EyeWorld India March 2013 Issue

28 EWAP CATARACT/IOL March 2013 Taking the spin out of toric rotation: Part 2 by Steven G. Safran, MD than the 13.0-mm haptic diameter (such as with a high myope), if there has been a disruption of the zonular apparatus so that the bag is not round (the IOL will tend to drift toward the greatest diameter), lack of evacuation of the VED (countering the effect of the tackiness of the acrylic material or laying down of fibronectin), or zonular variation or anterior capsular fibrosis that diminishes the fibrosis or ‘shrink wrapping’ of the capsular leaves (a case for not vacuuming all of the sub-anterior capsular cells). “This case is a high myope, but in addition, he had a vitrectomy. This surgery increases the risk of zonular disruption, making the bag irregular. In this case, insertion of a CTR makes sense. “In my experience, sometimes practice does not follow theory. There are unexplained rotations and inexplicable refractive surprises. I then turn to corneal laser vision correction to erase the residual refractive error when not contraindicated.” Lisa Arbisser, MD , adjunct clinical associate professor, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA, and in private practice, Eye Surgeons Associates, Iowa and Illinois Quad Cities, would also implant a CTR here. “Since the CCC is on the optic, you can open the bag and insert a CTR and rotate the lens.” Jeff Horn, MD , Vision for Life, Nashville, Tenn., USA, on the other hand, would simply wait a bit, rotate and only use a CTR to facilitate rotation if it were proving to be difficult otherwise. “In this patient whose lens has rotated, I would wait at least three more weeks for the capsule to begin to contract. There is no rush. I would then return to the OR, viscodissect the lens with a dispersive OVD, and rotate it to the proper axis. If there were any difficulty in rotating it, I would implant a CTR, and then rotation will be easy.” Stephen Lane, MD , medical director, Associated Eye Care, St. Paul, Minn., USA, and adjunct professor of ophthalmology, M ichael Wong, MD , Princeton Eye Group, Princeton, NJ, USA, commented, “Toric IOL rotational stability derives from at least five factors: rotational friction of the haptics at the equator of the capsular bag, the square edge of the profile of the IOL, the tackiness of the acrylic material, the adhesiveness of fibronectin between the IOL and bag, and later the fibrosis of the capsular leaves around the haptics. “Conversely, postoperative rotation of the IOL can occur if the diameter of the bag is larger Figure 1. Post-op at one week shows the lens at 67 degrees. Figure 2. IOL in proper position post-op Source: Steven G. Safran, MD T his is the second case in a two- part series looking at the subject of toric rotation and how to manage it. This is a young, male, high myope (53 years old) with a history of macula-off retinal detachment (RD) repair in the right eye who presented with rather impressive cataracts in both eyes. I did cataract surgery in the left eye first with a standard monofocal IOL, and the patient did very well with a 20/20 uncorrected outcome. The OD had 1.75 diopters of cornea astigmatism with the steep axis at 100 degrees and is 27.35 mm so an 11 diopter T4 was chosen with a surprisingly good post-op day 1 visual outcome—20/40+ uncorrected. This is a bit better than expected because of the history of a macula-off detachment. At one week post-op, however, he noticed that his vision had dropped, and he presented with uncorrected 20/100-1. The axis of the lens has rotated from 100 degrees as planned to 67 degrees. He refracts to about 20/30 with an Rx that includes about 1.5 D of astigmatism. The other eye is plano = 20/20. He is an avid golfer and sportsman and would like to avoid glasses for distance. What would you do? He’s one week post-op, and the IOL has rotated 33 degrees off axis, completely negating the astigmatic benefit of the toric lens. Figure 1 is his post-op photo at one week showing the lens at 67 degrees when it should be at 100 degrees.