Timing is everything when managing misaligned toric IOLs

Chicago-When misalignment of a toric IOL underlies a suboptimal outcome and the problem is identified during early postoperative follow-up, surgeons should not procrastinate about taking the patient back to the operating room for a repositioning procedure, said Roger F. Steinert, MD.

“It is easy to open the capsular bag and rotate the IOL within the first several weeks after surgery. So if the IOL is in the wrong place, fix it,” said Dr. Steinert, Irving H. Leopold Professor and Chair, Department of Ophthalmology, University of California, Irvine.

Outlining the steps for correcting toric IOL misalignment, Dr. Steinert said the first task is to determine the current axis, and there are now two free smartphone apps (iHandy level and Axis Assistant) that can help.

The next step is to decide how to shift the IOL. While this may be done by vector analysis, a much easier way is to use an online tool developed by John Berdahl, MD, and David Hardten, MD. Available as a free download at www.astigmatismfix.com, it uses refractive data and automatically does the vector analysis to determine exactly where the implant should be aligned to achieve the minimum astigmatism.

To ensure that the implant remains stable after it is repositioned, surgeons can consider two options. They can insert a capsule tension ring, which is probably the more favored adjunctive technique, Dr. Steinert said.

Alternatively, they can perform anterior capture of the optic, leaving the haptics in the capsular bag. However, Dr. Steinert cautioned that when the implant has a sharp edge optic, surgeons need to ascertain that there is adequate iris-anterior capsule clearance in order to avoid iris chafe by the optic.