfortable doing cataract surgery. It does not require expensive instrumentation, intraoperative aberrometry, or a femtosecond laser to do relaxing incisions. It doesn't require an excimer laser to deliver a postoperative corneal correction. It is a one-step procedure that can be done with minimal preparation in the office. The only pieces of equipment needed are the IOLMaster (Carl Zeiss Meditec, Dublin, Calif.) version of the A-scan biometer and a topographer. As long as the surgeon is comfortable obtaining the image and reading the result, the type of topographer is unimportant. The steps that surgeons need to take to be successful with toric IOLs are common sense, and they are things that most of us are already doing routinely. Topography is the key to determining the patient's suitability for a toric lens. Beyond that, it just becomes a matter of taking care to mark the axis of the intended position of the implant, and that's one additional step that is done prior to the patient lying down on the table to start the operation. This is relatively easy to do, but it requires active participation on the part of the surgeon or a skilled assistant in the preoperative area because accuracy is important. These are the only additional steps, so there are minimal barriers to entry. The rest is just a matter of delivering a consistent result. Sophisticated patients As cataract surgery has evolved into refractive surgery, our patient population has become increasingly sophisticated. The days of, "You're the doctor, you decide" are over. Today's patients are far more involved in their healthcare and the decisionmaking process than ever before. They are also more knowledgeable about the IOL options and potential outcomes. As patients are more aware of their options, they are less resistant to the concept of delivery of a premium outcome. Most patients with astigmatism already know they have astigmatism when they present to our office. They have always paid more for their glasses. Their contact lenses have always had an additional feature and have required special fittings. To begin the conversation about premium lenses, I typically ask patients how much they paid for their most recent pair of glasses. Generally, they will remember. With toric IOLs, there is an additional cost, but they also eliminate the cost of an astigmatic correction in patients' glasses or contact lenses, and they may eliminate the need for spectacle correction altogether. Patients understand and respond well to that. I typically offer astigmatic correction to any patient who has 0.75 D or more of astigmatism. I draw the line at that level simply because I think that's where astigmatic contributions to refractive error become meaningful in a clinical way. However, an argument can be made for offering toric IOLs to patients with lower levels of astigmatism. Dr. Vukich is surgical director, Davis Duehr Dean Center for Refractive Surgery, Madison, Wis. He can be contacted at javukich@gmail.com. 3 reasons to consider adding toric IOLs to your practice Implantation can be easily done by any surgeon who is comfortable doing cataract surgery. Offering toric IOLs does not require expensive instrumentation. Today's sophisticated patients are knowledgeable about premium lenses.

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