Surgeons can take steps to overcome underutilization of toric IOLs
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Improving toric IOL designs plus advanced diagnostic technology can improve surgeons’ confidence.
Although almost three-quarters of cataract patients have more than 0.5 D of astigmatism, just 7% of IOL procedures involve a toric implant. This is despite the fact that astigmatism as low as 0.5 D can affect functional as well as low-contrast visual acuity. Addressing astigmatism at the time of cataract surgery has a measurable impact on patients’ ocular comfort and visual performance.
Reasons for not implanting
There are several reasons why surgeons may be reluctant to implant toric IOLs.
- Technique and skills. Not every surgeon is confident in their ability to align a toric lens along the proper axis, and they do not feel comfortable doing the necessary marking. Surgeons must also be able to keep the posterior capsule intact.
- Cost. Some surgeons continue to use limbal relaxing incisions as a cheaper alternative to toric implants. The cost barrier may seem significant; however, the cost of prescription eyeglasses over time can be more expensive than a toric lens.
- Intimidation. Today, surgeons can choose from a plethora of advanced diagnostic tools. These technological advancements appear overwhelming, and some surgeons may simply not know how to get started.
- Less than stellar early experience. Still other surgeons do not implant toric lenses due to negative feelings about the technology that may stem from experience with earlier iterations of the lenses.
Necessary tools
To implant toric IOLs, one needs certain diagnostic equipment, including corneal topography. Corneal topography is straightforward to interpret, and most devices have readouts alerting to any abnormality and its cause. The devices are more affordable and smaller than ever.
The other required piece of equipment is an up-to-date, later-generation optical biometry device. Diagnostic devices are more accurate than in the past, helping to ensure surgeons hit the refractive target.
Talking with patients
In my practice, the technician starts the toric conversation while taking measurements, asking patients if they are aware they have astigmatism. They tell patients that if it is corrected during surgery, they will normally only need over-the-counter spectacles for reading. The tech adds that toric lenses are not covered by insurance.
Current-generations IOLs have demonstrated excellent stability. But no matter what toric technology surgeons select, they should not panic if the result is slightly off axis. This not uncommon occurrence is why Drs. John Berdahl and David Hardten developed www.astigmatismfix.com. The surgeon enters the patient’s refraction and the lens implanted, and the calculator will determine exactly which way to rotate the lens and by how much. When lens rotation is done early, it is safe, fast and reimbursable. The possibility for a rotation should be part of the preoperative discussion.
- References:
- Miller AD, et al. Opt Vis Sci. 1997;doi:10.1097/00006324-199707000-00020.
- Nichamin LD. Ophthalmol Clin North Am. 2006;doi:10.1016/j.ohc.2006.07.004.
- Prevalence of corneal astigmatism prior to cataract surgery. http://www.doctor-hill.com/physicians/docs/Astigmatism.pdf. Accessed April 16, 2021.
- Schellini S, et al. Int J Ophthalmol. 2016;doi:10.18240/ijo.2016.11.20.
- For more information:
- David A. Goldman, MD, can be reached at Goldman Eye, 3502 Kyoto Gardens Drive, Suite B, Palm Beach Gardens, FL 33410; email: drdavidgoldman@gmail.com.
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