Providing OptimalOptics For Your Astigmatic Cataract Patients
Release Date: November 2009
Expiration Date: November 30,2010
Premium IOLS present an excellent opportunity for optometrists and their patients, specifically with toric IOLs which can limit large amounts of astigmatism. This articles focues on toric lens technology, patient benefits and selection process and post op-experience.
David Geffen, O.D., F.A.A.O.
This course is qualified for 2 hours of CE Credit. COPE ID: 26815- PO. Check with your local state licensing board to see if this counts toward your CE requirement for relicensure.
This continuing education course is joint sponsored by the University of Alabama School of Optometry. This course is supported by an unrestricted grant from Alcon.
Dr. Geffen is on the speakers’ bureau for Alcon.
Cataract surgery has
advanced faster in the
past three years than
it has in the previous
20. Today, we are seeing a revolution in how we treat and educate
our older patients when it comes
to their options for visual correction. Aspheric, accommodative,
multifocal and now toric intraocular
lenses have truly made cataract surgery a refractive procedure. When
discussing visual options with any
patient over 50 years of age, one
needs to speak about the changes
the individual will experience over
the next 20 years. The ability to
correct nearsightedness, farsightedness, astigmatism and now presbyopia needs to be explained in
detail. The focus of this article will
address the impact the new toric
IOLs make on our practice and for
The market numbers are staggering! In 2006, the amount of “Baby
Boomers” grew to 80 million. And,
by 2020, it is estimated that close
to 55 million people in the U.S. will
be over the age of 65. Adding to
these statistics, more than 10,000
people are turning 50 every day.
Of course, this older population translates to more patients
who will need cataract surgery.
Just consider some of these statistics that illustrate the impact
this condition can have if it goes
untreated: Worldwide, cataracts
are one of the leading causes of
blindness, affecting over 18 million people. Additionally, 62 million have low vision as a result of
cataracts. This is quite sad in that
it is often preventable and even
restorable with advances in cataract
surgery. Today, cataract surgery
is more advanced and offers even
more options for our patients than
ever before—and more opportunities for our practice. Just consider,
“Baby Boomers” are the group who
are willing to spend more of their
income on themselves. They want
to look younger, feel better and
have fun. These are the patients
in your practice who are looking
for new technology and want to be
informed of all their options.
Currently 43% of the 79 million
adults over 50 use the Internet 11-30 hours per week.1,2 These adults utilize online information
about their eyes and will typically
come into your office with printed
pages of questions. According to
research from MarketScope, the
amount of cataract surgeries are
expected to continue to grow: In
2008, 3.092 million cataract surgeries were performed; in 2012,
3.490 million cataract surgeries are
expected to be performed, and by
2015, that number is expected to
grow to 3.851 million.3
Will YOU be ready to take care
of these patients?
Cataract surgery today IS refractive surgery. We have bridged the
gap between refractive and cataract
surgery. Today, the goal of cataract
surgery is not just to provide a clear
lens to see through. We are expected to provide a specific refractive
outcome after surgery. Patients
expect to see clearly in the distance
without a correction.They expect
better vision and a fast recovery.
O.D.'s Role in Cataract Surgery
As optometrists, we have
long-term relationships with our
patients, which make us uniquely
able to discuss with the patient the
appropriate options for cataract
surgery. We can convey this knowledge to the surgeon, so the surgeon
understands which lens may be
appropriate. We need to educate
the patient about possible visual
outcomes as well as possible complications. Our job is to manage the
patient expectations so as to underpromise and over-deliver to them.
We are in a service economy, and
unless we create a true life enhancing experience for our patients,
they will seek care in other offices.
We need to analyze the patient’s
prescription and determine the
amount of residual astigmatism
we expect to find. Pre-operative
keratometry readings are important
to take. Once the crystalline lens
is replaced, the lenticular astigmatism present pre-op will be gone. If there appears to be greater than
three quarters of a diopter of corneal astigmatism, it is time to start
the discussion with the
patient about possible
In our office, I have
found the discussion
of deluxe lens options
to be quite straightforward. Patients understand astigmatism will
decrease their acuity.
Patients also understand
that they are not able to
read without the help of
some near correction.
While the multifocal
option involves lengthy
discussions and education, I have found our
embrace the idea of toric IOLs.
This is similar to our soft lens
patients with moderate amounts of
cylinder; they readily accept toric
soft lenses. The patient also readily
understands that the more sophisticated design has an additional cost
associated with it.
Pre-op considerations for toric
IOLs are no different than those
for other types of lenses. Careful
case histories are important.It is
especially imperative to get a complete health history as well as all
medications that are taken. Some
health concerns can influence the
type of lens you would recommend,
the type of procedure and where it
should take place. Certain patients
at high risk should only have the
procedure done at a hospital surgery center instead of an officebased center.
As mentioned, medications are also critical; patients on medications such as Flomax (Boehringer
Ingelheim) are at risk for floppy
iris syndrome if the surgeon does
not take proper precautions. Many
seniors today are on antidepressants, and if they are have issues
with depression or other mental
disorders, they may not be an
ideal candidate for a deluxe procedure, or possibly any operation.
Conditions such as diabetes, heart
disease and arthritis need to be
evaluated for severity.Conditions
that may affect the healing process
must be considered. Diabetes,
lupus and many others can cause
Careful keratometry readings and
topography need to be performed.
Slit lamp biomicroscopy is a critical
test to perform with and without
staining. Dry eyes are very common
in this age group, and any anterior segment disorder may affect
the resultant vision. Meibomium
gland dysfunction is one of the
most under-diagnosed problems
in today’s patients. Aggressively
treat any meibomium gland disease
and concurrent dry eye problem.
We are currently utilizing Azasite
(Inspire Pharmaceuticals, Inc.) b.i.d., OU for one week and q.d. for two more weeks, accompanied
by 20mg doxycycline b.i.d. for 30
days and q.d. for 30 days more. We
add a steroid antibiotic combination drop such as Tobradex (Alcon)
or Zylet (Bausch & Lomb) q.i.d. for two weeks. Hot compresses
and lid scrubs b.i.d. complete the
aggressive regime. This treatment
has worked in the vast majority of
our patients. We utilize Restasis
(Allergan) as well as artificial tears
aggressively, too. Remember, the
most beautiful surgery will be
ruined by a poor tear film, as it
will cause distorted optics for your
patient. Finally, a dilated fundus
exam is important to rule out any
possible retinal defect, especially
macular changes. If any early macular change is seen, the patient may
not be a good deluxe lens patient.
Benefits of Toric IOLs
Our practice has truly embraced
toric IOLs. We have found that
the cylinder corrected closer to the
nodal point of the eye yields excellent optics for our patients. Most
of our patients prefer to have one
procedure to address their cataract
and astigmatism rather than returning for a secondary surgery such as
LASIK. I believe we are minimizing
potential complications by taking
care of the cylinder in one procedure. Patients remark how crisp
their vision is with these lenses and
enjoy only having to wear readers.
We can also use these lenses in a
monovision form as well as possibly
performing a secondary multifocal
refractive technique. It also won’t
be long until we see a toric form of
multifocal IOLs, too.
Toric IOLs on the Market
There are currently two toric
lenses available to our patients, the
STAAR Toric (STAAR Surgical)
and the AcrySof Toric (Alcon). The
STAAR Toric comes in two models, correcting 1.50D or 2.25D of
astigmatism. The early model of the
STAAR lens, the TF, was plagued
by rotation stability problems. The
latest model, the TL, seems to have
improved the stability of the lens.
The STAAR material is a silicone
and is a one-piece design.
The AcrySof Toric currently
comes in three models, correcting
approximately 1.00D, 1.62D and
2.25D of astigmatism. The AcrySof
lens is built on the same platform
as the AcrySof aspheric lens. The
aspheric optics in the lens help to
neutralize the positive spherical
aberration from the cornea and
thereby give the patient crisper
vision at all distances under most
any condition. These lenses work
by decreasing positive spherical
aberration which increases contrast
sensitivity for the patient. This will
improve the person’s reaction time
for such tasks as stopping a car.
Our patients are amazed at how much better their night vision is
with these lenses.
The high quality optics obtained
by the AcrySof Toric can be attributed to the aspheric optics as well
as the unique design to create rotational stability. The Alcon acrylic
material has a “tacky” surface
quality that promotes short-term
stability and generates fibronectin
and other natural tissue adhesives
that stabilizes the implant
to the capsule bag over the
long term. The design of
the haptics also helps to
stabilize the lens. The haptics are open-loop modified L-haptics with three
reference dots on each side
that mark the axis of the
cylinder on its posterior
the mean rotation for the
Acrysof Toric was less than
four degrees from initial
alignment 12 months postoperatively.4 The silicone
surface of the STAAR lens
is much more slippery, and
therefore tends to rotate
Surgical technique proceeds as with other types of cataract surgery. Reference marks are
placed on the cornea to help align
Phacoemulsification is performed
and the foldable toric lens is inserted with a Monarch-II injector.
The lens is rotated approximately
15 degrees off axis before the
ophthalmic viscosurgical device is
After the removal, the lens is
then rotated into position and
aligned with the reference marks.
Postoperative care is also similar
to other types of IOLs.Our typical
treatment is Vigamox (Alcon) q.i.d.
for two weeks, Omnipred (Alcon) q.i.d. for two weeks and Xibrom
(Ista Pharmaceuticals) q.i.d. for two
weeks. Visits are performed at one
day, two weeks, six weeks and three
months. Tonometry, slitlamp, and
a manifest are performed at each
visit. A dilated exam is done at six
weeks to check on the alignment
of the lens. If there is a decrease in
vision due to rotation of the lens,
the surgeon can go back into the
eye through very small incisions
and rotate it back.If there is still
residual correction, the surgeon
can elect to do a laser procedure
on the cornea to get the final Rx.
Typically these patients need only
a reading prescription after surgery
and are happy to only have to deal
Let’s review some actual patient
results from our office:
- WM is a 62-year-old white male
who came to our office to inquire
about refractive surgery. He feels
like his vision is changing,
and his eyes are not working as well together as in
the past. He is an attorney
who works many hours at
a computer. Refraction
shows: OD: +4.00 – 3.25
x 100, 20/20 and OS:
+2.50 – 1.25 x 92, 20/20.
Keratometry readings are:
OD:45.25/43.25 @92, OS:
44.50/43.62 @ 92. Slit lamp
biomicroscopy showed a
clear cornea but nuclear
sclerosis was evident OU.
Due to the patient’s Rx
and lenticular changes, we
recommended a RLE procedure over LASIK. We
felt the quality of vision
would be better with a
much more long term result with
the RLE. Surgery was done on each
eye with the following lens choice:
OD: Toric SN6AT3 24.5 @ 11, OS:
Toric SN6AT3. Surgery proceeded
as planned. The three month postop visit showed excellent vision with
little residual power. Refraction:
OD: +0.25 -0.75 x 25, 20/20+, and
OS:-0.25DS, 20/15. Uncorrected
acuity:OD:20/25+, OS: 20/15-.
The patient only wears readers for
his near work and is quite pleased.
His symptoms of eyestrain have completely abated.
- LM is an 81-year-old white male who came to us
complaining of blurred vision in his right eye. He had
previous cataract surgery in the left eye by another
surgeon. Refraction shows: OD: -0.50 – 1.25 x 92,
20/30 and OS: -2.50DS, 20/40. Slit lamp revealed a
grade 1+ cataract in the right eye and grade 2 posterior
capsular opacification in the left eye. Early macular
changes were noted in the left eye. The lens chosen for
the right eye was an Alcon Toric SN6AT3 18.5 @ 143.
Surgery proceeded as expected and a YAG capsulotomy was done on the left eye. The six week visit showed
excellent vision in the right eye and some improvement
in the left. Uncorrected visual acuity was:OD:20/25
and OS:20/200. Refraction was:OD:+0.25 – 0.25
x 60, 20/25 and OS:-2.25 – 0.25 x 90, 20/30+. LM is
very pleased with the result in his toric IOL eye.
The ability to correct astigmatism in cataract surgery
is a great advance for the improvement of our patient’s
lives. The advent of the new deluxe lens options has
made cataract surgery truly a refractive procedure.
Toric aspheric IOLs greatly improve the optics to function in a new world of high tech devices. Small incision
surgery with these IOLs are providing both excellent
results for our patients with very quick healing times.
- Jupiter Communications.
- 2002 U.S. Census Bureau.
- MarketScope (4/09)
- Chang, DF. J Cataract Refract Surg. 2008 Nov;34(11):1842-7.
Dr. David Geffen is currently director of optometric
and refractive services at the Gordon & Weiss Vision
Institute in San Diego, California. He has lectured
and written extensively on contact lenses, refractive surgery procedures and intraocular lenses. He is
the current treasurer for the Optometric Council on
Refractive Technology (OCRT). He is currently serving as the Chair for the Optowest Advisory Panel for
the California Optometric Association. Dr. Geffen has
conducted dozens of contact lens related studies for
many manufacturers and has served as an industry
consultant for several companies over the years.