advancements in toric iols - paul ernest,...

ADVANCEMENTS IN TORIC IOLS

Supplement to

This Ocular Surgery NewS supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

MARCH 25, 2015

2 OCULAR SURGERY NEWS US EDITION | MARCH 25, 2015 | Healio.com/Ophthalmology

© Copyright 2015, SLACK Incorporated. All rights reserved. No part of this publication may be reproduced without written permission. The ideas and opinions expressed in this Ocular Surgery NewS® supplement do not necessarily reflect those of the editor, the editorial board or the publisher, and in no way imply endorsement by the editor, the editorial board or the publisher.

Paul H. Ernest, MD,is a cataract and refractive specialist and founder of TLC Eyecare and Laser Centers in Jackson, Michigan. Dr. Ernest is a consultant, speaker and clinical investigator for Alcon Laboratories, Inc.

Damien F. Goldberg, MD,is a partner at Wolstan & Goldberg Eye Associates, chief of ophthalmology surgery at the Torrance Memorial Medical Center in Torrance, Calif., and a clinical instructor at the UCLA Jules Stein Eye Institute. Dr. Goldberg is a consultant for Alcon Laboratories, Inc.

Bonnie An Henderson, MD,is a clinical professor of ophthalmology at Tufts University School of Medicine and partner at the Ophthalmic Consultants of Boston in Boston. Dr. Henderson is a consultant for Alcon Laboratories, Inc.

Edward J. Holland, MD,is the director of cornea services at the Cincinnati Eye Institute in Cincinnati. He is a professor at the University of Cincinnati Department of Ophthalmology and practices in Cincinnati and Northern Kentucky. Dr. Holland is a consultant, speaker and clinical investigator for Alcon Laboratories, Inc.

FACULTY

Introduction

Toric IOLs can provide a significant number of cataract patients with astigmatism the best opportunity to achieve overall visual acuity and lower spectacle dependence. Surgeons can have confidence in their ability to achieve successful outcomes with toric IOLs by applying the tools and techniques they already have in their practices. Doing so can help improve patient satisfaction and provide a large population of patients with the best overall visual acuity.

Ocular Surgery NewS, through the sponsorship of Alcon Laboratories, Inc., interviewed surgeons who have experience with toric IOLs to discuss how they can be implemented into any surgeon’s practice to help improve outcomes for patients with astigmatism.

I thank the faculty for their participation and Alcon Laboratories, Inc., for sponsoring this supplement. For educational activities on this topic, visit Healio.com/Ophthalmology/Education-Lab.

Richard L. Lindstrom, MDChief Medical EditorOcular Surgery NewS

3OCULAR SURGERY NEWS US EDITION | MARCH 25, 2015 | Healio.com/Ophthalmology

When considering the prevalence of astigmatism and cataract patient demographics, it becomes clear that a great number of patients can ben-efit from choosing a toric IOL. Surgeons can gain confidence with recommending toric IOLs knowing that the patient is thoroughly aware of its ben-

efits and knowing that they have chosen the right patients for the procedure. All surgeons, whether beginner or advanced, can improve patients’ overall visual acuity by choosing candidates who will ben-efit from astigmatism correction.

Prevalence of astigmatismThere are a significant number of cataract patients

that can benefit from surgeons treating their corneal astigmatism. Warren Hill, MD, observed more than 6,000 cases in the cataract patient population and examined the prevalence of corneal astigmatism and found that approximately 52% of patients have 0.75 D of astigmatism or greater.1 These patients fall into the category of patients who would ben-efit from a toric IOL. Most physicians believe that 0.75 D of astigmatism or greater is worth managing because of the effect on uncorrected visual acuity. Even correcting low levels of astigmatism will give more patients improved outcomes and lower spec-tacle dependence.

Patient selectionToric IOL is a proven effective available method

for managing astigmatism.2 Astigmatism correction is something patients can understand and the effects of residual astigmatism should be explained to every patient with astigmatism. The patients can have an informed discussion and decide whether astigmatism management is worth their financial investment.

A potential candidate for a toric IOL would have regular, symmetrical astigmatism (Figure 1). They should also have the desire to achieve excellent

distance vision with reduced dependence on glass-es. Patients with irregular astigmatism, especially with marked irregularity, often will not respond well to any type of astigmatism management, including toric IOLs. In fact, sometimes trying to manage ir-regular astigmatism can cause a reduction in the quality of vision.

Patient educationIt is essential that the staff understands the im-

portance of correcting patients’ astigmatism as well. It is part of their duty to help in the patient education process, as astigmatism can be compli-cated for some patients to understand and must be explained to them thoroughly.

Patients should first learn about astigmatism cor-rection, including toric IOLs, when they are checked in during the initial technician interview. In addi-tion, the technician performing the IOL calcula-tions and topography has the opportunity to discuss it further. Finally, the decision can be made after the patient discusses the surgical options with the surgeon. If patients first learn about these com-plicated decisions at the end of the exam, they may be overwhelmed and do not fully comprehend all

Treating patients who need astigmatism correctionEdward J. Holland, MD

Edward J. Holland, MD

Figure 1: The topography map shows regular astigmatism.

Source: Holland EJ

Please refer to page 15 for important information about the Alcon products mentioned in this supplement.This Ocular Surgery NewS supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.


of the information. The more times patients expe-rience the education process, the better the patient understands their choices. This includes pre-exami-nation information. At my practice, we mail the pre-examination information to the patient so they have time to read about it at their own pace prior to ex-amination. This comprehensive educational process ensures that cataract patients with astigmatism will know the various surgical options.

Cylinder powerSurgeons must calculate the amount of astigma-

tism the patient has and then choose the appropriate toric IOL power. An increasing number of patients are able to benefit from toric IOLs because this technology provides a wide range of cylinder pow-ers that can correct different levels of astigmatism (Figure 2). My toric IOL preference is the AcrySof IQ Toric IOL (Alcon Laboratories, Inc.), which can correct a variety of powers of astigmatism. The cyl-inder power ranges from 1.5 D to 6 D at the IOL

plane, which corresponds to 1 D to 4 D at the cor-neal plane.

Gaining confidence implanting toric IOLsIn the AcrySof IQ Toric IOL study for U.S. Food

and Drug Administration approval, 97% of the patients who received toric IOLs bilaterally were spectacle-free.4 This demonstrated that there is a high success rate for distance vision after 6 months and improved patient satisfaction associated with astigmatism correction with toric IOLs.4 Addition-ally, this trial showed excellent results with surgeons marking the eyes manually; the surgeons were not able use advanced technology to help mark and position the IOLs. Surgeons were also not permit-ted to change the location of the incision; they were required to operate at the 180° meridian. Sur-geons now know that changing the location of the incision is another technique that can help enhance toric IOL results. Therefore, this study showed that indeed excellent outcomes were achieved in an

Figure 2: The estimated distribution of preoperative cylinder powers.

Source: AcrySof® IQ Toric IOL Directions for Use

Please refer to page 15 for important information about the Alcon products mentioned in this supplement.


era prior to the advanced technology that is now available. Surgeons may be moving toward more advanced technologies like preoperative eye regis-tration and intraoperative aberrometry to further improve outcomes. Advanced systems such as the Verion Image-Guided System (Alcon Laboratories, Inc.) and ORA intraoperative aberrometry system (WaveTec Vision) should help take surgeon accu-racy to an even higher level.

Surgeons should have confidence in the technol-ogy of a toric IOL and know that correcting astigma-tism is not much more complicated than perform-ing standard cataract surgery. It involves accurate preoperative testing, marking the axis of the eye, and then rotating the IOL into position toward the end of the procedure. Each of these steps is straight-forward to perform for any cataract surgeon, and it does not take long to adjust to incorporating these steps into his or her cataract surgical technique.

For surgeons just beginning their experience with toric IOLs, they should choose patients who do not have a complicated ocular history. Avoid pa-tients who do not dilate well or who had intraoper-ative floppy iris syndrome, because it is difficult to see the markings on the IOL with a small pupil. A patient with relatively low and regular astigmatism who has a widely dilated pupil is a great candidate for inexperienced toric IOL surgeons. It is best for surgeons to address the more complicated cataract

patients after they become more familiar with the technology. Surgeons who have little to no expe-rience implanting toric IOLs can further improve their confidence by speaking with experienced col-leagues, learning tips and techniques and attend-ing astigmatism management courses.

ConclusionIn terms of surgical technique, implanting to-

ric IOLs to correct astigmatism is not a great leap from the standard cataract surgery surgeons typi-cally perform. It is within the realm of any cataract surgeon to achieve outstanding outcomes with to-ric IOLs, and there is a significant cataract patient population that can benefit.

References

1. Provided courtesy of Dr. Warren Hill. URL: http://www.doctor-hill.com/iol-mail/astigmatism_chart.htm. Accessed October 20, 2014.

2. Holland E, Lane S, Horn JD, Ernest P, Arleo R, Miller KM. The AcrySof Toric intraocular lens in subjects with cataracts and corneal astigmatism: a randomized, subject-masked, parallel-group, 1-year study. Ophthalmology. 2010;117(11):2104-11.

3. AcrySof® IQ Toric IOL Directions for Use.

4. Lane SS, Ernest P, Miller KM, Hileman KS, Harris B, Waycaster CR. Comparison of clinical and patient reported outcomes with bilateral AcrySof Toric or spherical control intraocular lenses. J Refractive Surgery. 2009;25:899-901.



Implementing toric IOLs into cataract and refractive practices is a simple and effec-tive process, even for surgeons who typically use basic IOLs. Surgeons can gain confidence in their ability to implant toric IOLs knowing that they simply need to obtain accurate preop-erative measurements, imple-

ment an effective wound construction and know their surgically induced astigmatism (SIA). Doing so may lead to successful outcomes and satisfied patients, because toric IOLs can achieve quality dis-tance vision as well as lower spectacle dependence.

Patient selectionAll patients with 0.75 D of astigmatism and

higher may benefit from toric IOLs. The excep-tion is when a patient has a pre-existing disease entity that will negate the visual improvement of such treatment. Therefore, if a surgeon encoun-ters a patient with macular degeneration or isch-emic optic neuropathy, then attempting to correct low levels of astigmatism with a toric IOL is not going to be beneficial for that patient. I choose to correct patients’ astigmatism when the patient has a healthy enough eye and therefore will be able to appreciate the improvement in his or her vision, which is the result of correcting astigma-tism with a toric IOL.

Preoperative measurements and marksThere are simple steps surgeons must take to be-

gin implanting toric IOLs. The first key to success-fully implanting a toric IOL is gathering accurate data. If surgeons do not obtain accurate preopera-tive measurements, then they will not achieve suc-cessful outcomes.

In my practice, I take different sets of measure-ments to verify that my data are accurate. I often ob-tain both manual keratotomy and autokeratometry

measurements at least six times per case. I also use biometry and take three sets of measurements with the IOLMaster (Carl Zeiss Meditec). I then use a Pentacam (OCULUS), which measures the anterior topography of the cornea and the total corneal power. Another data point surgeons must account for is the posterior corneal curvature. If I find that each of these data points closely align, then no further measurements are needed. If there is a great disparity between the data points, then I will have a different technician repeat the mea-surement process. If I find that the inconsistent measurements are due to surface issues such as dry eye, I sometimes ask patients to first manage their dry eye and return for surgery on a different day to repeat the measurements.

After obtaining accurate measurements, sur-geons must also mark the eye correctly to ensure that the IOL is placed in the proper position. I use markers and magnifying loops when the patient is sitting upright and at the edge of the surgical area. I mark the 3 o’clock and 9 o’clock positions. In the operating room, I use a 360° ring protractor that I hold in my left hand and a marker that I hold in my right hand to mark the axis on which I will place the IOL.

Wound constructionWound construction is one of the most vital

components of implanting a toric IOL, as it can help lower SIA, lower the standard deviation for surgeons’ SIA and lead to better outcomes. It is a common misconception that the only factor impacting SIA is wound size. However, two im-portant components are also the geometry of the wound and its location.

Wound locationWhen surgeons began performing sutureless

cataract surgery, I became involved with the cor-neal component not to prevent the use of sutures, but instead to prevent postoperative complications

Wound construction is key for implanting toric IOLsPaul H. Ernest, MD

Paul H. Ernest, MD



like microhyphemas and filtering blebs. Surgeons made scleral tunnel incisions that would enter the eye at the iris root and, in doing so, they would experience microbleeds anterior to the suture. The wound would be satisfactory on postopera-tive day 1, but patients would report blurriness and small microhyphemas coming from the top of the wound on postoperative day 2. In order to reduce these complications, I changed the location of the wound by making my incisions further into the cornea. I use the internal pressure to create a seal so that blood does not escape around it, which eliminates the need for an external suture. This also prevents the iris from prolapsing into the in-ternal part of the incision and causing blebs, which was another common complication surgeons expe-rienced when originally constructing scleral tun-nel incisions.

A wound that is constructed more peripherally results in less flattening of the cornea1 and a lower in-cidence of SIA. With the same arc length, astigmatic keratotomy causes more SIA than limbal relaxing incisions. Therefore, the more anterior the surgeon places an incision of the same wound size, the more astigmatism is being induced by the incision.

Wound geometryI discovered the importance of wound geom-

etry when Norman Jaffe, MD, first suggested that if surgeons want to prevent a significant amount of against-the-rule astigmatism and wound slide, then they need to have vertical supports on the edges of their incisions. The idea was not to cre-ate a large horizontal incision, but to create ver-tical support at both the 3 o’clock and 9 o’clock locations. As cataract and refractive surgical tech-niques evolved to phacoemulsification, I began creating a trapezoid-shaped wound to incorpo-rate vertical incisions. I then experimented with the stability of square-shaped wounds (Figure 1). I found that a posterior limbal square wound, even with an endpoint pressure of up to 525 PSI, does not leak like a rectangular wound (Figure 2). I also observed refractive outcomes with a posterior lim-bal square wound measuring 4 mm wide and 4 mm long. I found that my SIA was 0.7 D, with minimal shifting of the axis of astigmatism at the preopera-tive level.2

These findings became more significant when toric IOLs were introduced into cataract surgery. I implant toric IOLs using a posterior limbal square wound construction and, in a prospective study,3

my SIA was 0.3 D with a standard deviation of ±0.2. The co-investigator used a clear corneal incision and had an SIA of 0.6 D with a standard deviation of ±0.4. Both the SIA and standard deviation were two times greater with a 2.4-mm clear corneal in-cision than with a 2.2-mm posterior limbal square wound. Then, in a retrospective study published in April 2011,4 my SIA was 0.25 D with a standard de-viation of ±0.14, which is similar to my SIA in our previous study. Therefore, it became clear that a posterior limbal square wound consistently helped lower my SIA and standard deviation. Standard deviation is a central factor because it shows how much a surgeon’s outcomes vary. The less variation that exists between surgeons’ outcomes, the more confident they will become in terms of the amount of SIA they create.

Richard Potvin, OD, Warren Hill, MD, and I also reviewed international data for 2.2-mm inci-sions and clear corneal incisions. We found that the average SIA for 2.2-mm clear corneal incisions was approximately 0.65 D with a standard devia-tion of ±0.45.4 These data are similar to the data we calculated using a 4-mm by 4-mm scleral tunnel square wound 20 years prior. When you compare the 2.2-mm posterior limbal square wound on two separate occasions, it shows consistency in tech-nique and outcomes regarding SIA and standard deviation. These are results surgeons can have con-fidence in when implanting toric IOLs.

Figure 1: The process of constructing a posterior limbal square-shaped wound.

Source: Ernest PH



Also, when we went up two standard deviations in the international study, one of the surgeons in-duced 2 D of astigmatism. It is impossible for sur-geons to treat 1 D or 0.75 D of astigmatism if the wound is creating 1 D or more of astigmatism. Dr. Hill has shown that about 52% of the U.S. popula-tion has 0.75 D or more of astigmatism. Of that 52%, 34.6% have between 0.75 D and 1.5 D of astigma-tism.5 This means that almost 70% of all toric IOLs would need to treat low powers of astigmatism.

Ultimately, I was able to significantly lower my SIA by staying more peripheral when constructing the wound and maintaining a square geometry. Therefore, the location and geometry of the wound are more integral than its size. When surgeons successfully construct a posterior limbal square wound, their SIA and standard deviation will de-crease. Maintaining a lower and more predictable SIA will help surgeons feel more confident in their outcomes when implanting toric IOLs.

Centering the IOLIt is important for surgeons to use an effective

technique for centering a toric IOL to minimize

its rotation postoperatively and intraoperatively. I have used the bimanual technique for remov-ing cortical material for more than 20 years. This technique is widely used in Europe and I learned it from my colleagues while lecturing abroad in the early 1990s. With the bimanual technique, the sur-geon uses separate tools in each hand rather than a single handpiece to remove cortical material.

The bimanual technique has many advantages. First, it allows the surgeon to thoroughly remove all cortical material, whereas single handpieces cannot remove all of the cortical material under the inci-sion. Second, the set of surgical instruments I use can go through a 1-mm paracentesis incision. The aspiration handpiece has a diamond-blasted tip that allows surgeons to thoroughly polish the posterior capsule. When I begin inserting the toric IOL, I will first remove all of the viscoelastic from behind and in front of the implant. Then, I use an irrigating can-nula through one of the paracenteses and a blunt-tip hook through the second paracentesis incision so that the IOL is almost free-floating. As I rotate the IOL and line up the marks on the IOL with the marks on the cornea, the IOL remains stationary.

Figure 2: Graph shows that geometric square incisions give maximum resistance to deformation pressure independent of location. Rectangular incisions have significant lower resistance to deformation pressure and are dependent on intraocular pressure.

Source: Ernest PH



Conversely, when surgeons exit the eye using a single handpiece, there is a significant decrease in the anterior chamber depth, which causes the IOL to shift at least 5°. Surgeons do not experience this shift when using the bimanual technique.

Another advantage of the bimanual technique is that the surgeon is constantly irrigating while rotating the IOL. Therefore, any small pockets of viscoelastic that the surgeon did not remove prior to rotation are washed out of the fornices of the capsular bag. Overall, I have experienced great success in centering the IOL more precisely with this technique. It allows surgeons to feel confident that they removed all cortical material and set up the best foundation for a successful outcome.

ConclusionWound construction is the foundation of the to-

ric IOL procedure. It is similar to building a house; a solid foundation is needed before assembling the walls. Once surgeons become confident in their wound construction, the remaining steps for im-planting a toric IOL are straightforward.

I encourage surgeons who want to learn more about implanting toric IOLs to observe my cases

live or via video footage. Doing so can help elimi-nate any learning curve for surgeons with limited experience constructing a posterior limbal square wound or implanting toric IOLs in general. Sur-geons can benefit if they are willing to take the time to not only watch the surgical process, but also discuss the process with me throughout each step. Once surgeons are accustomed to the proper technique and are conscious of their SIA, they will be able to achieve better outcomes and patient sat-isfaction when implanting toric IOLs.

References

1. Menapace R, Skorpik C, Wedrich A. Evaluation of 150 consecutive cases of poly HEMA posterior chamber lenses implanted in the bag using a small-incision technique. J Cataract Refract Surg. 1990;16(5):567-577.

2. Ernest P. Corneal lip tunnel incision. J Cataract Refract Surg. 1994;20(2):154-157.

3. Alcon prospective study. Data on file.

4. Ernest P. Effects of preoperative corneal astigmatism orientation on results with a low-cylinder-power toric intraocular lens. J Cataract Refract Surg. 2011;37(4):727-732.

5. Provided courtesy of Dr. Warren Hill. URL: http://www.doctor-hill.com/iol-main/astigmatism_chart.htm. Accessed October 20, 2014.



Although advancements in cataract and refractive surgery technology, like image-guided systems, can help streamline preoperative measurements and improve patient outcomes when implanting toric IOLs, they are not necessary for surgeons to achieve success-ful outcomes. Toric IOLs are a great starting point for sur-

geons looking to implement advanced technology IOLs into their practice because they can feel con-fident with implanting them using the technology they already have.

Choosing an IOLWhen counseling patients with a significant

amount of corneal astigmatism about IOL options, I offer a toric IOL as my recommendation rather than an option. Patients want to know which IOL will give them the best vision and, if they have astigma-tism, then the best option is the toric IOL because it corrects both sphere and cylinder refractive errors. This will provide the patient with clearer distance vision and reduced spectacle dependence over-all. Toric IOLs, such as the AcrySof IQ Toric IOL (Alcon Laboratories, Inc.), can correct astigmatism in patients with 0.75 D to >3.0 D of refractive error in the cylinder. It is also beneficial for patients who are not candidates for incisional surgery or patients who have opposing astigmatism in their lens vs. their cornea.

In my experience, if a toric IOL is the appropriate choice for the patient and the surgeon strongly be-lieves in the benefits of the toric IOL, then the con-versation about IOL options is generally brief.

Preoperative measurements and marksImplementing toric IOLs is as straightforward

as implanting nontoric IOLs; the only additional

steps involve marking the eye and aligning the IOL. Often, surgeons who have limited experience with refractive IOLs worry that toric IOLs are difficult to use, but the opposite is true. This is the type of ad-vanced technology IOL that delivers great outcomes and yields satisfied patients without a steep learning curve. If surgeons are careful in collecting accurate preoperative measurements and marking the eye, then they can achieve successful outcomes.

Preoperatively, it is important to accurately as-sess the corneal astigmatism. Therefore, in addition to using a noncontact biometer to measure the axial length and corneal keratometry readings, obtaining a corneal topography is useful. I obtain additional measurements with both an automated keratom-eter and a manual keratometer to confirm that the corneal measurements are consistent and, therefore, accurate. No additional surgical training is needed to do so; any competent cataract surgeon can make the correct orientation marks required to success-fully implant a toric IOL.

Aligning the toric IOL is simple to learn. Watch-ing live surgery or video footage of experienced sur-geons implanting toric IOLs is sufficient for most surgeons to feel comfortable with the procedure. I start out by making the reference marks in the op-erating room preoperatively with the patient seated upright. I ask the patient to look straight ahead as I approach the eye from the side. I use a handheld marking instrument that has been dotted with ink to mark the cornea at the 3, 6 and 9 o’clock posi-tions. By marking the patient’s eye while upright and then marking the steep axis while supine, surgeons can set the foundation to significantly decrease cyclorota-tion errors and astigmatism and improve uncorrected vision without using an advanced image-guided sys-tem. Once the patient is prepped and draped for sur-gery and the lid speculum is placed, I use the biman-ual technique with an open-degree gauge instrument, which is centered around the limbus, and a separate instrument to mark the steep axis.

Simple techniques for implanting toric IOLsBonnie An Henderson, MD

Bonnie An Henderson, MD



Surgeons can successfully implant toric IOLs simply using ink markers, although having ad-vanced systems such as the Verion Image Guided System or ORA Aberrometer (WaveTec Vision) could be helpful with streamlining the toric IOL process. Mastering the preoperative process by obtaining accurate measurements, thereby mark-ing the cornea properly as a result, ensures proper alignment and optimizes visual results.

Implanting the toric IOLI always construct the clear corneal incision on

the steep axis, regardless of whether I am using a to-ric IOL or a nontoric IOL. Fortunately, the location of the incision and surgically induced astigmatism (SIA) are considered with the online toric calcula-tor, so these variables are incorporated into the final toric power determination. If the surgeon is using a femtosecond laser to create the incisions, then the incisions are created automatically. If the surgeon is not using a femtosecond laser, then it is important to pay close attention to the architecture of the inci-sion. The dimensions and depth should be square and long enough to create a self-sealing wound. This will prevent wound gape and possible rotation of the toric IOL in the early postoperative period.

I place the IOL using the Monarch (Alcon Laboratories, Inc.) IOL delivery system, ensuring that both haptics are completely in the capsular bag. I then use a lens manipulator, such as a Y-hook, to dial the IOL and align the marks on the optic with the steep axis marks on the cornea (Figure). Before I began using intraoperative aberrometry, I would place the IOL one clock hour counterclockwise to the steep axis in case the IOL rotates during remov-al of the viscoelastic solution.

I then follow a three-step method to remove the ophthalmic viscosurgical device (OVD). First, I place the automated irrigation and aspiration port on top and in the center of the optic of the IOL to avoid disrupting the IOL’s position, rather than placing the I&A port under the IOL. With low aspi-ration settings, I gently remove the large bolus of co-hesive OVD that is in the anterior chamber and on

top of the optic. Second, I gently tap the I&A on the right side of the optic and gently press posteriorly on the optic. This will remove the OVD from under the right side of the optic. Often, this can rotate the IOL slightly counterclockwise as the OVD evacuates from under the right side of the optic. Third, I gently tap the I&A on the left side of the optic, gently press-ing posteriorly to remove the OVD from under the left side of the IOL. This action slightly rotates the IOL in the clockwise direction to correct the slight counterclockwise movement in step 2.

In my experience with removing the OVD with this three-step method, it is unusual for the IOL to rotate away from the intended location. This method ensures proper alignment of the toric IOL and, therefore, im-proves the probability of a successful outcome.

ConclusionIdeally, all surgeons would have access to image-

guided systems and intraoperative aberrometry to streamline the process of implanting toric IOLs. However, surgeons do not need to wait to purchase these systems to begin successfully implanting toric IOLs. Surgeons have been implanting toric IOLs for more than 15 years and have been achieving excellent patient satisfaction without advanced systems. Once surgeons embrace the simple technique required to implant toric IOLs, they will be better able to achieve excellent outcomes and patient satisfaction as well.

Figure: The surgeon aligns an AcrySof Toric IOL.

Source: Alcon Laboratories, Inc.



The high incidence of pre-operative corneal astigma-tism among cataract surgery patients has led to a signifi-cant patient need for toric IOL procedures. The Toric Pro app, for the Apple iPad, can be downloaded for free through the Apple iTunes store (Figure 1). It provides

an abundance of resources categorized into dif-ferent sections that can enlighten and assist sur-geons with the most effective tips and techniques for successfully implanting toric IOLs. With the Toric Pro app, all types of surgeons, from the inexperienced to experienced, are able to access detailed information on the procedure quickly and easily in a multimedia platform. The Toric Pro app is a free, user-friendly, highly interactive app that is designed to inform surgeons on key in-formation needed to begin successfully implant-ing toric IOLs as well as confidently recommend them to patients who will benefit from correcting corneal astigmatism at the time of surgery.

Toric IOL procedureThere are several sections within the app that

surgeons can navigate depending on the type of in-formation they are seeking. Within the app, a navi-gation feature includes a section on the toric IOL procedure. This section is divided into four infor-mative portions: equipment needed to acquire the data to successfully plan the procedure; informa-tion needed preoperatively, such as how to select the appropriate patient for a toric IOL and includes instructive videos such as Bonnie An Henderson, MD, discussing how to precisely mark the eye (Figure 2); information required intraoperatively, such as how to confirm proper toric IOL align-ment (Figure 3); and lastly, information needed postoperatively.

One feature in this section that is especially useful for beginners is the preoperative marker simulation. It is sometimes challenging to mark the eye properly with a pen and the toric marker in the preoperative area. This simulation allows surgeons to practice marking the eye and it gives feedback by judging how well the surgeon has marked the eye. This is a fun, interactive feature that helps surgeons to get comfortable with pre-operative marks.

Tools and techniquesIn another section, the app offers tools and

techniques for better communication with pa-tients in order to make confident recommenda-tions and ultimately achieve patient satisfaction (Figure 4). This section includes a tab on tips for patient consultation, with videos featuring expert recommendations on how to interact with pa-tients and discuss the toric IOL procedure with patients. This is beneficial for beginners, as it pro-vides videos of surgeons such as Stephen Scoper, MD, and Bret Fisher, MD, speaking about the ba-sics of the surgery and the technology. They also discuss how they first adopted toric IOLs into their practices. For more experienced surgeons, the videos provide nuanced information about more difficult cases as well as strategies for talking to patients and teaching them about the technol-ogy. It is an opportunity for experienced surgeons to re-examine the way they manage astigmatism and cataract surgery.

Other tabs in this section include an intro-duction to biometry with in-depth detail on equipment, measurements and calculations for successful implantation; access to the Toric IOL calculator to help determine the right toric IOL power for each patient; access to the surgically in-duced astigmatism data export tool; and an inter-active simulation tool (Figure 5), where users are able to practice preoperative reference marking

Toric Pro app engages surgeons with multimedia toolsDamien F. Goldberg, MD

Damien F. Goldberg, MD



Figure 1: The Toric Pro app home screen.

Source: Toric Pro app, Alcon Laboratories, Inc.

Figure 4: The tools and techniques section of the Toric Pro app.


Figure 5: (A) The simulation prompts the user to hold the iPad in an upright position to simulate a patient sitting in an upright position, and then the user can press the “show the beam” button to simulate bringing down the slit lamp beam. (B) Once the user presses the button, he or she can put two fingers on the screen to control the virtual marker and drag it to the desired location.


Figure 2: Users who are inexperienced with toric IOLs can watch videos of surgeons, such as Bonnie An Henderson, MD, showing surgeons how to mark the eye.


Figure 3: The Toric Pro app home screen.




and intraoperative axis marking of the eye with five patient cases.

Other key featuresAt the bottom of the navigation feature, there

are tabs with detailed information on the toric IOL product, a place for users to offer feedback and suggestion on the app, as well as a references and bookmark tab.

The bookmark feature is available in each sec-tion and allows users to easily refer back to a section or tab once they have reviewed the information by

clicking the bookmark icon at the top right of the screen (Figure 6). This allows the user to quickly and easily refer back to information that they find particularly useful or want more detailed informa-tion about. Users can also email information to themselves or a colleague by clicking on the mail icon located next to the bookmark icon at the top of the screen in each tab. These tools make it easy for surgeons to access and share important information that is helpful for improving their techniques.

ConclusionThe Toric Pro app is a fantastic resource for

surgeons, providing all of the reference material needed for the toric IOL procedure in one multi-media platform. It allows surgeons of all experi-ence levels to hone their skills while tracking their progress along the way. While print journals and books are informative resources for surgeons, the app allows surgeons to quickly access a wealth of information in an engaging digital format that stores extensive information in one place. It gives surgeons the opportunity to watch experts per-form surgery, watch them talk to patients, and observe how they have that conversation, rather than read about it. Surgeons can use this stimulat-ing tool to help improve various aspects of their toric IOL techniques so they are confident in their outcomes and patient satisfaction.

Figure 6: The Toric Pro app allows users to bookmark and email specific pages of the app that interest them.




AcrySof® IQ Toric Intraocular Lenses – Important Product Information

Caution: Federal (USA) law restricts this device to the sale by or on the order of a physician.

Indications: The AcrySof® IQ Toric posterior chamber intraocular lens-es are intended for primary implantation in the capsular bag of the eye for visual correction of aphakia and pre-existing corneal astigmatism secondary to removal of a cataractous lens in adult patients with or without presbyopia, who desire improved uncorrected distance vision, reduction of residual refractive cylinder and increased spectacle inde-pendence for distance vision.

Warning/precaution: Careful preoperative evaluation and sound clin-ical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient with any of the conditions described in the Directions for Use labeling. Toric IOLs should not be implanted if the posterior capsule is ruptured, if the zonules are dam-aged, or if a primary posterior capsulotomy is planned. Rotation can reduce astigmatic correction; if necessary lens repositioning should occur as early as possible prior to lens encapsulation. All viscoelastics should be removed from both the anterior and posterior sides of the lens; residual viscoelastics may allow the lens to rotate.

Optical theory suggest, that, high astigmatic patients (ie, > 2.5 D) may experience spatial distortions. Possible toric IOL related factors may include residual cylindrical error or axis misalignments. Prior to surgery, physicians should provide prospective patients with a copy of the Patient Information Brochure available from Alcon for this product informing them of possible risks and benefits associated with the Ac-rySof® IQ Toric Cylinder Power IOLs.

Studies have shown that color vision discrimination is not adverse-ly affected in individuals with the AcrySof® Natural IOL and normal color vision. The effect on vision of the AcrySof® Natural IOL in subjects with hereditary color vision defects and acquired color vision defects secondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve diseases) has not been studied. Do not resterilize; do not store over 45° C; use only sterile irri-gating solutions such as BSS® or BSS PLUS® Sterile Intraocular Irrigating Solutions.

Attention: Reference the Directions for Use labeling for a complete listing of indications, warnings and precautions

VERION™ Image Guided System – ECP FACING Brief Statement

VERION™ Reference Unit and VERION™ Digital MarkerCaution: Federal (USA) law restricts this device to sale by, or on the or-der of, a physician.

Intended uses: The VERION™ Reference Unit is a preoperative mea-surement device that captures and utilizes a high-resolution reference image of a patient’s eye. In addition, the VERION™ Reference Unit pro-vides pre-operative surgical planning functions to assist the surgeon with planning cataract surgical procedures. The VERION™ Reference Unit also supports the export of the reference image, preoperative measurement data, and surgical plans for use with the VERION™ Digi-tal Marker and other compatible devices through the use of a USB memory stick. The VERION™ Digital Marker links to compatible surgi-cal microscopes to display concurrently the reference and microscope images, allowing the surgeon to account for lateral and rotational eye movements. In addition, details from the VERION™ Reference Unit surgical plan can be overlaid on a computer screen or the physician’s microscope view.

Contraindications: The following conditions may affect the accuracy of surgical plans prepared with the VERION™ Reference Unit: a pseu-dophakic eye, eye fixation problems, a non-intact cornea, or an irregu-lar cornea. In addition, patients should refrain from wearing contact lenses during the reference measurement as this may interfere with the accuracy of the measurements. The following conditions may af-fect the proper functioning of the VERION™ Digital Marker: changes in a patient’s eye between pre-operative measurement and surgery, an irregular elliptic limbus (e.g., due to eye fixation during surgery, and

bleeding or bloated conjunctiva due to anesthesia). In addition, the use of eye drops that constrict sclera vessels before or during surgery should be avoided.

Warnings: Only properly trained personnel should operate the VERION™ Reference Unit and VERION™ Digital Marker. Use only the provided medical power supplies and data communication cable. Power supplies for the VERION™ Reference Unit and the VERION™ Digi-tal Marker must be uninterruptible. Do not use these devices in com-bination with an extension cord. Do not cover any of the component devices while turned on. The VERION™ Reference Unit uses infrared light. Unless necessary, medical personnel and patients should avoid direct eye exposure to the emitted or reflected beam.

Precautions: To ensure the accuracy of VERION™ Reference Unit measurements, device calibration and the reference measurement should be conducted in dimmed ambient light conditions. Only use the VERION™ Digital Marker in conjunction with compatible surgical microscopes.

Attention: Refer to the user manuals for the VERION™ Reference Unit and the VERION™ Digital Marker for a complete description of proper use and maintenance of these devices, as well as a complete list of con-traindications, warnings and precautions.

ORA System® Important Product Information Caution: Federal (USA) law restricts this device to sale by, or on the or-der of, a physician.

Intended use: The ORA System® uses wavefront aberrometry data in the measurement and analysis of the refractive power of the eye (i.e. sphere, cylinder, and axis measurements) to support cataract surgical procedures.

Contraindications: The ORA System® is contraindicated for patients:.who have progressive retinal pathology such as diabetic retinopathy, macular degeneration, or any other pathology that the physician deems would interfere with patient fixation;• who have corneal pathology such as Fuchs’, EBMD, keratoconus,

advanced pterygium impairing the cornea, or any other pathol-ogy that the physician deems would interfere with the measure-ment process;

• whose preoperative regimen includes residual viscous sub-stances left on the corneal surface such as lidocaine gel or vis-coelastics;

• with visually significant media opacity (such as prominent float-ers or asteroid hyalosis) what will either limit or prohibit the mea-surement process; or

• who have received retro or peribulbar block or any other treat-ment that impairs their ability to visualize the fixation light.

• In addition, utilization of iris hooks during an ORA System® image capture is contraindicated, because the use of iris hooks will yield inaccurate measurements.

Warnings and precautions:• Significant central corneal irregularities resulting in higher order

aberrations might yield inaccurate refractive measurements.• Post refractive keratectomy eyes might yield inaccurate refrac-

tive measurement.• The safety and effectiveness of using the data from the ORA

System® have not been established for determining treatments involving higher order aberrations of the eye such as coma and spherical aberrations.

• The ORA System® is intended for use by qualified health person-nel only.

• Improper use of this device may result in exposure to dangerous voltage or hazardous laser-like radiation exposure.

• Do not operate the ORA System® in the presence of flammable anesthetics or volatile solvents such as alcohol or benzene, or in locations that present an explosion hazard.

Attention: Refer to the ORA System® Operator’s Manual for a complete description of proper use and maintenance of the ORA System®, as well as a complete list of contraindications, warnings and precautions.

© 2015 Novartis 3/15 TOR14065JS

6900 Grove Road, Thorofare, NJ 08086 USAphone:856-848-1000•www.healio.com•Healio.com/Ophthalmology

This Ocular Surgery NewS supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

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