Eyeworld

32 | EYEWORLD | SUMMER 2025 ATARACT C About the physicians Soroosh Behshad, MD, MPH Associate Professor of Ophthalmology Gavin Herbert Eye Institute University of California, Irvine Irvine, California Bryan Lee, MD, JD Altos Eye Physicians Los Altos, California Robert Osher, MD Professor of Ophthalmology University of Cincinnati College of Medicine Medical Director Emeritus Cincinnati Eye Institute Cincinnati, Ohio Mitchell Weikert, MD Professor Cullen Eye Institute Baylor College of Medicine Houston, Texas Reference 1. Osher RH. Iris fingerprinting: new method for improving accuracy in toric lens orienta- tion. J Cataract Refract Surg. 2010;36:351–352. Relevant disclosures Behshad: None Lee: Zeiss Osher: None Weikert: Heidelberg, Zeiss by Liz Hillman Editorial Co-Director M anual marking, digital marking, manual and digital marking—toric IOL alignment methods continue to be an important topic. "Ten years ago, I'm sure there was an article saying that manual marking was going to be gone, but it's still around," said Soroosh Behshad, MD, MPH, who uses both manual and digital marking with his toric cases. The reason both methods still have a place, Dr. Behshad said, is multifactorial—both have their pros and cons. Dr. Behshad said he marks the meridians preoperatively using a corneal marker that hooks into his cell phone, then uses the toriCAM app by Graham Barrett, MD, to aid in aligning his marks. In the OR, he has access to a Callisto (Zeiss), which he uses to confirm he is aligning toric IOLs correctly. He said having both gives him confidence in his alignment. Some of the main benefits of manual marking, Dr. Behshad said, are that it's low cost, simple, and quick. To ensure accuracy with manual marking, Dr. Behshad said he talks his patients through what he's doing every step of the way because they're sitting up and haven't had anesthesia yet. In addition, as a cornea spe- cialist, he said regardless of if you mark man- ually, digitally, or use both for toric alignment, success postop begins preop. He said to look at the ocular surface, manage dry eye, pterygium, anterior basement membrane syndrome, and other pathologies that would affect your preop calculations. Dr. Osher, like Dr. Behshad, uses a "belt and suspenders" approach, as he put it. Dr. Osher Why it's still important to discuss toric IOL marking methods said astigmatic correction at the time of cata- ract surgery dates to the early 1980s when he introduced astigmatic keratotomy combined with phacoemulsification for the reduction of pre-existing astigmatism. This procedure, he said, was an art. With the invention of the toric IOL in the 1990s by Kimiya Shimizu, MD, astig- matic correction became a science. Over time, Dr. Osher created a technique called iris fingerprinting to accurately perform manual marking for toric alignment. 1 Iris land- marks, unlike blood vessels, don't change from the preop dilated exam to what surgeons see in surgery. Dr. Osher said he uses a Haag-Streit camera to take a picture of the patient's iris, and with that photograph, he draws a horizon- tal line at 0 and 180, followed by the inferior 90-degree mark. "With these, I have three accu- rate landmarks to guide me in surgery … I hang those photographs on the microscope … and have those right next to me," he said. In surgery, Dr. Osher would make very small, almost imperceptible dots on the con- junctiva with a cautery pen called ThermaDot. "Once I have my ThermaDots, I know I can align that lens perfectly." In addition to align- ment with the manual marks, Dr. Osher uses a circular dial called the Osher-Mendez marker, confirming his correct ThermoDot placement. "I will turn on and register the Callisto. Ninety- nine percent of the time, the target meridian lines up perfectly," he said. Dr. Osher acknowledged peer-reviewed studies that have concluded the results with manual vs. digital markers are similar. How- ever, he noted that even a few degrees off on alignment can affect outcomes. Taking a dual approach with precise manual marking that's confirmed in the OR with a digital marking sys- tem does take more time and, with the digital marker, a significant financial investment. Dr. Osher said that if the patient is paying out of pocket for a toric lens and with one shot to get placement right in the OR, it's worth it. "I can spend that extra time and invest that extra effort because it satisfies my OCD, and it confirms my conviction that we have one chance in the patient's entire life to give them the best vision possible," he said. " There's a beauty to having this dual approach, a safe approach, because you never know." —Robert Osher, MD

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