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To compare toric intraocular lens (IOL) alignment assisted by image-guided surgery or manual marking methods and its impact on visual quality. This prospective comparative study enrolled 80 eyes with cataract and astigmatism ≥1.5 D to undergo phacoemulsification with toric IOL alignment by manual marking method using bubble marker (group I, n=40) or Callisto eye and Z align (group II, n=40). Postoperatively, accuracy of alignment and visual quality was assessed with a ray tracing aberrometer. Primary outcome measure was deviation from the target axis of implantation. Secondary outcome measures were visual quality and acuity. Follow-up was performed on postoperative days (PODs) 1 and 30. Deviation from the target axis of implantation was significantly less in group II on PODs 1 and 30 (group I: 5.5°±3.3°, group II: 3.6°±2.6°; =0.005). Postoperative refractive cylinder was -0.89±0.35 D in group I and -0.64±0.36 D in group II ( =0.003). Visual acuity was comparable between both the groups. Visual quality measured in terms of Strehl ratio ( <0.05) and modulation transfer function (MTF) ( <0.05) was significantly better in the image-guided surgery group. Significant negative correlation was observed between deviation from target axis and visual quality parameters (Strehl ratio and MTF) ( <0.05). Image-guided surgery allows precise alignment of toric IOL without need for reference marking. It is associated with superior visual quality which correlates with the precision of IOL alignment.

Since the introduction of the first toric intraocular lens (IOLs) in the early 1990s, these lenses have become the preferred choice for surgeons across the globe to correct corneal astigmatism during cataract surgery. These lenses allow patients to enjoy distortion-free distance vision with excellent outcomes. They also have their own set of challenges. Inappropriate keratometry measurement, underestimating the posterior corneal astigmatism, intraoperative IOL misalignment, postoperative rotation of these lenses, and IOL decentration after YAG-laser capsulotomy may result in residual cylindrical errors and poor uncorrected visual acuity resulting in patient dissatisfaction. This review provides a broad overview of a few important considerations, which include appropriate patient selection, precise biometry, understanding the design and science behind these lenses, knowledge of intraoperative surgical technique with emphasis on how to achieve proper alignment manually and with image-recognition devices, and successful management of postoperative complications.

The aim of this study was to develop software for the universal objective evaluation of factors influencing intraocular correction of astigmatism, such as decentration, tilt, axial position and angular orientation the toric intraocular lens (IOL). Software was developed using the MS Visual Studio environment. The analysis was presented using images of 67 eyes with an implanted IOLs of the SN6ATx model series. Decentration and angular position of the lens were obtained from images of the anterior segment of the eye, using a Visucam unit. Tilt was measured on tomographic images from OCT Avanti (in meridian of highest tilt and perpendicular meridian) and preoperative biometry parameters of eye (axial length, anterior chamber depth - ACD, ocular lens thickness - LT, limbus diameter and mean keratometry value) including postoperative anterior chamber depth (pACD) were measured using Lenstar LS900. Applying the software methodology to the evaluation of individual toric IOL parameters, the following results were obtained: mean decentration 0.25 ± 0.17 mm which was observed in 61.19% of eyes, mean misalignment to the planned axis equal to 3.8 ± 3.6 degrees, mean highest inclination equal to 3.7 ± 1.2 degrees and mean difference of pACD and ACD was equal to 1.46 ± 0.31 mm. There was only a weak nonsignificant correlation between preoperative ACD versus decentration and tilt of IOL or a weak significant correlation between preoperative LT and both decentration and misalignment of IOL. The use of the presented methodology for determining the positional parameters of the toric IOL provided comparable results with the results of recent studies. Software design can be considered as a suitable alternative to previously published techniques, with the significant advantage of the possibility of using universal input images, their graphical editing and especially the possibility of comprehensive analysis of all parameters.

Purpose To compare the rotational stability of a monofocal and a diffractive multifocal toric intraocular lens(IOLs) with identical design and material. Methods This prospective study enrolled patients who underwent plate-haptic toric IOL (AT TORBI 709 M and AT LISA 909 M) implantation. Propensity score matching (PSM) was performed to balance baseline factors. Follow-up examinations were conducted at 1 h, 1 day, 3 days, 1 week, 2 weeks, 1 month, and 3 months postoperatively. A linear mixed model of repeated measures was used to investigate the changes in IOL rotation over time. A 2-week timeframe was utilized to assess differences in IOL rotation between the two groups. Result After PSM, a total of 126 eyes were selected from each group for further analysis. Postoperatively, the time course of IOL rotation change in the two groups remained consistent, with the greatest rotation occurring between 1 h and 1 day postoperatively. At the 2-week postoperative mark, the monofocal toric IOL exhibited a higher degree of rotation compared to the multifocal toric IOL (5.40 ± 7.77° vs. 3.53 ± 3.54°, P  = 0.015). In lens thickness(LT) ≥ 4.5 mm and white-to-white distance(WTW) ≥ 11.6 mm subgroups, the monofocal toric IOL rotated greater than the multifocal toric IOL ( P  = 0.026 and P  = 0.011, respectively). Conclusion The diffractive multifocal toric IOL exhibits superior rotational stability compared to the monofocal toric IOL, especially in subgroups LT ≥ 4.5 mm and WTW ≥ 11.6 mm. Moreover, the time course of IOL rotation change is consistent for both, with the maximum rotation occurring between 1 h and 1 day postoperatively.

Purpose: To compare the slit-lamp method and wavefront aberrometry method based on outcomes of toric realignment surgeries. Settings: Tertiary care ophthalmic hospital. Design: Retrospective study. Methods: This study included all eyes undergoing toric intraocular lens (TIOL) realignment surgery between January 2019 and December 2021 for which TIOL axis assessment by slit-lamp method and wavefront aberrometry method was available. Data were retrieved from electronic medical records, and we documented demographics, uncorrected visual acuity (UCVA), subjective refraction, and TIOL axis by slit-lamp and wavefront aberrometry methods on postoperative day 1 and day 14. In patients with misalignment, TIOL was realigned to the original position in group 1 (27 patients) and to an axis based on calculations provided by wavefront aberrometer in group 2 (25 patients). Post-realignment surgery, UCVA, subjective refraction, and TIOL axis by slit-lamp and wavefront aberrometry methods were assessed and analyzed. Results: We analyzed 52 eyes and found that the mean preoperative misalignment with the slit-lamp method (44.9° ±20.0°) and wavefront aberrometry (47.1° ±19.5°) was similar. The corresponding degrees of misalignment post-TIOL repositioning surgeries were 5.2° ±5.2° (slit-lamp method) and 4.7° ±5.1° (wavefront aberrometry) (P = 0.615). Both groups showed significant improvement in median log of minimum angle of resolution (logMAR) UCVA and reduction in median refractive cylinder. Conclusions: Slit-lamp method is as good as wavefront aberrometer method to assess TIOL axis. Toric realignment surgery is found to be safe, and realigning TIOL based on either slit-lamp method or wavefront aberrometer method equally improved UCVA and decreased residual refractive cylinder.

To assess the efficacy of five calculators for toric intraocular lenses (IOL). Retrospective comparative case series in cataract patients undergoing implantation of trifocal toric IOLs (PhysIOL FineVision POD FT). Inclusion criteria were age-related cataract and a corneal astigmatism between 0.90D and 4.50D. Refractive astigmatism predictability of five different toric calculators or calculation methods were compared. Furthermore, two groups were differentiated according to the type of astigmatism. The mean absolute error and the centroid errors in the predicted residual astigmatism from each calculator were evaluated. Fifty-one eyes of 43 patients were included in the study. For the standard toric calculator using anterior keratometry values only, the centroid prediction error was 0.39D±0.41@166º, which was reduced by the application of the PhysIOL toric calculator that includes the Abulafia-Koch regression formula and adjustment for the effective lens position (0.05D±0.34@167º), and also by the application of the Barrett toric calculator (0.07D±0.28@160º). Regarding the techniques that directly evaluate posterior corneal surface, the Holladay toric calculator, using total corneal power provided by a color-LED topographer, generated better results (0.10D±0.44@156º) than those using Scheimpflug camera data (0.23D±0.56@158º). Similar results were found for both types of astigmatism. The PhysIOL and the Barrett toric calculators taking into account the posterior corneal astigmatism by mathematical models, yielded lower astigmatic prediction errors compared to a standard toric calculator based on anterior keratometry data only. When total corneal power measurements were used, prediction errors were lower with color-LED than with Scheimpflug based topography.

Purpose We describe a scleral suture fixation technique for dislocated plate haptic toric intraocular lens (IOL) implantation. Materials and methods A double-armed 10-0 straight polypropylene suture was passed into the eye from the sclera (2 mm away from the limbus). A suture needle was passed through the hole on the corner of the IOL and pulled out from the paracentesis with a 27-gauge needle. Afterward, the suture needle was reinserted from the same paracentesis and then removed from the eye with the help of a 27-gauge needle entering the eye from a nearby point to the first scleral entrance. The needle was passed through the end of the loop and pulled slightly to initiate the formation of a cow-hitch knot. The same procedure was applied to the other hole on the plate haptic. Both sutures were adjusted and fixed to the sclera with a Z suture. Results No complications were observed and at the follow-up visits, uncorrected visual acuity was 0.8 with decimal. Conclusion Axial, sagittal, and rotational stability rules are taken into consideration, scleral fixation surgery for a dislocated plate haptic foldable toric IOL is an alternative method to eliminate astigmatic refractive error.

Purpose. To compare the original method of single-step manual marking of the position axis of a toric intraocular lens with the marking made by a digital image-guided system (Verion, Alcon Inc.). Material and methods. The study included 90 patients (130 eyes) who underwent phacoemulsification with implantation of toric IOLs from various manufacturers. The original manual and digital Verion markings were used to position the toric IOL. The following parameters were evaluated: the technical ability of marking, intraoperative stability of the marking axis position, intraoperative deviation of digital marking from manual one and the manual marking condition in the postoperative period. Results. Manual marking was applied in 100%, digital marking in 87%. In 17 cases (13%), digital marking could not be used due to post-keratotomic scars (70.6%), corneal opacities (17.6%) and the inability to match images (11.8%). Manual marking has always had a stable position. The digital marking had only one stable located axis in 34 cases (30.1%), or two or more variants of the axis location in 79 cases (69.9%). In most cases 90 (79.6%), the intraoperative deviation of manual marking from digital marking was within 2 degrees, in the range of 3–5, 6–10 and 11–20 degrees, 5 (4.4%), 11 (9,8%) and 7 (6,2%) of cases, respectively. 1 day and 1 month after the surgery, the manual marking was visualized in 100%, after 11–14 months in 25 (69.4%) of cases. Conclusion. The proposed method of manual marking of the toric IOL is not inferior to digital systems, while it is convenient, safe, universal and can be used to assess the rotational stability of toric IOL in the early and late postoperative period, in all medical institutions. Key words: toric IOL, manual marking, digital marking

To investigate the dynamic visual acuity (DVA) after implantation of toric bifocal or trifocal intraocular lens in age-related cataract patients. This was a prospective randomized controlled trial. Of one hundred and twenty-four patients enrolled and randomized to receive unilateral phacoemulsification and toric trifocal (939 M/MP, Carl Zeiss Meditec AG, Jena, Germany) or toric bifocal (909 M, Carl Zeiss Meditec AG, Jena, Germany) intraocular lenses (IOL) implantation, ninety-nine patients completed the follow-up and were included in final analysis. Postoperatively, uncorrected and corrected distance (UDVA and CDVA), intermediate (UIVA and DCIVA) and near (UNVA and DCNVA) static visual acuity, manifest refraction and uncorrected and corrected distance DVA (UDDVA and CDDVA) at 20, 40 and 80 degrees per second (dps) were evaluated at one week, one month and three months. Three months postoperatively, the UDVA were 0.13 ± 0.11 and 0.14 ± 0.13 in the toric trifocal and bifocal IOL group, respectively. Significant better UIVA (trifocal, 0.17 ± 0.13 vs. bifocal, 0.23 ± 0.13,  = 0.037) and DCIVA (trifocal, 0.16 ± 0.11 vs. bifocal, 0.20 ± 0.12,  = 0.048) were observed in patients implanting toric trifocal than bifocal IOL at three months postoperatively. Patients implanted with toric bifocal IOL obtained better CDDVA at 80 dps (0.5607 ± 0.2032) than the trifocal group (0.6573 ± 0.2450,  = 0.039) at three months. Postoperative UDDVA and CDDVA at 20, 40 and 80 dps were significantly associated with age (  < 0.05, respectively) and postoperative static visual acuity (  < 0.05, respectively). Toric trifocal IOL provides better static intermediate visual acuity, and toric bifocal IOL implantation provides better distance dynamic visual acuity at high speed.

To determine the frequency, magnitude, and direction of toric intraocular lens (IOL) planning discrepancies between the Johnson & Johnson (J&J) official calculator and European Society of Cataract and Refractive Surgeons (ESCRS)-hosted toric engines, and to identify preoperative predictors of clinically relevant disagreements. This retrospective, single-center study included 182 eyes of 127 patients undergoing toric IOL implantation (TECNIS). For each eye, planning results were generated using identical biometric data (IOLMaster 700, CASIA2 keratometry) across all calculators. The primary comparison was J&J with posterior corneal astigmatism correction enabled (PCA-ON) versus ESCRS-Barrett - secondary comparisons included Kane, EVO 2.0, and Hoffer QST. Clinically relevant discrepancy (ClinRel) was defined as a toric cylinder step difference ≥ 1 and/or axis difference ≥ 10°. Logistic regression, including Firth-penalized estimation, identified predictors of ClinRel. The primary analysis set comprised one eye per patient (n=127). ClinRel between J&J PCA-ON and Barrett occurred in 59.8% of eyes (76/127; 95% CI: 51.1-68.0%), driven almost only by step differences. J&J PCA-ON recommended a higher step in 56.7% of eyes, with only 2.4% showing the opposite. Discrepancies were concentrated in with-the-rule eyes (72.3%) and nearly absent in against-the-rule eyes (5.6%). Rates were higher for secondary engines (Kane 83.8%, EVO 74.4%, Hoffer QST 76.7%). An Alpins-style paired-planning analysis yielded a Correction Index of 1.20, with the Difference Vector concentrated at the vertical meridian (84°). Posterior corneal astigmatism grade was the strongest independent predictor (Firth-adjusted OR = 203.5; p=0.014). An empirical PCA threshold of 0.36 D (Youden index; sensitivity 91.6%, specificity 56.0%) identified eyes at elevated risk of calculator disagreement. Calculators' variability in toric IOL planning is substantial (~60% of eyes) and concentrated in with-the-rule eyes with elevated posterior corneal astigmatism. In this subgroup, consulting multiple calculators is recommended; in against-the-rule eyes, calculator choice rarely alters the recommendation.