Posted by: Kutryb Eye Institute
By Michael Kutryb, MD | Kutryb Eye Institute | Titusville, Florida
When considering cataract surgery with a premium toric lens implant, like the Panoptix Pro Toric or Tecnis Puresee Toric most patients understandably focus on the lens itself. They want to know which lens will give them the best vision, reduce their dependence on glasses, and fit their lifestyle.
But there is another important part of the equation that deserves just as much attention: surgical precision.
At Kutryb Eye Institute in Titusville, Florida, I have performed more than 30,000 cataract procedures during my career. This includes over 2500 toric lens implants. My approach to cataract surgery combines surgical experience, advanced technology, careful preoperative measurements, and attention to the details that can make a difference in a patient’s visual outcome. Some people think I have my technicians take some measurements of the eye and I just show up and do the surgery. What they don’t see is the hours of homework I do the night before surgery days, checking the accuracy of the measurements, running multiple calculations, comparing them, and picking a final best lens and final best astigmatism axis for implantation.
Unlike a standard lens implant, a toric lens must be positioned at a very precise angle inside the eye. Even a small amount of rotation can reduce its ability to correct astigmatism. That’s why precise alignment is so important.
Astigmatism occurs when the cornea, the clear front surface of the eye, has an irregular curvature. Instead of being equally curved in all directions, it is shaped more like a football than a basketball. This can cause blurred or distorted vision at both distance and near.
A toric intraocular lens (IOL) is designed with different focusing powers in different meridians to compensate for this irregular curvature.
However, there is an important catch: the lens must be positioned at the correct axis.
In fact, approximately 3.3% of a toric lens’s astigmatism-correcting effect can be lost for every degree of rotation away from its intended axis. That is a significant difference, especially for someone choosing a premium lens with the expectation of excellent visual quality.
This rule of thumb has been embedded in my brain ever since the first toric lens implants came out over 20 years ago and it is why we work so diligently and use LenSx laser-assisted toric IOL positioning whenever possible.
Can Laser-Assisted Cataract Surgery Improve Toric Lens Alignment?
This is a question worth asking, and recent research provides some encouraging answers.
Traditional toric lens implantation often relies on manually marking the eye with ink before surgery. One of my favorite toric markers in the past had a mini carpenter’s level. We would use a surgical marking pen to apply ink to the instrument. Sometimes the ink would fade and be hard to read, or spread out too much. These original marks created a reference at 0 and 180 degrees so we could use a second device to find and mark the exact axis. It was like using a slide rule instead of a calculator. It could be accurate, but only if done with extreme skill and experience.
Later, I moved on to a device called the Robomarker, which has a far better gyroscopic design, so you could set the device to an exact axis and skip the first horizontal marks. The Robomarker is a step up and creates a mark that doesn’t fade, but it is still tricky to get it centered and on the true axis. I still use the Robomarker for patients that cannot have laser-assisted surgery. I consider it the best you can do, without the LenSx On-Axis astigmatism marking we use today.
LenSx laser-assisted cataract surgery offers a much more advanced option: creating precise reference marks on the lens capsule itself to guide toric lens positioning. The newest version is called On-Axis Technology and we were one of the first in Florida to get this upgrade.
The potential advantage is that laser-created reference marks can provide a consistent, visible guide for positioning the toric implant, rather than relying exclusively on marks placed manually on the cornea. Because the laser marks are made right in the lens capsule that holds the toric lens in place, they literally could not be any closer. This reduces parallax error that can occur with marks placed on the cornea which is significantly farther away. Also they never fade and are centered exactly through the visual axis. In addition to our LenSx laser there is another laser system called the LENSAR ALLY that does pretty much the same thing.
The evidence supporting more precise toric lens alignment continues to develop.
A 2025 study published in Photodiagnosis and Photodynamic Therapy. Researchers compared manual marking, digital image-guided marking, and femtosecond laser-assisted capsular marking in 105 eyes.
The investigators reported that the femtosecond laser-assisted marking group had significantly less toric lens misalignment and lower residual astigmatism than the manual and digital marking groups at one and three months after surgery.
Another prospective study, published in 2023, compared femtosecond laser-assisted capsular marking with digital marking in patients receiving toric implants. The researchers found average alignment errors of approximately 1.71 degrees with laser-assisted capsular marking compared with 2.64 degrees with digital marking.
Since the LenSx On-Axis Technology and the LENSAR ALLY systems have only been in use for a few years, research is ongoing, but I expect future studies to continue to show that laser-assisted marking made directly on the lens capsule will outperform manual toric alignment marks.
My takeaway is straightforward: technology that helps us establish and maintain a more accurate alignment reference is a meaningful tool when implanting a premium toric lens.
Technology is important, but it does not replace surgical experience.
Successful premium cataract surgery begins well before the day of the procedure. It requires accurate measurements of the eye, evaluation of corneal astigmatism, appropriate lens power calculations, and careful consideration of each patient’s visual goals.
During surgery, the surgeon must also create an appropriately sized capsular opening, remove the cataract, maintain the integrity of the capsular bag, and position the implant accurately.
The LenSx laser is one part of this process. Its femtosecond laser technology assists with key steps of cataract surgery, including creating a precise capsulotomy and providing laser-assisted reference marks when used for toric alignment.
Combining this technology with the experience gained from performing more than 30,000 cataract procedures allows me to approach each case with an appreciation for both the big picture and the small details.
At Kutryb Eye Institute, we offer several premium lens options, allowing us to tailor lens selection to the patient’s ocular health, visual needs, and lifestyle.
These include:
There is no single premium lens that is best for everyone. Some patients prioritize reading vision, others prioritize distance and intermediate vision, and some prefer a more traditional monofocal approach with excellent distance correction.
My job is to help patients understand the differences and select an implant that makes sense for their individual eyes and expectations.
If you have cataracts and astigmatism, a toric lens may be an excellent option. If you are considering a premium lens, however, it is worth looking beyond the name of the implant.
Ask about the surgeon’s experience, the measurements used to calculate lens power, how the intended axis is determined, and what technology is used to help ensure accurate positioning.
Small details can matter when the goal is high-quality vision.
At Kutryb Eye Institute, we believe that excellent cataract surgery involves more than simply removing a cloudy lens and replacing it with an artificial one. It involves thoughtful planning, advanced technology, surgical experience, and attention to precision at every step.
The right lens matters. But getting it in the right position matters, too.
If you are considering cataract surgery or a premium toric lens implant, I invite you to schedule a consultation at Kutryb Eye Institute in Titusville, Florida. We can evaluate your eyes, discuss your options, and determine which approach may best meet your visual goals.
Michael Kutryb, MD
Kutryb Eye Institute
Titusville, Florida
Scientific References:
1. Yang F, et al. (2025). Comparison of manual, image-guided, and femtosecond laser-assisted marking techniques for toric intraocular lens alignment. Photodiagnosis and Photodynamic Therapy. 55:104772 Femtosecond laser-assisted capsulotomy marking provided the best visual outcomes and accurate alignment for toric IOLs.
3. Comparison of toric intraocular lens alignment between femtosecond laser-assisted capsular marking and digital marking (2023). This prospective study found mean misalignment of 1.71 degrees with femtosecond laser-assisted capsular marking versus 2.64 degrees with digital marking. Only 25 eyes were included in the final analysis, so the results are promising rather than definitive.
Frequently Asked Questions:
Does a toric lens need to be positioned at a specific angle?
Absolutely yes – that’s basically the whole idea. If you have ever been refracted for glasses you’ll remember the phrase “better one, or two.” Well, during the refraction the technician or doctor at some point is moving the astigmatism axis a little clockwise and a little counterclockwise to see where you see best. That is aligning the toric axis in your glasses. While we are in surgery we are not measuring for glasses, but we are implanting a new lens implant. We rely on super accurate measurement of the eye before surgery with the Zeiss IOLMaster 700 and the Alcon Argos and use software to recommend which axis to set a toric lens implant such as Panoptix Pro Toric or PureSee Toric. The closer the new lens is set to the proper axis the better the final vision will be.
Does laser-assisted cataract surgery improve toric lens alignment?
Recent studies have shown that using femtosecond laser-assisted toric markings can help Toric lens alignment be slightly more accurate than manual marking with ink on the eye. Since the arrival of the LenSx On-Axis laser-assisted platform and the LENAR ALLY laser-assisted platform, I suspect that more studies will come out showing their improvements over manual ink marking.
What premium toric lenses are available at Kutryb Eye Institute?
Options include PanOptix Pro Toric, TECNIS PureSee Toric, Clareon Toric, enVista Toric, and enVista Aspire Toric, depending on individual patient suitability.
Who performs cataract surgery at Kutryb Eye Institute?
Dr. Michael Kutryb, MD and Bradley Shoss, MD are board-certified ophthalmologists with extensive experience with LenSx laser-assisted cataract surgery and perform surgery here in Titusville, Florida.
