Accuracy of toric intraocular lens power calculation depending on different keratometry values using a novel network based software platform.

Purpose: To compare different corneal keratometry readings (swept-source-OCT-assisted biometry and Scheimpflug imaging) with a novel software platform for calculation of toric intraocular lenses. Setting: Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany. Design: Retrospective, non-randomized, clinical trial. Methods: Twenty-three eyes undergoing toric intraocular lens implantation were included. Inclusion criteria were preoperative regular corneal astigmatism of at least 1.00 D, no previous refractive surgery, no ocular surface diseases and no maculopathies. Lens exchange was performed with CALLISTO eye (Zeiss). For each patient, the expected postoperative residual refraction was calculated depending on three different corneal parameters of two different devices: standard K-front (K) and total keratometry (TK) obtained by a swept-source-OCT-assisted biometry system (IOL Master 700, Zeiss) as well as total corneal refractive power (TCRP) obtained by a Scheimpflug device (Pentacam AXL, Oculus). Barrett's formula for toric intraocular lenses was used for all calculations within a novel software platform (EQ workplace, Zeiss FORUM®). Results were statistically compared with postoperative refraction calculated according to the Harris dioptric power matrix. Results: The standard K values (mean PE 0.02 D ± 0.45 D) and TK values (mean PE 0.09 D ± 0.43 D) of the IOL Master 700 reached similar results (p = 0.96). 78% of eyes in both K and TK groups achieved SE within ±0.5 D of attempted correction and all eyes (100%) were within ±1.0 D of attempted correction in both groups. By contrast, the prediction error in the IOL calculation using the TCRP of the Scheimpflug device was significantly greater (mean PE -0.56 D ± 0.49 D; p = 0.00 vs. standard K and p = 0.00 vs. TK) with adjusted refractive indices. Thirty-nine and Ninety-one percentage of eyes in the TCRP group achieved SE within ±0.5 D (p = 0.008 K vs. TCRP and p = 0.005 TK vs. TCRP) and ± 1.0 D (p = 0.14 vs. TCRP) of attempted correction, respectively. Conclusion: All three corneal parameters (standard K, TK, TCRP) performed well in calculating toric IOLs. The most accurate refractive outcomes in toric IOL implantation were achieved by IOL calculations based on swept-source-OCT-assisted biometry. The SS-OCT-based K-front and TK values achieve comparable results in the calculation of toric IOLs.

Intraocular lens power calculation using total keratometry and ray tracing in eyes with previous small incision lenticule extraction - A case series.

Purpose: To assess the IOL power calculation accuracy in post-SMILE eyes using ray tracing and a range of total keratometry based IOL calculation formulae. Observations: Ray tracing showed excellent predictability in IOL power calculation after SMILE and its accuracy was clinically comparable with the Barrett TK Universal II and Haigis TK formula. Conclusions and importance: Incorporating posterior corneal curvature measurements into IOL power calculation after SMILE seems prudent. The ray tracing method as well as selected TK-based formulae yielded excellent accuracy and should be favored in post-SMILE eyes.

One-stage versus two-stage bilateral implantable collamer lens implantation: a comparison of efficacy and safety.

Implantable collamer lens implantation (ICL) represents a safe and effective treatment for myopia and myopic astigmatism. To compare the outcomes of a bilateral one-stage same day approach to a two-stage approach, the databases of the University Eye Hospital Munich, Ludwig Maximilians-University and Smile Eyes Linz, Austria were screened for eyes that had undergone ICL implantation. Two-stage surgery was performed at an interval of 1 day (17 patients), 2 days (19 patients) and 1 week (2 patients). Variables analyzed were preoperative, 1-day and last follow-up uncorrected distance (UDVA) and corrected distance visual acuity (CDVA), manifest refraction, refractive spherical equivalent (SEQ), astigmatism, age, endothelial cell count (ECD), intraocular pressure (IOP) and ICL vaulting. In total, 178 eyes (100 eyes one-stage, 78 eyes two-stage) of 89 patients were included in this study. Mean follow-up was 1.1 ± 0.8 and 1.3 ± 0.5 years. Mean preoperative SEQ was - 7.9 ± 2.6 diopters (D) in the one-stage and - 8.0 ± 1.7 D in the two-stage group (p = 0.63) and improved to 0.00 ± 0.40 and - 0.20 ± 0.40 D at end of follow-up, showing slightly better stability in the one-stage group (p = 0.004). There was no difference in the efficacy (1.1 vs. 1.2, p = 0.06) and the safety index (1.2 vs. 1.2, p = 0.60) between the two groups. No eye (0%) in either group lost 2 lines or more of UDVA (p > 0.99). Refraction within ± 0.50 D and ± 1.00 D around target was achieved comparably often (89 vs. 86%, p = 0.65; 99 vs. 99%, p > 0.99). Endothelial cell loss was slightly higher in the two-stage group (1.3 vs. 4.3%). Vaulting at the final follow up was higher in the one-stage group (373.8 ± 205.4 µm vs. 260.3 ± 153.5 µm, p = 0.00007). There were no serious intraoperative complications in either group. In conclusion, this study demonstrates that both the one- and two-stage approaches are equally effective, predictable and safe. Regarding endothelial cell loss, vaulting and SEQ stability, the one-stage group showed slightly better outcomes, but these results are clinically questionable because they are so small. Larger studies are needed to quantitatively evaluate a potential benefit.

Optimizing Refractive Outcomes of SMILE: Artificial Intelligence versus Conventional State-of-the-Art Nomograms.

PURPOSE: AI (artificial intelligence)-based methodologies have become established tools for researchers and physicians in the entire field of ophthalmology. However, the potential of AI to optimize the refractive outcome of keratorefractive surgery by means of machine learning (ML)-based nomograms has not been exhausted yet. In this study, we wanted to comprehensively compare state-of-the-art conventional nomograms for Small-Incision-Lenticule-Extraction (SMILE) with a novel ML-based nomogram regarding both their spherical and astigmatic predictability. METHODS: A total of 1,342 eyes were analyzed for creation of three different nomograms based on a linear model (LM), a generalized additive mixed model (GAMM) and an artificial-neuronal-network (ANN), respectively. A total of 16 patient- and treatment-related features were included. Each model was trained by 895 eyes and validated by the remaining 447 eyes. Predictability was assessed by the difference between attempted and achieved change in spherical equivalent (SE) and the difference between target induced astigmatism (TIA) and surgically induced astigmatism (SIA). The root mean squared error (RMSE) of each model was computed as a measure of overall model performance. RESULTS: The RMSE of LM, GAMM and ANN were 0.355, 0.348 and 0.367 for the prediction of SE and 0.279, 0.278 and 0.290 for the astigmatic correction, respectively. By applying the created models, the theoretical yield of eyes within ±0.50 D of SE from target refraction improved from 82 to 83% (LM), 84% (GAMM) and 83% (ANN), respectively. Astigmatic outcomes showed an improvement of eyes within ±0.50 D from TIA from 90 to 93% (LM), 93% (GAMM) and 92% (ANN), respectively. Subjective manifest refraction was the single most influential covariate in all models. CONCLUSION: Machine learning endorsed the validity of state-of-the-art linear and non-linear SMILE nomograms. However, improving the accuracy of subjective manifest refraction seems warranted for optimizing ±0.50 D SE predictability beyond an apparent methodological 90% limit.

Optical coherence tomography-based misdiagnosis and morphological distinction in pachychoroid neovasculopathy vs. polypoidal choroidal vasculopathy.

PURPOSE: To evaluate the rate of misdiagnosis of aneurysmatic pachychoroid type 1 choroidal neovascularization/polypoidal choroidal vasculopathy (PAT1/PCV) among cases diagnosed as non-aneurysmatic pachychoroid neovasculopathy (PNV) and to define optical coherence tomography (OCT) features facilitating their distinction. METHODS: The database of the Department of Ophthalmology, Ludwig-Maximilians University Munich, was screened for patients diagnosed with PNV. Multimodal imaging was screened for the presence of choroidal neovascularization (CNV) and aneurysms/polyps. Imaging features facilitating the diagnosis of PAT1/PCV were analysed. RESULTS: In total, 49 eyes of 44 patients with a clinical PNV diagnosis were included, of which 42 (85.7%) had PNV and 7 (14.3%) represented misdiagnosed PAT1/PCV. SFCT was comparable (PNV: 377 ± 92 vs. PAT1/PCV: 400 ± 83 µm; p = 0.39). Whereas no difference was detected in total pigment epithelium detachment (PED) diameter (p = 0.46), maximum PED height was significantly higher in the PAT1/PCV group (199 ± 31 vs. 82 ± 46, p < 0.00001). In a receiver operating characteristic (ROC) analysis, the optimum cutoff for defining "peaking PED" was 158 µm with an area under the curve of 0.969, a sensitivity of 1.0 (95% CI: 0.59-1.0), and a specificity of 0.95 (95% CI: 0.84-0.99). Sub-retinal hyperreflective material (SHRM; p = 0.04), sub-retinal ring-like structures (SRRLS; p < 0.00001), and sub-RPE fluid (p = 0.04) were significantly more frequent in eyes with PAT1/PCV. CONCLUSION: A relevant percentage of eyes diagnosed with PNV might instead suffer from PAT1/PCV. The detection of a maximum PED height ("peaking PED") exceeding approximately 150 µm, SHRM, SRRLS, and sub-RPE fluid might greatly aid in the production of a more accurate diagnosis.

Scleral Thickness as a Risk Factor for Central Serous Chorioretinopathy and Pachychoroid Neovasculopathy.

In the pathophysiology of central serous chorioretinopathy (CSC), scleral changes inducing increased venous outflow resistance are hypothesized to be involved. This work aims to investigate anterior scleral thickness (AST) as a risk factor for pachychoroid disorders. A randomized prospective case-control study was performed at the Ludwig Maximilians University, Department of Ophthalmology. In patients with CSC or pachychoroid neovasculopathy (PNV) and in an age- and refraction-matched control group, swept source optical coherence tomography (SS-OCT) was used to measure anterior scleral thickness (AST). Subfoveal choroidal thickness (SFCT) was assessed using enhanced depth imaging OCT (EDI-OCT). In total, 46 eyes of 46 patients were included in this study, with 23 eyes in the CSC/PNV and 23 eyes in the control group. A significantly higher AST was found in the CSC/PNV compared with the control group (403.5 ± 68.6 (278 to 619) vs. 362.5 ± 62.6 (218 to 498) µm; p = 0.028). Moreover, the CSC/PNV group showed a higher SFCT (392.8 ± 92.8 (191-523) vs. 330.95 ± 116.5 (167-609) µm, p = 0.004). Compared with the age- and refraction-matched controls, patients with CSC and PNV showed a significantly thicker anterior sclera. Scleral thickness might contribute to the venous overload hypothesized to induce pachychoroid phenotypes.

Posterior Segment Involvement in Infantile Nephropathic Cystinosis - A Review.

Cystinosis is a rare lysosomal storage disease with a prevalence of 1 : 100 000 - 1 : 200 000 cases. It is caused by biallelic mutations in the CTNS gene, which encodes cystinosin, that transport cystine out of the lysosomes. Due to its dysfunction, cystine crystals accumulate in the lysosomes and ultimately cause apoptosis of the cell. Since cystinosin is ubiquitously present in the body, cystine crystals are deposited in every body structure and lead to the dysfunction of various organ systems in the course of time. Cystine crystals deposited in the cornea are a clinical hallmark of the disease, while there is less awareness of concomitant posterior segment alterations. Symmetrical pigment epithelial mottling and patches of depigmentation frequently start in the periphery and progress towards the posterior pole and can be encountered upon fundus biomicroscopy. Spectral-domain optical coherence tomography (SD-OCT) is an elegant tool for visualizing chorioretinal cystine crystals at the posterior pole. An SD-OCT-based clinical grading of the severity of the chorioretinal manifestation can potentially be applied as a biomarker for systemic disease status and for monitoring oral therapy adherence in the future. Along with previous histological examinations, it may also give information about the location of cystine crystals in the choroid and retina. This review aims to increase the awareness of vision-threatening retinal and choroidal changes in cystinosis and the concomitant findings in SD-OCT.

[Enhancement Options after Lens and Corneal Refractive Surgery]. / Enhancement-Optionen nach Linsen- und refraktiver Hornhautchirurgie.

BACKGROUND: Modern preoperative diagnostics as well as current surgical techniques allow cataract and refractive surgery to deliver precise refractive results.Occasionally, unsatisfactory refractive and visual results occur despite all the care taken. In these cases, subsequent improvement is required to achieve the best final visual outcome. This article shows the therapeutic options for the treatment of residual refractive errors after lens and corneal refractive surgery. KEY MESSAGES: The causes of postoperative refractive errors after refractive laser- or lens-based procedures are very diverse and require extensive workup of the cause as well as an individual solution to achieve the desired result. Before any further surgical intervention, specific complications of the primary procedure as well as concomitant ocular diseases must be excluded or treated. The appropriate enhancement after keratorefractive surgery depends primarily on the type of primary surgery, residual stromal thickness, possible complications from the initial surgery, and the patient's personal preference. For enhancements using surface treatments, such as PRK, the use of mitomycin C is recommended for prophylaxis of haze formation. After lens surgery, for low-grade postoperative refractive errors (spherical and astigmatic), keratorefractive enhancements provide the most accurate results. For higher refractive errors, lens-based procedures can be used, with add-on IOLs being safer and more precise compared with one IOL exchange. Low astigmatisms can be successfully treated with LRI or keratorefractive surgery, but higher astigmatisms should be corrected with an IOL exchange in the early postoperative period and with an add-on IOL in the later postoperative period. IOL explantations should be performed very cautiously, especially in cases of pronounced capsular fibrosis, previous posterior capsulotomy, and existing weakness of the zonular apparatus.

Corneal Manifestation in Patients with Infantile Nephropathic Cystinosis.

Nephropathic cystinosis is a rare autosomal recessive disease caused by mutations in the CTNS gene. This causes dysfunction of cystinosin, a protein that transports cystine out of lysosomes, causing cystine crystals to accumulate in cells in most organ systems. While renal complications predominate in the early forms of cystinosis, corneal crystal accumulation will inevitably manifest in all patients. The main symptoms are photophobia along with glare sensitivity and blepharospasm. In addition, corneal crystal accumulation can cause other complications, such as recurrent corneal erosions, punctate or filamentary keratopathy, and chronic dry eye. Eventually, peripheral corneal neovascularization and limbal stem cell deficiency may develop. Ophthalmologists play a key role in the early diagnosis of patients with cystinosis. This review aims to not only raise awareness of secondary complications of corneal crystal accumulation, but also to highlight current treatment options and challenges that ophthalmologists and pediatricians might face.

Comparison of Visual and Refractive Outcome between Two Methods of Corneal Marking for Toric Implantable Collamer Lenses (TICL) in Phakic Eyes.

PURPOSE: To compare the efficacy of digital-assisted reference marking for toric implantable collamer lenses (Callisto Eye System) with manual marking technique using a slit lamp markeur. METHODS: This study included patients that underwent implantation of a toric implantable collamer lens (EVO Visian toric ICL, Staar Surgical). Patients were included if they had a myopia above -3 diopters (D) and regular corneal astigmatism of 0.75 diopters or higher. Between both groups a 1:2 matching regarding similar preoperative level of myopia and astigmatism was performed. Visual and refractive outcomes were evaluated. Vector analysis was performed to evaluate total astigmatic changes. RESULTS: This study comprised 57 eyes of 57 patients with 19 eyes in the digital group and 38 eyes in the manual marking group. Postoperatively there were no statistically significant differences between both groups in UDVA (p = 0.467), spherical equivalent (SE) (p = 0.864), sphere (p = 0.761) and cylinder (p = 0.878). Vector analysis showed a slightly more accurate postoperative refractive astigmatism in the manual group (0.26 D at 107° ± 0.50 D) compared to the digital marking group (0.31 D at 107° ± 0.45 D), nevertheless with no statistically significant differences between both groups. CONCLUSIONS: A digital tracking approach for toric ICL alignment was an efficient and safe method for toric marking with similar results regarding visual and refractive outcomes compared to a conventional corneal marking method. Nevertheless, image-guided surgery helped to streamline the workflow in refractive ICL surgery.

Spectral domain optical coherence tomography-based retinochoroidal cystine crystal score: a window into infantile nephropathic cystinosis.

PRÉCIS: Cystinosis is a lysosomal storage disease leading to an accumulation of cystine crystals in several organs. We aim to comprehensively describe chorioretinal cystine crystals via spectral domain optical coherence tomography (SD-OCT) and elaborate a new biomarker for systemic disease control. BACKGROUND/AIMS: Cystinosis is a rare lysosomal storage disease leading to an accumulation of cystine crystals in several organs. This study aims to describe the deposition of retinochoroidal crystals in infantile nephropathic cystinosis and to elucidate their potential value as an objective biomarker for systemic disease control. METHODS: This cross-sectional study was carried out by the University Eye Hospital of the Ludwig-Maximilian University (Munich, Germany) in collaboration with the German Cystinosis Study Group. A complete ophthalmologic examination was performed, along with posterior segment SD-OCT (Spectralis; Heidelberg Engineering GmbH, Heidelberg, Germany). Retinochoroidal crystals were graded by employing a novel semiquantitative grading system-the retinochoroidal cystine crystal score (RCCCS). To quantify quality of vision, patients completed a specific questionnaire. A total of 85 eyes of 43 patients with cystinosis were included (mean age 22.3±8.8 years, range 6-39; male:female ratio=23:20). RESULTS: Cystine crystals were detectable in all neuroretinal layers and the choroid, most frequently in the choriocapillaris. The RCCCS was negatively correlated with cysteamine intake (r=0.533, p=0.001) and positively with cystatin C, a stable parameter of renal function (r=0.496, p=0.016). Moreover, the value of the RCCCS affected subjective quality of vision. Genetic analysis indicated pronounced crystal deposition in patients with heterozygous mutations containing the 57-kb-deletion allele of the CTNS gene. CONCLUSION: Ocular cystinosis leads to retinochoroidal crystal accumulation in every stage of the disease. Crystal deposition may be markedly influenced by oral cysteamine therapy. Therefore, the presented SD-OCT based grading system might serve as an objective biomarker for systemic disease control.

Pharmacological drug screening to inhibit uveal melanoma metastatic cells either via EGF-R, MAPK, mTOR or PI3K.

AIM: To screen five potential pharmacological substances specifically targeting EGF-R, MAPK, mTOR, or PI3K for their antiproliferative effects, possible impact on cell viability, as well as cell death rates on three different uveal melanoma metastasis cell lines in vitro. METHODS: Three different uveal melanoma metastasis cell lines (OMM2.5, OMM2.3, and OMM1), that originated from human hepatic and subcutaneous metastasis, were exposed to inhibitors of different targets: erlotinib (EGF-R), everolimus (mTOR), selumetinib (MAPK), trametinib (MAPK) or the alkylphosphocholine erufosine (PI3K). Cell viability was assessed with a 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide (XTT) dye reduction assay after 24h of treatment. Antiproliferative effects were evaluated separately after a 72-hour incubation of the cells with the pharmacological substance. Subsequently, the IC50 was calculated. Tumor cell death was investigated using a double stain apoptosis detection assay. RESULTS: Selumetinib, trametinib, and erufosine significantly decreased cell viability of all OMM cell lines (P<0.04). In addition, selumetinib and trametinib showed a significant inhibition of cell proliferation (P<0.05). Everolimus and erlotinib solely inhibited cell proliferation at the used concentrations (P<0.05). Besides an increase of necrotic cells after erufosine treatment (P<0.001), no changes in the number of dead cells for the other substances were observed. CONCLUSION: The preliminary drug screening demonstrates five new candidates, successfully targeting the canonical MAPK/ERK and PI3K/AKT/mTOR pathways in uveal melanoma metastasis cells in vitro. Hence, these findings provide an experimental basis to explore future single or combined therapy strategies for metastatic uveal melanoma.

IOL Power Calculations and Cataract Surgery in Eyes with Previous Small Incision Lenticule Extraction.

Small incision lenticule extraction (SMILE), with over 5 million procedures globally performed, will challenge ophthalmologists in the foreseeable future with accurate intraocular lens power calculations in an ageing population. After more than one decade since the introduction of SMILE, only one case report of cataract surgery with IOL implantation after SMILE is present in the peer-reviewed literature. Hence, the scope of the present multicenter study was to compare the IOL power calculation accuracy in post-SMILE eyes between ray tracing and a range of empirically optimized formulae available in the ASCRS post-keratorefractive surgery IOL power online calculator. In our study of 11 post-SMILE eyes undergoing cataract surgery, ray tracing showed the smallest mean absolute error (0.40 D) and yielded the largest percentage of eyes within ±0.50/±1.00 D (82/91%). The next best conventional formula was the Potvin-Hill formula with a mean absolute error of 0.66 D and an ±0.50/±1.00 D accuracy of 45 and 73%, respectively. Analyzing this first cohort of post-SMILE eyes undergoing cataract surgery and IOL implantation, ray tracing showed superior predictability in IOL power calculation over empirically optimized IOL power calculation formulae that were originally intended for use after Excimer-based keratorefractive procedures.

Corneal Collagen Crosslinking (CXL) for Corneal Ectasia after Small Incision Lenticule Extraction (SMILE). / Korneales Kollagen-Crosslinking (CXL) bei Hornhautektasie nach SMILE (Small Incision Lenticule Extraction).

With an estimated incidence of 0.011%, the SMILE procedure seems to have the lowest risk of postoperative keratectasia among contemporary keratorefractive procedures. Nevertheless, due to the novelty of the procedure as well as the lack of data, no clear superiority over femto-LASIK or PRK can be stated at this time. In this respect, application of the identical tomographic screening criteria previously developed for excimer-based procedures is of paramount importance to minimize the risk of corneal ectasia. As an adjunct to conventional corneal tomography, newer imaging modalities such as OCT-based epithelial mapping should be used for preoperative screening before keratorefractive surgery. Corneal crosslinking is an established treatment modality for post-SMILE keratectasia, which promises high success rates especially in early stages. The present case report illustrates these diagnostic and therapeutic considerations.

[Phototherapeutic keratectomy for recurrent corneal erosion of various epithelial origins: influence of depth of ablation on pachymetry and refraction]. / Phototherapeutische Keratektomie bei rezidivierenden Hornhauterosionen verschiedener epithelialer Genese: Einfluss der Ablationstiefe auf Pachymetrie und Refraktion.

BACKGROUND: Phototherapeutic keratectomy (PTK) is an established treatment method for patients suffering from either genetic corneal dystrophy or recurrent corneal erosion (RCE) without underlying basement membrane dystrophy, often caused by trauma. OBJECTIVE: This study aimed to describe the changes in manifest subjective refraction and pachymetry after PTK treatment in patients suffering from epithelial basement membrane dystrophy (EBMD) and traumatic or atraumatic RCE without underlying EBMD. MATERIAL AND METHODS: This was a retrospective, single-center study performed at the Department of Ophthalmology of the Ludwig-Maximilians University (Munich). Patient data were retrospective collected using the smart-eye database of the Department of Ophthalmology including diagnostic data from an autorefractometer and from the Pentacam HR. All laser treatments were performed with an ablation depth of 10 µm for EBMD patients and 6 µm for RCE patients without EBMD. RESULTS: Both collectives showed a decrease in pachymetry larger than the calculated ablation depths after a follow-up interval of 126 days (95% CI 104-147 days). While the EBMD collective receiving an ablation of 10 µm showed a decrease of 25.8 µm (N = 74; 95% CI 21.2-30.3; p < 0.001), the non-EBMD collective receiving an ablation of 6 µm showed a decrease of 12.3 µm (N = 44, 95% CI 7.0-17.7; p < 0.001). Both, total corneal refractive power (TCRP) as well as spherical equivalent (SE) offered no significant change in preoperative and postoperative comparison for the EBMD collective. On the other hand, patients without underlying EBMD showed a significant myopic decrease in SE of 0.4 dpt (±0.7 dpt SD, p < 0.05). The mean follow-up interval was 126 days (95% CI 104-147 days). CONCLUSION: PTK treatment offers an effective method for patients suffering from either EBMD dystrophy or RCE syndrome without underlying EBMD. The final ablation based on pachymetry at the apex can be estimated at 2.3 to 2.6 times higher compared to the original ablation depth. The reasons for this are on the one hand the laser ablation itself and the influence of the reactive wound healing of the corneal epithelium.

Saving of Time Using a Software-Based versus a Manual Workflow for Toric Intraocular Lens Calculation and Implantation.

Background: To determine whether there is a significant saving of time when using a digital cataract workflow for digital data transfer compared to a manual approach of biometry assessment, data export, intraocular lens calculation, and surgery time. Methods: In total, 48 eyes of 24 patients were divided into two groups: 24 eyes were evaluated using a manual approach, whereas another 24 eyes underwent a full digital lens surgery workflow. The primary variables for comparison between both groups were the overall time as well as several time steps starting at optical biometry acquisition until the end of the surgical lens implantation. Other outcomes, such as toric intraocular lens misalignment, reduction of cylinder, surgically induced astigmatism, prediction error, and distance visual acuity were measured. Results: Overall, the total diagnostic and surgical time was reduced from 1364.1 ± 202.6 s in the manual group to 1125.8 ± 183.2 s in the digital group (p < 0.001). The complete time of surgery declined from 756.5 ± 82.3 s to 667.3 ± 56.3 (p < 0.0005). Compared to the manual approach of biometric data export and intraocular lens calculation (76.7 ± 12.3 s) as well as the manual export of the reference image to a portable external storage device (26.8 ± 5.5 s), a highly significant saving of time was achieved (p < 0.0001). Conclusions: Using a software-based digital approach to toric intraocular lens implantation is convenient, more efficient, and thus more economical than a manual workflow in surgery practice.