EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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12 EW NEWS & OPINION November 2012 Anterior segment grand rounds Taking the spin out of toric rotation: Part 1 by Steven G. Safran, M.D. I n the next two columns I'd like to examine the topic of toric IOL rotation. We will examine two patients who had this problem starting with the presentation of this month's case. The patient is a 48-year-old male engineer who was a high myope (27 mm eye). He had cataract surgery in the OD 4 years earlier with a toric IOL by a highly respected, expert cataract surgeon. The 11.0 D AcrySof SN60T5 toric lens (Alcon, Fort Worth, Texas) that was placed at that time rotated on its axis twice in the post-op period and had to be repositioned two times. The first repositioning was done 14 days after his cataract surgery, but the lens rotated again, and the second repositioning was done 23 days later and ended up with a stable outcome at the proper axis. The patient contacted me by email asking if I'd be willing to see him for a con- sultation and to perform cataract surgery in the second eye. He lived 3,000 miles away but was willing to travel. His goal was to avoid the repositionings that were required after his first eye surgery, as he found these to be more stressful than the initial cataract surgery. I The right eye (dominant eye) has an AcrySof toric in proper position, 3-4+ glistenings, and a best corrected vision of 20/20 with a –0.75–0.75X 107 refraction. Uncorrected vision was 20/50. The non-dominant left eye had a dense NS cataract with 20/200 best corrected vision. This eye was also 27 mm and, like the first eye, had 2.37 D of topo- graphic astigmatism with a corneal topog- raphy that was a bit "funny" with slightly non-orthogonal astigmatism that made me nervous about doing LRIs or LASIK (Figures 1 and 2). Steven G. Safran, M.D., ASGR editor consulted a panel of Stephen Lane, M.D., Michael Wong, M.D., Jeff Horn, M.D., and Lisa Arbisser, M.D., to ask what they would do for this patient's left eye given the problems he had with toric IOL rotation twice in his right eye after cataract surgery. Figure 3 is an image of the OD that had cataract surgery 4 years ago. Note the advanced glistenings and the rhexis that extends beyond the optic nasally. Dr. Wong (Princeton Eye Group, Princeton, N.J.) said, "In this case, high myopia is a predisposing factor for toric malrotation. The history of the first eye does not make clear whether the malrotation went to the same axis each time. Nevertheless, a large bag diameter that is greater than the IOL diameter is the likely cause. Some surgeons have suggested inserting capsular tension rings (CTRs) in these cases as it evenly distributes the forces at the equator, to make the bag taut so the capsular leaves come in closer proximity, and to simply put material in the for- nices to increase rotational friction. On the other hand, if the effect of the CTR is to further stretch the edge of the bag beyond the haptics, it is conceivable to make matters worse. I am not aware of a study that has tackled this issue. I would be less aggressive than usual in vacu- uming the underside of the anterior capsule during surgery. In choosing the toric IOL axis goal, I would give greater weight to the axis of the bigger bowtie." Dr. Arbisser (adjunct clinical associate professor, John A. Moran Eye Center, University of Utah, Salt Lake City, and in private practice, Eye Surgeons Associates, Iowa and Illinois Quad Cities) agreed with Dr. Wong completely but was committed to the use of a CTR in the second eye. Like Dr. Wong, she would be less aggressive with polishing of the anterior capsule to remove lens epithelial cells. "CTR is the only thing to be done differently, in my opinion. The CTR should be placed this time with the toric, and he should be told that no matter what is done, short of a two-staged procedure where the astigmatism is fixed on the cornea, there is always a small chance of required repositioning. I would be certain to remove all OVD from the posterior chamber under the lens, and I would not aggressively polish LECs off the anterior capsule to pro- mote an early sandwich effect for IOL stability," Dr. Arbisser said. Dr. Lane (Associated Eye Care, Figure 1. Topography OD eye s/p cataract surgery with toric IOL Figure 2. Topography of left eye St. Paul, Minn.) would also use a toric lens in this case but take a dif- ferent approach altogether. He said, "This patient, in my opinion, should receive a toric IOL. … I would per- form standard phacoemulsification, being sure that the capsulorhexis was well centered and no larger than 5.0- 5.5 mm in diameter. Perhaps this would be a good indication for the use of the femtosecond laser to achieve this. I would then place the toric IOL in the bag, prolapse the optic out of the bag (keeping the haptics in the bag, i.e., reverse cap- sule capture) and then rotate the IOL to the proper position using either previously placed ink marks or preferably the SMI [SensoMotoric Instruments, Teltow, Germany]. By capturing the IOL in this way I be- lieve you have assurance the lens will not rotate or come out of posi- tion; it has essentially been locked in place and return visits to the OR are avoided. Depending upon the power