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    Presbyopic IOLs changing game for astigmatic patients

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


    I personally incorporate the true net power (Figure 2) into my calculations and then plug the resulting magnitude into the manufacturer’s toric IOL calculator. One of the features about the Tecnis toric calculator is that it has the ability to change the prediction of toricity power based on effective lens position (ELP). Some calculators underestimate the toric power needed at the lens plane in long eyes.

    Although I do not use intraoperative aberrometry in every case, I do find it helpful in very long or short axial length cases or eyes with inconsistent keratometry measures, and it is incredibly reliable at improving predictions in post-refractive eyes.

    Surgically induced astigmatism (SIA) remains a concern in perfecting IOL power choices. Although my average SIA for a 2.4-mm incision is 0.3 D, the SIA in any individual case could be as high as 0.8 D or even 1 D. Corneal biomechanics are possibly responsible for these outliers, but it is nevertheless important to be aware that SIA can lead to a postoperative surprise, no matter how low one’s average.

    Care must also be taken intraoperatively not to do anything that could compromise lens fixation, position, or stability. There are no toric presbyopia-correcting IOL options for the sulcus, so an inadvertent capsular bag tear can mean a major change of plans.

    In summary, achieving good refractive outcomes with toric presbyopia-correcting IOLs requires meticulous preoperative measurements and careful surgical technique.

    Although there are data to suggest toric EDOF lenses are tolerant of some residual sphere or cylinder, it is still best to aim for highly precise biometry and power calculation, given there continue to be some factors, such as individual wound healing response and ELP, that are beyond the surgeon’s control.



    1. Koch DD, Jenkins RB, Weikert MP, et al. Correcting astigmatism with toric intraocular lenses: Effect of posterior corneal astigmatism. J Cataract Refract Surg. 2013;39:1803-1809.
    2. Reitblat O, Levy A, Kleinmann G, et al. Effect of posterior corneal astigmatism on power calculation and alignment of toric intraocular lenses: Comparison of methodologies. J Cataract Refract Surg. 2016;42:217-225.


    Jeremy Z. Kieval, MD

    P: 781/862-1620     E: [email protected]

    Dr. Kieval is in private practice at Lexington Eye Associates, Lexington, MA. He is a consultant to Johnson & Johnson Vision/Abbott.

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