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EW INTERNATIONAL 82 May 2016 by Matt Young and Gloria Gamat EyeWorld Contributing Writers calculation, toric IOL alignment, clinical outcomes and complications were some of the factors needing careful consideration. "Toric IOLs should be avoided in patients with corneal dystrophies that might need a corneal trans- plant in the future and should be used with caution in patients with potential capsular bag instability," they said. "Post-radial keratotomy (RK) pa- tients are often difficult to treat with a toric lens," Dr. Sheppard said. "As multifocal toric IOLs split the available light between the dis- tance and near foci, they should not be implanted in patients with ocular comorbidities that affect the visual acuity or the quality of vision, such as amblyopia, maculopathy, glauco- ma, and uveitis," reported Ventura and colleagues in the February 2014 issue of Arquivos Brasileiros de Oftal- mologia. Other complications related to toric IOL implantation, according to Ventura and colleagues, are those linked with cataract surgery directly (i.e., posterior capsule opacification, cystoid macular edema, and retinal detachment). "Toric IOLs are an effective and safe tool to treat corneal astigmatism in patients who undergo cataract surgery. However, patients' out- comes depend on accurate corneal astigmatism measurement, accurate marking of corneal meridians and angle of alignment, and accurate and stable IOL alignment," they concluded. EW References 1. Kessel L, et al. Toric intraocular lenses in the correction of astigmatism during cataract surgery: a systematic review and meta-analy- sis. Ophthalmology. 2016;123:275–286. 2. Ventura BV, et al. Surgical management of astigmatism with toric intraocular lenses. Arq Bras Oftalmol. 2014;77:125–131. Editors' note: The sources have no financial interests related to their comments. Contact information Jain: contactus@advancedeyehospital.com Sheppard: docshep@hotmail.com postop period only with little rota- tion after 1 week of implantation. "Once you get the correct posi- tion intraoperatively, toric IOLs are not delicate or unstable at all," Dr. Sheppard said. "All approved toric lenses in the U.S. have very good stability, and it's rare to have to reposition them; occasionally we will do a laser enhancement for residual combined cylinder and spherical error," he added. However, Dr. Sheppard em- phasized that toric lenses have the lowest enhancement rate among premium IOLs for surgeons in his practice. "Several toric IOL platforms are available in the U.S., and all have excellent rotational stability," he said. In a systematic review and meta-analysis, Kessel and colleagues 1 assessed the benefits and drawbacks that came with implantation of toric IOLs during cataract surgery. Investigators systematical- ly searched the literature in the Embase, PubMed, and CENTRAL databases within the Cochrane Library. Randomized clinical trials that compared toric with non-to- ric IOL implantation (i.e., relaxing incisions) in patients with regular corneal astigmatism and age-related cataracts were included. Postoperative uncorrected dis- tance visual acuity (UCDVA) and distance spectacle independence were recorded as outcomes, while harm was evaluated as surgical com- plications and residual astigmatism. "We found that toric IOLs provided better UCDVA, greater spectacle independence, and lower amounts of residual astigmatism than non-toric IOLs even when relaxing incisions were used," Kessel and colleagues reported in the Feb- ruary 2016 issue of Ophthalmology. Critical factors in toric IOL implantation In another comprehensive review conducted by Ventura and col- leagues, 2 the research team was able to provide an overview of astigma- tism management using toric IOLs. Relevant patient selection criteria, corneal astigmatism measurement, toric IOL power Preoperative average corneal astigmatism was 5.28 D, with the follow-up period ranging from 1 to 4 years. "Based on our findings [mean decimal BCVA was 0.63 and average manifest cylinder refraction was 2.28 D at last follow-up time point], toric IOL implantation is efficacious in the management of high astig- matism in complex corneal condi- tions," Dr. Jain concluded. John Sheppard, MD, professor of ophthalmology, microbiology and molecular biology, and clinical direc- tor, Thomas R. Lee Center for Ocular Pharmacology, Eastern Virginia Medical School, Norfolk, Virginia, agreed that toric IOLs can work well for complex cases. "We have excellent long-term experience and generally favorable results with toric IOLs in patients with keratoconus, corneal trans- plants, anterior basement membrane disease, and before or after corneal collagen crosslinking," Dr. Sheppard said. Why toric IOLs? One characteristic that continues to attract ophthalmic surgeons to toric IOLs is that toric IOLs can correct up to 6 D of astigmatism, as opposed to relaxing incisions, which can generally correct up to 2 D of astigmatism. While toric IOLs also come with some disadvantages such as the fact that they can rotate postoperatively, they have been reported to show the greatest rotation in the early Indian researchers find toric IOLs are solutions even after penetrating keratoplasty S ome physicians might think that a toric IOL's ability to rotate after surgery would make it more delicate and hard to employ for complex cases, but this is not so, according to recent research. At the 2015 American Academy of Ophthalmology annual meeting, a group from Mumbai, India, headed by Pooja Jain, MBBS, Advanced Eye Hospital and Institute, Mumbai, pre- sented the successful management of complex eyes with cataract and high astigmatism with implantation of toric IOLs. This research indicates that many complex cases can benefit from toric IOL implantation. Outcomes of India case series To evaluate the outcomes of toric IOL implantation in complex corne- al conditions with cataract and high astigmatism, Dr. Jain and colleagues conducted a retrospective analysis of 8 eyes of 5 patients (aged 35 to 50 years) who underwent phacoemulsi- fication with toric IOL implantation. Among the patients included, 3 were post-lamellar keratoplasty, 1 was post-compressive and pen- etrating keratoplasty (PK), 3 were post-PK, and 1 was post-collagen crosslinking. Successful management of complex corneal conditions with toric IOL implants International outlook

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