Eyeworld

57 EW FEATURE June 2015 Toric IOLs EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line. Poll size: 227 Corneal marker with level for creating toric reference marks at 3, 6, and 9 o'clock with patient sitting upright prior to surgery (ASICO, Westmont, Ill.) Source: Rex Hamilton, MD University Medical Center, Chicago, uses a slightly different technique. "Preoperatively, I mark the 6 o'clock position on the limbus with a very fine tip surgical marker with the patient looking at my nose with both eyes open," he said. "Then in the operating room, I align the 6 o'clock mark with the 90-degree axis mark on a Dell astigmatic mark- er. I twist the internal bezel of the Dell marker to be aligned with the patient's steep axis of astigmatism, therefore making the 2 marks on the limbus at the steep axis of astigmatism." Dial the lens (almost) into position and remove the viscoelastic To prevent postop rotation of the lens, make sure that all viscoelastic and cortical material are removed before dialing the lens into its final position. "If you have problems with the subincisional cortex, you might give some thought to using bimanual [irrigation and aspiration, I/A] to remove it," Dr. Hamilton said. "You want even contraction of the cap- sule over the lens." After phacoemulsification, align the lens with the axis or leave it slightly counterclockwise to the axis, remove the viscoelastic, and then tap it into the final position. Although these are the basic steps, most surgeons have their own preferred method for executing this procedure. Dr. Kontos prefers to leave the lens slightly counterclockwise to the intended axis before removing the viscoelastic. "I'll place the lens in the bag and spin it into position, pretty close to the position it needs to be in," he said. "I'll go in under the lens with a cannula and squirt balanced salt solution back there to make sure there's no viscoelastic behind the lens, and then I rotate the lens into its final position with a Sinskey hook." "I leave the lens about 10 de- grees on the counterclockwise side of the mark," Dr. Hamilton said. "I remove the viscoelastic and use the I/A handpiece to block the clock- wise rotation that tends to occur as you remove viscoelastic from the bag. Then I use the I/A handpiece with irrigation going to finalize the position, and I do a little tap on the center of the lens to push it against the posterior capsule." "I place my toric IOL on axis and then gently keep the IOL from rotating with my soft-tipped I/A handpiece while removing the viscoelastic," Dr. Rubenstein said. "I slide the IOL back and forth, on axis, until all of the viscoelastic shakes out from behind the IOL. You see a flutter when the cohesive OVD is removed, but by holding the IOL with the I/A tip, the IOL does not rotate." After all of the viscoelastic is removed, the lens should be aligned with the axis and positioned secure- ly against the posterior capsule to prevent postop rotation. "I check the final alignment af- ter all of the viscoelastic is removed and after the incisions are stromally hydrated," Dr. Rubenstein said. "If minor adjustments are needed, they can be done with a long-tipped 27-gauge balanced salt solution can- nula. I always tap on the lens with the cannula through the paracente- sis port to make sure that the IOL is firmly against the posterior capsule." Use intraoperative aberrometry (or don't) When it comes to the question of using intraoperative aberrometry for implanting toric IOLs, physicians are split. Dr. Hamilton has had success using the ORA system with VerifEye (Alcon, Fort Worth, Texas), which provides real-time feedback of where the residual astigmatism is as the lens is being rotated. "I also think that using the ORA aberrometer is useful in checking the toric IOL alignment after the lens continued on page 58

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