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.

Marking the Eye

Marking the eye is the cornerstone for successful toric IOL alignment and is typically performed in two stages: preoperative reference marking and intraoperative marking of the steep axis.

Reference marking

Reference marks account for cyclorotation — the change in the orientation of the eye when a patient moves from a sitting to supine position. Average cyclorotation of the eye is 2–4 degrees; however, some patients will experience up to 15 degrees of cyclorotation.1 Marking the patient’s eye while they are sitting up will ensure correct orientation of the toric IOL and provide placement guidelines during the procedure.

See an animated demonstration of the reference marking process.

See an animated demonstration of the reference marking process.
See an animated demonstration of the reference marking process.

How to create reference marks

Step 1. After dilating drops, have the patient sit upright and align the patient’s head straight forward. Have the patient fixate on an image in the distance.
Step 2. Place marks at 3, 6 and 9 o'clock using a reference marker with ink dotted on its touch points. Or, if marking by hand, mark only at 6 o’clock as it is difficult to mark exactly 180 degrees apart.
Step 3. Prep and drape the patient for surgery.

Reference marking tips

  • Make sure numbing drops are dry prior to marking the steep axis.
  • Enhance fading marks by marking by hand if necessary.

Axis marking

Axis marks identify the steep axis of astigmatism to ensure optimal alignment. Using the preoperative reference marks you made while the patient was sitting upright, mark the eye at two positions (180 degrees apart) to define the optimal axis to align the toric IOL.

See an animated demonstration of the axis marking process.
See an animated demonstration of the axis marking process.

How to mark the steep axis

Step 1. Reference the recommended lens placement axis as determined by the toric calculator and corneal topographer.
Step 2. Dial the axis marker to the angle that corresponds with the axis as determined in Step 1, and mark the dialable touch points with ink.
Step 3. Align the stationary touch points of the axis marker with the preoperative reference mark to account for cyclorotation.
Step 4. Place two marks 180 degrees apart on the steep axis of astigmatism.

Axis marking tips

  • Avoid excess ink to prevent smearing.
  • Check the axis again right before implanting.
  • Mark the eye prior to capsulorhexis, incisions and blocks.

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).