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Cataract Surgery | Jul/Aug 2009

Pearls for Pediatric Use of the Toric IOL

I have been using the AcrySof Toric IOL (Alcon Laboratories, Inc., Fort Worth, Texas) for more than 1 year. At first, I was reluctant to adopt toric IOLs. I thought I would use them only in patients with higher degrees of astigmatism. But as I saw the results, I began using them in patients with astigmatism of 1.00 D or greater, especially with against-the-rule astigmatism.

It is striking to me that this lens works well even in complicated cases, such as patients who have previously undergone radial keratotomy or even in patients with irregular astigmatism and cataract after keratorefractive or other corneal surgery.

I did my residency in pediatric ophthalmology, and of the 3,000 cataract surgeries I perform per year, perhaps 100 to 200 are pediatric cataract. I find the toric IOL to be of value in this pediatric cataract population, in which approximately 90% of patients have concomitant astigmatism. Amblyopia treatment for young patients is easier postoperatively if we correct their astigmatism with the IOL; they do not need complicated optics in their contact lenses or glasses for the treatment of amblyopia. We began using toric IOLs in pediatric cataract patients approximately 1 year ago, but results of amblyopia treatment in these patients, so far, is much better than in patients with spherical lenses. It is important in pediatric patients to mark the principal axes of the eye clearly before surgery because after general anesthesia the eye is not in its normal position. I use corneal markers on the limbus or other prominent marking points to mark the principal axes with the child in a seated position before surgery. Marking the principal axes well preoperatively is the greatest pearl for using toric lenses successfully in children.

There is no major change of cataract surgical technique for toric IOLs. We use the AcrySof Toric Calculator (www.acrysoftoriccalculator.com) to select the IOL. Once the patient is on the table, the axis of orientation of the IOL is marked with a corneal marker. I perform phacoemulsification through a 1.8-mm temporal limbal clear corneal incision, which induces minimal astigmatism.

Kirill Pershin, MD, is an ophthalmic surgeon at the Excimer Clinic in Moscow, Russia. Dr. Pershin states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +7 495 912 14 22; e-mail: kpershin@mail.ru.