Q: I have a patient with 3.00D of cylinder who is just about ready for cataract surgery. When do I talk to the patient about the possibility of a toric IOL?
“Always talk about it,” says Walter O. Whitley, O.D., M.B.A., director of optometric services at Virginia Eye Consultants. “The only contraindication for a toric IOL is no astigmatism,” he quips.
“One of the questions I always pose to O.D.s is: Would you ever prescribe a pair of glasses without treating the patient’s astigmatism?” Dr. Whitley asks. “Generally the answer is no, we’re always going to treat the astigmatism to some degree.”
The same holds true with an astigmatic cataract patient and a toric IOL. There’s no reason not to offer to treat the astigmatism, he says.
For this patient, make sure he or she has a visually significant cataract, of course. Then, perform manual keratometry and topography to make sure that the patient’s 3.00D of cylinder is true corneal astigmatism, not total astigmatism.
“In our center, if patients have more than one diopter of corneal astigmatism, then we offer a toric IOL,” Dr. Whitley says. “I tell them, ‘Congratulations, you have a cataract!
It’s a great time to have cataract surgery because we have several different options for you. As you know, you have astigmatism and we now have an implant that can treat that. A few years ago we could not offer you this technology.’”
He briefly talks about how a toric lens works—how it will sharpen distance vision, but often requires reading glasses to see up close. Then he explains that it’s a premium lens and insurance does not cover it, so it’s an out-of-pocket expense.
The only difference with toric IOL implantation is a post-op check to be sure the lens is in position.
But, he says, “how many things do we purchase that we get to use every single day for the rest of our lives? Then I leave it up to them. I make a recommendation, but it’s ultimately their decision.”
If the patient says OK, have your staff make the appointment with the surgeon’s office you recommend, Dr. Whitley says. Send along any patient notes, including manual K’s and topography if available, a referral request form with your recommendations (and your reasons behind them), and the consent for comanagement form.
But, if the patient declines, document this in the chart. Document also that you’ve presented the patient with all the available options.
Q: Postoperatively, what do I need to do differently for a cataract patient with a toric IOL?
“Nothing,” Dr. Whitley says. “It’s the same postoperative exam as with any cataract surgery, with only one minor exception: At the one-week visit, make sure you dilate the eye and check the implant’s toric axis markers to verify that the IOL is positioned properly.”
For every degree that the IOL is off axis, the patient loses about 3.3% of astigmatic correction. So, in the event that the IOL is off axis, “communicate your findings with the surgeon and explain the patient’s symptoms,” Dr. Whitley says. Ask the surgeon’s office about following the patient or scheduling a repositioning procedure.
With rare exception, these lenses are very stable within the eye, he says, and patients are very satisfied with their surgical and visual outcome. The results are more predictable than with limbal relaxing incisions, and higher astigmatic errors can be corrected up to 3.00D. An expanded range of powers will be available next year, he says, and look for the toric lens to be incorporated into a multifocal lens in 2012.
