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    Presbyopic IOLs changing game for astigmatic patients

    New options change conversation but not need for precision, careful planning

    The availability of toric presbyopia-correcting IOLs has changed what refractive cataract surgeons can offer to patients with astigmatism, making preoperative patient education considerably easier.

    Surgeons now have several toric presbyopia-correcting IOLs, each of which is quite different in design and function. Trulign (Bausch + Lomb) is a toric version of the Crystalens platform. Both the Tecnis Symfony Toric (Johnson & Johnson Vision/Abbott) and the AcrySof ReStor Multifocal (Alcon Laboratories) are toric versions of the single-piece IOLs of the same names.

    The ReStor toric is available as a + 2.5 D and a + 3.0 D-add multifocal IOL, while the Symfony is an extended-depth-of-focus (EDOF) lens which elongates the focal range from mid-near to distance. 

    One-step correction

    Regardless of preference among these lenses, the big change is surgeons can offer patients with significant astigmatism a much easier, one-step correction of presbyopia. In the past, if patients were interested in presbyopic correction I would offer a low-add multifocal with laser astigmatic keratotomy (AK) incisions to those who had <1.75 D of astigmatism.

    However, had I not been trying to give them near vision, I would have preferred the predictability of a toric IOL, as I do for most patients with > 1 D of astigmatism.

    Decision-making and patient counseling was trickiest for those with ≥ 1.75 D of astigmatism because it would mean the patient would have to be a good candidate for both the multifocal implant and for a corneal ablation, and be willing to accept a two-stage procedure.
    Dry eye or thin corneas could rule out laser vision correction and leave us without an option for spectacle independence, or we could simply lose the patient because it all sounded complicated.

    I no longer have to go through all these caveats. If the patient wants presbyopia correction and has ≥ 1 D of astigmatism, they will now typically get a toric EDOF lens. This allows me to focus on the patient’s visual goals of spectacle independence rather than the limitations of a particular technology for a patient with astigmatism.

    Careful still counts

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