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    Toric IOLs in abnormal corneas: How the two can work together

    Careful patient selection, expectation management, adjunctive procedures are paramount to success


    Many patients who have undergone LASIK, PRK, RK, or conductive keratoplasty are now developing cataracts and are interested in premium IOL implantation. The catch-22 is this is arguably the most-motivated patient population for spectacle-independence, and yet, their IOL calculations are the most unpredictable, according to Dr. Starr.

    “The ASCRS [American Society of Cataract and Refractive Surgery] Post-Refractive IOL Calculator is a godsend for these patients,” he said. “Over time, it has become more and more accurate, and the range of IOL suggestions are much tighter now. I am much more comfortable now targeting plano than previously when I would target some myopia.”

    Other tools—such as intraoperative aberrometry and light-adjustable IOLs—have helped to improve refractive outcomes in these patients.

    Dr. Starr advised ruling out post-LASIK ectasia before implanting a toric IOL, with the presumption that a high degree of corneal astigmatism is present. He also recommended preoperatively assessing candidacy for a possible laser vision correction touch-up in the event of a refractive IOL “surprise.”

    Corneal ectasias

    When facing patients with keratoconus, pellucid marginal corneal degeneration, post-LASIK ectasia, post- keratoplasty (PK), and post-deep anterior lamellar keratoplasty, the rule of thumb is if patients can successful wear a rigid gas permeable or scleral lens postoperatively, a toric IOL should not be implanted.

    However, a toric IOL is a consideration if patients are contact lens-intolerant, have acceptable spectacle-corrected vision, and have a fairly regular central cornea over the long term as in older patients or after a crosslinking procedure.

    A toric IOL is also a reasonable choice in post-PK eyes in which there is a low risk of graft failure and the need for another PK, Dr. Starr explained.

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