1. Management of Corneal Astigmatism with Toric IOLs: Optimizing Outcomes
Adam Goddard, D.O.
Comprehensive Ophthalmologist
Associated Eye Care
Stillwater, MN

2. Financial Disclosures
None

3. Objectives Understand clinical considerations for Toric IOLs
Review of Toric IOL design and ranges of astigmatism correction
Application of preoperative and intraoperative technology for astigmatism management
Clinical measurements of astigmatism
Verion™ Image Guidance System
Pearls for optimizing visual outcomes

4. Overview Coexisting cataract and corneal astigmatism
Correcting astigmatism in the IOL plane

8. IOL Design: Technis Toric (AMO)

9. Range of Correction (D)
Technis Toric (AMO)
AMO Model
ZCT 150
ZCT 225
ZCT 300
ZCT 400
IOL Plane (D)
1.50
2.25
3.00
4.00
Corneal Plane (D)
1.03
1.55
2.06
2.75
Range of Correction (D)
0.75 to 1.50
1.50 to 2.00
2.00 to 2.75
2.75 to 3.62

10. IOL Design: Acrysof Toric (Alcon)

13. Preoperative Assessment
Regular corneal astigmatism
Corneal topography
IOL Master or LenStar Ks
Manual Ks
Refractive status
Corneal vs. lenticular astigmatism
Lenticular offset of corneal astigmatism

14. Preoperative Assessment
Keratometry instruments
LenStar, Verion, IOL Master, Topography, manual Ks, auto Ks
K readings should vary by no more than 0.5D
Steep axis for K readings should vary by no more than 10 degrees

15. Preoperative Assessment
Pearls for technical component
Input for post-LASIK (myopic vs. hyperopic) very important to avoid errors
Flag post-refractive patients
Clear communication between surgeon, ASC, advanced lens technology technician, and surgery schedulers is critical
QA process

16. Preoperative Assessment
Intact capsular bag and zonules
Continuous curvilinear capsulotomy
Careful consideration with prior corneal refractive surgery
Caution with pre-existing ocular disease
KCN, Fuchs dystophy

17. Preoperative Assessment
Posterior Corneal Astigmatism
Previous calculations assume anterior and posterior corneal curvature have a constant ratio
Dr. Doug Koch (Baylor) found posterior corneal curvature varies widely among individual patients
Ignoring posterior corneal astigmatism may yield incorrect estimation of total corneal astigmatism

18. Preoperative Assessment
Posterior corneal astigmatism (cont)
Average posterior cornea has slight plus power in the horizontal meridian, creating against-the- rule refractive astigmatism
Using anterior corneal measurements alone can result in:
Overcorrection of with-the-rule astigmatism
Undercorrection of against-the-rule astigmatism
Baylor Normogram

19. Preoperative Assessment
Online Toric Calculators
Alcon Toric Calculator
Barrett Toric Calculator
AMO Tecnis Toric Calculator

20. Surgery Capsular integrity
Orienting and marking eye for appropriate axis implantation
Careful placement of toric IOL and removal of viscoelastic

26. ORA with Verifye+ Validate / refine surgical plan
Refractive information, including IOL power, cylinder, and axis of astimatism
Account for anterior and posterior corneal astigmatism
Minimize undesired residual astigmatism postop

30. Case Presentation 73 y.o. F with symptomatic cataracts OU
Halos/glare, blurring at distance > near
Patient desires best uncorrected distance vision
Current Glasses
x010 = 20/ BAT = 20/400
x168 = 20/ BAT = 20/100
Exam
2+ NSC / 1+ ACC OU
No other pathology on SLE/DFE

38. Case Presentation Post-op Outcome
Very happy with subjective improvement and quality of uncorrected distance vision
VAsc: 20/25 OD, 20/20 OS
MRX:
x045 = 20/20
-0.25 sph = 20/20

39. Toric Alignment
Axis Assistant App

40. Toric Alignment
iHandy Level

41. Residual Refractive Error after Toric IOL?
Berdahl-Hardten
Manifest refraction in plus or minus power
Enter the axis of the current toric IOL
Calculate
No rotation, rotation, exchange

42. Future Multifocal/Toric IOL Awaiting FDA approval in the US
November 2014
US FDA’s Ophthalmic Devices Advisory Committee recommended FDA approval of ReSTOR Multifocal Toric IOL
Currently approved in Europe, Canada, Australia, Japan, and many countries in Central and South America

43. Summary
A wide range of astigmatism correction is now available with toric IOLs
Advancements in technology, including LenSx and Verion/Verifye+, have improved surgical precision
Attention to preoperative and intraoperative detail can help achieve optimal outcomes
Measurements should make sense
Consider posterior corneal astigmatism

44. Questions?
Thank You!

45. References
Visser N et al. J Cataract Refract Surg. 2011;37(8):
Koch DD et al. J Cataract Refract Surg. 2012;38(12):
Osher RH. J Cataract Refract Surg. 2010;36(2):