Eyeworld

EW FEATURE 56 Toric IOLs June 2015 Monthly Pulse Keeping a Pulse on Ophthalmology T he topic of this Monthly Pulse survey was "Toric IOLs." When asked about the percentage of their cataract patients that receives toric IOLs, most respondents said 5–15%. We asked, "What is your preferred method of correcting 2 D or less of corneal astigmatism in cataract patients?" A large majority said a toric IOL. The statement that best reflects most respondents' practice patterns regarding premium IOL use is, "Premium IOLs are actively encouraged for use in all appropriate patients." Finally, we asked, "What is the minimum amount of astigmatism you treat when associated with cataract surgery?" The majority of respondents said astigmatism of 1.0 D. by Lauren Lipuma EyeWorld Staff Writer Center, Los Angeles, the study's principal investigator. "I feel that's a bit more accurate." Mark the cornea appropriately Mark Kontos, MD, in private prac- tice, Empire Eye, Spokane, Wash., and Hayden, Idaho, marks all of his patients at 0, 90, and 180 degrees manually at the slit lamp prior to surgery and again with the Catalys femtosecond laser (Abbott Medical Optics, Abbott Park, Ill.). "I know that some people mark at the chair right before they go in, but I like to have the patient sitting at the slit lamp so I can have a good magnified view of everything," he said. "I think it gives me the oppor- tunity to get a finer mark." The alignment system on the Catalys also shows whether his pre- operative alignment marks line up with the marks from the laser. "By the time I go into the OR and sit down to the patient under the microscope, they have a mark that the laser has made on the cor- nea that makes it very easy for me to see how I'm going to orient the lens," he added. Jonathan Rubenstein, MD, vice chairman and Deutsch family professor of ophthalmology, Rush alignment, they can offer toric IOLs to more patients than ever before. Here, 3 experienced surgeons discuss the most important factors that con- tribute to final refractive outcomes and their pearls for nailing the intra- operative alignment and preventing postop rotation. Don't ignore the posterior cornea Accurately measuring the magnitude and axis of astigmatism preoper- atively is essential for completing the toric IOL case. Ignoring the contribution of the posterior cornea to the total astigmatism can have a detrimental effect on the final refrac- tive outcome. A study published in the Jan- uary 2015 issue of the Journal of Cataract & Refractive Surgery found that surgeons tend to overcorrect with-the-rule astigmatism and un- dercorrect against-the-rule astigma- tism when they do not factor in the posterior corneal surface. Manual keratometry only takes into account the anterior corneal surface, so map- ping the topography of the anterior and posterior cornea is key. "Because of that study, I now use the total astigmatism magnitude and axis from the Galilei [Ziemer Ophthalmic Systems, Port, Switzer- land] when I calculate my toric IOL powers," said D. Rex Hamilton, MD, associate clinical professor of ophthalmology, Stein Eye Institute, and director, UCLA Laser Refractive AT A GLANCE • Don't ignore the posterior corneal astigmatism. • Be consistent with surgical techniques to optimize the effective lens position. • After alignment, tap the lens to make sure it is pressed firmly against the posterior capsule. • Intraoperative aberrometry is helpful but not necessary if you're consistent with your surgical technique. Intraoperative pearls for nailing toric IOL alignment Experts share tips for hitting the axis and achieving the best refractive outcomes T oric IOLs are a great option for neutralizing astigma- tism and offering patients spectacle independence after cataract surgery. Unlike other premium IOLs, toric lenses do not require the patient to have a perfect macula, so they are an attractive option for a larger group of patients. Nailing toric IOL alignment can be a challenge, with many preoper- ative, intraoperative, and postoper- ative factors affecting the final lens position and refractive outcome. But once surgeons overcome these obsta- cles and consistently achieve good The Verion system (Alcon) projects an overlay through the microscope, identifying the correct meridian for aligning toric IOLs.

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