TORIC IOLs

Jagdish Dukre
 Modern cataract surgery is more of
refractive surgery.

Myopia & hypermetropia can be corrected

using appropriate spherical powers of
IOLs.

However approximately 20% of patients

who undergo cataract surgery have 1.25D
of corneal astigmatism or more.

It can be corrected with Toric IOLs.

 Other options for correction of co-existent
cataract and astigmatism

LRI during cataract surgery( upredictable

results)

Laser procedures postoperatively (are

associated with new set of complications).
 History of Toric IOLs
First introduced by Shimizu et al in 1994.

It was nonfoldable 3 piece toric IOL made

from PMMA.

It had oval optic with loop haptics ,available

in cylinder power 2-3 D.

Postoperatively 20% IOLs rotated > 30

degrees and 50% IOL rotated about 10
AVAILABLE
TORIC
IOLs
 Model of Acrysof IQ Toric
Model Cylinder power at Cylinder Power at
IOL plane(D) corneal plane(D)
SN60AT3 1.50 1.03

SN60AT4 2.25 1.55

SN60AT5 3.00 2.06

SN60AT6 3.75 2.57

SN60AT7 4.50 3.08

SN60AT8 5.25 3.60

SN60AT9 6.00 4.11

Spherical powers available are 16- 25 D.

 Factor Affecting Rotation of Toric IOL

(1) IOL material

Hydrophobic Acrylic < Hydrophilic Acrylic < PMMA <
Silicon
(2) Overall IOL diameter - Larger diameter prevents
rotation . Toric IOLs are available nowadays in
11-13 mm overall diameter.
(3) Haptic design
Initial concept
- Loop haptics prevent early rotation .
- Plate haptics prevent late rotation.
Recent concept No difference in incidence of post
operative
rotation between plate and loop haptics provided
Patient selection

Regular corneal astigmatism > 1.5 D

Vision compromising cataract

Patient wants spectacle

independence
 Facts
20% of patients with cataract have
astigmatism >1.25 D
Every incision on cornea induces additonal
astigmatism (SIA).
Implantation of monofocal lens will require
distance and near correction both in these
cases.
B/L Toric IOLs give high level of spectacle
independence(97%).
Requirement of near correction can be
overcome by multifocal toric IOL(AcriLisa
multifocal toric IOL)
Toric IOL power calculation :

Precise keratometry

Surgically induced astgmatism [SIA].

 Keratometry
Can be done with
Manual keratometer
Automated keratometer with steps of 0.12 only
Corneal topography

K readings from all the three show high

repeatability and are comparable.

Manual keratometer should be calibrated

regularly.
 Corneal topography is required in case of
unusual reading & poor quality mires.

Precautions
Reading must be quick to avoid drying of
cornea.
Dont rub on the cornea.
Centration must be proper.
 Surgically Induced
Astigmatism
Every incision changes the cornea.

Closer to the centre & larger the incision more

effect on corneal curvature.

Other factors affecting it are preoprative corneal

astigmatism, suture use and patients age.

In addition there is variability from patient to

patient.

Overall effect can be summed up with vector

analysis.
 SIA Calculation
Obtain SIA calculator

Fill it for 20-30 cases minimum

Be precise about axis and incision

Calculator auto calculates SIA

 AcrySof Toric IOL Calculator

Data input
Patient data
Keratometry
IOL spherical
power
Surgically induced
astigmatism
Incision location

15
Output screen
Recommended IOL
model and spherical
equivalent power
Optimal axis
placement
Magnitude and axis
of anticipated
residual astigmatism

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 Marking of Eye
Instruments
Bubble marker
Gravity marker
STEPS
A) Reference marking
Done prior to surgery with patient upright
Two reference markers placed at limbus 180
degree apart
Used to align marking instuments for placement
of axis marks
B) Axis marking : Using reference marks as a guide
the patient eye is marked accurately at two
positions 180 degree apart
TIPS:-
- Dry the conjunctiva with a swab
- Enhance marking at 3-9 o clock
- Apply mark with twisting action
 Surgery
Standard phacoemulsification

Incision size 1.5 3.4 mm

Well centered rhexis with diameter 5- 5.5 mm

with 360 degrees overlap of IOL margin

Marks on IOL indicate flat meridian or plus

cylinder axis of toric IOL

Cohesive viscoelastics are preferred.

 IOL alignment
Gross
alignment

OVD removal

Final alignment

If overshoots

Tap (nudge) IOL down into capsular bag

to seat lens onto the posterior capsule.
 If any compromise of zonular integrity or
capsule occurs please switch to standard
non toric IOL

Postoperative axis alignment :

Slit Lamp with dilated pupil

Wavefront aberrometry in undilated pupil

Realignment should be done in < 2 wks

 Complications
Rotational stability is critical
to effectiveness of toric IOLs.
1 rotation results in 3.3 %
IOL power loss
30 rotation negates
cylindrical correction of toric
IOL
Further rotation induces more
astigmatism

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 Conclusion

Bilateral toric IOL implantation shows

high percentage of spectacle
independence for distance vision.