Are You Implanting Toric IOLs Yet?

If not, here's what you need to consider.

By Ehsan Sadri, MD, FAAO, FACS

► Most young cataract surgeons don't routinely recommend advanced technology IOLs for their patients, despite the distinct advantages. Toric IOLs have an integral role in my work. If I chose not to recommend them, I wouldn't be offering my patients the best possible lens for their vision.

If you're a new ophthalmologist considering how you'll approach treatment of cataracts and astigmatism, I think you should dive right into the world of toric IOLs. Here are three key tips to consider:

1. Be competitive. Reimbursements are declining, while expectations for excellent vision continue to rise. I urge you to begin your career in the most competitive way possible. Don't be satisfied with basic IOLs when newer technologies offer the opportunity for better vision for qualified patients. Embrace the best options for your patients from the start of your career. This approach helps in many ways, especially patient outcomes and practice growth. The word of mouth of a satisfied patient is worth more than any advertising program and will increase your referrals. When I correct astigmatism with a toric IOL at the time of surgery, I have one of the happiest patients on the planet. These patients talk and share their positive experiences, and it helps build our practice.

2. Experiment. Try different IOLs. You can read the studies and talk to colleagues, but we all need to get our hands on all of the lenses available to build our confidence in using them. Choose a proven platform so that your learning curve is shorter.

3. Talk choices. You need to offer patients a variety of lenses to meet their needs, which means you must be comfortable discussing choices with your patients. With toric lenses in particular, once you've selected a good candidate, the conversation is easy. You explain what the lens is and how it will correct preexisting astigmatism for better uncorrected vision at distance.

Toric IOLs offer a host of advantages. Once you understand them, learn how best to discuss them with patients and feel comfortable with implantation; you'll have many patients who thank you for helping them see more clearly than they ever thought possible.

Understanding Torics

I've been in practice for 7 years, seeing about 100 cataract cases per month. I implant advanced technology lenses, such as toric IOLs, in about 80% of these patients whose preexisting astigmatism qualifies them as a candidate. Many cases are challenging, involving patients who have controlled glaucoma or other concurrent problems, which can affect vision. In thousands of patients, I've used all of the available toric IOLs, and I've seen the technology advance over the years to include what I consider to be phenomenal aspheric capabilities.

Toric IOLs correct cataract patients' preexisting astigmatism, while the aspheric optic improves contrast sensitivity. Besides astigmatism, lifestyle is important to consider as well. I discuss reading, driving and other activities that can tell me whether enhancing near vision or distance vision is the better choice. In most cases where I recommend a toric IOL, the patient is relatively younger for a cataract patient, doesn't read a great deal, drives a lot (possibly even for a living) or has other significant distance-dominated needs.

There are two major manufacturers of hydrophobic acrylic toric IOLs, Alcon and STAAR. The STAAR Toric IOL treats moderate astigmatism, while the AcrySof IQ Toric lens (Alcon) has models that treat minimal, moderate and high cylinder. It's interesting to get patients with different manufacturers' lenses in the chair and see how they do postoperatively. I have a patient with a previous STAAR Toric IOL implant in one eye and an AcrySof IQ Toric IOL that I implanted in her other eye.

Any patient for whom you recommend an advanced technology IOL needs good education. Whether it's a premium toric or a multifocal lens, patients want to know what the extra cost will get them.

Toric candidates should understand that with a toric IOL, they can expect their astigmatism to be treated without eyeglasses or contact lenses.

They can also expect better optical quality and better distance visual acuity for activities such as television, sports and driving. I tell my patients these two important points:

1. Driving: People with cataracts and bifocals often say they can't see other cars until they're right next to them. That affects their confidence to go out in the evenings. The AcyrSof IQ Toric IOL's Direction for Use demonstrates sharper vision, thus providing better awareness, especially during evening driving. Even a small change in visual acuity makes a big difference in confidence on the road.

2. Quality of life: My patients with toric IOLs are extremely pleased with their vision after surgery. The astigmatism correction and improved contrast sensitivity have a positive impact throughout their lives and help them enjoy some activities better than they have in years. For example, I have an 80-year-old patient ranked fifth in the world in tennis in her age category. Her vision used to be exquisitely clear, and now she can see the ball with clarity once again. A basic monofocal IOL wouldn't have been a poor decision in her case, but her vision is sharper and she is very satisfied.

Preparing to Use Torics

Although ophthalmologists are exposed to toric IOLs in residency, many don't have the opportunity to implant a lot of these lenses because of their setting. However, you don't need a great deal of experience implanting the AcrySof IQ Toric lens to feel comfortable using it. If you've implanted the AcyrSof IQ lens, you can implant AcrySof IQ Toric because it is built on the AcySof IQ platform. The single-piece lens has the same high refractive index as the SN60WF, and you can implant it through a micro-incision cataract surgery (MICS) incision if you choose.

The AcrySof IQ Toric's material is unique and adheres to the anterior surface of the capsular bag, while the haptic ensures that the lens stays put to prevent rotation. The biggest worry with a toric IOL is stability, so the haptic and adherence to the capsular bag help ensure that the lens stays put and remains effective.

Beyond the basic data about toric IOLs, it's most important to understand that it's essential to perform an accurate refraction and topography reading before surgery. You need to get the K1 and K2 ratings, corneal curvature (with the IOLMaster [Carl Zeiss Meditec] or immersion data), and A and B scans.

By plugging these numbers into the AcrySof IQ Toric IOL calculator (www.acrysoftoric-calculator.com), you can determine the best lens for your patients.

I also use the topography to determine the actual meridian that needs to be treated the most. I bring a printout of the topography with me into surgery. If you don't perform topography before surgery, you might be looking at a lenticular astigmatism that will be uncovered after the surgery.

By performing a refraction and comparing it against the topography, you can see if some cylinder needs to be treated or if the topography is consistent with other readouts.

Implanting the Lenses

Toric lens implantation is similar to any other IOL, but the procedure does carry a few of its own techniques related to proper placement and preventing rotation.

First, when you make reference marks on the limbus, have the patient sit upright at 90º. This prevents cyclorotation that occurs when the patient is supine and under medication. Mark 12, 3, 6 and 9 o'clock, and mark the meridian that the IOL calculator calls for. Ensure the lens sits at that meridian. It's quite easy to place this extra mark, since you're already meeting the patient and marking the eye and the patient usually has been treated with a topical numbing medication.

Intraoperatively, certain nuances can help ensure that the procedure is a success. When I insert the lens and line it up and everything is going well, I usually do a minimal aspiration of the anterior capsule. I don't polish the anterior capsule facing the lens implant, which allows the adherence of the haptics so that the lens doesn't rotate. Patients do very well without having an anterior capsule polishing, and the whole process stabilizes things nicely.

Finally, when hydrating the incision, keep an eye on the lens. If hydration is too aggressive, the influx of fluid can set up rotational movement and rotate the lens.

Bringing Passion to Education

I started using toric IOLs in 2004, when the first FDA-approved toric lens hit the market. Now advanced technology lenses are the lion's share of the work at my practice. It didn't just happen because the lenses were available — it happened because we brought passion to the discussion.

The key is not so much to explain the patient's physical problem and how the lens design can help, but to explain the reasons why we recommend a toric IOL over the basic version that is covered by insurance.

People are very visual, and naturally patients want the best vision they can achieve. When the best will cost a few thousand dollars, you have to explain the value to patients. I'm passionate about educating patients. When I tell my patients about this technology, I'm genuinely excited about the results that we can achieve. When you begin to offer toric IOLs, try to bring your passion about this IOL to the conversation. I have two pieces of advice in this regard.

1. Believe it. You can't educate people about something unless you believe in it. Offer toric IOLs because you believe in the technology, and because you're excited about the outcomes. Patients need to feel confident that you believe in what you're telling them. If you don't believe 100%, they know it, and there's no changing their minds.

2. Teach, don't sell. Let your passion come across through education, not a sales pitch. I don't have counselors in my practice because I have a large Medicare patient population, many of whom want to talk to the doctor. Patients are never receptive to a sales pitch, and this is especially true in a down economy, so just be real. Believe in the lens and educate your patients. Let patients absorb what you're saying, take their time and make a decision without pressure.

If you educate patients and show your passion for the technology, many patients will go with a toric IOL. The rewards are phenomenal for everyone: excellent outcomes, patient satisfaction and practice growth. nMD