Indian Journal of Ophthalmology

: 2020  |  Volume : 68  |  Issue : 4  |  Page : 587--588

Commentary: Toric intraocular lens alignment: Going markerless

Mahipal S Sachdev 
 Centre for Sight Group of Eye Hospitals, New Delhi, India

Correspondence Address:
Dr. Mahipal S Sachdev
Chairman and Medical Director, Centre for Sight Group of Eye Hospitals, B-5/24, Safdarjung Enclave, New Delhi - 110 029

How to cite this article:
Sachdev MS. Commentary: Toric intraocular lens alignment: Going markerless.Indian J Ophthalmol 2020;68:587-588

How to cite this URL:
Sachdev MS. Commentary: Toric intraocular lens alignment: Going markerless. Indian J Ophthalmol [serial online] 2020 [cited 2023 May 30 ];68:587-588
Available from:

Full Text

The incidence of pre-existing corneal astigmatism in patients undergoing cataract extraction is >1 diopter (D) in approximately 30% of the eyes, wherein one-thirds have an astigmatism exceeding 2D.[1] Residual astigmatism results in suboptimal visual outcomes with need for spectacles postoperatively. Thus, there is an increasing need to address the astigmatism during cataract surgery.

Placement of corneal incisions on the steep keratometry axis, paired opposite clear corneal incisions, limbal relaxing incisions, or arcuate keratotomies are easy to perform for lower degrees of astigmatism up to 1.5D.[2] However, outcomes are less predictable and prone to regression over time. Toric intraocular lenses (IOLs) provide greater precision in comparison to corneal-based approach for astigmatism management.[3]

To achieve optimum visual outcome with toric IOLs, accurate alignment of the implant is the most crucial step, as a 1 degree malrotation results in a 3.3% loss of astigmatic correction with a complete nullification following 30 degrees' rotation.[4] Improper alignment of the IOL may be due to intraoperative misalignment or postoperative rotation.

Different methods are used to accurately align the toric IOLs intraoperatively (manual methods, iris fingerprinting techniques, image guided systems, and intraoperative aberrometry-based methods). Traditional manual marking methods, although cost effective, are less precise and can fade or smudge by the time the patient is on the operating table. Marker-less systems have now been introduced to eliminate potential sources of human error and subjective miscalculations. Newer technologies include the Callisto Eye with Z-Align (Carl Zeiss Meditec AG), Verion Digital Marker (Alcon Laboratories), iTrace with Zaldivar Toric Caliper (Tracey Technologies), and TrueGuide software (TrueVision 3D Surgical, Inc).

Callisto eye with Z-Align is an eye-tracking technology that overlays a previously captured image over the live microscope image. Once Callisto eye has taken the images and relayed them to the Z Align module, the surgeon looking at the touchscreen, can use the images and visualize three parallel lines that represent the target meridian to which the toric lens is aligned.

The Verion Reference Unit is a modified keratometer that takes corneal power measurements and captures high-resolution images of the eye including iris landmarks, limbus, and scleral blood vessels. These serve as reference markers and any change in the position intraoperative determines the extent of cyclotorsion. Intraoperative overlay additionally provides guidance for placement of corneal incisions, capsulorhexis construction, and IOL positioning.

The iTrace system provides auto-refraction, corneal topography, ray tracing aberrometry, pupillometry, and auto-keratometry. It displays the corneal topography data and a reticule superimposed on a photograph of the patient's cornea and limbus. The Zaldivar Toric Caliper tool can be used to calculate the angle difference in degrees between the steep meridian (intended toric IOL axis) and iris or limbal landmarks. This information is printed and taken to the operating room for intraoperative guidance during toric IOL alignment.

The True Guide software uses a preoperative photograph and intraoperative registration to enable digital intraoperative surgical guidance and alignment of toric IOLs, without the need for preoperative ocular marking.

Intraoperative aberrometry devices such as ORA with VerifEye+ (Alcon WaveTec) and Holos IntraOp (Clarity Medical Systems) provide real-time lens power, sphere, cylinder, axis recommendations, and data validation. This is particularly useful in eyes wherein the IOL power calculation is challenging such as paediatric eyes and post keratoablative procedures.

Sharma et al. demonstrate the use of the Schiempflug imaging system goniometer as an added tool to check the slit-lamp reference marking, thereby improving the refractive outcome with toric IOLs.[5]

The advantage of digital-guided systems is that the projected meridians are objective and do not require subjective estimation. Also, eliminating the need to take the patient to the slit lamp or use a variety of ink marking instruments improves workflow. A disadvantage is the possibility that registration can fail either at the beginning of the procedure or during the operation.[6] Conjunctival chemosis, ballooning, and bleeding may interfere with intraoperative registration. Registration may also not be possible in extremely uncooperative patients or difficult orbital anatomy including extremely deep-set eyes or narrow palpebral apertures.

Postoperative IOL rotation may be observed as early as 1 hour after surgery, and a majority of rotations occur within the initial 10 days. Retained ophthalmic viscoelastic device causes early IOL rotation, whereas the IOL architecture and design cause late rotation of IOL. Other factors that can compromise rotational stability are cases with zonular weakness, large diameter capsular bags, and reduced equatorial friction in high myopes.[7] Maximum rotational stability is seen with hydrophobic acrylic material due to stronger capsular bag IOL adhesions secondary to increased fibronectin.[8]

Future technological advancements may further refine the outcomes of toric IOL, with more precise visual results and enhanced IOL stability.


1Ferrer-Blasco T, Montés-Micó R, Peixoto-de-Matos SC, González-Méijome JM, Cerviño A. Prevalence of corneal astigmatism before cataract surgery. J Cataract Refract Surg 2009;35:70-5.
2Nanavaty MA, Bedi KK, Ali S, Holmes M, Rajak S. Toric intraocular lenses versus peripheral corneal relaxing incisions for astigmatism between 0.75 and 2.5 diopters during cataract surgery. Am J Ophthalmol 2017;180:165-77.
3Miyake T, Kamiya K, Amano R, Iida Y, Tsunehiro S, Shimizu K. Long-term clinical outcomes of toric intraocular lens implantation in cataract cases with preexisting astigmatism. J Cataract Refract Surg 2014;40:1654-60.
4Till JS, Yoder PR Jr., Wilcox TK, Spielman JL. Toric intraocular lens implantation: 100 consecutive cases. J Cataract Refract Surg 2002;28:295-301.
5Sharma A, Batra A. Evaluation of Scheimpflug imaging system as an added tool in improving the accuracy of reference marking (as compared to the slit lamp marking system) for toric intraocular lens implantation. Indian J Ophthalmol 2020;68:583-7.
6Hura AS, Osher RH. Comparing the Zeiss Callisto eye and the Alcon Verion image guided system toric lens alignment technologies. J Refract Surg 2017;33:482.
7Xiangjia Zhu, Wenwen He, Keke Zhang, Yi Lu. Factors influencing 1-year rotational stability of acrysof toric intraocular lenses. Br J Ophthalmol 2016;100:263-8.
8Ong M, Wang L, Karakelle M. Fibronectin adhesive properties of various intraocular lens materials. Invest Ophthalmol Vis Sci 2013;54:819.