Reverse Optic Capture to Stabilize a Toric Intraocular Lens
A 38-year-old woman, with no known cause for premature cataract apart from a family history of early cataract surgery, underwent cataract extraction in the left eye with implantation of a 1-piece acrylic toric IOL (SN6AT4; Alcon Laboratories, Inc.), with a power of +17 D sphere, 2.25 D (IOL plane), and 1.55 D (corneal plane) toric power. She had undergone cataract surgery with spherical foldable IOL implantation in the right eye 1 year before. Apart from an immature cataract in the left eye, the rest of the ocular examination was unremarkable.\nThe preoperative manifest refraction in the left eye was −0.75 −1.25 × 148°. Her preoperative axial length was 24.8 mm and her keratometry values were 42.99 @ 158° and 44.76 @ 68° (1.77 D cyl) as measured by the IOL Master. According to the Acrysof IQ IOL calculator (), the recommended axis of implantation was 64° using a superior incision with zero-induced cylinder.\nPreoperatively, the horizontal axis was marked by the surgeon using a fine-tipped sterile marking pen under topical anesthesia (Surgeons marking pen 115; Medical Action Industries, Inc.). The marking was made at the 3 and 9 o’ clock positions on the limbus with the patient seated at the slit lamp, ensuring the 2 eyes were level with no head tilt. The 64° axis was marked under the operating microscope using the Cionni Reverse Bevel Mendez Fixation Ring (Mastel Precision). She underwent phacoemulsification under topical anesthesia using the chop divide and conquer technique through a superior conjunctiva sparing scleral tunnel incision []. A toric IOL was implanted with the axis aligned to 64°. After all the viscoelastic was aspirated the anterior chamber was reformed with balanced salt solution (BSS; Alcon Laboratories, Inc.), the wound and the paracentesis were hydrated, and the intraocular pressure brought to normal. The IOL was confirmed again to be at the 64° axis.\nOn the first postoperative day, the patient's uncorrected visual acuity was 20/70 with a manifest refraction of +0.75 −2.25 × 143°. The axis of IOL rotation was measured with pupils dilated using the slit lamp method with a thin slit beam aligned along the axis markings of the IOL, and also with an internal OPD map on the OPD-Scan refractive power/corneal analyzer system (Nidek). The axis of the IOL had rotated to 135°. The dilated OPD-Scan refraction showed an internal astigmatism of −1.41 at 120°. (fig. ). Because of the large degree of IOL rotation and refractive error, it was decided to not wait for capsule contraction before surgically repositioning the IOL. The repositioning procedure was done on the fifth day postoperatively.