The toric IOL with which I am most experienced is the T-Flex (Rayner Intraocular Lenses Ltd., Hove, United Kingdom; Figure 1). I like this IOL because of its handling characteristics, ease of injection, exceptional centration, and 360° enhanced square-edge design. The Rayner toric IOL calculator and ordering system, called Raytrace, is available online. After login, a data-entry page leads to an options page, where one can decide what option to order. Delivery times are generally short in the United Kingdom (typically overnight) and a back-up IOL is usually available on sale or return.
The surgery is in general straightforward, although one needs to orient the IOL on-meridian, as shown on the order sheet that accompanies every IOL. There are many devices for marking the meridian preoperatively, but I have found it adequate to mark the 90° and 180° meridia with a surgical marker pen immediately preoperatively. However, this has to be done (1) before anesthetic is applied, (2) before any sedation, (3) with the patient vertical (ie, not on his back looking at the ceiling), and (4) with the patient fixating on a distant target.
Implanting the Rayner T-Flex IOL uses the same injector as standard Rayner IOLs. When finalizing the IOL position, I leave the IOL slightly under-rotated with regard to the correct meridian, carefully remove all of the ophthalmic viscosurgical device (OVD) from the capsular bag, and then gently rotate the IOL the final few degrees into the correct position. Some surgeons have reported apparent postoperative rotation, probably due to retained OVD.
Finally, even in countries where first-day postop visits have now been abandoned (such as the United Kingdom), these patients should be reviewed on day 1 and the orientation of the IOL checked.
Charles Claoué, MA (Cantab), BChir, MD, DO, FRCS, FRCOphth, FEBO, MAE, is a Consultant Ophthalmic Surgeon and Honorary Lecturer in Ophthalmology at the Queen's University Hospital, London. Dr. Claoué states that he has received travel grants from Alcon Laboratories, Inc., Abbott Medical Optics Inc., and Medennium, and was previously a paid consultant to Bausch & Lomb. He is currently a paid consultant to Rayner Intraocular Lenses Ltd. He may be reached at e-mail: firstname.lastname@example.org.