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    Toric Versus Toric: Rotational Stability Rates

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    Researchers in California conducted a retro­spective study to compare the rotational stability of two commonly used toric presbyopia-correcting IOLs and their monofocal toric counterparts.1 They found that the presbyopia-correcting Tecnis Symfony (John­son & Johnson) was more likely to rotate and to require surgical repositioning than the ReStor (Alcon)—and that the Tecnis monofocal toric IOL (Johnson & John­son) was more likely to require surgical repositioning than the AcrySof monofocal toric IOL (Alcon).

    Study rationale. Lead author Bryan S. Lee, MD, JD, in private practice in Los Altos, California, explained, “Our previous study demonstrated that the AcrySof toric IOL was significantly less likely to rotate than the Tecnis toric IOL,2 but [these two IOLs] had not been compared to their presbyopia-correcting toric counter­parts.”

    Study methods and design. For this study, the same surgical technique was used by Dr. Lee and his col­league, David F. Chang, MD. Thorough irrigation and as­piration was used to remove all ophthalmic viscoelastic devices (OVDs), including within the capsular fornices and behind the toric IOL optic. The eye was left slightly soft, with an intraocular pressure in upper single digits as estimated by palpation.

    Consecutive patients receiving a study IOL were included. All patients had image-guided digital marking to verify toric IOL position at the conclusion of surgery. Postoperative rotation was determined by dilated exam-ination performed later on the day of surgery or the following morning.

    Eyes were excluded if digital marking could not be obtained preoperatively or was not able to be used intraoperatively.

    Patients were divided into two cohorts:

    • Those who received a presbyopia-correcting toric ReStor (n = 61) or Symfony (n = 779), from September 2016 to January 2019.
    • Those who received a monofocal toric AcrySof (n = 2,393) or Tecnis (n = 731), from April 2015 to January 2019.

    Results. The toric ReStor was less likely to rotate 5 or more degrees than the toric Symfony (91.8% vs. 79.0%; p = .01). This remained true for rotation of 10 or more degrees (100% vs. 89.5%; p < .003). Mean rotation was 2.3 degrees for the toric ReStor, compared to 4.5 for the toric Symfony (p = .01).

    In addition, significantly more toric Symfony eyes required a return to the OR for repositioning (6.9% Symfony vs. 0% ReStor; p < .03), and more eyes that received the Tecnis monofocal toric IOL required surgical repositioning than did those that received the AcrySof (3.5% vs. 1.2%; p < .001).

    A matter of the platform? Dr. Lee emphasized that use of digital axis marking (Callisto, Carl Zeiss Meditec) in every case “helped differentiate postoperative rota­tion from surgical misalignment.” He added, “We be­lieve the consistent rotational results from the previous paper to this one demonstrate that toric IOL stability is an IOL platform effect. Furthermore, the higher surgi­cal repositioning rate for the toric Symfony than the Tecnis [monofocal] toric helps show that toric presby­opia-correcting IOLs are less tolerant of misalignment and residual astigmatism.”

    Arthur Stone


    1 Lee BS et al. J Cataract Refract Surg. Published online Nov. 11, 2020.

    2 Lee BS, Chang DF. Ophthalmology. 2018;125(9):1325-1331.


    Relevant financial disclosures—Dr. Lee: None.

    For full disclosures and the disclosure key, see below.

    Full Financial Disclosures

    Dr. Apte EdenRoc Life Sciences: O; Genentech: C; Iveric bio: O; Liberty Biosecurity: C,O; Merck: C; Metro Biotech International: O; Metro International: O,P; Mylan: C; Novartis/Alcon: C; Ribomic: C.

    Dr. Lee None.

    Dr. Petrova None.

    Dr. Woo Abbvie: L; Allergan: L; Alteogen: C,S; Bayer: L; Curacle: C,S; Novartis/Alcon: C,L,S; Novelty Nobility: C,S; Panolos Bioscience: C; Philophos: C; Retimark: O; Samsung Bioepis: C,S; SCAI Therapeutics: L.; Taejoon: L.

    Disclosure Category



    Consultant/Advisor C Consultant fee, paid advisory boards, or fees for attending a meeting.
    Employee E Employed by a commercial company.
    Speakers bureau L Lecture fees or honoraria, travel fees or reimbursements when speaking at the invitation of a commercial company.
    Equity owner O Equity ownership/stock options in publicly or privately traded firms, excluding mutual funds.
    Patents/Royalty P Patents and/or royalties for intellectual property.
    Grant support S Grant support or other financial support to the investigator from all sources, including research support from government agencies (e.g., NIH), foundations, device manufacturers, and/or pharmaceutical companies.


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