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4 Intraoperative and postoperative steps to success with toric IOLs Subsequently, he removes all OVD from the eye. After OVD removal, he taps down on the center of the implant or applies gentle pressure so that the optic is in contact with the posterior capsule. Next, the wounds must be adequately hydrated and watertight, and the eye must not be overinflated. "Then you want to make sure that you check the wounds at the end of the surgery," he said. Postoperative astigmatism Because patients do not expect to wear glasses full time after toric IOL implantation, enhancements are a strong consideration for residual astigmatism after surgery, Dr. Kieval said. said. It is only when the surgeon wants to try to improve the outcomes and fully invest in the technology that the new equipment is useful, he said. Dr. Mah highlighted 6 steps to minimize postoperative rotation. First, the surgeon ensures that accurate alignment marks are placed on the limbus before surgery and used to finalize the IOL position. Second, good wound construction and correct capsulotomy size are necessary. Third, Dr. Mah uses a cohesive OVD in the IOL injection cartridge and to inflate the capsular bag. "You want to make sure that the implant lens is completely unfolded," he said. He rotates the lens to be sure the haptics are fully deployed into the capsular apex and aligns the IOL marks with the preoperative marks. Attention to detail is crucial in reducing spectacle dependence W hen patients invest in premium technology, such as toric intra- ocular lenses (IOLs), they expect premium outcomes, said Jeremy Z. Kieval, MD, director of cor- nea, cataract, and refractive surgery, Lexington Eye Associates, Lexington, Mass., during a presentation at the 2015 ASCRS•ASOA Symposium & Congress in April. To meet these expectations, surgeons must optimize each surgical step and be pre- pared to provide enhancements if necessary. Intraoperative strategies Stability of toric IOLs is critical (Figure 1). For each degree of IOL rotation, the patient loses approximately 3.3% of the power of the cylinder, said Francis S. Mah, MD, director of cornea and external disease, and co-director of refractive surgery, Scripps Clinic, La Jolla, Calif., during the ASCRS program. Surgeons can choose from low- and high-tech marking methods to guide IOL alignment; the key is that surgeons should mark and help alignment from the beginning. With manual marking techniques, precision and accuracy are key. Surgeons should make preoperative reference marks on the cornea while the patient is sitting up looking off into the distance to avoid excyclorotation, which invariably occurs when patients lie down, Dr. Mah said. When the patient is supine, the axis of toric IOL placement and the incision should be marked using the preoperative reference marks. If possible, to reduce some of the cylinder, he said, it helps to operate on the steep meridian. In addition, an array of total cataract refractive suites allow clinicians to capture information in a clinical area and transfer it to the intraoperative area, reducing the risk of error and helping to refine technique and im- prove outcomes. Although these technological advances are available, they are not essential to get started in the toric IOL arena, Dr. Mah Figure 1. The importance of stability of toric IOLs and effect of rotation on vision Source: Francis S. Mah, MD Figure 2. Ruling out organic or iatrogenic disease Source: Jeremy Z. Kieval, MD continued on page 5 90 o doubles astigmatism Degree of rotation Percentage cylinder power loss 1 o 3% 5 o 17% 10 o 35% 15 o 52% 30 o 100% Rule out organic or iatrogenic disease Ocular surface disease ABMD Other irregular astigmatism Surgically induced astigmatism Posterior astigmatism Extremes of axial length IOL tilt

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