REFRACTIVE 26 EWAP MARCH 2024 is OK and that it doesn’t need to be exchanged, we will usually be able to rotate the IOL using balanced salt solution on a cannula, trying to open the capsule as little as possible.” Dr. Zhu said patients with true IOL rotation often had 20/20 vision on their first day postop, but it dropped in the subsequent week or two. She said she’s honest with these patients, telling them that while it looks like the lens moved, the good news is it can be fixed. Dr. Zhu is able to perform office-based surgery, so she can take the patient back and rotate the IOL on the same day it’s identified. She also noted that if the cornea is healthy enough and if the patient doesn’t want to go back inside their eye, she’ll offer LASIK or PRK. “Laser vision correction is also a good option when you have a patient in whom residual refractive error is not completely explained by IOL rotation, where the calculations might be off or the wound is affecting the final astigmatism,” she said. Sometimes the issue isn’t IOL alignment but changes in corneal curvature postop. This can occur from wound contraction and scarring or relaxation, Dr. Hardten said. While most IOL calculators take into consideration posterior corneal astigmatism, it’s also a possible source of residual refractive error because it’s a difficult area to measure, he said. EWAP References 1. Singh A, et al. Rotational stability of toric intraocular lenses. Med J Armed Forces India. 2022;78:68–73. Editors’ note: Dr. Baartman practices at Vance Thompson Vision, Omaha, Nebraska. Dr. Hardten practices with Minnesota Eye Consultants, Minnetonka, Minnesota. Dr. Lee practices with Altos Eye Physicians, Los Altos, California. Dr. Zhu practices at NVISION Eye Centers, Rowland Heights, California. Dr. Hardten has interests with astigmatismfix.com; none of the other sources declared any relevant financial interests. Tetsuro Oshika, MD, PhD Department of Ophthalmology, Faculty of Medicine, University of Tsukuba, Japan 1-1-1 Tennoudai, Tsukuba, Ibaraki oshika@eye.ac ASIA-PACIFIC PERSPECTIVES Surgical outcomes of toric intraocular lens (IOL) implantation have significantly improved, thanks to advancements in surgical techniques and technologies, as well as enhancements in the materials, surface finishing, and design of IOLs. Despite these advancements, there remains an occasional, unexpected significant misalignment of toric IOLs. Such misalignments can lead to dissatisfaction among patients, potentially overshadowing the successes of otherwise successful cataract surgeries. Over the past decade, accumulating evidence has suggested several methods for reducing IOL misalignment and improving the outcomes of necessary realignment surgeries. To optimize the outcomes of toric IOL implantation, the following key precautions are recommended: 1. Capsulorhexis Coverage: Complete 360-degree coverage of the capsulorhexis (CCC) over the IOL optic is known to ensure better rotational stability of the toric IOL compared to partial coverage of the CCC edge. 1 2. Postoperative Rotation: The most significant rotation of toric IOLs occurs within the first hour following surgery, after which the lens remains highly stable. 2 It is essential that IOLs are fully deployed before concluding the surgery. Postoperatively, patients should rest for at least thirty minutes, preferably sitting rather than walking around, to assist in stabilization. 3. Repositioning Surgery: Repositioning surgery to correct toric IOL misalignment should not be performed immediately following primary cataract surgery, as this may lead to re-rotation of the lens in a similar direction, necessitating further surgical intervention. Better final surgical outcomes are achieved when repositioning surgery is performed one week or later after the cataract surgery. 3 The optimal time frame for realignment surgery appears to be between 1 week and 1 month following the initial cataract operation. 4. Digital Devices: Employing digital marking devices has proven beneficial in enhancing the precision of surgical procedures and improving the pre- and intra-operative workflow, contributing significantly to the overall success of the surgery. References 1.vSasaki K, et al. Anterior capsule coverage and rotational stability of an acrylic toric intraocular lens. J Cataract Refract Surg. 2021;47:618-621. 2. Inoue Y, et al. Axis misalignment of toric intraocular lens: Placement error and postoperative rotation. Ophthalmology. 2017;124:1424-1425. 3. Oshika T, et al. Incidence and outcomes of repositioning surgery to correct misalignment of toric intraocular lenses. Ophthalmology. 2018;125:31-35. Editors’ note: Dr. Oshika is a consultant for Alcon, Johnson & Johnson, and Santen.
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