Supplement December 2018/ January Focusing on Premium IOL Advances and Best Practices. Supported by an unrestricted educational grant from

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1 Supplement December 2018/ January 2019 Focusing on Premium IOL Advances and Best Practices Supported by an unrestricted educational grant from

2 ESCRS Clinical Survey Data: Maximising Outcomes with Presbyopia and Toric IOLs Rudy MMA Nuijts, MD, PhD Areview of the 2017 ESCRS Clinical Survey responses revealed interesting findings with respect to presbyopia and toric IOL correction trends, practices and beliefs. Of the 1,800 delegates surveyed, 70% or 1,260 responded. Trifocal and extended depth of focus (EDOF) IOL usage has exhibited remarkable growth expanding from 15% in 2016 to 22% in 2017 for EDOF lenses, and 39% in 2016 to 45% in 2017 for trifocal lenses. Bifocal IOL usage for presbyopia correction decreased from 34% in 2016 to 25% in Among the most striking responses to the annual survey were the following: First, 35% do not believe that 0.75D of postoperative cylinder error is likely to have an impact on visual quality and patient satisfaction in presbyopia IOL patients. This is not in line with what we know from the literature. Hayashi et al. outlined that this amount of residual astigmatism inadvertently effects uncorrected distance vision. 1 Second, 47% believe 10 degrees or more of post-op rotational error of toric IOLs is acceptable. This is clearly a misinterpretation, especially in the higher powered toric IOLs where 10 degrees of misalignment may lead to a loss of 1/3 of the effect on astigmatism correction. Another notable finding emerged from the related queries: What percentage of your current cataract procedures involve toric IOLs and if cost were not an issue, what percentage of your cataract patients with clinically significant astigmatism, would receive a toric IOL? Just 11% receive toric IOLs, but more than three times that amount 35% would get toric IOLs, if cost were taken out of the equation. In those cases where toric IOLs are used, respondents said they favoured manual marking of the intraoperative axis over the use of digital image registration tools such as wavefront aberrometry, with approximately 75% continuing to manually mark the axis. The 2017 ESCRS survey revealed that just under 10% of the respondents current cataract procedures involve presbyopiacorrecting IOLs, but that almost 45% of their cataract procedures are targeted for monovision or mini-monovision. As technology improves and newer presbyopia correcting lenses continue to mature, practice trends and usage patterns will inevitably evolve along with them. What type of presbyopia correcting IOL technology is used in the majority of your presbyopia correction patients? Growth in usage of EDOF and Trifocal between 2016 and 2017 REFERENCE 1. Hayashi K, Hirata A, Manabe S, et al. Long-Term Change in Corneal Astigmatism After Sutureless Cataract Surgery. Amer J Opthal 2011;151:4: Rudy MMA Nuijts, MD, PhD: Professor of Ophthalmology, University Eye Clinic Maastricht Medical University Center Maastricht, Netherlands. Phone: ; rudy.nuijts@mumc.nl Financial disclosure: Abbott, Alcon, Asico, Bausch & Lomb (S), Carl-Zeiss, Chiesi, HumanOptics, Ophtec, Oculentis, TheaPharma. Refractive IOLs: Where There s a Plan, There s a Way Béatrice Cochener-Lamard, MD PhD 1 Thanks to surgical advances such as microincisions and the associated reduction in induced astigmatism, refractive cataract surgery offers a more predictable and stable solution than corneal refractive surgery for correction of lowto-moderate ametropia of the ageing crystalline lens. Utilising effective preoperative diagnostics and arming patients with realistic expectations is key to delivering optimal outcomes. With respect to multifocal IOLs and even EDOF IOLs planning is easily as important as executing the surgery. You must explain what presbyopia is, and clearly delineate the advantages and limitations of these IOLs. You must choose patients carefully so that you have good candidates who are both motivated and not expecting or needing perfection at every distance under every condition. You must also rule out patients who have progressive ocular disease, such as glaucoma or maculopathy, or progressive systemic disease, such as diabetes, or any autoimmune disease that is not under control. All of these are contraindications for multifocal IOLs. Hyperopic patients are generally the best candidates for presbyopia correction, especially at the stage of early presbyopia indicated for corneal treatment. Myopes deal well with monovision, whereas emmetropic patients present unique challenges because these patients want to maintain their good far vision and just improve their near vision. Astigmatism is not a problem, but

3 when it is irregular you need to find a nice correlation between what you are measuring on your topography and what you are measuring in manifest refraction to allow the surgical treatment of this cylindrical component by laser or toric IOL. THE OCULAR SURFACE Ocular surface health has become a hot issue with respect to prepping for refractive IOL surgery. We know that ocular surface disease (OSD) is underestimated and can have an impact on refractive outcomes if it goes unchecked. Fifty percent of cataract patients report feelings of dryness after the surgery, and the same amount present with meibomian gland dysfunction (MGD) before surgery. We know that a pre-existing OSD will increase the risk and the severity of postoperative dry eye. We are dealing with an ageing population with many risk factors, such as mechanical changes in the lid and stability of the tear film. The stability of the tear film can impact the refractive measurements and the quality of vision after the surgery. A meibography system such as the LipiView ocular surface interferometer (TearScience) is one diagnostic tool that addresses this. It measures lipid layer thickness, captures blink rate and images meibomian gland structure. The intraocular lens solution is definitely the winner in the arsenal of presbyopic surgical treatment options Topography, optical coherence tomography (OCT), osmolarity testing and evaluation of biomarkers are all excellent ways to gather critical data that can be used to improve the presbyopia-correcting IOL patient s refractive outcome, in the selection and follow-up period. I would also like to call to your attention to aberrometers -- among them the Optical Quality Analysis System (OQAS) (Visiometrics), a double-pass aberrometry system. It objectively LipiView image showing good tear fluid LipiView image showing poor tear fluid The LipiView ocular surface interferometer (TearScience) measures lipid layer thickness, captures blink rate and images meibomian gland structure measures quality of vision via a specific index: OSI (Ocular Scatter Index), which is disturbed as soon as light goes through abnormal media such as pathological tear film. REALISTIC EXPECTATIONS Careful biometry, IOL calculation and intraoperative marking are all critical to the final refractive outcome, but patients need to know that even when everything goes perfectly according to plan, they will not return to the vision of their 20s. Postoperative visual performance is dependent on light conditions and a certain loss of contrast sensitivity cannot be avoided, as well as the neuroadaptation process that can take anywhere from a few weeks to as long as three months. Ultimately, the IOL solution is definitely the winner in the arsenal of presbyopic surgical treatment options. It offers a predictable, stable, faster recovery than the laser, an ability to treat a combined low to moderate ametropia and should be preferentially indicated when the crystalline lens is ageing. Béatrice Cochener-Lamard, MD, PhD: University Hospital of Brest, Brest, France. Phone: ; beatrice.cochener-lamard@chu-brest.fr Financial disclosure: Alcon, Zeiss, J&J AMO, Physiol, Thea, Allergan, Santen, Dompe, Cutting Edge. Monovision Remains a Suitable Option for Presbyopia Correction By Filomena Ribeiro, MD, PhD, FEBO Ideally, all lens-based presbyopia-correction options would provide continuous, clear, sharp vision from near to far. Reality has not yet caught up with that goal. In the meantime, monovision remains a viable option to satisfy the visual demands of presbyopic patients. Monovision is a satisfactory solution for select patients who cannot afford or are otherwise unsuited to a multifocal IOL. According to the 2017 ESCRS Survey, 85% of ESCRS delegates are performing monovision on some cataract patients and 43% of ESCRS cataract procedures are targeted for monovision or mini-monovision. Pseudophakic monovision is widely practised, but little studied. In fact, much of what we know comes from contact lens literature. Monovision relies on intraocular suppression of blur and also on neuroadaptation. This suppression comes with trade-offs in binocular summation, in stereopsis and in contrast sensitivity. PROS AND CONS There are pros and cons associated with monovision: It is cost-effective, it provides good monocular quality of vision, less sensitivity to decentration and less sensitivity to posterior opacification and capsular contraction. It is also a preferred option for patients at risk of developing macular disease or other conditions that reduce contrast sensitivity. Conversely, monovision is associated with a loss of stereopsis, loss of binocular summation, risk of asthenopia, limited intermediate vision and sometimes these patients need spectacles for night driving and prolonged reading. When considering this option, the first thing to bear in mind is ocular dominance, although it can be difficult to determine especially in cataract patients. One of the requirements for success is targeting the degree of anisometropia; the greater the anisometropia the greater the difficulty with neuroadaptation. A study led by Hayashi showed that with increasing anisometropia near acuity improved, but stereopsis worsened. 1 MONOVISION OPTIONS Conventional monovision can result in great patient satisfaction. Another option is cross-monovision, which is when the dominant eye is targeted for near and the non-dominant eye is targeted 2

4 for distance. In a study led by Zhang, where conventional monovision and cross-monovision were compared retrospectively, they found that psuedophakic cross-monovision can provide good patient satisfaction and spectacle independence. 2 The most popular version of monovision is, right now, the mini-monovision, which may protect distance vision, while improving intermediate acuity and reducing the need for spectacles. Another less relied upon method is modifying monovision. In this case, we are essentially modifying monovision with monocular-induced spherical aberration. This increases depth of focus and enhances binocular through-focus visual performance. 3-5 We can also combine mini-monovision with extended depth of focus (EDOF) IOLs. These lenses are more tolerant to residual error than multifocal IOLs, so they are well suited to monovision, and according to at least one study, micro-monovision with EDOF IOLs offers superior range of visual acuity and spectacle independence. 6 A meta-analysis comparing bilateral multifocal implantation to monofocal monovision revealed multifocal patients were more likely to achieve spectacle independence, but there was always a trade-off with respect to dysphotopsia. Ultimately, we have many solutions to correct presbyopia, and in cases where multifocal IOLs are not an option, monovision, micro-monovision and micro-monovision with EDOF IOLs are all suitable alternatives. Filomena Ribeiro, MD: University of Lisbon in Portugal, Hospital Da Luz. No financial interest to disclose. Phone: , filomenajribeiro@gmail.com Retrospective comparative cohort study Conventional vs Crossed Monovision Reviewed 7,311 cases 30 subjects had crossed monovision (Dominant eye for near; nondomin. for distance) Pseudophakic crossed monovision can provide good patients satisfaction and spectacle independance Conventional Group Crossed Group Very Happy 33.3% Happy 63.3% Neutral 3.3% None 0% Very Happy 60% Happy 40% Neutral 0% Unhappy 0% Psuedophakic cross-monovision can provide good patient satisfactionand spectacle independence REFERENCES 1. Hayashi K, Yoshida M, Manabe S, et al. Optimal Amount of Anisometropia for Pseudophakic Monovision. J Refract Surg 2011; 27(5) Zhang F, Sugar A, Arbisser L, et al. Crossed versus conventional pseudophakic monovision: Patient satisfaction, visual function, and spectacle independence. J Cataract Refract Surg 2015;41(9): Evans,BJ. Monovision: a review. Ophthalmic Physiol Opt 2 007;27(5): Handa T, Mukuno K, Uozato H, et al. Ocular dominance and patient satisfaction after monovision induced by intraocular lens implantation. J cataract Refract Surg 2004;30(4); Jain S, Arora I, Azar DT, et al. Success of monovision in presbyopes: review of the literature and potential applications to refractive surgery. Surv Ophthalmol 1996;40(6): Hogarty DT,Russel DJ, Ward BM, et al. Comparing visual acuity, range of vision and spectacle independence in the extended range of vision and monofocal intraocular lens. Clin Ophthalmol Trifocal IOLs Inspire High Patient Satisfaction Scores Thomas Kohnen, MD, PhD, FEBO 3 Trifocal intraocular lenses can provide high patient satisfaction, for presbyopic patients who have generally healthy eyes - clear corneas, regular astigmatism, a normal fundus - and a wish for spectacle independence. Trifocal lenses developed as an outgrowth of positive patient experiences with +3 bifocal IOLs, which have an intermediate gap in their defocus curve. Now, we have +3.5 and 1.75 trifocal IOLs, and the principle behind these lenses is a foci at 40cm, at 80cm and at distance. In our study of 27 patients (54 eyes) who had bilateral implantation of the AT LISA trifocal IOL (Carl Zeiss Meditec, Jena, Germany), analysis revealed good visual acuity (0.1 logmar or better) at far, intermediate, and near distance; high patient satisfaction despite some optical phenomena; and high spectacle independence 3 months postoperatively. 1 Postoperative examination at 1 and 3 months included manifest refraction; monocular and binocular uncorrected and distance-corrected visual acuity in 4 m, 80 cm, and 40 cm; slit-lamp examination; and tomography. At 3 months defocus testing, binocular contrast sensitivity (CS) under photopic and mesopic conditions, and a questionnaire on subjective quality of vision, optical phenomena, and spectacle independence were performed. Patient satisfaction got very high scores with 92% saying they would opt for the same lens again, and 88% saying they would recommend the lens. The only low rating was for night driving, which is a reflection of optical phenomena, such as halos and glare that occurred in approximately 60% of the study s cohort. This rate is similar to the optical phenomena incidence in bifocal IOL patients, but less perceived in trifocals. In Europe we have the advantage of having almost every trifocal lens available for use. They include PhysIOL FineVision, Zeiss AT Lisa Tri, Alcon PanOptix, and the newest addition, Rayner Trifocal. The Rayner Trifocal has fewer rings on the optic surface; this design is intended to reduce potential visual disturbance and improved night vision. Future studies are required to evaluate qualitative distinctions among the trifocal IOLs. The interesting thing about the Rayner lens is that it has an add-on feature so we can apply trifocal technology to our pseudophakic patients. FIVE PEARLS FOR TRIFOCAL IOLS These five pearls help define and position trifocal IOLs in the arsenal of presbyopia correction. 1.The number one indication for this lens is a desire for spectacle independence. 2. These lenses are contraindicated in severe dry eyes, as well as eyes with corneal disease, central corneal scars, pseudophakic exfoliation syndrome, glaucoma and retinal diseases; and they are so far not recommended for patients who have visually demanding jobs such as pilots or drivers.

5 3. Centration and size of the capsulorrhexis is very important; these optical systems demand good centration. 4. Binocular implantation is always advantageous. A 2005 study on binocular implantation of a bifocal +4.0 IOL showed that there is always improvement if the second eye is done2. 5.Finally, you should have the option of a touch-up procedure because sometimes the patient will end up non-emmetropic. REFERENCES 1. Kohnen T, Titke C, Bohm M.Trifocal Intraocular Lens Implantation to Treat Visual Demands in Various Distances Following Lens Removal. Am J Ophthalmol. 2016;161: Kohnen T, Allen D, Boreau C. European Multicenter Study of the AcrySof ReSTOR Apodized Diffractive Intraocular Lens. Ophthalmology. 2006;113(4), Thomas Kohnen, MD, PhD, FEBO: Professor and chairman, Department of Ophthalmology, Goethe University, Frankfurt, Germany. Trifocal IOL principle is a foci at 40cm, at 80cm and at distance kohnen@em.uni-frankfurt.de Financial disclosure: Consultant and Research for Abbott/J&J, Alcon/Novartis, Oculentis, Oculus, Presbia, Schwind, Zeiss. Consultant for Allergan, Bausch & Lomb, Dompé, Geuder, Merck, Rayner, Santen, Staar, Thea, Tear Lab, Thieme, Uni-Med Verlag, Med Update, Ziemer. Research for Avedro, Hoya. EDOF IOLs Provide Continuous Elongated Focus By Milind Pande, DO, FRCS, FRCOphth E xtended depth of focus (EDOF) IOLs are distinguished by continuous elongated focus, and are a potential game-changer because of their high-contrast vision. No lens provides a perfect solution, however, so binocular lens customisation is critical to achieving good results. The Tecnis Symfony was the first EDOF IOL to enter the market (Johnson & Johnson Vision). This was followed by the MINI WELL (SIFI), which relies on aspheric modulation to produce its continuous focus; the IC-8 (AcuFocus), which is distinguished by its reduced-aperture pinhole effect; and the Zeiss AT LARA (ZEISS) which uses Lightbridge technology to generate a continuous focus. With EDOF IOLs, at least 50% of patients should achieve 20/32 (logmar 0.2) or better at 1.5D, and they should have at least 0.5D more depth of focus compared to monofocal lenses at that same distance. Our patients primary interest is functional vision. They want to be able to perform daily tasks, such as reading, driving, shopping and using their desktops, without spectacles. In tune with that demand, I developed the Pan-Focal Visual Acuity test. Patients are seated at a desktop and a laptop and given four different reading tasks to assess how they perform in different standardised lighting conditions at standardised distances. We found that they must have at least 6/9 or 20/30 for all four VA measures to achieve complete spectacle freedom. SPECTACLE FREEDOM The vast majority of Symfony patients reported spectacle-free visual satisfaction at all distances and at night An IOL is EDOF if 50% of patients achieve BCDVA of 20/32 (logmar 0.2) or better at 1.5D For all patients in our practice, we start with a binocular vision target of 6/9 or better across all four categories with the goal of achieving complete spectacle freedom. We do not discuss that with the patients, because we do not want to influence their postoperative expectations. We do, however, discuss that with EDOF lenses there is a trade-off between quality of vision, dysphotopsia and focal range, and that lenses can only influence a retinal image and not their neuroadaptation. It is important that patients are aware of the neuroadaptive processes and are willing to take that on. The process starts with a preoperative Pan-Focal assessment of the 4

6 first eye with a target of emmetropia. After two weeks, we repeat the Pan-Focal Visual Acuity test and customise correction of the second eye based on patient feedback. A good strategy with EDOF lenses is to adjust the defocus. There are various terms that are used to describe this adjustment, such as monovision, which is a difference in isometropia of more than 1D. With EDOF lenses, I prefer to refer to this defocus as nanovision, given that the difference is only up to 0.75D. NANOVISION In my practice, when we performed binocular Pan-Focal VA testing and implanted Symfony IOLs using nanovision, 96% of a continuous cohort of 157 patients achieved spectacle independence in photopic conditions, and 74% of patients achieved spectacle independence in near mesopic conditions. Current IOL technology is capable of providing unaided binocular visual acuity of 6/9 or better at all distances in good light with minimal if any quality of vision compromise. To accomplish that at a monocular level, we need to achieve improvements in technology and in our assessments. Milind Pande, DO, FRCS, FRC Ophth, Vision Surgery & Research Centre, East Yorkshire, UK. Phone: ; visionsurgery@gmail.com Financial Disclosure: Johnson & Johnson, Hoya Surgical Optics, Bausch & Lomb Presbyopia-Correcting IOLs: Eight Tips for Astigmatism Correction By Douglas Koch, MD Consider the following eight strategies when managing astigmatism in presbyopia IOL patients: Number 1: The threshold for correction is very low in astigmatic patients who have presbyopiacorrecting IOLs. A monofocal patient can have acceptable vision with up to 0.75D of astigmatism, whereas a target of less than 0.5D of astigmatism is recommended for presbyopia-correcting IOL patients. 1 In this unique group of patients, you are essentially combining two sources of blur astigmatism and multifocality and they compound each other. Approximately 40-to-60% of our patients have greater than 0.5D of astigmatism. 2 Number 2: It is sometimes suggested that extended depth of focus (EDOF) lenses are more forgiving of astigmatism and our preliminary data do suggest that this is true. However, given that we are trying to squeeze as much near vision as possible out of these lenses, any amount of astigmatism will ultimately have a negative impact. The bottom line is that it is just as important to minimise astigmatism with EDOF lenses as with any other type of multifocal IOL. Number 3: Know your surgically-induced astigmatism (SIA). For those of us who rely on 2.4-mm temporal incisions, the SIA is very small at around 0.1D-0.2D. It can be higher, however, particularly if you are making larger incisions or incisions in the superior portion of the cornea. To calculate your SIA, I recommend Number 4: Rule out irregular astigmatism. It is a major cause of poor visual outcomes. You also need to ensure that the patient is a candidate for corneal enhancement because you may have to address residual astigmatism or ametropia. Number 5: Be very sceptical in acquiring and analysing your data. Perform more than one measurement and verify the quality of your raw data. You can do that by looking at the mires from the LEDs or standard deviations. Number 6: The posterior cornea is another source of error. You can use regression formulas based on averages, or measure it with Scheimpflug technology, reflective technology such as Cassini (i-optics) or optical coherence tomography (OCT). Most of us use regression formulas, and even as refined as these formulas are we only get about 80% ±0.5D. There can be a lot of variability from one patient to the next, so until we can measure that more precisely, we are going to have errors whenever we use formulas that are based on regression or on prior data. After Implanting a toric IOL, how many DEGREES of postoperative rotational error is acceptable before visual quality & degradation of visual acuity are significantly affected? Under 5 Degrees 5 to 9 Degrees 10 or more Degrees 40% believe 10 degrees or more of postoperative rotational error is acceptable. The 2017 ESCRS Clinical Survey revealed that 40% of participants believe that 10 degrees of misalignment is acceptable; however, 10 degrees of misalignment equates to 33% undercorrection of astigmatism Number 7: Correct alignment is critical. The 2017 ESCRS Clinical Survey revealed that 40% of participants believe that 10 degrees of misalignment is acceptable, and that is definitely incorrect. Ten degrees of misalignment equates to 33% under-correction of astigmatism (with a shift in the axis of refractive astigmatism), which is not acceptable for presbyopia-correcting IOLs. Number 8: With so many possible sources of error, you must listen to your patients complaints. Do not be satisfied with substandard or subpar distance or near vision. Investigate it, determine the causes and be willing and ready to treat the errors with the ultimate aim of refining the outcome to maximise patient satisfaction, or turn the conoid of blur into foci of clarity. REFERENCES 1. Villegas EL, Alcón E, Artal P. Minimum amount of astigmatism that should be corrected. J Cataract Refract Surg. 2014; 40: Ferrer-Blasco T, Montes-Mico R et al. Prevalence of corneal astigmatism before cataract surgery JCRS. 2009; 35:70-75 Douglas D. Koch, MD, Cullen Eye Institute, Baylor College of Medicine, Houston, TX. Phone: (713) ; dkoch@bcm.edu Financial Disclosure: Alcon, Zeiss, Johnson & Johnson Vision. 5

7 Mitigating Post-Operative Error in Refractive IOL Patients By H. Burkhard Dick, MD, PhD, FEBOS-CR There are several risk factors for postoperative refractive error: poor preoperative corrected distance visual acuity, ocular comorbidity, corneal opacification, small pupils, previous corneal refractive surgery and surgical difficulties and complications. Sources of residual astigmatism include preoperative measurements, surgically induced astigmatism (SIA), corneal astigmatism, incorrect or adjusted cylindrical IOL power or marking and misalignment. With respect to SIA, I recommend where you can calculate your SIA, keeping in mind that overcorrection comes along with with-the-rule astigmatism, and undercorrection is associated with against-the-rule astigmatism. Different biometric formulas yield different results. Some do not take into account the effective lens position (ELP) or posterior cornea and others implement the anticipated or estimated posterior corneal astigmatism (PCA) into their calculators, such as the Alcon online calculator (myalcon-toriccalc.com) and the Barrett toric calculator. Interestingly, in clinical trials both calculators yielded the lowest astigmatic prediction errors. The incidence of toric IOL misalignment over 10 degrees, which is unacceptable, varies in the literature from 2 to 32%. Weber and colleagues showed that digital marking resulted in significantly less misalignment compared to manual marking. 1 TOOLS OF ALIGNMENT Intraoperatively, we have reliable tools to align toric IOLs, such as Callisto (Zeiss), TrueGuide (TrueVision), VERION (Alcon) and ORA (Alcon). Comparative trials with preoperative calculation vs intraoperative calculation showed a slight, but clear, difference in terms of better outcomes for the intraoperative method. 2 Also, we now have intraoperative tools that help to align the toric IOLs, as well as intraoperative iris detection tools that allow us to easily read the rotation if there are stable and precise capsular marks (IntelliAxis). This enables easy realignment in the case of decentration or rotation. With respect to correcting residual astigmatism, our options include repositioning, IOL exchange, secondary implantation, nonablative (PiXL) or ablative-like excimer laser including LASIK or femtosecond laser-assisted arcuate incisions. Before proceeding with any of those options, we need to measure the corneal and internal astigmatism as well as aberrations. Almost all aberrometers can measure corneal and subtracted aberrations, and then the device suggests the amount and direction you should rotate and what change in dioptre and refractive cylinder you should expect. If you don t have an aberrometer, you could use Noel Alpins MD s ASSORT software program that uses vector analysers. Once data is input, the program suggests the best fit in terms of the rotational target for re-operation. There is also a toric results analyser that suggests where to target and in which axis to rotate the toric lens, as well as how much improvement you can expect, in response to the subjective refraction results that you input. SURGICALLY-INDUCED ASTIGMATISM In conclusion, for prevention of surgically-induced astigmatism, use a second-generation toric calculator and realize that SIA and PCA are dependent on the pre-existing amount of anterior astigmatism. Be aware that digital marking definitely will decrease the misalignment incidence, and analyse contributing factors for unexpected outcomes. If the toric IOL is misaligned, simulate where the rotation improves your outcome. If the amount of emmetropia and/or residual astigmatism is high, you can decide to rotate or exchange. If the deviation from target refraction is more than 1D, you may consider an IOL exchange. Alcon s online toric IOL calculator and the Barrett Toric Calculator implement the anticipated or estimated posterior capsule astigmatism (PCA) into their calculators Fortunately, the need for postoperative surgical correction is rare. The rate of realignment is at about 2%, and exchange as well as laser touch-up is only about 1%. These rates suggest that we have the tools and know-how to produce excellent results and satisfied patients. By H. Burkhard Dick, MD, PhD, FEBOS-CR: Director and Chairman, University Eye Hospital, Bochum, Germany. Phone: ; burkhard.dick@kk-bochum.de Financial Disclosure: Avedro, Zeiss. REFERENCES 1. Webers VSC, Bauer NJC, Visser N, et al. Image-guided system versus manual marking for toric intraocular lens alignment in cataract surgery. (2017) J Cataract Refract Surg (6): Woodcock MG, Lehmann R, Cionni RJ, et al. Intraoperative aberrometry versus standard preoperative biometry and a toric IOL calculator for bilateral toric IOL implantation with a femtosecond laser: One-month results. J Cataract Refract Surg. 2016;42(6):

8 Supplement December 2018/ January 2019 Supported by an unrestricted educational grant from