Toric alcon calculator

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I use this calculator because it is the only toric calculator that has prospective published data proving that it is effective. If you used one of those calculators and also added the Baylor or the GNAK, in principle you would over-adjust for the posterior cornea because you would adjust for it twice.

Now, you can simply use one of those calculators mentioned. What you will find is, when an adjustment is made for the posterior cornea in the calculation of the toric IOL, there is an adjustment made to the power of the cylinder that you are putting in, and you will also notice an adjustment to the axis of implantation.

This means that when you take the posterior cornea into consideration as well as the anterior cornea, you are playing with the total corneal power.

It is simple vector mathematics that makes sense. Notably, the steep axis of the total cornea may be quite different from what you have measured on the anterior surface. This will have the biggest impact for a toric lens to treat low-powered oblique astigmatism. A recent study revealed that when you are dealing with an eye with oblique anterior corneal astigmatism, there is no need to adjust the axis of toric IOL implantation from the steep axis of the anterior cornea.

It can be quite disconcerting to go against the recommendation of online calculators, so I recommend starting with simple with-the-rule or against-the-rule eyes. In some instances, toric IOL calculators can provide various powers with different options. For example, one cylinder power option will suggest leaving the eye with 0. Essentially, you underpower the treatment.

This could be reasonable, or you could put in the next cylinder magnitude step up and flip the axis of astigmatism but leave that person with only 0. With glasses, we know that you should not flip the axis, but inside the eye, minimal residual astigmatism regardless of axis is beneficial in terms of visual quality. My advice is to aim for the smallest predicted residual astigmatic error and not to worry at all about flipping the axis of astigmatism.

The other consideration that often arises with targeting minimal residual astigmatism is whether patients should be left with some with-the-rule astigmatism so that they are happy as they age and their cornea changes shape. We know that at a population level, there is more against-the-rule corneal astigmatism in older age and more with-the-rule astigmatism in younger patients.

However, we cannot currently predict at an individual level whether an eye will change with time. I instead prefer to aim for the best possible unaided visual acuity initially and to deal with any change in the future. This comes down to personal preference. The idea for this comes from our knowledge that if a toric IOL is not aligned correctly to the steep corneal axis, then it has less optical effect to neutralise astigmatism at that axis.

However, the cylinder power does not magically disappear; it is still inside the eye. The best optical result you can achieve is when the cylinder of the toric IOL is aligned with the steep axis of the cornea.

Rotating it away from this location to depower it and precisely treat the astigmatism on the steep axis will only add residual astigmatism at another axis. This can be proven mathematically and graphically but the technique is still commonly discussed.

My advice is to calculate a toric IOL with the best cylinder power to treat the astigmatism in the eye and to aim to leave it on that steep corneal axis. It may slightly under- or over-treat the corneal astigmatism but it will ultimately give the best achievable refractive outcome with that IOL.

When inputting your data and plans into toric calculators, you will be asked for a surgically induced astigmatism SIA prediction. What you are basically doing is telling the calculator, when it is doing the vector maths and taking into consideration the anterior and posterior corneal astigmatism as well as that of the toric IOL, to add a vector of a certain magnitude acting at the axis of your planned incision. This should seem straightforward enough.

If you were to plot the SIA figures from multiple eyes onto a double-angle vector diagram or a centroid plot, you would obtain roughly 0. Many surgeons would say that is what you should put into the calculator, a 0.

This estimate does work but the problem is that we do not know where that surgically induced astigmatism is going to act in an individual eye. When we make a cut into a cornea, we simply do not know enough about corneal biomechanics to be able to predict how it will respond.

If only life were that simple! Certainly, this is the case for very large incisions, however, for smaller phaco incisions the orientation of the average flattening effect is extremely unpredictable. The centroid value is reasonable since, when you add the vectors of all the SIA values and average them, a 0. I realise that the difference between zero and 0. So, we have chosen a patient, taken biometry and calculated a toric IOL. The next step is to perform surgery.

In the third and final part of this series on getting started with toric IOLs I will discuss what I consider the key points of the surgical and postoperative periods to achieving successful outcomes and how to deal with problems. Published on: November 25, Dr Ben LaHood. Hydrophilic vs hydrophobic One of the key considerations is hydrophilic versus hydrophobic designs.

Axis adjustment What you will find is, when an adjustment is made for the posterior cornea in the calculation of the toric IOL, there is an adjustment made to the power of the cylinder that you are putting in, and you will also notice an adjustment to the axis of implantation.

Age considerations The other consideration that often arises with targeting minimal residual astigmatism is whether patients should be left with some with-the-rule astigmatism so that they are happy as they age and their cornea changes shape. Surgically induced astigmatism When inputting your data and plans into toric calculators, you will be asked for a surgically induced astigmatism SIA prediction.

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