TORIC IOLS

and

CATARACT
SURGERY
Dr Brad Townend
BSc(Med), MBBS, MPH, MMed,
FRANZCO

Gosford and Wyong Eye

Toric IOL

Correction of corneal
astigmatism

Conoid of Sturm

Q1: Astigmatism is:

A What you have when you dont have
a stigma
B Uncorrectable with glasses or
intraocular lenses
C Able to be ignored in intraocular lens
selection
D A difference in the curvature and
therefore focusing power of the cornea
at 90 degree axes

WHY ARE TORICS

GOOD?
Usually result in low residual astigmatism
Higher visual outcome demands from patients
Toric IOLs are superior and more predictable
in reducing corneal astigmatism than limbal
relaxing incisions (Mingo-Boton et al, JCRS
2010)

TORIC
LIMITATIONS
Neutralise corneal astigmatism in the
plane of the Effective Lens Position (ELP)
Higher order aberrations (Hayashi et al, JCRS 2012)

Time consuming
Reliability of outcomes

THRESHOLD FOR
USE
1.5 Dioptres of corneal astigmatism

WHY LESS THAN

PERFECT?
Not an exact
science

WHY LESS THAN

PERFECT?
Limited range of lens
powers

WHY LESS THAN

PERFECT?
Approximation of final
anterior chamber depth

WHY LESS THAN

PERFECT?

Keratometry axis variable

WHY LESS THAN

PERFECT?
MARKING
Patients head not straight
Big and blotchy pen tips
Markings wash away!
Parallax error

WHY LESS THAN

PERFECT?
Surgically Induced Astigmatism
variable
Size of keratome blade
Superior vs Temporal incision location
Anterior vs Posterior wound

WHY LESS THAN

PERFECT?
Lens rotation in bag post-operatively
Worse with long axial length (Shah et al)
Most occurs in first week
? Intra-operative re-positioning
<10 rotation <0.5D change (generally)

Lens skewed in bag

Lens not centred in bag

WHY LESS THAN

PERFECT?
Irregular capsulorhexis size or shape
can mean final effective lens position
is not as predicted unpredicted
anti-astigmatic effect
Anterior chamber depth
consideration critical to accuracy of
toric outcome

WHY LESS THAN

PERFECT?
No consideration of
posterior corneal surface

WHY LESS THAN

PERFECT?
Cascade of potential error

Q2: Which of the following is NOT a

limiting factor in toric lens surgery

A Approximation of final anterior

chamber depth
B Keratometry axis variability
C Surgical wound induced
astigmatism
D The availability of Tim Tams in the
tea room of the Day Surgery

Improving Toric
Outcomes
Counsel patients
appropriately
Plate haptic lenses offer
better capsule stability and
less rotation post-operatively

Improving Toric
Outcomes
Use a formula that utilises ACD
E.g. Haigis or Holladay2

Await technology and mathematics

that will allow assessment and
utilisation of posterior corneal
surface in lens power and axis
estimates

Improving Toric
Outcomes
Manage paralax error
ASICO electronic toric marker
Built-in protractor

Improving Toric
Outcomes
Surgically Induced Astigmatism (SIA)
Mark wound location with toric marker
Use consistent keratome size
Concentrate on making a consistent antpost position of your wound
Perform a good surgical audit to
calculate your SIA
Key contributor to toric outcome (W Hill,
JCRS, 2008)

Improving Toric
Outcomes
Toric lenses are being used more
frequently
Potential to improve patient
outcomes significantly
Understand their limitations and use
initiative to minimise these

Q3: Toric IOLs:

A Take less surgical time than standard
spherical IOLs
B Require less pre-operative planning
than standard spherical IOLs
C Require less pre-operative discussion
with patients than standard spherical
IOLs
D Minimise but rarely completely
eliminate the effect of corneal
astigmatism