A Violinist's Duet With Bilateral Toric Iols

The purpose of this case report is to highlight an unusual cause of a post-operative toric lens rotation, secondary to playing the violin.

A 55 year old moderately myopic female had immediate sequential bilateral cataract surgery with implantation of toric lenses at Moorfields Eye Hospital. Pre-operative refraction was -3.50/-1.50 x 17 in the right eye (RE) and -5.50/-1.50 x 147 in the left eye (LE), with regular corneal astigmatism of 2.03 D and 2.74 D in the respective eyes. Axial lengths were 26.23 RE and 26.48 LE. A Toric Alcon SN6AT4 lens was used in both eyes with a refractive aim of -2.00 D.

The patient reported her vision was clear on post-operative day 1 and 2, but this deteriorated on day 3. At her 2-week post-operative appointment RE and LE refractions were -1.00/-2.00 x 30 and -1.25/-1.50 x 21, respectively. The patient described blur and distortion. On examination, both lenses were well-centred but rotated clockwise by similar degrees; the RE IOL from 91 to 63 degrees and LE IOL from 97 to 65 degrees. Capsulorhexes were 5mm, overlapping the optic 360 degrees with well centred lenses. On probing, the patient reported playing high tempo music with her violin in the early post-operative period. We suspect her bilateral symmetrical lens rotation was due to sustained left head tilt and rapid vibrato head jerking during violin play post-operatively compounding the slightly higher risk of rotation in large myopic capsular bags. She had bilateral IOL repositioning surgery within 3 weeks, utilising astigmatismfix.com and both the original IOL master and a new post-rotation IOL Master to confirm the new lens position. Following careful dissection of the anterior capsular-IOL adhesions, clockwise rotation of the toric lens was completed with the bag full of viscoelastic, leaving it just shy of the desired axis. Final alignment was achieved once viscoelastic was removed. She was advised to refrain from playing the violin in the early post operative period. Subsequent post operative refraction was -1.75/-0.50 x 170 in the RE and -2.00/-0.25 in the LE.

This case highlights an uncommon cause of toric lens rotation. It emphasises the importance of enquiring about activities and hobbies that involve head tilting before surgery which should be avoided in the immediate post-operative period. Furthermore, measures should be taken to avoid toric IOL rotation: appropriately sized capsulorhexis overlapping the optic; anterior capsular rim polish to promote capsule-IOL adherence; and avoid implanting capsular tension rings (unless indicated for zonular weakness) which can negatively impact decentration and tilt whilst conferring no added benefit of preventing IOL rotation.