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.
*Dr. Tipperman is a paid consultant for Alcon.
Aligning Toric IOLs
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.
- Gross IOL alignment
- IOL stabilization during viscoelastic removal
- 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.
As the IOL is unfolding in the capsular bag, rotate it clockwise to approximately 20 to 30 degrees short of the steep axis.
Rotate the IOL to within 20 to 30 degrees short of the steep axis.
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.
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.
- 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.