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Managing the Refractive “Surprise” After Toric IOL Placement Brad H Feldman, MD Derek DelMonte, MD Alan N Carlson, MD Authors have no financial interests Duke Eye Center Durham, NC Case Presentation 53 year-old man referred to the Duke Eye Center for 2nd opinion regarding residual astigmatism after undergoing cataract extraction with Toric IOL left eye Patient originally chose Toric IOL on surgeon recommendation to achieve astigmatic neutrality and decrease spectacle dependence Patient completely unsatisfied with outcome immediately after surgery Surgeon indicated there was nothing more he could offer the patient Prior Ocular History Note: patient underwent myopic LASIK OU in 1999 with monovision OS Pre-LASIK OS MRx: -6.75 +1.25 x 080 Post-LASIK OS MRx: -1.50 sphere Cataract noted in August 2007 with BCVA of 20/50 OS OS MRx: -3.00 –1.25 x 170 Prior History Continued Pre-Cataract Surgery Evaluation OS April 2008 (Still at Outside Facility) MRx: -2.75 -1.00 x 170 BCVA: 20/60 Orbscan Keratometry: 42.90/43.70 x 098 + 0.8D x 098 IOL Master K Values: 42.13/43.21 x 092 +1.1D x 092 Manual Keratometry 40.20/42.20 x 098 +2.0D x 098 US Pachymetry 479 microns IOL Calculations: (Outside Facility) Patient chose Toric “Premium” Lens Lens Power: IOL Master Derived SRK/T Clinical History Method Astigmatism Power: Alcon AcrySof Toric Calculator Used Based on Manual K’s As per instructions of online calculator Note difference in power of K axes between Orbscan, IOL Master, and Manual K’s (see prior slide) IOL Calculations Postoperative Course UCVA 20/60; plano –2.50 x 100 = 20/20 Examination Axis flipped despite properly achieving the intended axis Position: asymmetric fixation, superior loop in sulcus, inferior loop in bag, optic decentered superiorly and tilted Assessment: Pantoscopic tilt with optic decentration making astigmatic correction by the IOL overly effective, causing over correction and axis f