Eyeworld

EW FEATURE 46 AT A GLANCE • Offering toric IOLs enhances your practice and gives patients with astigmatism additional options to become spectacle-free. • Although toric IOLs do not have a steep learning curve, they do require the use of multiple pieces of equipment to assess astigmatism and determine the ideal IOL for patients. • Surgeons and staff both need to explain astigmatism and toric IOLs to patients in an easy-to-understand way. • The cost for toric IOLs should cover any possible need for enhancements. by Vanessa Caceres EyeWorld Contributing Writer Above all, aim for precision, Dr. Braga-Mele advised. "You'll be hap- piest with this lens if you have the right tools to measure astigmatism and are precise in your marking and alignment of the lens. If you do all of that, your retreatment rate will be low," she said. Presenting toric IOLs to staff and patients Everyone from the front office to back office staff needs to know what toric IOLs can offer before you can confidently discuss them with pa- tients, Dr. Wortz said. "There needs to be comprehensive staff-wide education to talk about the message that's delivered if patients call and need cataract surgery," he said. When a cataract patient has astigmatism and may be a toric IOL candidate, Dr. Wortz likes to discuss the positive changes that accompa- ny life without glasses. He usually finds 1 of 3 responses. In one group, patients say they will always wear their glasses—perhaps for cosmetic reasons, such as to help cover bags under their eyes. In this group, Dr. Wortz typically drops the subject. In the next group, patients say they want to learn more. In the third and most common group, patients say the possibility sounds nice but it depends on the cost. Carolina, Charleston, and adjunct assistant professor of bioengineer- ing, Clemson University, Clemson, S.C. "We feel that all patients should be given the opportunity to see the best they can with and without spectacles. The key is approaching every patient as though they have the opportunity to reduce their dependence on spectacles for at least something, if not everything," he said. Although astigmatic keratotomy and limbal relaxing incisions are other ways to treat astigmatism in cataract patients, the surgeons inter- viewed for this article find that toric IOLs help to treat higher degrees of astigmatism, avoid associated dry eye, and lead to more predictable outcomes. There are some tools of the trade to learn when adding toric IOLs. Getting started with toric IOLs First, equip your practice with numerous ways to measure astigma- tism. "You need 2 or 3 ways to mea- sure it," said Rosa Braga-Mele, MD, professor of ophthalmology, Uni- versity of Toronto. Dr. Braga-Mele suggests the use of manual keratom- etry and biometry with the use of an IOLMaster (Carl Zeiss Meditec, Jena, Germany) or LENSTAR LS-900 (Haag-Streit, Koniz, Switzerland) as well as corneal topography. Corneal topography is particularly important for astigmatism management, Dr. Waring said. You also need to get comfortable with the variety of online calculators to help calculate the right IOL for patients. One more recent consider- ation that surgeons interviewed for this article mentioned is posterior corneal astigmatism, brought to the forefront by Douglas D. Koch, MD, Houston. Although there are various calculators available, the Barrett Toric IOL calculator on the ASCRS website allows for the consideration of posterior corneal astigmatism, Dr. Braga-Mele said (www.ascrs.org/ barrett-toric-calculator). Surgeons who cannot invest in pricey equipment for toric IOL inser- tion shouldn't be deterred, Dr. Wortz said. "There's a lot of technology out there that provides incremental gains. If a simple IOLMaster is all you have and you base calculations off of that, you'd probably get very close to what someone with duplica- tive and more expensive technology would get for patients with normal corneas," he said. One exception is with intraoper- ative aberrometry, which Dr. Wortz described as a game-changer for the field. Additionally, "the ability to place the IOL in the proper orienta- tion is still lacking with the typical techniques, and there is mounting clarity that improved registration of the IOL to the preexisting corneal astigmatism may improve results," Dr. Hardten said. Another key part of toric IOL use is identifying who is and who is not a suitable candidate. One part of this is analyzing ocular surface health via topography and confirm- ing findings via a clinical exam, Dr. Waring said. It is also important to look out preoperatively for corneal abnormalities like keratoconus or map dot fingerprint dystrophy; it is best to avoid toric IOLs in these patients, Dr. Braga-Mele cautioned. Patients with skewed central radial axes or non-descriptive astigmatism patterns may not be ideal candidates for toric IOLs, Dr. Waring said. An- other group to avoid at least initially is very high myopes, as they have more of a tendency to rotate postop- eratively, Dr. Wortz said. How to get started with toric IOLs Toric lens with slight rotation from asymmetric capsule contraction Source: David R. Hardten, MD The A to Z on technical accuracy and administrative acumen with torics I ncorporating toric IOLs into your practice requires a com- mitment to precision, an investment in some of the right equipment, and a desire to edu- cate both staff and patients on what toric IOLs can offer. "To increase the number of pa- tients that have their goals met with cataract surgery, correcting astigma- tism is a big part of meeting the ex- pectations," said David R. Hardten, MD, Minnesota Eye Consultants, Minnetonka, Minn. "By learning to do this effectively, your practice is in a much better position." If you are interested in adding torics, the learning curve is not that steep. "It shouldn't be much of a challenge for cataract surgeons," said Gary Wortz, MD, Commonwealth Eye Surgery, Lexington, Ky. "In real- ity, placing a toric lens follows all of the same well-known principles as correcting astigmatism in a phorop- ter. Instead of spinning the dial, you are rotating the lens." Offering toric IOLs is part of the big picture of astigmatism man- agement for patients, said George O. Waring IV, MD, FACS, assistant professor of ophthalmology, director of refractive surgery, Storm Eye In- stitute, Medical University of South continued on page 48 Toric IOLs June 2015

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