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    Strategies for performing a reverse optic capture of toric IOL

    Case illustrates benefits of femtosecond laser for alignment, repositioning of toric lenses

    Steven Dewey, MDColorado Springs, CO—A few months ago, I performed femtosecond laser-assisted cataract surgery on the left eye of a 67-year-old female patient, and implanted a toric lens (SN6AT9, Alcon Laboratories). Surgery was uneventful and the IOL was nicely aligned at the close of the case.

    On the second day, the patient had a spike in IOP. I tapped the sideport incision to relieve pressure and placed the patient on brimonidine tartrate/timolol maleate (Combigan, Allergan) twice a day.

    A few days later, closing in on the 1-week mark, she complained of blur. Ray tracing showed the IOL had rotated 69Ëš counterclockwise (Figure 1).

    Related: How to manage cataracts with ocular surface disease

    Her refraction was now +2.75 -8.34 x 33. I wanted to give the capsular bag a chance to contract so we waited another 2 weeks to reposition the lens. At that point, the lens was easily rotated back into position and was perfectly aligned when I closed the eye, just as it had been at the initial surgery. This time I put the patient on Combigan and oral Diamox for 1 week as a preventive measure and she did not have an IOP spike.

    Related: How IOL platform designs are achieving quality of vision

    However, she returned 2 weeks later with the same symptoms of blur: The lens had rotated out of position a second time, clockwise again, but this time only 44Ëš. This time, partly due to the patient’s schedule, we waited another 2 months for the repositioning. I found the lens was still surprisingly mobile in the bag, with less fibrosis than expected.

    Recent: Are extended-depth-of-focus IOLs hitting the visual sweet spot?

    I re-aligned the lens as before, but this time, tucked the nasal capsule under the IOL and then tucked the temporal capsule under the lens for a reverse optic capture (Figure 2).

    Her vision improved to J1 at near with a -2.75 + 0.75 x 070 refraction. This (fortunately) very understanding patient was quite satisfied with the final result, and her lens has remained perfectly positioned ever since. In fact, 3 weeks after the second repositioning, we proceeded with toric lens surgery on her right eye, with no further rotational issues.

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