EyeWorld Asia-Pacific March 2019 Issue

37 March 2019 EWAP CATARACT / IOL is called for, we are more likely to use it.” In addition to considering placement of a CTR, Dr. Baartman noted several other intraoperative pearls to help reduce the risk of lens rotation. One is diligent removal of all viscoelastic from the capsular bag, including behind the lens. Another is nailing the capsulotomy to ensure 360 degrees of capsular overlap with the optic because it’s thought increased contact helps prevent lens tilt and rotation postop, Dr. Baartman said. Surgeons can also consider leaving the eye somewhat soft relative to the patient’s usual ocular tension at the end of the case, with the idea that it will allow proper collapse of the capsular bag around the lens, Dr. Baartman said. “Lastly,” he added, “I think all patients getting premium lens implants, including torics, should be made aware of the potential for residual astigmatism and the possibility of a fine tune in the future, which could include a laser or IOL rotation. When you have these discussions with patients before surgery and you do encounter the scenario after surgery, it’s less of a surprise to the patient and makes it feel like less of a complication to both parties.” Dr. Safran said using a cohesive viscoelastic in the injector may slightly reduce the risk of rotation postoperatively because it is less likely to coat the haptics and remain in place compared to a dispersive viscoelastic. He also recommended polishing lens epithelial cells from the capsular bag, thinking it makes the “capsular bag a little tackier” for the IOL to stay in position. “Some surgeons think that the increased fibrosis and capsule contraction caused by retained LECs prevents rotation, but these LEC-induced capsular bag changes do not occur for weeks, until long after the lens is likely rotate.” Postoperative management Careful postoperative refraction is critical in determining the possible need for a toric adjustment, Dr. Baartman said. He prefers to wait until the patient’s refraction is stable before going in to reposition the lens, though if the rotation is significant he might go in earlier. “Generally, I like to be sure of the refractive stability and the patient’s lens position, that it’s not going to continue to move before going in for a second surgery. The caveat here is waiting too long puts the patient through a longer delayed optimal position and might make the procedure difficult if the bag seals down,” he said. Dr. Baartman said he uses astigmatismfix.com, a program that helps identify the optimal toric lens position of a given toric IOL and the postoperative refraction. “You get a magnitude of change required in the exact position compared to its current position to reduce the amount of astigmatism,” he explained. If, after plugging numbers in, he finds residual astigmatism even after toric rotation would still be visually significant, Dr. Baartman said he considers IOL exchange or laser ablation. “Sometimes when there is a pristine cornea and no irregular astigmatism noted on topography and we know that we are at a good position with the toric lens rotationally but our spherical power is off, we’re more likely to go in and change the lens power. Generally, if we’re within a diopter of spherical equivalent, we’ll do a laser, which is less risk for the patient than going in and exchanging the lens,” Dr. Baartman said. When Dr. Baartman is going 9LHZV IURP $VLD 3DFLÀF T here are several other important issues that should be brought to attention in order to obtain satisfactory outcomes with toric IOLs. As for IOL misalignment, we found that the most IOL rotation occurs within 1 hour after cataract surgery. 1 This fact implies two things. First, during surgery, it is critical to wait until the toric IOL fully unfolds EHIRUH \RX ÀQLVK WKH FDVH 6RPH OHQVHV DUH VORZHU WR XQIROG DQG WKH tips of the IOL haptics cannot be directly visualized. You should take enough time before you close the case and let the patient wake up WR OHDYH WKH 25 6HFRQG WKH SDWLHQWV VKRXOG EH LQVWUXFWHG WR VWD\ DW rest for at least 1 hour after surgery, and refrain from walking around. Postoperatively, the timing of repositioning surgery, when necessary, is important. If reorientation surgery is done within a few days after the primary cataract surgery, the IOL may rotate again to the similar GLUHFWLRQ DV WKH ÀUVW GLVRULHQWDWLRQ 2 It is recommended to perform repositioning surgery before 1 week and 3 weeks after cataract surgery. References 1. Inoue Y, et al. Axis misalignment of toric intraocular lens: Placement error and postoperative rotation. Ophthalmol. 2017;124:1424-1425. 2. Oshika T, et al. Incidence and outcomes of repositioning surgery to correct misalignment of toric intraocular lenses. Ophthalmol. 2018;125:31-35. (GLWRUV· QRWH 'U 2VKLND LV D FRQVXOWDQW IRU $OFRQ )RUW :RUWK 7H[DV -RKQVRQ -RKQVRQ 9LVLRQ -DFNVRQYLOOH )ORULGD 6DQWHQ 3KDUPDFHXWLFDO 2VDND -DSDQ 7RSFRQ 7RN\R -DSDQ DQG 0LWVXELVKL 7DQDEH 7RN\R -DSDQ Tetsuro OSHIKA, MD Professor, Department of Ophthalmology, Faculty of Medicine, University of Tsukuba 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575 Japan oshika@eye.ac ... most IOL rotation occurs within 1 hour after cataract surgery. This fact implies two things: First, during surgery, it is critical to wait until the toric IOL fully unfolds before you finish the case. ...Second, the patients should be instructed to stay at rest for at least 1 hour after surgery... — Testuro Oshika, MD Continued on page 38