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TORIC IOL’S
and
CATARACT SURGERY
Dr Brad Townend
BSc(Med), MBBS, MPH, MMed, FRANZCO
Gosford and Wyong Eye Surgery
Toric IOL
Correction of corneal
astigmatism
Conoid of Sturm
Q1: Astigmatism is:
A What you have when you don’t have a
stigma
B Uncorrectable with glasses or intraocular
lenses
C Able to be ignored in intraocular lens
selection
D A difference in the curvature and therefore
focusing power of the cornea at 90 degree
axes
WHY ARE TORICS GOOD?
• Usually result in low residual astigmatism
• Higher visual outcome demands from patients
• Toric IOL’s are superior and more predictable in
reducing corneal astigmatism than limbal relaxing
incisions (Mingo-Boton et al, JCRS 2010)
TORIC LIMITATIONS
• Neutralise corneal astigmatism in the plane of
the Effective Lens Position (ELP)
 Higher order aberrations (Hayashi et al, JCRS 2012)
• Time consuming
• Reliability of outcomes
THRESHOLD FOR USE
• 1.5 Dioptres of corneal astigmatism
WHY LESS THAN
PERFECT?
Not an exact science
WHY LESS THAN
PERFECT?
Limited range of lens powers
WHY LESS THAN
PERFECT?
Approximation of final anterior
chamber depth
WHY LESS THAN
PERFECT?
Keratometry axis variable
WHY LESS THAN
PERFECT?
MARKING
– Patient’s head not straight
– Big and blotchy pen tips
– Markings wash away!
– Parallax error
WHY LESS THAN
PERFECT?
Surgically Induced Astigmatism variable
– Size of keratome blade
– Superior vs Temporal incision location
– Anterior vs Posterior wound
WHY LESS THAN
PERFECT?
• Lens rotation in bag post-operatively
– Worse with long axial length (Shah et al)
– Most occurs in first week
– ? Intra-operative re-positioning
– <10 rotation  <0.5D change (generally)
• Lens skewed in bag
• Lens not centred in bag
WHY LESS THAN
PERFECT?
• Irregular capsulorhexis size or shape can mean
final effective lens position is not as predicted
 unpredicted anti-astigmatic effect
• Anterior chamber depth consideration critical
to accuracy of toric outcome
WHY LESS THAN
PERFECT?
No consideration of
posterior corneal surface
WHY LESS THAN
PERFECT?
Cascade of potential error
Q2: Which of the following is NOT a
limiting factor in toric lens surgery
A Approximation of final anterior
chamber depth
B Keratometry axis variability
C Surgical wound induced astigmatism
D The availability of Tim Tams in the tea
room of the Day Surgery
Improving Toric
Outcomes
• Counsel patients appropriately
• Plate haptic lenses offer better
capsule stability and less rotation
post-operatively
Improving Toric
Outcomes
• Use a formula that utilises ACD
– E.g. Haigis or Holladay2
• Await technology and mathematics that will
allow assessment and utilisation of posterior
corneal surface in lens power and axis
estimates
Improving Toric
Outcomes
• Manage paralax error
– ASICO electronic toric marker
• Built-in protractor
Improving Toric
Outcomes
• Surgically Induced Astigmatism (SIA)
– Mark wound location with toric marker
– Use consistent keratome size
– Concentrate on making a consistent ant-post
position of your wound
– Perform a good surgical audit to calculate your SIA
• Key contributor to toric outcome (W Hill, JCRS, 2008)
Improving Toric
Outcomes
• Toric lenses are being used more frequently
• Potential to improve patient outcomes
significantly
• Understand their limitations and use initiative
to minimise these
Q3: Toric IOL’s:
A Take less surgical time than standard
spherical IOL’s
B Require less pre-operative planning than
standard spherical IOL’s
C Require less pre-operative discussion with
patients than standard spherical IOL’s
D Minimise but rarely completely eliminate
the effect of corneal astigmatism
Toric IOL's and Cataract Surgery

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Toric IOL's and Cataract Surgery

  • 1. TORIC IOL’S and CATARACT SURGERY Dr Brad Townend BSc(Med), MBBS, MPH, MMed, FRANZCO Gosford and Wyong Eye Surgery
  • 2. Toric IOL Correction of corneal astigmatism
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  • 6. Q1: Astigmatism is: A What you have when you don’t have a stigma B Uncorrectable with glasses or intraocular lenses C Able to be ignored in intraocular lens selection D A difference in the curvature and therefore focusing power of the cornea at 90 degree axes
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  • 10. WHY ARE TORICS GOOD? • Usually result in low residual astigmatism • Higher visual outcome demands from patients • Toric IOL’s are superior and more predictable in reducing corneal astigmatism than limbal relaxing incisions (Mingo-Boton et al, JCRS 2010)
  • 11. TORIC LIMITATIONS • Neutralise corneal astigmatism in the plane of the Effective Lens Position (ELP)  Higher order aberrations (Hayashi et al, JCRS 2012) • Time consuming • Reliability of outcomes
  • 12. THRESHOLD FOR USE • 1.5 Dioptres of corneal astigmatism
  • 13. WHY LESS THAN PERFECT? Not an exact science
  • 14. WHY LESS THAN PERFECT? Limited range of lens powers
  • 15. WHY LESS THAN PERFECT? Approximation of final anterior chamber depth
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  • 20. WHY LESS THAN PERFECT? MARKING – Patient’s head not straight – Big and blotchy pen tips – Markings wash away! – Parallax error
  • 21. WHY LESS THAN PERFECT? Surgically Induced Astigmatism variable – Size of keratome blade – Superior vs Temporal incision location – Anterior vs Posterior wound
  • 22. WHY LESS THAN PERFECT? • Lens rotation in bag post-operatively – Worse with long axial length (Shah et al) – Most occurs in first week – ? Intra-operative re-positioning – <10 rotation  <0.5D change (generally) • Lens skewed in bag • Lens not centred in bag
  • 23. WHY LESS THAN PERFECT? • Irregular capsulorhexis size or shape can mean final effective lens position is not as predicted  unpredicted anti-astigmatic effect • Anterior chamber depth consideration critical to accuracy of toric outcome
  • 24. WHY LESS THAN PERFECT? No consideration of posterior corneal surface
  • 25. WHY LESS THAN PERFECT? Cascade of potential error
  • 26. Q2: Which of the following is NOT a limiting factor in toric lens surgery A Approximation of final anterior chamber depth B Keratometry axis variability C Surgical wound induced astigmatism D The availability of Tim Tams in the tea room of the Day Surgery
  • 27. Improving Toric Outcomes • Counsel patients appropriately • Plate haptic lenses offer better capsule stability and less rotation post-operatively
  • 28. Improving Toric Outcomes • Use a formula that utilises ACD – E.g. Haigis or Holladay2 • Await technology and mathematics that will allow assessment and utilisation of posterior corneal surface in lens power and axis estimates
  • 29. Improving Toric Outcomes • Manage paralax error – ASICO electronic toric marker • Built-in protractor
  • 30. Improving Toric Outcomes • Surgically Induced Astigmatism (SIA) – Mark wound location with toric marker – Use consistent keratome size – Concentrate on making a consistent ant-post position of your wound – Perform a good surgical audit to calculate your SIA • Key contributor to toric outcome (W Hill, JCRS, 2008)
  • 31. Improving Toric Outcomes • Toric lenses are being used more frequently • Potential to improve patient outcomes significantly • Understand their limitations and use initiative to minimise these
  • 32. Q3: Toric IOL’s: A Take less surgical time than standard spherical IOL’s B Require less pre-operative planning than standard spherical IOL’s C Require less pre-operative discussion with patients than standard spherical IOL’s D Minimise but rarely completely eliminate the effect of corneal astigmatism