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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...
WHY ARE TORICS GOOD?
• Usually result in low residual astigmatism
• Higher visual outcome demands from patients
• Toric IO...
TORIC LIMITATIONS
• Neutralise corneal astigmatism in the plane of
the Effective Lens Position (ELP)
 Higher order aberra...
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 e...
WHY LESS THAN
PERFECT?
Surgically Induced Astigmatism variable
– Size of keratome blade
– Superior vs Temporal incision lo...
WHY LESS THAN
PERFECT?
• Lens rotation in bag post-operatively
– Worse with long axial length (Shah et al)
– Most occurs i...
WHY LESS THAN
PERFECT?
• Irregular capsulorhexis size or shape can mean
final effective lens position is not as predicted
...
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
...
Improving Toric
Outcomes
• Counsel patients appropriately
• Plate haptic lenses offer better
capsule stability and less ro...
Improving Toric
Outcomes
• Use a formula that utilises ACD
– E.g. Haigis or Holladay2
• Await technology and mathematics t...
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 k...
Improving Toric
Outcomes
• Toric lenses are being used more frequently
• Potential to improve patient outcomes
significant...
Q3: Toric IOL’s:
A Take less surgical time than standard
spherical IOL’s
B Require less pre-operative planning than
standa...
Toric IOL's and Cataract Surgery
Toric IOL's and Cataract Surgery
Toric IOL's and Cataract Surgery
Toric IOL's and Cataract Surgery
Toric IOL's and Cataract Surgery
Toric IOL's and Cataract Surgery
Toric IOL's and Cataract Surgery
Toric IOL's and Cataract Surgery
Toric IOL's and Cataract Surgery
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Toric IOL's and Cataract Surgery

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Toric IOLs and cataract surgery - patient selection, advantages, limitations, complications, management

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Toric IOL's and Cataract Surgery

  1. 1. TORIC IOL’S and CATARACT SURGERY Dr Brad Townend BSc(Med), MBBS, MPH, MMed, FRANZCO Gosford and Wyong Eye Surgery
  2. 2. Toric IOL Correction of corneal astigmatism
  3. 3. Conoid of Sturm
  4. 4. 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
  5. 5. 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)
  6. 6. 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
  7. 7. THRESHOLD FOR USE • 1.5 Dioptres of corneal astigmatism
  8. 8. WHY LESS THAN PERFECT? Not an exact science
  9. 9. WHY LESS THAN PERFECT? Limited range of lens powers
  10. 10. WHY LESS THAN PERFECT? Approximation of final anterior chamber depth
  11. 11. WHY LESS THAN PERFECT? Keratometry axis variable
  12. 12. WHY LESS THAN PERFECT? MARKING – Patient’s head not straight – Big and blotchy pen tips – Markings wash away! – Parallax error
  13. 13. WHY LESS THAN PERFECT? Surgically Induced Astigmatism variable – Size of keratome blade – Superior vs Temporal incision location – Anterior vs Posterior wound
  14. 14. 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
  15. 15. 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
  16. 16. WHY LESS THAN PERFECT? No consideration of posterior corneal surface
  17. 17. WHY LESS THAN PERFECT? Cascade of potential error
  18. 18. 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
  19. 19. Improving Toric Outcomes • Counsel patients appropriately • Plate haptic lenses offer better capsule stability and less rotation post-operatively
  20. 20. 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
  21. 21. Improving Toric Outcomes • Manage paralax error – ASICO electronic toric marker • Built-in protractor
  22. 22. 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)
  23. 23. 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
  24. 24. 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

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