Improving Toric IOL Outcomes, Part 2

Improving toric IOL outcomes part 2 2017/4/11 22(41
Improving toric IOL outcomes, part 2

Reducing a patients ocular astigmatism with
toric IOLs is on the rise and deservedly so.
Ocular Surgery News U.S. Edition, June 10, 2011
Jack T. Holladay, MD, MSEE, FACS
Part 1 of this article, in the May 25 issue of Ocular Surgery News, covered
measuring corneal astigmatism and toric IOL calculators. In part 2 we will
discuss toric optimizer, choosing the residual astigmatic target, proper IOL
alignment and centration, and managing unfortunate outcomes of residual
astigmatism and higher-order aberrations.
Featured One advanced feature that is included in the

Holladay IOL Consultant and will probably
soon appear on commercial toric calculators is the toric incision location
optimizer. If one enters the pre- and postop keratometry and has operated
at many incision angles, then it is possible to determine the average
magnitude of the surgically induced astigmatism (SIA) as a function of
incision angle (Figure 1). With the patients original keratometry readings
and knowledge of the magnitude of the SIA by location, it is possible to
determine the precise location of the incision to eliminate or minimize the
residual astigmatism. The program takes the patients original astigmatism
and calculates the residual astigmatism for every possible angle of the
surgical incision. The result is shown in Figure 2. Notice there are four
locations (50, 130, 230 and 310) for which the residual astigmatism is
zero. This is usually the case, unless the step size of the toricity of the IOL
is not small enough to correct fully the necessary corneal astigmatism, in
which case there are two minima (in Figure 1 it would be 90 or 270 and
the entire curve would be above zero residual astigmatism). In any case,
the computer can always find the best result with the constraints present to
http://www.healio.com/ophthalmology/refractive-surgery/news/pr-4e52-af42-e2dea31e39f0%7D/improving-toric-iol-outcomes-part-2 1 8
give the surgeon the optimal locations for the incision.
Figure 1.
Double angle
plot of
surgically
induced
astigmatism.
Note the
variation in
magnitude
and variability
as a function
of the axis.
Images:
Holladay JT
Choosing the optimal residual astigmatism
At the beginning of your experience with a toric IOL, you may be

uncomfortable placing the incision at any meridian (some surgeons are
only comfortable temporally or superiorly), so it will not be possible to
completely eliminate the final residual ocular astigmatism. For example,
you may have a choice between a 1.50 D toricity yielding 0.50 D 90 of
residual astigmatism and the 2.25 D toricity yielding 0.12 D 180. If the
patient had with-the-rule astigmatism initially and you were taught never
to flip the axis of astigmatism, many surgeons would choose the first
option and leave more residual astigmatism: This is incorrect. Flipping the
axis is only of concern in glasses, in which meridional aniseikonia and
spatial distortion from spectacles occur due to the base curves, power,
astigmatism and vertex distance. Because the goal of a toric IOL is
spectacle independence, without glasses the only difference is the size of

the blur circle in the conoid of Sturm, so the choice should always be to
minimize the residual astigmatism. A patient with 0.50 D of with-the-rule
or against-the-rule astigmatism has the same blur on the retina. One
should always try to minimize the residual astigmatism to provide the best
overall quality of vision. Only if the choice is exactly equal would you
choose the IOL with lower toricity. If postoperatively the axis is flipped and
the patient needs a spectacle, consider leaving out the cylinder and giving
the spheroequivalent prescription. It is paramount that you always choose
the toric IOL that achieves the lowest residual astigmatism to attain the
best uncorrected vision, regardless of the axis.
Proper IOL alignment, centration
The correct toric alignment is always with the steepest meridian of the
postoperative cornea, because the reference marks on the IOL are always
on the lowest power meridian. Any deviation from aligning the lowest
power meridian of the IOL with the steepest axis of the cornea will result in
greater amounts of residual astigmatism. Predicting this axis with the
cross-cylinder solution of the SIA and original corneal astigmatism before
the cataract incision is very accurate provided the original corneal
astigmatism is regular and the magnitude and location of the SIA induced
from the incision are precise. Because the SIA is on the order of 0.5 D or
less in most small-incision surgery, the change in the axis of astigmatism
will be more with lower amounts of original astigmatism than in more
astigmatic corneas. Patients with 1.00 D of original corneal astigmatism
will have more change in the resulting cross cylinder magnitude and axis
from 0.50 D of SIA than 2.00 D of original corneal astigmatism.
Because the toric IOL normally centers in the bag, it will be on the optical
axis that is co-linear with the optical axis of the cornea, which in turn is
concentric with the limbus (Figure 3). Just like the crystalline lens, the
cornea and IOL form an optical axis. The human eye is turned temporally
~5.2 (horizontal angle alpha) and up ~1.3 (vertical angle alpha) to place
the image point of fixation on the foveola. The visual axis is the line from
the point of fixation through the nodal point (near the posterior pole of the
crystalline lens or IOL) to the foveola (Figure 4). The cornea and crystalline
lenses are therefore tilted by angle alpha, relative to the visual axis, which
induces small amounts of astigmatism and coma. It also results in a
decentration of the IOL temporally relative to the cornea. For spherical
surfaces (or nearly spherical as with a prolate ellipsoid cornea), this
astigmatism and coma are on the order of 0.25 D to 0.50 D and have little
effect on the final refraction. For toric surfaces (cornea and IOL), the tilt
and decentration result in secondary astigmatism, coma and other higher-
order aberrations. For corneal astigmatism greater than 3 D, the induced
aberrations are often the limiting factor in the visual quality. As with
diffractive multifocal IOLs, the optimal location of the IOL is centered on
the 3 mm to 4 mm pupil as shown in Figure 5. Therefore, the IOL should
be slightly nasal in the bag to achieve pupillary centration. In most cases,
the haptics have to be vertical or slightly oblique to achieve this location. If
the haptics are horizontal, self-centering lenses will move back to the
center of the bag and appear temporal to the pupil within a few minutes to
hours. For toric IOLs, due to this decentration relative to the cornea, it is
usually impossible to align the IOL toric marks with the marks on the
limbus; at best they can be parallel to this axis as shown in Figure 3.
Figure 3.
Optical axis
and visual axis
of the eye at
the corneal
plane. In this
right eye, the

limbal center
is 0.37 mm
temporal to
the Purkinje-
Sanson I
image (vertex
normal,
almost exactly
the visual
axis). This
angle is
referred to as
angle alpha
and is 0.6 mm
temporal to
the visual axis
on the
average. Angle
kappa is the
angle between
the pupil
center (small
blue dot
between
optical center
and vertex
normal) and
the visual axis,
which is
usually one-
half angle
alpha or 2.6
horizontally.
Figure 4.
Optical and
visual axis in
horizontal
cross section.
Angle alpha is
the angle
between the
geometric
centers of the
cornea and
crystalline
lens (or IOL)
forming the
optical axis
and visual axis
of the eye. The
average value
is temporally
~5.2
(horizontal
angle alpha)
and up ~1.3
(vertical angle
alpha) to place
the image
point of
fixation on the
foveola.
Figure 5. A
centered
multifocal
IOL. Note
diffraction
rings are
exactly
concentric
with the pupil.
All of these factors result in the toric IOL being placed within ~10 of the
optimal axis, but decentration and tilt are rarely considered even by the
most meticulous surgeons. New intraoperative instruments such as the
ORange from WaveTec have helped reduce any rotational error, but
centering the IOL on the pupil is much more difficult because there are no
central rings on the optic as with diffractive multifocal IOLs. Intraoperative
measurements will become more robust and accurate as the technology
improves. These instruments will continue to improve the outcomes of the
toric IOL alignment as well as eliminating spheroequivalent refractive
surprises.
Managing unfortunate outcomes
When the final refractive outcome has greater than expected residual
astigmatism, the first step is to assure that the toric IOL is not tilted or
decentered significantly. The second step is to measure the postoperative
corneal astigmatism and make sure that the alignment marks on the toric
IOL are parallel with the steepest meridian of the cornea. If it is not aligned
with the postoperative steep meridian, then the treatment is to rotate the
toric IOL to this meridian. Back toric calculators also will be available that
will take the postoperative refraction and keratometry to calculate the axis
of the toric IOL to confirm that it is the same as the axis measured at the
slit lamp. If the axis at the slit lamp and the axis determined by the back
calculator do not agree, then something else is wrong, such as
decentration, tilt or mislabeled toric IOL.
If the toric IOL is aligned at the steep meridian of the cornea, the residual
refractive astigmatic axis will be at or 90 away from the steep meridian of
the cornea, depending on whether it was slightly under- or overcorrected
by the toric IOL (and whether one uses plus or minus cylinder for the
refraction). A wavefront may be obtained, and if the coma, secondary
astigmatism and other higher-order aberrations are significant and they
are not on the topographic wavefront, then the IOL is decentered or tilted.
In most of these cases, if the wavefront is stable and repeatable, a
wavefront-guided ablation may be performed to achieve the best vision.
Moving the IOL would be unpredictable for correcting the higher-order
aberrations.
Toric IOLs are here to stay, are on the rise, and will soon be the dominant
form of astigmatism correction with IOL implantation. Following these
recommendations should help the surgeon achieve the full potential of
these lenses and provide our patients with the best visual outcome.
References:
Solomon R, Donnenfeld, Perry H, Stein J, Su M, Holladay J. Argon

laser iridoplasty to improve visual function following multifocal
IOL implantation. Presented at: American Academy of
Ophthalmology; November 2007; New Orleans. Presented at:
Association for Research in Vision and Ophthalmology; April-May
2008: Fort Lauderdale, Fla.
Wang L, Koch DD. Effect of decentration of wavefront-corrected
intraocular lenses on the higher-order aberrations of the eye. Arch
Ophthalmol. 2005;123(9):1226-1230.
Vinciguerra P. Centering diffractive IOL to pupillary center with 30
G needle at slit lamp. Presented at: Refractive Online 2009;
September 2009; Milan, Italy.
Jack T. Holladay, MD, MSEE, FACS, can be reached at Holladay

Consulting Inc., P.O. Box 717, Bellaire, TX 77402; fax: 713-669-
9153; email: holladay@docholladay.com; website:
www.hicsoap.com.
Disclosure: Dr. Holladay is a consultant to AcuFocus, Allergan,
AMO, Nidek, Oculus, WaveTec and Zeiss.

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Improving toric IOL outcomes part 2 2017/4/11 22(41