REFRACTIVE EWAP MARCH 2024 25 speculum and to let the OR chair do the work of sitting up,” Dr. Lee said. “We ask patients to restrict bending, lifting, straining, and eye rubbing and to avoid close activities such as reading, cell phone use, and computer use for 24 hours.” Even with perfect surgery, calculations, and placement, malpositioning still occurs. Intraoperatively, this is usually due to incorrect data acquisition (incorrect estimation of axis of astigmatism) or misjudged cyclorotation. Dagny Zhu, MD, said it can occur in the early postop days because the capsule hasn’t contracted enough to hold the IOL in place. If rotation were to occur later, it is more likely due to trauma, Dr. Zhu said. Management When it comes to residual astigmatism, Dr. Lee said it’s important to distinguish between incorrect axis due to the surgical plan vs. IOL rotation. Unreliable biometry and unrecognized corneal factors could mean the chosen toric power or axis were suboptimal, so treating the ocular surface and remeasuring may be helpful. Dr. Lee said there used to be a large difference in postoperative toric IOL stability among manufacturers, but this has significantly improved. Dr. Baartman said most cases of rotation occur early in the postop period, and it’s often the patient notifying the surgeon that something seems off. “The earlier these patients are evaluated and refracted if UCVA does not meet expectations, the earlier you can identify malposition,” he said. “For the sake of optimal patient satisfaction, I think it’s best to identify and address the problem as early as possible.” If unexpected residual refractive error is detected in toric IOL patients (whether it’s a monofocal, EDOF, or multifocal), Dr. Baartman said the evaluation starts at the slit lamp. “Proper slit lamp measurement of the current rotational position is critical, and it’s also important to ensure the lens implant is centered in the bag with proper anterior capsular overlap and that neither haptic has found its way into the sulcus,” Dr. Baartman said. “If the intraoperative position was documented at the end of the case, you’ll know which direction the lens needs to be rotated in and by how much. You can use an astigmatism calculator like astigmatismfix.com.” If rotation is necessary, Dr. Baartman said he’ll bring patients back within a week, reopen the primary incision, and insert just enough cohesive viscoelastic to free up and rotate the lens. If residual refractive error is recognized a month or more postop, Dr. Baartman said he’ll usually use a laser refractive procedure to correct it. Dr. Lee recommended waiting about 2 weeks to allow the capsule to tighten before going back in to rotate. “This has been shown to reduce re-rotation. There are different calculators to help determine the ideal axis of the toric IOL based on the IOL power, position, and postoperative refraction,” he said. “Assuming the IOL power Removing viscoelastic behind the IOL may help reduce the risk of toric rotation. Source: Bryan Lee, MD, JD Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. LESSONS LEARNED Dr. Baartman: I think early identification and intervention of postoperative problems is always a worthwhile pursuit, particularly if dealing with a refractive cataract patient with unexpected outcomes. They have usually paid out of pocket for their outcome, and they’re going to want to know you’re invested in their success. It’s nice when you have staff check in on patients as they go through the healing process, especially if they’d traveled a distance for surgery and may be doing their postoperative care elsewhere. Dr. Hardten: One of the main lessons I’ve learned over time for astigmatism correction is to utilize toric IOLs for regular astigmatism. There have been some reports of using torics for keratoconus, post-RK, or post-PRK/LASIK, but these are very difficult cases, and it’s likely that leaving the astigmatism alone, or considering astigmatic keratotomy in non-ectatic eyes and later PRK, is more useful. Dr. Lee: Although toric IOLs can rotate, the rate is very low, and the success rate for repositioning is very high. Correcting astigmatism is so advantageous for patients that I don’t think rotation is something to fear.
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