Michael J Kutryb, MD  

Specialties: Ophthalmology, Cataract Surgery, glaucoma

Interests: Ophthalmology
Kutryb Eye Institute - Titusville
Titusville, FL
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Toric IOLs for Cataract Surgery

Jan 28, 2011 - 22 comments

Of all the new "Premium IOLs" for cataract surgery it has been the Acrysoft Toric IOL that has been the most widely accepted and praised by cataract surgeons like myself.  I personally have been very pleased with this IOL, because it delivers better results for patients with significant levels of astigmatism and with very little downside.  Also, the cost for the patient is less that half of the cost for a multifocal IOL.

Patients who are good candidates are those with:
1. Amounts of astigmatism in the 1.50 to 4.00 diopter range.
2. Regular astigmatism that measures the same on a consistant basis.
3. Patients with minimal other eye problems such as macular degeneration, retinal disease, or corneal diseases.
4. Patients with an understanding that glasses may still be needed for the very best possible vision

Going forward, it is very important to talk about the patients that are not good toric IOL candidates.  These include:
1.  Keratoconus patients, since their astigmatism is usually quite irregular.  Results are generally disappointing.
2.  Patients with signifincant map dot fingerprint dystrophy - again they often have irregular astigmatism.
3.  Previous radial keratotomy patients.
4.  Some patients with previous lasik - these cases can go either way but they are not optimum cases in general.

Finally, regarding toric IOLs, there is an expectation from patients that they will see fairly well without glasses, so it is of the utmost importance for the surgeon to get excellent measurments of the eye before surgery.  This means using an IOL Master or Lenstar unit, and multiple manual and automated readings of the corneal astigmatism making sure that the reading are clear and consistant.  A corneal topography reading is also needed.  Using Holladay IOL Consultant software and personally adjusted A-constants are very helpful as well.

If you have any specific questions about toric IOL's, don't hesitate to ask.  A very common question is when are limbal relaxing incisions (LRI's) a better choice?  We can get into that next time, but in general, LRI's may be better for lesser levels of astigmatism in the 1.00 to 1.50 diopter range as long as the patients don't have corneal surface problems like bad dry eyes.

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Avatar universal
by ledbrv, Feb 22, 2011
Dear Dr. Michael,

I read another post of yours about monovision, and find it very usefull. But this post interested me even more.
I am a 43 year old Brazilian who had a IOL implanted on my RE last friday night (02/18), less than a week.
So far I am very satisfied wih the results. My RE vision is crystal clear, and my Dr. told me it will get even better.
A primary evaluation on satudary morning showed that my RE already was at 20/40, eve with my pupil still very dilated.
I will need a reading right lens, but I already known that. I had presbyopia, so it is not a big deal.
My both eyes was measured by IOL Master.
IOL Master reports 13.0 (REF -0.18) and -0.05 D @20º on RE.
The IOL implanted was a AcrySof IQ SN60WF monofocol 13.0 D non toric.
So basically we are expecting near 0 myopia on RE with negligible astigmatism.
Ok. maybe it will not get plano, but even so if I get a little myopia on my RE, it is still much better than that terrible multiple images (4 or 5 images) I was viewing with cataract.
At night the streets seemed a Christmas Tree, and I was avoinding drive ate night because of that.
I am a IT professional, so I work all day with computers, it was a nightmare.

But ... Yes, there is always a "but".
My LE, which does not have cataract, and so does not need surgery, has a glass prescription of -3.75 (myopia) and -2.0 of astigmatism @79.
When I put my backup glasses (yes, I put a plano lens on the right), the images are great, but I can`t use it more than a few minutes.
I discovered (well, my Dr. had told me that maybe I will not want to were my glasses after surgery), that this is "anisometrophia".
I can see a big difference on images sizes from RE (bigger) to LE (smaller).
Now I know that I already had it before surgery, but the power difference was smaller (2.25), so it didn`t bother me too much, but I remembered seeing double images for example.
Maybe it explains some mysterious headaches I had before.

Well, I did`t discussed it with my doctor yet, but I found that there are two solutions: implant a IOL lens on LE (even without cataract) or use contact lens.
I don`t know if I will feel comfortable with contacts, but it is easy to do a "test drive" with it before decide to implant a IOL.
Contact lens is a reversible solution, implanting a IOL is not.

My doubt is regarding toric IOLs.
IOL Master measures of my LE: Cyl.: [email protected]º. For Alcon SN60WF IOL Master suggestions are (beside others) 15.0 D (REF -0.28), 15,5 (REF -0.62), 14.5 (REF 0.05).
If I understand it right, a good choice for better distance vision would be 15.0 D.
What is your opinion ? A toric IOL like AcrySoft IQ Toric would be a good option ? I know that there is a risk of rotation.
I would need glasses for astigmatism correction if I decide to go with a monofocal IOL like SN60WF, right ?
For me it is ok. I don`t mind to using glasses, I prefer a safer solution.

I forget to mention, I also have glaucoma under control with no visual lost.
I learned that implanting a IOL could help keep IOP under control, right ?

Thanks in advance for any help,

Luis Bravo

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by Michael J Kutryb, MDBlank, Feb 23, 2011
Looks like about -0.79 diopter of astigmatism at 83 degrees.  That is not enough to treat with a toric IOL according to that measurement which I don't necessarily trust.   You HAVE to have a corneal topography and MANUEL keratometry readings and even autorefractor readings to see exactly how much CORNEAL astigmatism you have.  The corneal astigmatism is what will be treated with a toric IOL.  In the meantime your best option is to wear a toric contact lens unless you cannot tolerate it then you will need to probably have cataract surgery but quite likely without a toric IOL.  I can't pick your implant power for you - there are too many variables and I have to see how reliable and accurate the measurements are.  You are assuming the measurements are accurate.  90% of the time if there is an inacurrate reading it involves the corneal power readings.

Avatar universal
by ledbrv, Feb 23, 2011
Dr Michael,

Thank you for your help.
Today I went to my second post surgery review of my RE.
As I was expecting, based on my personal post surgery viewing experience, my RE results were perfect.
My surgery was last friday, and today, I could get a 20/20 on a preliminary acuity exam of my RE without difficulty.
Now I must choose if I will use contact lens, or if I will get a IOL implant.
Because of this anisometrophia I just can`t use my glasses.
For now I decided to try contact lens.
I will wait a full RE surgery recovery before thinking about LE surgery, so I thought contact lens could be a good ideia.
It also allows me to try monovision.
By the way, on your opinion, what power should I choose if I decide for monovision (or mini) ?
My doctor said a -1.0 on LE would be a safer choice.
Right now, with -3.75 on LE, I think I am experiencing a HUGE monovision, is this conclusion right ?
With -3.75 on LE, I can manage to do many activities without glasses, even drive, so with -1.0 on LE maybe I will not even notice monovision.
Regarding IOL choices (toric x non toric) my doctor advised me to choose a non toric.
He also thinks -0.79 is not enough to treat with a toric IOL.
I don`t mind wear glasses, so we could treat any astigmatism left behind with glasses.
The current astigmatism power of my glasses is -2.0 (LE) and 0.0 (RE).
But I will talk to him about these exams you suggested.

Once again, thank you.

Avatar universal
by johnnygaddar, Mar 22, 2011
My Father is going to go for cataract surgery and his numbers are as follows:

Glasses Right: OD-9 cylinder-0.75, axis:44 vn:0.5
Glasses Left: OS-7.75 cylinder -1.25, axis:133 vn:-

Autorefraction Right Eye: OD-7.25, cylinder -1.00, axis 39
Autorefraction Left Eye: OS-6.25, cylinder -1.25, axis 169

The Surgeon suggested to go for Acrysof IQ IOL in Right Eye, and Acrysof TORIC IOL in Left Eye.

I just wanted to know that is Toric IOL neccessarily required to correct Left Eye Cylinder of -1.25 or would you suggest getting normal Acrysof IQ IOL in the Left Eye also.

The Doctor said that they would be able to complete correct the distance vision with putting Acrysof IQ IOL in Right Eye and Acrysof TORIC IOL in Left Eye.

I would highly appreciate reply from the doctors on this forum at the earliest since my father's surgery is scheduled on thursday 24th march 2011 for the right eye and on monday 28th march 2011

Avatar universal
by 123kt123, May 03, 2014
Dear Dr. Michael,

PLEASE!!!!! I REALLY need help!  I am a healthy 47 year old female (aside from hypothyroidism since a young age).  I had a standard distance lens put in the right eye Dec. 2013.  It went pretty well and now has some clouding and probably needs a YAG I am told (I can handle that).  That is not my problem...…For the left eye I had an astigmatism. One previous doctor said something like 1.15.  My current doctor said 1.2?- 1.3? (approx.)  I cannot remember exactly, but both doctors recommended the toric for that left eye.  I was hesitant because of the money and some things I had read, but I thought that they were specialists and I had two opinions.  So, I did the toric model SN6AT3 (1.5 CYL) 25.0 D. on 4-23-2014.  I have good vision for 5-6 feet (excluding reading- it is a distance lens) and then after that it is blurry (after reading it sounds like what is called waxy vision???). My doctor thinks I should see really well---  all his tests come out good.  But I cannot see clearly (crisply) after 5-6 feet.  He is trying to listen to me, but he now wants me to talk to other doctors for new opinions.  He said the lens is in the right place and everything looks good (of coarse there is still inflammation). He has told me to go from 4 to 6 drops of prednisolone daily.  He did say that in both eye the lens is a bit forward in the sac.  After searching internet, I have read that the lens can cause waxy vision and that this will many times resolve itself as the lens regains the factory manufactured shape (one online article). I don't know what to do or what to think.  I am scared.  What do you know?  What is your advise?

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by Michael J Kutryb, MDBlank, May 05, 2014
There are a couple of possibilities.  First and foremost you need to find out how close you are to the refractive target.  In other words, is the implant power on the mark, is the amount of astigmatism in the IOL on the mark and is the IOL on the right axis.  Obviously, you need to rule out problems like dry eyes, cystoid macular edema, epiretinal membrane and things like that.  I would do a retinal OCT scan to rule out macular problems and do a careful refraction to see where your refraction is.  The lens being forward in the bag sounds to me like another way of saying you ended up being nearsighted.  We are presently using ORA scans by Wavetech on all our toric patients to fine tune the toric power and placement in the eye.  The shape thing that you mentioned sounds like a non-issue.

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by CurlyButterfly, Jul 13, 2014
Dear Dr. Kutryb, I am scheduled for cataract surgery in a few weeks. It appears I cannot have anything but the Toric Astigmatism IOL if I want clear vision. My vision is a -4.25 in one eye and a -5.00 in the other with the cylinder being a .25 in each eye and the axis being 163 and 154 with an add of +2.50.  They are setting me up for a - 2.5 so I can keep my close vision. Will I have any variance to my vision at all or will I only see at about 14-16"? Will I be able to see any closer than 14" perfectly CLEAR or only that 14"? At the present time I do a lot of detail sewing, artwork, jewelry, computer work. This concerns me greatly. I do not want to wear glasses to thread a needle, paint the close up details on a painting, or do jewelry work (that type of tiny stuff). I was told that if I got a multifocal IOL that there would be a yellow tint, decreased contrast and possible halos. I threw that idea out right away but I am still having doubts about the decision to keep the close vision (as I've had my whole life).  Besides that the assistants (whom I spoke with the 2nd time I went there when I had additional tests) told me I would not have much variance of vision (accommodation?) so that made me think I'd be LOSING that nice close up 10-12" vision I now have. I felt like if I had to wear readers to do all the things I love, only see at 14-16", and then nothing out in the distance, I'd rather have the 10-12" close! I do not object to wearing glasses/am used to it.  No one really explained how bad my astigmatism is and according to your information (above), a 1.50 -4.00 Diopter range is more successful? I think they told me mine was about a 1 (not exactly sure). At the present I can still see rather well in my Left eye, it's the Right eye that has a type of cataract that is more centrally located and it gives me trouble. Most of the time I think I can see good until I close my good eye and then nothing is clear. I feel like I may be jumping the gun and getting this done too soon and with all the bad experiences people have....oh my! Any advice would be immensely appreciated. I also wondered if my 'blurry' distance vision will be worse than my blurry is now (without glasses) and the blurry will be the same amount  whether it's 15 feet or 100 feet. Lastly, if I did opt to get the IOL set for distance, just how close up could I see without glasses. Thank you SO MUCH and I apologize for the very lengthy post. I really need help!

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by Michael J Kutryb, MDBlank, Jul 13, 2014
It's complicated for you.  First I often don't bother with a Toric if leaving a patient nearsighted because the astigmatism doesn't bother near vision nearly as much.  If your other eye is not ready it gets really complicated and you're kind of in a pickle unless you can wear a contact in another.  On other note being a -4 is a little too nearsighted in my opinion.  Sure you can definitely see way up close but -2 or so is stil plenty to read comfortable so if I had only one eye to do and had to leave the other alone I personally would probably go for about -2.5 to 3 in the other and I would go ahead and do the Toric Iol if your astigmatism was more than 1.50.  If less than that I would leave it alone because it really wouldn't make a meaningful difference for near.  I think you'll be very happy just leave a good amount of nearsightedness to balance you out maybe -3.00 would be a good compromise.

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by Michael J Kutryb, MDBlank, Jul 13, 2014
Just an update I've been incredibly pleased with my Toric IOL results!!!  Just recently I've been using the Wavetechvision ORA aberrometer in the operating room to get real time measurements to confirm and sometimes adjust the power of the implant and to help to place the implant on the proper axis.  There are some nice videos on YouTube.   It's really awesome technology!! Definitely a perfectionists friend.  I have no financial interest.  We use it on all Toric cases.

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by Michael J Kutryb, MDBlank, Jul 13, 2014
A few more notes.  The Toric IOL's work extremely well on the right cases.  My rule if thumb is that all 3 technologies I use to measure the astigmatism have to agree on the amount and axis of astigmatism and the corneal topography must show a regular, normal pattern.  Having the topography on display in the operating room and using the ORA machine should make it almost impossible to make a major axis error.

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by CurlyButterfly, Jul 14, 2014
Dr Kutryb, Thank you SO much for your input. I think I understand what you said correctly. If I had the Dr. do a -2.5 or -3, 'about' how close could I see ( I know it's not an exact science).  While at those numbers I may be able to read comfortably, my worry is I will not be able to see tiny objects such as a 1mm hole that I'm trying to drill (I do jewelry work), or an eyelash in my eye or get a splinter out. It seems odd to think I could see something super clearly at 14" (that seems too far). It seems to me that if I can only see at 14-16" and no closer (since there's no clear all the way in to closer), I will have to wear some type of glasses for tiny work, PLUS glasses for regular. Am I thinking right? ~~ I am hoping that my Dr. will not see me as argumentative when I present your (& possibly other) opinions to them.  If I do NOT have astigmatism over 1.50, and DID get a toric anyway (if they won't do it differently), would it help my far vision any (in glasses) or make the lenses thinner? (just a side thought). And....if I did get a -3 in one eye and left my other a -4.25, do you think my eyes would work together without  aneisometrophia(I think that is what it is called).  Last thought: Is there a benefit in waiting if you can 'get by'.  Thank you again so much and I apologize for the many questions but I am truly grateful for your input. Blessings, Erin.

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by Michael J Kutryb, MDBlank, Jul 15, 2014
Remember you can always add more power for extra small stuff using reading glasses.   You may be over analyzing things.  Very unlikely to get anisotropia at these powers.  My original plan is still my favorite -3.00 range in surgery eye.  Your distance will be extremely blurry with or without Toric Iol due to myopia.  No real benefit at all for glasses either.  May not be much benefit at all for near vision depending on how much astigmatism and what axis.  Discuss that with doctor - why is Toric necessary if the eye will be a reading eye and sometimes certain amounts of astigmatism can help the near vision to some degree.  Take your other eye for example does it have the same amount of astigmatism and can you read well with it?

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by Michael J Kutryb, MDBlank, Jul 15, 2014
Not much benefit to waiting except you will eventually get so bad "anything" will be an improvement.  You can always add glasses if you need for tiny tiny stuff.

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by CurlyButterfly, Jul 16, 2014
Dr, K, Just a quick note: I went to see my Dr. today. She is very willing to let me have a -3 in the eye and wait on the other, then when it does finally get bad enough, she said then if I didn't like the -3, that I could have the -2.5 in that eye or maybe -2. She also thought I was over analyzing :-), and she said if I was seeing badly enough, I probably wouldn't be worrying & analyzing so much. I thought  --- yes, so maybe I'll wait. Since I've come home, I am thinking again about doing the bad eye a -3. At least I'd be able to see clearly out of both eyes and quite fighting with moving my glasses around in different positions trying to see. I really think she wants me to wait much longer (after we talked) but I'm going to call tomorrow and see about going ahead. Thanks SO MUCH for all of your input. It is truly appreciated.

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by CurlyButterfly, Jan 29, 2015
Hello Dr. K, just a follow up  to let you know that I did have cataract surgery in the one eye, and the target was set for a
-3, and a Toric IOL was used. I'm about 6 weeks from the surgery now and all is pretty good. I did find out that my astigmatism went from a 1.00 to a .50 and I don't know why the Toric didn't correct it 100%. Do you know why?
Other than that I'm patiently awaiting my new pair of glasses which should be next week. I cannot see as close in the fixed eye(RE) as I can in my LE which I do miss some but it is nicer to see a bit further out. Both eyes work well together. I want to thank you again for all of your input and help. You are doing a great service to all of us as the Drs. in offices really do not have the time to address a lot of questions.

Avatar universal
by MarkBahaa, May 30, 2015
Dr. What is the pros and cons of a SN6aT3 lens vs. Doing a Lasik ?

I have Cataract and astigmatism on my both eyes.

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by Michael J Kutryb, MDBlank, May 30, 2015
LASIK would not be needed if you have cataract surgery.  LASIK only works on the cornea but if you have a clouded lens inside the eye (cataract) no amount of laser on the cornea will correct your vision.  I have had really amazing results with torics IOL's and part of that success is using the ORA system by Wavetec (now Alcon) which checks not only the alignment of the implant but the overall power of the IOL both of which are critically important.  Make sure a corneal topography is done pre-op because some eyes will have irregular astigmatism which will see poorly with a toric IOL.  Overall toric IOL's have been a great part of my practice with no real downside.

Avatar universal
by ebw317, Jun 02, 2015
I am preparing a case to present to my insurance company to cover my toric IOL's during my cataract surgery.  I  have keratoconus.  My Ophthalmologist has said and insists on the Toric IOL, to insure quality results.  I am looking for some research to substantiate the statement that Toric IOL's are not just best practice for Keratoconus patients but it is the standard practice.

Can you point me in the right direction?

Truth is, I do not believe my Ophthalmologist would do the cataract surgery and implant a standard IOL because he cannot assure satisfactory results.

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by Michael J Kutryb, MDBlank, Jun 02, 2015
It will not be covered.  Torics Iols for kerataconus is a controversial subject.  I do a lot of toric cases and have the advantage of years of experience and an ORA machine and I decided against a toric  IOL for a recent case for the good of the patient.  For some cases keratoconus they may be an option but I've seen quite unpredictable results in other cases.  Bottom line it's an option for you but you will need to pay cash.  Ask your surgeon to give you a break on the price since the results may be unpredictable.

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by Michael J Kutryb, MDBlank, Jun 02, 2015
It was a keratotoconus patient I decided against the torics IOL with.  I told her I could not predict the result and that she would need glasses after surgery.  For other cases with more a more stable keratoconus pattern and reproducible consistent readings I have used torics Iol's with good success.  Each case is unique.

Avatar universal
by a15lbers, Apr 03, 2016
I had cataract surgery jan 20th. He accidentally put in the wrong size lens. 9.5 was supposed to be 7.5. He decided to replace the iol lens on the 17th of feb. Made it even worse. He bruised the cornea, he said. After over 6 weeks he determined that the lens is moving around,won't stay in place. Now he wants to do another surgery again to stitch it down in place. Plus I woke up during the last surgery and felt him sticking me in the eye. I'm not a bad person.  I'm scared to let him do another surgery. What should I do? Lost and confused. Should I consult another ophthalmologist?

Avatar universal
by a15lbers, Apr 03, 2016
By the way. This Dr. Wants to do this surgery friday the 8th of April. I've tried calling texting anyone I could to get an opinion. Haven't gotten any where. I hope and pray you can help me. Thank you for your time.

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