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EW San Diego 2015 7 7 pearls for technique with toric IOLs 1. Corneal marking 2. Capsulorhexis size 3. Assistance with IOL unfolding and positioning 4. OVD removal under the IOL 5. Fixation of the IOL to the capsular bag 6. Final IOP in low to mid teen range 7. Final check of lens position the refraction and ocular surface are stable. If you go in too early, you may not have accurately determined where the astigmatism actually is. Additionally, postoperatively you need to focus on the refractive astigmatism as opposed to corneal astigmatism. An online calculator published by John Berdahl, MD, and Dave Hardten, MD (www. astigmatismfix.com) can help you determine where you want to rotate that lens. Dr. Kontos: In addition, incorrect data entry into an IOL calculator can produce errors. As a check, we keep the topography in the operat- ing room and match the orientation of the lens on the calculator picture with the orientation on the topogra- phy during our time-out. Dr. Mah: Another tip is to bring the printout from the IOL calculator to the operating room. In addi- tion, in larger eyes it's important to remember that sometimes IOLs placed with-the-rule tilt one way or another. Figure 7. Use the I/A probe to orient the toric IOL to target axis. In this case the Zeiss Callisto system aids the surgeon intraoperatively. Figure 8. Final orientation of toric IOL on target as verified by the Zeiss Callisto system Source: Sumit "Sam" Garg, MD Dr. Vukich: It's easy to prevent some of these problems with the pre-flight checklist. Make sure that you have the proper axis where you can dou- ble check it quickly during surgery. Dr. Garg: Many of these errors are avoided with newer technologies such as the Callisto Eye because the information travels seamlessly from the IOLMaster to the Callisto Eye and then into your scope without transcription. Dr. Donnenfeld: How do you correct residual refractive error after implan- tation of a toric IOL? Dr. Hovanesian: It depends on the source of the residual refractive er- ror. Typically it's a small amount of sphere or cylinder. If the patient is symptomatic and we are so inclined, it's reasonable to perform a laser refraction procedure. Rotating the lens is another option if you suspect the lens is off-axis. Dr. Garg: If the spherical equivalent is close to zero, and depending on how much cylinder is left, you could consider LRIs. For spherical and larger astigmatic errors, you could consider laser vision correction. If they're hyperopic, you could use piggyback lenses or an IOL ex- change. Dr. Donnenfeld: Once you've placed a toric IOL, you can't base your astigmatic surgery on the keratom- etry; you base it on the refraction. In patients with small amounts of cylinder, we perform an LRI. For large astigmatic errors we rotate the IOL when it is displaced, and for combined spherical and astigmatic errors, we most commonly perform laser vision correction. What would you say to surgeons who have not adopted toric IOLs about entering the field of refractive cataract surgery? Dr. Garg: With increasing patient expectations, you're doing your patients a disservice if you don't perform refractive cataract surgery. We can improve their vision signifi- cantly by offering toric IOLs. Dr. Kontos: Cataract surgery for most people is already a refractive surgery procedure. Astigmatism is a major component of refractive surgery procedures, and toric lenses allow you to manage that. If you want to have a vibrant practice in the future, you need to embrace this technology. Dr. Donnenfeld: It's our obligation as ophthalmologists and physicians to provide patients with an informed consent process that considers what the patient wants and allows us to offer patients what meets their needs. It's also our obligation to recommend what is in the patient's best interest. For many patients, a toric IOL is going to be the best option for visual rehabilitation. Adding toric IOLs to your surgical armamentarium is the most effective way to enter refractive cataract surgery. This supplement was produced by EyeWorld and supported by an educational grant from Abbott Medical Optics. Copyright 2015 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS.

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