Step 3: Toric Procedure

Subtle procedural differences distinguish cataract surgery with a monofocal IOL from cataract surgery with a toric lens. These simply include: accounting for cyclorotation using reference marks, marking the steep axis and aligning the IOL once it is implanted.

Watch as Richard Tipperman, MD,* walks through the eye marking process.

Watch as Richard Tipperman, MD, walks through the eye marking process.
Watch as Richard Tipperman, MD,* walks through the eye marking process.

*Dr. Tipperman is a paid consultant for Alcon.

Aligning Toric IOLs

See an animated demonstration of implantation and toric alignment.

See an animated demonstration of implantation and toric alignment.
See an animated demonstration of implantation and toric alignment.

After the steep axis is marked, perform a standard cataract procedure. Then during implantation, manipulate the IOL into place within 20 to 30 degrees short of the intended axis.

Toric alignment occurs in three steps.

  1. Gross IOL alignment
  2. IOL stabilization during viscoelastic removal
  3. Final IOL alignment

Remember, you rotate every IOL that you implant; the only difference with toric IOLs is that you will stop rotation so that the toric marks are aligned with your previously marked axis of implantation.

Gross alignment

As the IOL is unfolding in the capsular bag, rotate it clockwise to approximately 20 to 30 degrees short of the steep axis.

IOL rotation
Rotate the IOL to within 20 to 30 degrees short of the steep axis.

Stabilization

Use a second instrument to keep the IOL stabilized during viscoelastic removal, making sure it does not rotate beyond the intended final axis location.

If the IOL rotates too far, add more viscoelastic. Then, rotate the IOL in a clockwise direction until the lens is once again a few degrees shy of the intended axis.

Remove residual viscoelastic while eye is inflated, ensuring all viscoelastic is removed.

Some surgeons use a “rock and roll” technique, pushing down on one side of the IOL with the tip of an instrument and lifting the other side to let the viscoelastic out.

Final alignment

Rotate the lens clockwise into final position.

Gently compress the lens to seat it in the capsular bag. This helps to ensure good adhesion to the bag to prevent rotation following surgery.

Confirm the alignment of the IOL is correct to ensure an optimal patient outcome.

Polymer I/A tips work especially well for this step.

Look at the eye with the operating microscope before patching the eye to ensure the IOL is still properly aligned. Speculum removal can sometimes affect the lens position.

Alignment tip

  • Practice makes perfect. The process of manipulating an IOL becomes easier after you’ve performed it a few times. Try rotating a standard monofocal lens in a few patients to build your experience.

Test Your Knowledge

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View Important Product Information for
AcrySof® IQ Toric IOL+

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 lenses 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 independence for distance vision.

WARNINGS/PRECAUTIONS: Careful preoperative evaluation and sound clinical 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 damaged, 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 suggests that high astigmatic patients (i.e., > 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 AcrySof® IQ Toric Cylinder Power IOLs.

Studies have shown that color vision discrimination is not adversely 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 irrigating 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.

Click here to view the AcrySof® IQ Toric IOL Directions for Use (DFU).

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 lenses 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 independence for distance vision.

WARNINGS/PRECAUTIONS: Careful preoperative evaluation and sound clinical 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 damaged, 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 suggests that high astigmatic patients (i.e., > 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 AcrySof® IQ Toric Cylinder Power IOLs.

Studies have shown that color vision discrimination is not adversely 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 irrigating 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.

Click here to view the AcrySof® IQ Toric IOL Directions for Use (DFU).