NOV 2012

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November 2012 Figure 3 of the IOL (I assume it will be a rela- tively low power IOL due to the axial length), it could be adjusted 0.2-0.5 D (or not at all if a low enough power) to account for the slightly an- terior position of the IOL." Dr. Lane's novel approach of anterior optic capture would likely be successful but may make some surgeons who have seen pigment dispersion due to interaction of the iris and one-piece AcrySof lenses a bit nervous, whether or not they have actual cause to be in this pro- posed situation. Dr. Horn (Vision for Life, Nashville, Tenn.) would take a more conventional approach. "Anecdotally, there does seem to be a higher incidence of rotation in long eyes with presumably large capsular bags," he said. "In these cases, the lens has been reported to rotate again even after reposition- ing, and in at least some of these cases, the lens seems to rotate to the same position, implying that there is a 'home' in these particular eyes, which would suggest the bags are not round, but oval. So there may be place for a CTR, which would presumably 'round out' the capsular bag, reducing rotation if the lens were initially oriented in the long axis or diameter of the bag. Other things regarding surgical technique may be important to prevent rotation, such as evacuat- ing all the OVD from behind the lens. Some have suggested that not polishing or vacuuming the underside of the anterior capsule increases the 'stickiness' of the lens. I don't believe this to be true. "This patient is highly sensitive to a less-than-spectacular result and is willing to travel great distances to achieve that. First, his astigmatism clearly needs to be managed surgi- cally. Because of the slight skewing Figure 4 of the astigmatism on topography, and because of my confidence in the toric lens, I would still implant the toric. But in order to reduce the odds the lens rotated, I would implant a CTR prophylactically prior to implantation of the lens." I agree with Dr. Horn here, and this is basically the approach that I took. I have seen or consulted in a handful of cases of toric rotation, and all have been in high myopes who rotated within the first week or so. Since rotation occurs before the LECs remaining on the anterior cap- sule have undergone any fibroblas- tic transformation and prior to any resultant bag contracture, I see no benefit to purposefully leaving LECs behind. They will not be able to pre- vent the early rotation that we typi- cally see in these cases, although later on they will certainly cause fi- brotic changes that will "lock things in place." Within the first week or so, I don't believe the presence of LECs helps and, in fact, may pre- vent some of the tacky adhesion be- tween the optic and the capsule that we typically see with the AcrySof material. Anyone who has tried to rotate a toric lens after removing all the viscoelastic knows that there is an immediate adhesion between the tacky AcrySof material and the capsule that is somewhat unique to this material. To rotate the lens without stressing the capsule, one often needs either additional vis- coelastic or an infusion line to dilate the bag. As Dr. Horn stated, I believe that in high myopes the bag may be a bit too large for the lens and it may not be perfectly round, which creates a "preferred axis" that the lens may gravitate toward. I believe that the use of a CTR will both round out the bag and make the equator of the bag slightly smaller, creating a frictional resistance to Source (all): Steven G. Safran, M.D. early rotation. If the lens does not rotate immediately (within the first 10 days or so), then it is extremely unlikely to rotate at all. In this case I did choose to use an 11 D T5 toric lens (Alcon) to correct astigmatism and targeted a –0.25 spherical outcome for better distance vision as per the patient's request. I used my normal surgical approach, creating a centered round rhexis (effectively achieved without the benefit of a femtosecond laser) that covered the optic 360 degrees followed by meticulous removal of LECs with a Singer Sweep (Epsilon Surgical, Ontario, Calif.). I did choose to place a CTR with the hope that this would prevent rotation and then removed all viscoelastic from behind the lens and took extra precaution to press the optic down against the posterior capsule at the end of the case to create adhesion against the posterior capsule. The patient did very well with no IOL rotation post-op and a –0.25 refrac- tive outcome with 20/20 uncor- rected distance vision. He was very happy with this. Figure 4 is an image of the eye 1 month post-op. It does appear that the use of the CTR inhibited the rotation of the lens in this patient. I do think that it is reasonable to consider the primary use of a CTR for toric IOL cases at high risk for rotation. All of the cases of rotation I've seen so far have been relatively young, highly myopic males, so in a patient fitting this demographic, especially with a history of rotation in the first eye, I would certainly consider using this approach again. EW Contact information Arbisser: drlisa@arbisser.com Horn: jeff.horn@bestvisionforlife.com Lane: sslane@AssociatedEyeCare.com Wong: mwong2020@gmail.com

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