IN TORIC IOLS ADVANCEMENTS. Supplement to MARCH 25, 2015

Supplement to MARCH 25, 2015 ADVANCEMENTS IN TORIC IOLS This Ocular Surgery News supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

2 OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology Introduction Toric IOLs can provide a significant number of cataract patients with astigmatism the best opportunity to achieve overall visual acuity and lower spectacle dependence. Surgeons can have confidence in their ability to achieve successful outcomes with toric IOLs by applying the tools and techniques they already have in their practices. Doing so can help improve patient satisfaction and provide a large population of patients with the best overall visual acuity. Ocular Surgery News, through the sponsorship of Alcon Laboratories, Inc., interviewed surgeons who have experience with toric IOLs to discuss how they can be implemented into any surgeon s practice to help improve outcomes for patients with astigmatism. I thank the faculty for their participation and Alcon Laboratories, Inc., for sponsoring this supplement. For educational activities on this topic, visit Healio.com/Ophthalmology/Education-Lab. Richard L. Lindstrom, MD Chief Medical Editor Ocular Surgery News FACULTY Paul H. Ernest, MD, is a cataract and refractive specialist and founder of TLC Eyecare and Laser Centers in Jackson, Michigan. Dr. Ernest is a consultant, speaker and clinical investigator for Alcon Laboratories, Inc. Damien F. Goldberg, MD, is a partner at Wolstan & Goldberg Eye Associates, chief of ophthalmology surgery at the Torrance Memorial Medical Center in Torrance, Calif., and a clinical instructor at the UCLA Jules Stein Eye Institute. Dr. Goldberg is a consultant for Alcon Laboratories, Inc. Bonnie An Henderson, MD, is a clinical professor of ophthalmology at Tufts University School of Medicine and partner at the Ophthalmic Consultants of Boston in Boston. Dr. Henderson is a consultant for Alcon Laboratories, Inc. Edward J. Holland, MD, is the director of cornea services at the Cincinnati Eye Institute in Cincinnati. He is a professor at the University of Cincinnati Department of Ophthalmology and practices in Cincinnati and Northern Kentucky. Dr. Holland is a consultant, speaker and clinical investigator for Alcon Laboratories, Inc. Copyright 2015, SLACK Incorporated. All rights reserved. No part of this publication may be reproduced without written permission. The ideas and opinions expressed in this Ocular Surgery News supplement do not necessarily reflect those of the editor, the editorial board or the publisher, and in no way imply endorsement by the editor, the editorial board or the publisher.

OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology 3 Treating patients who need astigmatism correction Edward J. Holland, MD When considering the prevalence of astigmatism and cataract patient demographics, it becomes clear that a great number of patients can benefit from choosing a toric IOL. Surgeons can gain confidence with recommending toric IOLs Edward J. Holland, MD knowing that the patient is thoroughly aware of its benefits and knowing that they have chosen the right patients for the procedure. All surgeons, whether beginner or advanced, can improve patients overall visual acuity by choosing candidates who will benefit from astigmatism correction. Prevalence of astigmatism There are a significant number of cataract patients that can benefit from surgeons treating their corneal astigmatism. Warren Hill, MD, observed more than 6,000 cases in the cataract patient population and examined the prevalence of corneal astigmatism and found that approximately 52% of patients have 0.75 D of astigmatism or greater. 1 These patients fall into the category of patients who would benefit from a toric IOL. Most physicians believe that 0.75 D of astigmatism or greater is worth managing because of the effect on uncorrected visual acuity. Even correcting low levels of astigmatism will give more patients improved outcomes and lower spectacle dependence. Patient selection Toric IOL is a proven effective available method for managing astigmatism. 2 Astigmatism correction is something patients can understand and the effects of residual astigmatism should be explained to every patient with astigmatism. The patients can have an informed discussion and decide whether astigmatism management is worth their financial investment. A potential candidate for a toric IOL would have regular, symmetrical astigmatism (Figure 1). They should also have the desire to achieve excellent Figure 1: The topography map shows regular astigmatism. Source: Holland EJ distance vision with reduced dependence on glasses. Patients with irregular astigmatism, especially with marked irregularity, often will not respond well to any type of astigmatism management, including toric IOLs. In fact, sometimes trying to manage irregular astigmatism can cause a reduction in the quality of vision. Patient education It is essential that the staff understands the importance of correcting patients astigmatism as well. It is part of their duty to help in the patient education process, as astigmatism can be complicated for some patients to understand and must be explained to them thoroughly. Patients should first learn about astigmatism correction, including toric IOLs, when they are checked in during the initial technician interview. In addition, the technician performing the IOL calculations and topography has the opportunity to discuss it further. Finally, the decision can be made after the patient discusses the surgical options with the surgeon. If patients first learn about these complicated decisions at the end of the exam, they may be overwhelmed and do not fully comprehend all This Ocular Surgery News supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

4 OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology Figure 2: The estimated distribution of preoperative cylinder powers. Source: AcrySof IQ Toric IOL Directions for Use of the information. The more times patients experience the education process, the better the patient understands their choices. This includes pre-examination information. At my practice, we mail the preexamination information to the patient so they have time to read about it at their own pace prior to examination. This comprehensive educational process ensures that cataract patients with astigmatism will know the various surgical options. Cylinder power Surgeons must calculate the amount of astigmatism the patient has and then choose the appropriate toric IOL power. An increasing number of patients are able to benefit from toric IOLs because this technology provides a wide range of cylinder powers that can correct different levels of astigmatism (Figure 2). My toric IOL preference is the AcrySof IQ Toric IOL (Alcon Laboratories, Inc.), which can correct a variety of powers of astigmatism. The cylinder power ranges from 1.5 D to 6 D at the IOL plane, which corresponds to 1 D to 4 D at the corneal plane. Gaining confidence implanting toric IOLs In the AcrySof IQ Toric IOL study for U.S. Food and Drug Administration approval, 97% of the patients who received toric IOLs bilaterally were spectacle-free. 4 This demonstrated that there is a high success rate for distance vision after 6 months and improved patient satisfaction associated with astigmatism correction with toric IOLs. 4 Additionally, this trial showed excellent results with surgeons marking the eyes manually; the surgeons were not able use advanced technology to help mark and position the IOLs. Surgeons were also not permitted to change the location of the incision; they were required to operate at the 180 meridian. Surgeons now know that changing the location of the incision is another technique that can help enhance toric IOL results. Therefore, this study showed that indeed excellent outcomes were achieved in an

OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology 5 era prior to the advanced technology that is now available. Surgeons may be moving toward more advanced technologies like preoperative eye registration and intraoperative aberrometry to further improve outcomes. Advanced systems such as the Verion Image-Guided System (Alcon Laboratories, Inc.) and ORA intraoperative aberrometry system (WaveTec Vision) should help take surgeon accuracy to an even higher level. Surgeons should have confidence in the technology of a toric IOL and know that correcting astigmatism is not much more complicated than performing standard cataract surgery. It involves accurate preoperative testing, marking the axis of the eye, and then rotating the IOL into position toward the end of the procedure. Each of these steps is straightforward to perform for any cataract surgeon, and it does not take long to adjust to incorporating these steps into his or her cataract surgical technique. For surgeons just beginning their experience with toric IOLs, they should choose patients who do not have a complicated ocular history. Avoid patients who do not dilate well or who had intraoperative floppy iris syndrome, because it is difficult to see the markings on the IOL with a small pupil. A patient with relatively low and regular astigmatism who has a widely dilated pupil is a great candidate for inexperienced toric IOL surgeons. It is best for surgeons to address the more complicated cataract patients after they become more familiar with the technology. Surgeons who have little to no experience implanting toric IOLs can further improve their confidence by speaking with experienced colleagues, learning tips and techniques and attending astigmatism management courses. Conclusion In terms of surgical technique, implanting toric IOLs to correct astigmatism is not a great leap from the standard cataract surgery surgeons typically perform. It is within the realm of any cataract surgeon to achieve outstanding outcomes with toric IOLs, and there is a significant cataract patient population that can benefit. References 1. Provided courtesy of Dr. Warren Hill. URL: http://www. doctor-hill.com/iol-mail/astigmatism_chart.htm. Accessed October 20, 2014. 2. Holland E, Lane S, Horn JD, Ernest P, Arleo R, Miller KM. The AcrySof Toric intraocular lens in subjects with cataracts and corneal astigmatism: a randomized, subjectmasked, parallel-group, 1-year study. Ophthalmology. 2010;117(11):2104-11. 3. AcrySof IQ Toric IOL Directions for Use. 4. Lane SS, Ernest P, Miller KM, Hileman KS, Harris B, Waycaster CR. Comparison of clinical and patient reported outcomes with bilateral AcrySof Toric or spherical control intraocular lenses. J Refractive Surgery. 2009;25:899-901. This Ocular Surgery News supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

6 OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology Wound construction is key for implanting toric IOLs Paul H. Ernest, MD Implementing toric IOLs into cataract and refractive practices is a simple and effective process, even for surgeons who typically use basic IOLs. Surgeons can gain confidence in their ability to implant toric IOLs knowing that they simply Paul H. Ernest, MD need to obtain accurate preoperative measurements, implement an effective wound construction and know their surgically induced astigmatism (SIA). Doing so may lead to successful outcomes and satisfied patients, because toric IOLs can achieve quality distance vision as well as lower spectacle dependence. Patient selection All patients with 0.75 D of astigmatism and higher may benefit from toric IOLs. The exception is when a patient has a pre-existing disease entity that will negate the visual improvement of such treatment. Therefore, if a surgeon encounters a patient with macular degeneration or ischemic optic neuropathy, then attempting to correct low levels of astigmatism with a toric IOL is not going to be beneficial for that patient. I choose to correct patients astigmatism when the patient has a healthy enough eye and therefore will be able to appreciate the improvement in his or her vision, which is the result of correcting astigmatism with a toric IOL. Preoperative measurements and marks There are simple steps surgeons must take to begin implanting toric IOLs. The first key to successfully implanting a toric IOL is gathering accurate data. If surgeons do not obtain accurate preoperative measurements, then they will not achieve successful outcomes. In my practice, I take different sets of measurements to verify that my data are accurate. I often obtain both manual keratotomy and autokeratometry measurements at least six times per case. I also use biometry and take three sets of measurements with the IOLMaster (Carl Zeiss Meditec). I then use a Pentacam (OCULUS), which measures the anterior topography of the cornea and the total corneal power. Another data point surgeons must account for is the posterior corneal curvature. If I find that each of these data points closely align, then no further measurements are needed. If there is a great disparity between the data points, then I will have a different technician repeat the measurement process. If I find that the inconsistent measurements are due to surface issues such as dry eye, I sometimes ask patients to first manage their dry eye and return for surgery on a different day to repeat the measurements. After obtaining accurate measurements, surgeons must also mark the eye correctly to ensure that the IOL is placed in the proper position. I use markers and magnifying loops when the patient is sitting upright and at the edge of the surgical area. I mark the 3 o clock and 9 o clock positions. In the operating room, I use a 360 ring protractor that I hold in my left hand and a marker that I hold in my right hand to mark the axis on which I will place the IOL. Wound construction Wound construction is one of the most vital components of implanting a toric IOL, as it can help lower SIA, lower the standard deviation for surgeons SIA and lead to better outcomes. It is a common misconception that the only factor impacting SIA is wound size. However, two important components are also the geometry of the wound and its location. Wound location When surgeons began performing sutureless cataract surgery, I became involved with the corneal component not to prevent the use of sutures, but instead to prevent postoperative complications

OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology 7 like microhyphemas and filtering blebs. Surgeons made scleral tunnel incisions that would enter the eye at the iris root and, in doing so, they would experience microbleeds anterior to the suture. The wound would be satisfactory on postoperative day 1, but patients would report blurriness and small microhyphemas coming from the top of the wound on postoperative day 2. In order to reduce these complications, I changed the location of the wound by making my incisions further into the cornea. I use the internal pressure to create a seal so that blood does not escape around it, which eliminates the need for an external suture. This also prevents the iris from prolapsing into the internal part of the incision and causing blebs, which was another common complication surgeons experienced when originally constructing scleral tunnel incisions. A wound that is constructed more peripherally results in less flattening of the cornea 1 and a lower incidence of SIA. With the same arc length, astigmatic keratotomy causes more SIA than limbal relaxing incisions. Therefore, the more anterior the surgeon places an incision of the same wound size, the more astigmatism is being induced by the incision. Wound geometry I discovered the importance of wound geometry when Norman Jaffe, MD, first suggested that if surgeons want to prevent a significant amount of against-the-rule astigmatism and wound slide, then they need to have vertical supports on the edges of their incisions. The idea was not to create a large horizontal incision, but to create vertical support at both the 3 o clock and 9 o clock locations. As cataract and refractive surgical techniques evolved to phacoemulsification, I began creating a trapezoid-shaped wound to incorporate vertical incisions. I then experimented with the stability of square-shaped wounds (Figure 1). I found that a posterior limbal square wound, even with an endpoint pressure of up to 525 PSI, does not leak like a rectangular wound (Figure 2). I also observed refractive outcomes with a posterior limbal square wound measuring 4 mm wide and 4 mm long. I found that my SIA was 0.7 D, with minimal shifting of the axis of astigmatism at the preoperative level. 2 These findings became more significant when toric IOLs were introduced into cataract surgery. I implant toric IOLs using a posterior limbal square wound construction and, in a prospective study, 3 Figure 1: The process of constructing a posterior limbal square-shaped wound. Source: Ernest PH my SIA was 0.3 D with a standard deviation of ±0.2. The co-investigator used a clear corneal incision and had an SIA of 0.6 D with a standard deviation of ±0.4. Both the SIA and standard deviation were two times greater with a 2.4-mm clear corneal incision than with a 2.2-mm posterior limbal square wound. Then, in a retrospective study published in April 2011, 4 my SIA was 0.25 D with a standard deviation of ±0.14, which is similar to my SIA in our previous study. Therefore, it became clear that a posterior limbal square wound consistently helped lower my SIA and standard deviation. Standard deviation is a central factor because it shows how much a surgeon s outcomes vary. The less variation that exists between surgeons outcomes, the more confident they will become in terms of the amount of SIA they create. Richard Potvin, OD, Warren Hill, MD, and I also reviewed international data for 2.2-mm incisions and clear corneal incisions. We found that the average SIA for 2.2-mm clear corneal incisions was approximately 0.65 D with a standard deviation of ±0.45. 4 These data are similar to the data we calculated using a 4-mm by 4-mm scleral tunnel square wound 20 years prior. When you compare the 2.2-mm posterior limbal square wound on two separate occasions, it shows consistency in technique and outcomes regarding SIA and standard deviation. These are results surgeons can have confidence in when implanting toric IOLs. This Ocular Surgery News supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

8 OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology Figure 2: Graph shows that geometric square incisions give maximum resistance to deformation pressure independent of location. Rectangular incisions have significant lower resistance to deformation pressure and are dependent on intraocular pressure. Source: Ernest PH Also, when we went up two standard deviations in the international study, one of the surgeons induced 2 D of astigmatism. It is impossible for surgeons to treat 1 D or 0.75 D of astigmatism if the wound is creating 1 D or more of astigmatism. Dr. Hill has shown that about 52% of the U.S. population has 0.75 D or more of astigmatism. Of that 52%, 34.6% have between 0.75 D and 1.5 D of astigmatism. 5 This means that almost 70% of all toric IOLs would need to treat low powers of astigmatism. Ultimately, I was able to significantly lower my SIA by staying more peripheral when constructing the wound and maintaining a square geometry. Therefore, the location and geometry of the wound are more integral than its size. When surgeons successfully construct a posterior limbal square wound, their SIA and standard deviation will decrease. Maintaining a lower and more predictable SIA will help surgeons feel more confident in their outcomes when implanting toric IOLs. Centering the IOL It is important for surgeons to use an effective technique for centering a toric IOL to minimize its rotation postoperatively and intraoperatively. I have used the bimanual technique for removing cortical material for more than 20 years. This technique is widely used in Europe and I learned it from my colleagues while lecturing abroad in the early 1990s. With the bimanual technique, the surgeon uses separate tools in each hand rather than a single handpiece to remove cortical material. The bimanual technique has many advantages. First, it allows the surgeon to thoroughly remove all cortical material, whereas single handpieces cannot remove all of the cortical material under the incision. Second, the set of surgical instruments I use can go through a 1-mm paracentesis incision. The aspiration handpiece has a diamond-blasted tip that allows surgeons to thoroughly polish the posterior capsule. When I begin inserting the toric IOL, I will first remove all of the viscoelastic from behind and in front of the implant. Then, I use an irrigating cannula through one of the paracenteses and a blunttip hook through the second paracentesis incision so that the IOL is almost free-floating. As I rotate the IOL and line up the marks on the IOL with the marks on the cornea, the IOL remains stationary.

OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology 9 Conversely, when surgeons exit the eye using a single handpiece, there is a significant decrease in the anterior chamber depth, which causes the IOL to shift at least 5. Surgeons do not experience this shift when using the bimanual technique. Another advantage of the bimanual technique is that the surgeon is constantly irrigating while rotating the IOL. Therefore, any small pockets of viscoelastic that the surgeon did not remove prior to rotation are washed out of the fornices of the capsular bag. Overall, I have experienced great success in centering the IOL more precisely with this technique. It allows surgeons to feel confident that they removed all cortical material and set up the best foundation for a successful outcome. Conclusion Wound construction is the foundation of the toric IOL procedure. It is similar to building a house; a solid foundation is needed before assembling the walls. Once surgeons become confident in their wound construction, the remaining steps for implanting a toric IOL are straightforward. I encourage surgeons who want to learn more about implanting toric IOLs to observe my cases live or via video footage. Doing so can help eliminate any learning curve for surgeons with limited experience constructing a posterior limbal square wound or implanting toric IOLs in general. Surgeons can benefit if they are willing to take the time to not only watch the surgical process, but also discuss the process with me throughout each step. Once surgeons are accustomed to the proper technique and are conscious of their SIA, they will be able to achieve better outcomes and patient satisfaction when implanting toric IOLs. References 1. Menapace R, Skorpik C, Wedrich A. Evaluation of 150 consecutive cases of poly HEMA posterior chamber lenses implanted in the bag using a small-incision technique. J Cataract Refract Surg. 1990;16(5):567-577. 2. Ernest P. Corneal lip tunnel incision. J Cataract Refract Surg. 1994;20(2):154-157. 3. Alcon prospective study. Data on file. 4. Ernest P. Effects of preoperative corneal astigmatism orientation on results with a low-cylinder-power toric intraocular lens. J Cataract Refract Surg. 2011;37(4):727-732. 5. Provided courtesy of Dr. Warren Hill. URL: http://www. doctor-hill.com/iol-main/astigmatism_chart.htm. Accessed October 20, 2014. This Ocular Surgery News supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

10 OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology Simple techniques for implanting toric IOLs Bonnie An Henderson, MD Bonnie An Henderson, MD Although advancements in cataract and refractive surgery technology, like image-guided systems, can help streamline preoperative measurements and improve patient outcomes when implanting toric IOLs, they are not necessary for surgeons to achieve successful outcomes. Toric IOLs are a great starting point for surgeons looking to implement advanced technology IOLs into their practice because they can feel confident with implanting them using the technology they already have. Choosing an IOL When counseling patients with a significant amount of corneal astigmatism about IOL options, I offer a toric IOL as my recommendation rather than an option. Patients want to know which IOL will give them the best vision and, if they have astigmatism, then the best option is the toric IOL because it corrects both sphere and cylinder refractive errors. This will provide the patient with clearer distance vision and reduced spectacle dependence overall. Toric IOLs, such as the AcrySof IQ Toric IOL (Alcon Laboratories, Inc.), can correct astigmatism in patients with 0.75 D to >3.0 D of refractive error in the cylinder. It is also beneficial for patients who are not candidates for incisional surgery or patients who have opposing astigmatism in their lens vs. their cornea. In my experience, if a toric IOL is the appropriate choice for the patient and the surgeon strongly believes in the benefits of the toric IOL, then the conversation about IOL options is generally brief. Preoperative measurements and marks Implementing toric IOLs is as straightforward as implanting nontoric IOLs; the only additional steps involve marking the eye and aligning the IOL. Often, surgeons who have limited experience with refractive IOLs worry that toric IOLs are difficult to use, but the opposite is true. This is the type of advanced technology IOL that delivers great outcomes and yields satisfied patients without a steep learning curve. If surgeons are careful in collecting accurate preoperative measurements and marking the eye, then they can achieve successful outcomes. Preoperatively, it is important to accurately assess the corneal astigmatism. Therefore, in addition to using a noncontact biometer to measure the axial length and corneal keratometry readings, obtaining a corneal topography is useful. I obtain additional measurements with both an automated keratometer and a manual keratometer to confirm that the corneal measurements are consistent and, therefore, accurate. No additional surgical training is needed to do so; any competent cataract surgeon can make the correct orientation marks required to successfully implant a toric IOL. Aligning the toric IOL is simple to learn. Watching live surgery or video footage of experienced surgeons implanting toric IOLs is sufficient for most surgeons to feel comfortable with the procedure. I start out by making the reference marks in the operating room preoperatively with the patient seated upright. I ask the patient to look straight ahead as I approach the eye from the side. I use a handheld marking instrument that has been dotted with ink to mark the cornea at the 3, 6 and 9 o clock positions. By marking the patient s eye while upright and then marking the steep axis while supine, surgeons can set the foundation to significantly decrease cyclorotation errors and astigmatism and improve uncorrected vision without using an advanced image-guided system. Once the patient is prepped and draped for surgery and the lid speculum is placed, I use the bimanual technique with an open-degree gauge instrument, which is centered around the limbus, and a separate instrument to mark the steep axis.

OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology 11 Surgeons can successfully implant toric IOLs simply using ink markers, although having advanced systems such as the Verion Image Guided System or ORA Aberrometer (WaveTec Vision) could be helpful with streamlining the toric IOL process. Mastering the preoperative process by obtaining accurate measurements, thereby marking the cornea properly as a result, ensures proper alignment and optimizes visual results. Implanting the toric IOL I always construct the clear corneal incision on the steep axis, regardless of whether I am using a toric IOL or a nontoric IOL. Fortunately, the location of the incision and surgically induced astigmatism (SIA) are considered with the online toric calculator, so these variables are incorporated into the final toric power determination. If the surgeon is using a femtosecond laser to create the incisions, then the incisions are created automatically. If the surgeon is not using a femtosecond laser, then it is important to pay close attention to the architecture of the incision. The dimensions and depth should be square and long enough to create a self-sealing wound. This will prevent wound gape and possible rotation of the toric IOL in the early postoperative period. I place the IOL using the Monarch (Alcon Laboratories, Inc.) IOL delivery system, ensuring that both haptics are completely in the capsular bag. I then use a lens manipulator, such as a Y-hook, to dial the IOL and align the marks on the optic with the steep axis marks on the cornea (Figure). Before I began using intraoperative aberrometry, I would place the IOL one clock hour counterclockwise to the steep axis in case the IOL rotates during removal of the viscoelastic solution. I then follow a three-step method to remove the ophthalmic viscosurgical device (OVD). First, I place the automated irrigation and aspiration port on top and in the center of the optic of the IOL to avoid disrupting the IOL s position, rather than placing the I&A port under the IOL. With low aspiration settings, I gently remove the large bolus of cohesive OVD that is in the anterior chamber and on Figure: The surgeon aligns an AcrySof Toric IOL. Source: Alcon Laboratories, Inc. top of the optic. Second, I gently tap the I&A on the right side of the optic and gently press posteriorly on the optic. This will remove the OVD from under the right side of the optic. Often, this can rotate the IOL slightly counterclockwise as the OVD evacuates from under the right side of the optic. Third, I gently tap the I&A on the left side of the optic, gently pressing posteriorly to remove the OVD from under the left side of the IOL. This action slightly rotates the IOL in the clockwise direction to correct the slight counterclockwise movement in step 2. In my experience with removing the OVD with this three-step method, it is unusual for the IOL to rotate away from the intended location. This method ensures proper alignment of the toric IOL and, therefore, improves the probability of a successful outcome. Conclusion Ideally, all surgeons would have access to imageguided systems and intraoperative aberrometry to streamline the process of implanting toric IOLs. However, surgeons do not need to wait to purchase these systems to begin successfully implanting toric IOLs. Surgeons have been implanting toric IOLs for more than 15 years and have been achieving excellent patient satisfaction without advanced systems. Once surgeons embrace the simple technique required to implant toric IOLs, they will be better able to achieve excellent outcomes and patient satisfaction as well. This Ocular Surgery News supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

12 OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology Toric Pro app engages surgeons with multimedia tools Damien F. Goldberg, MD The high incidence of preoperative corneal astigmatism among cataract surgery patients has led to a significant patient need for toric IOL procedures. The Toric Pro app, for the Apple ipad, can be downloaded for free Damien F. Goldberg, MD through the Apple itunes store (Figure 1). It provides an abundance of resources categorized into different sections that can enlighten and assist surgeons with the most effective tips and techniques for successfully implanting toric IOLs. With the Toric Pro app, all types of surgeons, from the inexperienced to experienced, are able to access detailed information on the procedure quickly and easily in a multimedia platform. The Toric Pro app is a free, user-friendly, highly interactive app that is designed to inform surgeons on key information needed to begin successfully implanting toric IOLs as well as confidently recommend them to patients who will benefit from correcting corneal astigmatism at the time of surgery. Toric IOL procedure There are several sections within the app that surgeons can navigate depending on the type of information they are seeking. Within the app, a navigation feature includes a section on the toric IOL procedure. This section is divided into four informative portions: equipment needed to acquire the data to successfully plan the procedure; information needed preoperatively, such as how to select the appropriate patient for a toric IOL and includes instructive videos such as Bonnie An Henderson, MD, discussing how to precisely mark the eye (Figure 2); information required intraoperatively, such as how to confirm proper toric IOL alignment (Figure 3); and lastly, information needed postoperatively. One feature in this section that is especially useful for beginners is the preoperative marker simulation. It is sometimes challenging to mark the eye properly with a pen and the toric marker in the preoperative area. This simulation allows surgeons to practice marking the eye and it gives feedback by judging how well the surgeon has marked the eye. This is a fun, interactive feature that helps surgeons to get comfortable with preoperative marks. Tools and techniques In another section, the app offers tools and techniques for better communication with patients in order to make confident recommendations and ultimately achieve patient satisfaction (Figure 4). This section includes a tab on tips for patient consultation, with videos featuring expert recommendations on how to interact with patients and discuss the toric IOL procedure with patients. This is beneficial for beginners, as it provides videos of surgeons such as Stephen Scoper, MD, and Bret Fisher, MD, speaking about the basics of the surgery and the technology. They also discuss how they first adopted toric IOLs into their practices. For more experienced surgeons, the videos provide nuanced information about more difficult cases as well as strategies for talking to patients and teaching them about the technology. It is an opportunity for experienced surgeons to re-examine the way they manage astigmatism and cataract surgery. Other tabs in this section include an introduction to biometry with in-depth detail on equipment, measurements and calculations for successful implantation; access to the Toric IOL calculator to help determine the right toric IOL power for each patient; access to the surgically induced astigmatism data export tool; and an interactive simulation tool (Figure 5), where users are able to practice preoperative reference marking

OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology 13 Figure 1: The Toric Pro app home screen. Source: Toric Pro app, Alcon Laboratories, Inc. Figure 2: Users who are inexperienced with toric IOLs can watch videos of surgeons, such as Bonnie An Henderson, MD, showing surgeons how to mark the eye. Source: Toric Pro app, Alcon Laboratories, Inc. Figure 3: The Toric Pro app home screen. Source: Toric Pro app, Alcon Laboratories, Inc. Figure 4: The tools and techniques section of the Toric Pro app. Source: Toric Pro app, Alcon Laboratories, Inc. Figure 5: (A) The simulation prompts the user to hold the ipad in an upright position to simulate a patient sitting in an upright position, and then the user can press the show the beam button to simulate bringing down the slit lamp beam. (B) Once the user presses the button, he or she can put two fingers on the screen to control the virtual marker and drag it to the desired location. Source: Toric Pro app, Alcon Laboratories, Inc. This Ocular Surgery News supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

14 OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology clicking the bookmark icon at the top right of the screen (Figure 6). This allows the user to quickly and easily refer back to information that they find particularly useful or want more detailed information about. Users can also email information to themselves or a colleague by clicking on the mail icon located next to the bookmark icon at the top of the screen in each tab. These tools make it easy for surgeons to access and share important information that is helpful for improving their techniques. Figure 6: The Toric Pro app allows users to bookmark and email specific pages of the app that interest them. Source: Toric Pro app, Alcon Laboratories, Inc. and intraoperative axis marking of the eye with five patient cases. Other key features At the bottom of the navigation feature, there are tabs with detailed information on the toric IOL product, a place for users to offer feedback and suggestion on the app, as well as a references and bookmark tab. The bookmark feature is available in each section and allows users to easily refer back to a section or tab once they have reviewed the information by Conclusion The Toric Pro app is a fantastic resource for surgeons, providing all of the reference material needed for the toric IOL procedure in one multimedia platform. It allows surgeons of all experience levels to hone their skills while tracking their progress along the way. While print journals and books are informative resources for surgeons, the app allows surgeons to quickly access a wealth of information in an engaging digital format that stores extensive information in one place. It gives surgeons the opportunity to watch experts perform surgery, watch them talk to patients, and observe how they have that conversation, rather than read about it. Surgeons can use this stimulating tool to help improve various aspects of their toric IOL techniques so they are confident in their outcomes and patient satisfaction. This Ocular Surgery News supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.

OCULAR SURGERY NEWS US EDITION MARCH 25, 2015 Healio.com/Ophthalmology 15 AcrySof IQ Toric Intraocular Lenses Important Product Information Caution: Federal (USA) law restricts this device to the sale by or on the order of a physician. Indications: The AcrySof IQ Toric posterior chamber intraocular lenses are intended for primary implantation in the capsular bag of the eye for visual correction of aphakia and pre-existing corneal astigmatism secondary to removal of a cataractous lens in adult patients with or without presbyopia, who desire improved uncorrected distance vision, reduction of residual refractive cylinder and increased spectacle independence for distance vision. Warning/precaution: Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient with any of the conditions described in the Directions for Use labeling. Toric IOLs should not be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is planned. Rotation can reduce astigmatic correction; if necessary lens repositioning should occur as early as possible prior to lens encapsulation. All viscoelastics should be removed from both the anterior and posterior sides of the lens; residual viscoelastics may allow the lens to rotate. Optical theory suggest, that, high astigmatic patients (ie, > 2.5 D) may experience spatial distortions. Possible toric IOL related factors may include residual cylindrical error or axis misalignments. Prior to surgery, physicians should provide prospective patients with a copy of the Patient Information Brochure available from Alcon for this product informing them of possible risks and benefits associated with the AcrySof IQ Toric Cylinder Power IOLs. Studies have shown that color vision discrimination is not adversely affected in individuals with the AcrySof Natural IOL and normal color vision. The effect on vision of the AcrySof Natural IOL in subjects with hereditary color vision defects and acquired color vision defects secondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve diseases) has not been studied. Do not resterilize; do not store over 45 C; use only sterile irrigating solutions such as BSS or BSS PLUS Sterile Intraocular Irrigating Solutions. Attention: Reference the Directions for Use labeling for a complete listing of indications, warnings and precautions VERION Image Guided System ECP FACING Brief Statement VERION Reference Unit and VERION Digital Marker Caution: Federal (USA) law restricts this device to sale by, or on the order of, a physician. Intended uses: The VERION Reference Unit is a preoperative measurement device that captures and utilizes a high-resolution reference image of a patient s eye. In addition, the VERION Reference Unit provides pre-operative surgical planning functions to assist the surgeon with planning cataract surgical procedures. The VERION Reference Unit also supports the export of the reference image, preoperative measurement data, and surgical plans for use with the VERION Digital Marker and other compatible devices through the use of a USB memory stick. The VERION Digital Marker links to compatible surgical microscopes to display concurrently the reference and microscope images, allowing the surgeon to account for lateral and rotational eye movements. In addition, details from the VERION Reference Unit surgical plan can be overlaid on a computer screen or the physician s microscope view. Contraindications: The following conditions may affect the accuracy of surgical plans prepared with the VERION Reference Unit: a pseudophakic eye, eye fixation problems, a non-intact cornea, or an irregular cornea. In addition, patients should refrain from wearing contact lenses during the reference measurement as this may interfere with the accuracy of the measurements. The following conditions may affect the proper functioning of the VERION Digital Marker: changes in a patient s eye between pre-operative measurement and surgery, an irregular elliptic limbus (e.g., due to eye fixation during surgery, and bleeding or bloated conjunctiva due to anesthesia). In addition, the use of eye drops that constrict sclera vessels before or during surgery should be avoided. Warnings: Only properly trained personnel should operate the VERION Reference Unit and VERION Digital Marker. Use only the provided medical power supplies and data communication cable. Power supplies for the VERION Reference Unit and the VERION Digital Marker must be uninterruptible. Do not use these devices in combination with an extension cord. Do not cover any of the component devices while turned on. The VERION Reference Unit uses infrared light. Unless necessary, medical personnel and patients should avoid direct eye exposure to the emitted or reflected beam. Precautions: To ensure the accuracy of VERION Reference Unit measurements, device calibration and the reference measurement should be conducted in dimmed ambient light conditions. Only use the VERION Digital Marker in conjunction with compatible surgical microscopes. Attention: Refer to the user manuals for the VERION Reference Unit and the VERION Digital Marker for a complete description of proper use and maintenance of these devices, as well as a complete list of contraindications, warnings and precautions. ORA System Important Product Information Caution: Federal (USA) law restricts this device to sale by, or on the order of, a physician. Intended use: The ORA System uses wavefront aberrometry data in the measurement and analysis of the refractive power of the eye (i.e. sphere, cylinder, and axis measurements) to support cataract surgical procedures. Contraindications: The ORA System is contraindicated for patients:. who have progressive retinal pathology such as diabetic retinopathy, macular degeneration, or any other pathology that the physician deems would interfere with patient fixation; who have corneal pathology such as Fuchs, EBMD, keratoconus, advanced pterygium impairing the cornea, or any other pathology that the physician deems would interfere with the measurement process; whose preoperative regimen includes residual viscous substances left on the corneal surface such as lidocaine gel or viscoelastics; with visually significant media opacity (such as prominent floaters or asteroid hyalosis) what will either limit or prohibit the measurement process; or who have received retro or peribulbar block or any other treatment that impairs their ability to visualize the fixation light. In addition, utilization of iris hooks during an ORA System image capture is contraindicated, because the use of iris hooks will yield inaccurate measurements. Warnings and precautions: Significant central corneal irregularities resulting in higher order aberrations might yield inaccurate refractive measurements. Post refractive keratectomy eyes might yield inaccurate refractive measurement. The safety and effectiveness of using the data from the ORA System have not been established for determining treatments involving higher order aberrations of the eye such as coma and spherical aberrations. The ORA System is intended for use by qualified health personnel only. Improper use of this device may result in exposure to dangerous voltage or hazardous laser-like radiation exposure. Do not operate the ORA System in the presence of flammable anesthetics or volatile solvents such as alcohol or benzene, or in locations that present an explosion hazard. Attention: Refer to the ORA System Operator s Manual for a complete description of proper use and maintenance of the ORA System, as well as a complete list of contraindications, warnings and precautions.

2015 Novartis 3/15 TOR14065JS Delivering the best in health care information and education worldwide 6900 Grove Road, Thorofare, NJ 08086 USA phone: 856-848-1000 www.healio.com Healio.com/Ophthalmology This Ocular Surgery News supplement is produced by SLACK Incorporated and sponsored by Alcon Laboratories, Inc.