Cataract surgeons interested in learning more about how to use LRIs can consult a Web-based planning tool that operates similarly to Dr. Hills SIA Calculator (mentioned in the box, above). All necessary data exists within the manuscript. Nonetheless, in a large randomized, multicenter clinical trial of the AcrySof toric IOL (n = 517), 39.1 percent of the toric IOL recipients reported some degree of spectacle dependence for distance vision at six months postop. The investigators dilated the pupil in order to visualize the marking dots in the periphery of the toric IOL. They may also help reduce your reliance on glasses for certain types of tasks. J Cataract Refract Surg. If so, can I adapt to seeing glare and halos around lights when I drive? A Review of Smartphone Apps Used for Toric Intraocular Lens Calculation and Alignment. So far, the Clarity system is still not available, although a prototype was shown at the 2012 American Academy of Ophthalmology meeting in Chicago. To prepare for a conversation with your ophthalmologist, you should think about your priorities for your IOLs, as well as aspects that arent as important to you. This approach is a little bit time-consuming, but it gives you extremely accurate orientation., Dr. Osher notes that this method requires following a few basic principles. 3 Holland E et al. J Cataract Refract Surg 2020;46:793794, 3. We found that this produced a slightly different measurement. Preventing and Fixing Misaligned IOLs - Advanced Vision Care Toric IOL For Astigmatism Correction - All About Vision 5. Clinical outcomes of TECNIS toric intraocular lens implantation after cataract removal in patients with corneal astigmatism. So we began checking in the clinic to see whether the outcomes were better if the correction was based on the Pentacams total corneal refractive power measurement, and how it compared to the outcomes using keratometry from the IOLMaster and Lenstar, he continues. Phakic lenses are typically implanted in younger individuals while trying to preserve the natural human lens, to correct for near-sightedness in people who dont qualify for laser refractive surgery. Dr. Berdahl is a consultant to Alcon. But he prefers to do a lens exchange and/or rotate the lens to the correct meridian for larger amounts. We were curious to find out whether this was an issue. Its an inexact science. In general, reference and alignment of axes were marked manually with the patient in an upright position prior to surgery to prevent cyclotorsion errors. recently published the exact and complete methodology for determining the predicted refraction after implantation of a toric IOL and the postoperative back calculation of the necessary rotation for a misaligned toric IOL in the article titled, Calculation of Total Surgically Induced Astigmatism with a Toric Intraocular Lens.2 The original description showing the residual astigmatism for a specific angular error of a toric IOL is shown in Figure 2 of the 2001 article by Holladay et al.3 We will only discuss the pertinent points in this letter and recommend accessing these references for any further details. So instead of using ink and having the mark diffuse or disappear, the tiny dot remains throughout the case. The only way the full potential of advanced technology lenses such as torics or multifocals will be reached is to have either the diagnostic, preoperative technology or the intraoperative technology to confirm emmetropia on the spherical side, and make sure the axis is dead-on on the cylindrical side of the equation. National Library of Medicine PMC Especially for high cylinder power IOLs, better refractive outcome can be seen when performing a back-calculation before realignment. Initially I tried orienting the lens by using the limbal vessels as landmarks, he says. Once thats done and everything looks perfect, I dry the cornea a little at the periphery and I take a Weck-Cel sponge with ink on it and reinforce the intended axis mark to ensure it wont wash away. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 3. None of us as surgeons can get it right every time. If you also correct the preop near- or far-sightedness, the patient will see better than ever. Normally, the monofocal IOLs for both of your eyes are set to the same range (like distance). You receive IOLs during eye lens replacement surgery, most commonly during cataract surgery. However, Drs. Theyll perform some simple, painless tests to measure your eye size and shape, too. Postoperatively, if the toric IOL is misaligned from the ideal axis, the amount of rotation necessary to achieve ideal alignment can be calculated from the postoperative refraction, the axial length, the actual effective lens position and the SEQ power, IOL toricity, and observed axis of the IOL (not intended). Although most IOLs show stability, rotation from the intended position is possible. Lucisano and colleagues evaluated postoperative IOL rotation in 15 eyes of nine patients. When the air bubble is exactly in the center of the two marks on the chamber, you know that the marker is horizontally aligned. Teichman JC, Baig K, Ahmed II. Best contacts for screen use: Bausch + Lomb ULTRA Multifocal for . But over time, you should be able to rely less on your reading glasses. The investigators reported a relatively low rate of misalignment (0.653%). Prior to seeing those patients, I had started a study along with Li Wang and Mitchell Weikert in our group, looking at posterior corneal astigmatism, he continues. Impact of Material and Lens Design on Repositioning Surgery of Toric Intraocular Lenses: A Single-Arm Meta-Analysis. In addition, the toric IOL is almost never the perfect toricity (step sizes are usually 0.75 D of cylinder), so the residual cylinder will often be slightly larger for a given misalignment. Copyright 2017 American Academy of Ophthalmology. The initial company I worked with was Micron Imaging. If youre basing your orientation on really accurate readings, I dont think an aberrometer will change the axis that much, says Dr. Davison. This allows you to see if this method of correction feels comfortable to you. Toric IOLs are an option for providing better distance UCVA, greater spectacle independence, and lower degrees of residual astigmatism in patients with significant preoperative corneal astigmatism.4-8 Precisely positioning a toric IOL along the correct axis at the time of cataract surgery is crucial to its efficacy: A 30 rotation can negate the toric correction completely and require surgical repositioning of the IOL.4-8. Our advertisers are important supporters of this site, and content cannot be accessed if ad-blocking software is activated. Refractive and Visual Outcome of Misaligned Toric Intraocular Lens Toric intraocular lenses: historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes and complications. Pseudophakic Dysphotopsia: Review of Incidence, Cause, and Treatment of Positive and Negative Dysphotopsia. Among 6431 eyes implanted with toric IOLs, 42 eyes (0.653%) of 42 patients underwent repositioning surgery at an average of 9.97.5 days (range, 0-30 days) after IOL implantation. However, some devices make this easier. Results: You dont need any preoperative information. You may be trying to access this site from a secured browser on the server. 2023 Jun 8. doi: 10.1007/s10384-023-01001-x. Toric lenses help people who have astigmatism. The emphasis (among both ophthalmologists and patients) on precision and accuracy in cataract and refractive surgery continues to grow. I go back to surgery and use the original incision. Dr. Hill said he sometimes uses LRIs to reduce small amounts of residual astigmatic error. Not only are toric IOLs imperfect, but so are the ophthalmologists who implant them, added Dr. Hill. 3 Dr. Chu advises emphasizing this possible outcome during the informed consent process. A similar experience led Douglas D. Koch, MD, professor of ophthalmology at Baylor College of Medicine in Houston, to uncover some key factors that can affect the outcome when implanting a toric IOLboth in the near and long term. At the same time, I treated another patient who started out with against-the-rule astigmatism; if anything, that patient should have ended up slightly overcorrected, but instead she was undercorrected. No eyes over 20.5 D had to be reoriented. J Cataract Refract Surg 2019;45:272283, 5. After realizing this I began to look at other patients and found I was seeing this all the time, Dr. Koch continues. For calculating the spherical power of a toric IOL, this instrument works quite well, Dr. Hill said. With that in mind, several surgeons with extensive experience . Incidence, timing, and outcomes of repositioning surgery. 2 Shammas HJ, Hoffer KJ. If you then correct the astigmatism, the patient will see even better still, but thats the icing on the cake. J Cataract Refract Surg. We observe from Table 1, that, up to 30 degrees, this is approximately true: for every degree of misalignment, there will be an increase in the residual cylinder of 3.3% of the original. (https://www.aao.org/eye-health/diseases/cataracts-iol-implants). J Cataract Refract Surg. Finally, there are the intangible factors that cant always be controlled, said Y. Ralph Chu, MD, a cataract and refractive surgeon in Bloomington, Minn. Theres an art to implanting a toric IOL. We hope that this discussion clarifies the subject of residual astigmatism for toric misalignment. 2014;40(10):1654-1660. They recorded identical IOL rotation with the patients head tilted right and left, thus maintaining the values of misalignment found in primary position. Please try after some time. Among the 6,431 eyes that received a toric IOL at the time of cataract surgery, 42 (0.653%) underwent repositioning surgery 9.9 7.5 days (range, 030 days) postoperatively on average. Long-term clinical outcomes of toric intraocular lens implantation in cataract cases with preexisting astigmatism. Impact of axis misalignment of toric intraocular lenses on refractive Dr. Koch says he soon found another factor worth taking into account. J Cataract Refract Surg 2001;27:6179, 4. As technology continues to evolve, IOLs will offer more features with fewer drawbacks. Use of a toric IOL during cataract surgery does not increase the risk of common cataract surgery complications, but a misaligned toric IOL can cause blurred vision that cannot easily be corrected with eyeglasses or contact lenses. The algorithm will tell you if you should rotate that lens or not. As the use of toric IOLs to address astigmatism during cataract surgery grows, it is important that surgeons be aware of possible IOL rotation and the best course of management. Online ahead of print. Disclaimer. There was no obvious explanation. In two eyes that underwent repositioning within 24 hours, the IOL rotated again considerably, and additional surgical intervention was required to correct the problem. eCollection 2022. The problem is, if you deliberately try to make the capsulotomy smaller, you might make it smaller than 4.6 mm, he says. Also, ask them about common side effects associated with cataract surgery or refractive lens exchange. Champaign, IL, USA. This article is from April 2012 and may contain outdated material. No ophthalmologist in the office would identify a significant amount of astigmatism and ignore it. The ThermoDot is a tiny dot created by a specially designed wet-field cautery tip, making an indelible mark on the target meridian, he explains. When perfectly aligned, the residual cylinder is 0, but when the 1.0 D cylinder is rotated to 180 degrees (angle between of 90 degrees), the resulting residual cylinder is 2.0 D @ 90 degrees with an SEQ = 0 D. The magnitude of the residual astigmatism for orientations of the 1.0 D cylinder between 90 degrees and 180 degrees are given by 2 times the sine of the angle between the 2 IOLs:Residualcylinder=2sin(anglebetween). This should be our noble goal, and I believe its within our reach.. The LRI Calculator performs mathematical vector analysis of topography or keratometry data the surgeon provides. Postoperatively, if the toric IOL is misaligned from the ideal axis, the amount of rotation necessary to achieve ideal alignment can be calculated from the postoperative refraction, the axial length, the actual effective lens position and the SEQ power, IOL toricity, and observed axis of the IOL (not intended). (https://pubmed.ncbi.nlm.nih.gov/32652203/). And it has other advantages, such as confirming emmetropia, which is very important. to maintaining your privacy and will not share your personal information without The open-access website for the preoperative toric calculator and the postoperative toric misalignment calculator implement all of the above-mentioned considerations.A. The relationship of visual acuity, refractive error, and pupil size after radial keratotomy. 1. Theyll tell you what to expect based on your medical history, eye health and other factors. The details of the IRB/oversight body that provided approval or exemption for the research described are given below: No IRB/oversight body was required in preparing this manuscript. FOIA Holos does real-time dynamic wavefront aberrometry scanning. Youre just enhancing the optical properties of the eye, he said. Toric IOLs have been used to correct corneal astigmatism during cataract surgery. Digital overlay technique for documenting toric intraocular lens axis orientation. 2012;153(1):55-61.e2. Simultaneously, the Lenstar uses optical low-coherence reflectometry to measure corneal curvature; corneal, lens and retinal thickness; pupil and white-to-white corneal width; axial length; aqueous and anterior chamber depth; and eccentricity of the visual axis. Of course, that technology will get better. Ophthalmology. But with monovision, the lens for each eye has a different focusing power. As toric intraocular lenses become more popular, accurate alignment of the lens inside the eye remains a key concern. Disclosures: Neither author has a financial or proprietary interest in any material or method mentioned. The https:// ensures that you are connecting to the The fine-tip marker makes a pretty small dot, he notes, in contrast to a medium tip marker that can make a dot thats 10 degrees wide, or a small tip, which makes a dot thats probably about three degrees wide. If it looks like there has been a significant lens rotation, then I go in and rotate it into the correct orientation, he said. That system has been the leader in intraoperative wavefront aberrometry. Failure to take into account the impact of surgically induced astigmatism. Researchers comparing Lenstar to other measuring instruments have reported favorable results.1,2. In my experience, the lenses stay in place after this.. However, when a patients residual astigmatism is unexpectedly high, there are several postsurgical solutions to help remedy the situation. Nemeth G. One degree of misalignment does not lead to a 3.3% effect decrease after implantation of a toric intraocular lens. Best contacts for visual clarity: Biotrue ONEday for Astigmatism. Above 30 degrees, the residual astigmatism exceeds the original astigmatism. IOLs (intraocular lenses) are clear artificial lenses that a healthcare provider will implant in your eye to replace your natural lens. Reproduction in whole or in part without permission is prohibited. Your brain adjusts to these zones and chooses the focusing power you need for any given task (like driving or reading). Before What kind of hobbies and activities do I enjoy the most and how much dependency on glasses am I OK with for these activities. Most markers, including this one, come in two versions: One just makes the horizontal reference marks; the other allows you to directly mark the target axis for the IOL., Robert H. Osher, MD, professor of ophthalmology at the University of Cincinnati, is a leading advocate of finding better ways to align toric lenses. Ophthalmology. J Cataract Refract Surg. To analyze the incidence and appropriate timing of repositioning surgery to correct misalignment of acrylic foldable toric intraocular lenses (IOLs). The first is iris imaging, he says. (He has no financial interest.) Arch Ophthalmol 1991;109:7076. So if the capsulorhexis is 4.6 mmwhat I think is the perfect size for a high myopethe internal little dot on the toric lens should touch the edge of the capsulotomy when youre done. Online ahead of print. But the IOLMaster lacks the overall precision required to consistently determine the steep and the flat meridians because it has just six optical sampling points on the cornea, spaced 60 degrees apart, he said. Intraocular Lens Complications: Decentration, Uveitis-Glaucoma-Hyphema Syndrome, Opacification, and Refractive Surprises. Methods In the most common surgical situation where both mismatch and misalignment exist, we present an analysis of the point at which overcorrection and undercorrection residuals coincide, yielding a simple but powerful methodology to predict the optimal degree of overcorrection with a tIOL. Additionally, images are acquired and assessed automatically, independent of the operators skill, and they have a resolution power of 1, affording high interobserver repeatability. J Ophthalmol. Avoiding Flip Flops, Endocrinology (including Diabetes Mellitus and Metabolic Disease), Intensive Care and Critical Care Medicine, Rehabilitation Medicine and Physical Therapy. Ive heard of people trying to do it at the slit lamp, but I think thats risky. There was a significant negative correlation between the interval from cataract surgery to repositioning procedure and the degree of residual misalignment (r = -0.439, P < 0.001). We take a photo of the iris, use software to overlay a protractor onto the image and then either inject it into the microscope view or print it. This calculation requires detailed knowledge of vector algebra, trigonometry, and the crossedcylinder solution.2,5 An example calculation with the specific equations is provided in the article and is accurate to 6 decimal places for validation.2, Although the actual calculation for the necessary rotation is tedious and complicated, it might be simplified conceptually to the problem of 2 equal-magnitude crossed cylinders of opposite sign. Surgeons share their experience and offer strategies for making the most of these intraocular lenses. The study by Oshika and colleagues adds to the information on astigmatism management available to cataract surgeons. Barber KM, O'Connor S, Mackinder P, Chih A, Jones B. Int Ophthalmol. These data suggest that repositioning surgery should be performed 1 week after IOL implantation. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event. J Cataract Refract Surg. (Visit www.LRICalculator.com, from AMO.). They serve to improve the quality of the vision delivered. A relationship was found between the timing of repositioning surgery and surgical outcome. Several markers have a bubble level, she explains. Toric IOLs: Four Options for Addressing Residual Astigmatism Main outcome measures: J Refract Surg. So the with-the-rule patient who was overcorrected had posterior corneal astigmatism that was adding to his against-the-rule refractive power. Supplemental Toric Intraocular Lenses in the Ciliary Sulcus for Correction of Residual Refractive Astigmatism: A Review. Matching the Patient to the Intraocular Lens: Preoperative Considerations to Optimize Surgical Outcomes. 2000;11(1):47-50. https://crstoday.com/articles/july-2018/misaligned-toric-iols, Director of Cornea and Refractive Surgery, Stanford Laser Eye Center, Stanford, California, Professor of Ophthalmology, Stanford University School of Medicine, Stanford, California, Cornea, cataract, and refractive surgeon, Lindenhurst Eye Physicians and Surgeons, Babylon, New York, Ophthalmology resident, New York Medical College, Valhalla, New York. Dr. Berdahl said residual astigmatism can also be caused by incorrect IOL power at the corneal plane (reported with the AcrySof toric), 1 by the patients posterior corneal curvature, or by measurement variability. At 30 degrees misalignment, the magnitude of the residual astigmatism is equal to the magnitude of the original astigmatism, so the patient sees no improvement. It literally measures the eyes toricity on the table, and as you rotate the lens, you see what effect the rotation has in real time. For example, the lens for your right eye might correct for distance, with the lens for your left eye correcting for close-up vision. For any other magnitudes, the percentages might be multiplied by the original cylinder. Dr. Davison cites a study he did with New Mexico surgeon Art Weinstein, MD. Pay attention to your keratometry, Dr. Hill advises. J Cataract Refract Surg, 34 (2008), pp. Because its a minus lens, it creates refractive power horizontally, or against-the-rule refractive power at 180 degrees. Design: MeSH Incidence and outcomes of repositioning surgery to correct misalignment of toric intraocular lenses. (, The most obvious way to see whether your capsulorhexis is the right size is to check it against the three little dots on the toric lens, he adds. Get useful, helpful and relevant health + wellness information. The researchers determined an optimal time frame for IOL repositioning, should it be necessary. Sometimes, no matter how good your mathematical model, youre still going to have residual astigmatism. Dr. Chu is an adjunct associate professor of ophthalmology at the University of Minnesota, Minneapolis. 2014;40(12):1949-1952. The repositioning surgery significantly reduced misalignment from 32.915.7 to 8.89.7 (P < 0.001), which was measured at 7.65.0 weeks postoperatively. Because lets face it: If you take the cataract out, the patient should see better. The second approach is limbal registration, he continues. Oshika T, Inamura M, Inoue Y, et al. (https://pubmed.ncbi.nlm.nih.gov/32619547/). 2014 Oct;40(10):1654-60. doi: 10.1016/j.jcrs.2014.01.044. We also see from Table 1 that this 3.3% approximation becomes progressively less accurate above 40 degrees. Extensive misalignment of plate-haptic rotationally asymmetric multifocal toric intraocular lens. I used to have to reorient 1.2 percent of these cases postop. You may still need to use glasses for close-up tasks like reading. So if a toric IOL is misaligned by 10 degrees, thats a 33 percent loss of the toric correction, said Warren E. Hill, MD, medical director of East Valley Ophthalmology in Mesa, Ariz. And if the toric IOL is misaligned by 30 degrees, its as though you put in a spherical IOLthe IOL isnt correcting any astigmatism., Positioning errors have the largest impact at higher cylinder powers, which became available in the United States last spring for AcrySof (Alcon) toric IOLs, said John P. Berdahl, MD, a cataract and refractive surgeon in Sioux Falls, S.D. Wolters Kluwer Health Consequently, toric IOL surgeons advise making this a last-ditch option. Key Facts About Toric Lens Implants. Ask your ophthalmologist about which type of IOL is best for you. Evaluation of postoperative toric intraocular lens alignment with anterior segment optical coherence tomography. Unlike multifocal lenses, EDOF lenses contain one long focal point that expands your corrected range of vision and depth of focus. We use the Lenstar, IOLMaster and two topographers. Transient elastometry, currently used to measure the stiffness of liver and breast tissues, shows promise as an ophthalmic tool. With monovision, your eyes work together to help you see both distant and close-up objects. Data is temporarily unavailable. Toric intraocular lenses: historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications. Although residual astigmatism often reflects improper alignment, it might also mean the surgeon should have compensated for surgically induced astigmatism (SIA) from the phaco incisions when placing the toric lens, said Dr. Chu. That will let you loosen the adhesions that have formed by three weeks. Toric IOLs: Four Options for Addressing Residual Astigmatism, Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Minority Ophthalmology Mentoring Campaign, Global Programs and Resources for National Societies, Dr. Richard Mills' Opinions, 2002 to 2016, International Society of Refractive Surgery, Incorrect marking of reference points on the cornea. Conclusions: If too much fluid leaks out of the incision using the 30-ga. cannula, I can go in and do the rotation with the silicone irrigation/aspiration tip. The investigators assessed postoperative IOL alignment at each visit. Refractive cylinder was significantly reduced from 2.41.1 diopters (D) to 1.10.8 D (P < 0.001). You receive IOLs during cataract surgery and refractive lens exchange. Patients who had undergone phacoemulsification and implantation of toric IOL at 8 surgical sites. I cant get these toric IOLs to work. I tell them that they need to know what their SIA numbers are in the real world. He urges toric IOL surgeons to learn their personal SIA number and to use it to achieve better results. The .gov means its official. His patients can choose between LASIK and PRK, whichever they prefer, with one exception. One drawback of multifocal lenses is that you may notice rings or halos around lights, like when driving at night. Your message has been successfully sent to your colleague. Am I OK wearing glasses for these tasks? The latest in prevention, diagnostics and treatment options for a wide spectrum of eye conditions - from the routine to the complex. 4. If rotation is indicated, or if the patient needs an IOL with a different refractive power, the surgeon should act promptly, before fibrotic healing can interfere with the procedure. An official website of the United States government. Oshika and colleagues found a significantly negative correlation between the interval from cataract surgery to repositioning surgery and the degree of residual misalignment. Unlike monofocal lenses, multifocal lenses contain several focal zones. We havent analyzed all of our data yet, but our impression is that were getting better results using the total corneal refractive power measurement for with-the-rule, against-the-rule, and obliquely oriented astigmatism.. If its 30 degrees off, its a total lossthe lens will have zero effect. Here, four experienced surgeons share their advice on getting toric IOL alignment right. These procedures customize your lens prescription to bring you as close to your desired visual outcome as possible. New anterior segment OCT software for analyzing toric IOL alignment after surgery provides ophthalmologists with another method by which to evaluate and optimize outcomes. Oshika T, Nakano S, Inamura M, Ikai N, Kato Y, Izumi I, Shimokawabe K. Jpn J Ophthalmol. The new technique is easy to perform and less subjective than other methods. Holladay JT, Lynn MJ, Waring GO, Gemmill M, Keehn GC, Fielding B. Theyll help you customize your IOL selection to suit your vision needs, lifestyle and personal preferences. Purpose To show current approaches for overcorrecting astigmatism and "flipping" its axis need be reconsidered in light of methods we introduce that take into account both mismatch and misalignment of the toric intraocular lens (tIOL) with respect to the astigmatism to be corrected at the time of cataract surgery. Refractive cylinder also decreased to 1.10 0.80 D (range, 03.25 D). Holladay JT, Moran JR, Kezirian GM. If realignment is required, it should be performed with a toric back calculator if cylindrical power of IOL is >2 diopter (D). If the steep meridian lines up with 0, 60, 150 and 180 degrees, IOLMaster may work well. Curr Opin Ophthalmol. 2023 Bryn Mawr Communications, LLC.All Rights Reserved | Privacy Policy, Operating Despite Extreme Positional Difficulty, Foldable Lens Trends: Seeking the Greatest Biocompatibility, Dry Eyes and Increasing Myopia After LASIK, Early Identification of Patients With Keratoconus and Post-LASIK Ectasia, Reimbursement for CXL: Current Status and Best Practices, Under the Microscope: Examining the Role of the Ophthalmic Technician, Evaluating the Retina Before Cataract Surgery, World-Class Refractive Cataract Practice Gets Infusion of New Blood, A Custom Iris Prosthesis Finally Gains FDA Approval, Chess and Cataract Surgery: Multiple Games, Cataract and Glaucoma After Penetrating Keratoplasty, Alanna S. Nattis, DO; and Eric D. Rosenberg, DO, Lucisano A, Ferrise M, Balestrieri M, et al1. Experienced toric IOL surgeons say that todays tools and techniques often enable them to keep the disappointments to a minimum. Intangibles. You must know the best place to put your incision, relative to the corneas steepest meridian., Dr. Hill said, Physicians call me and say, I dont know whats wrong. The device can also provide an auditory cue when the marker is horizontal, so you dont have to look away from the eye to know when the orientation is correct.
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