Inclusion and exclusion criteria were established for identifying smartphone apps ( Table 1). Healthcare provider stores, commercial app stores and popular, non-peer-reviewed ophthalmology websites were searched using the following keywords: “toric lens”, “toric IOL”, “refraction”, “astigmatism”, “ophthalmology”, “eye calculator”, “ophthalmology calculator” and “refractive calculator”. In our experience, 72% of the eyes with preoperative astigmatism between 0.75 and 2.5 diopters (D) were within 0.5 D of residual manifest astigmatism and 63% of eyes had an astigmatic error of ≤0.5 D relative to the expected residual astigmatism at 12 months after toric IOL implantation. These errors, subsequently, may require further treatment in the form of IOL repositioning, exchange or laser refractive surgery. In an extensive retrospective review of 4949 eyes, the primary sources of error identified during toric IOL surgery included preoperative measurements of the cornea (27%), IOL misalignment (14.4%) and IOL tilt (11.3%). Intraoperatively, implanting the IOL at the correct axis is of utmost importance as deviations as small as 3 degrees from the intended axis can result in a clinically significant 10% loss in astigmatism correction, with a rotation of 30 degrees resulting in a 100% loss of astigmatic correction. There are multiple steps involved in the preoperative planning for toric IOL implantation, including patient selection, accurate biometry, consistency with regular and symmetric corneal astigmatism on corneal topography and reference markings. Toric intraocular lens (IOL) implantation is one of the most effective ways to correct corneal astigmatism during cataract surgery however, its practical use relies on accurate calculation, selection and alignment of the toric IOL. Current literature, though limited, suggests that axis marking smartphone apps can achieve similar levels of misalignment reduction when compared to digital systems. Toric Calculator for iPhone and iToric Patwardhan were the highest-scoring toric IOL calculator and axis marker, respectively. Our review identified and objectively scored ten smartphone apps available for toric IOL surgery adjuncts. Phase III ranked Toric Calculator for iPhone (Apple iOS, MAQ 4.13 average MAQ 3.34 ± 0.54) as the highest-scoring toric IOL calculator, and iToric Patwardhan (Android OS, MAQ 4.13 average MAQ 3.41 ± 0.44) was the highest-scoring axis marker in our study. Three studies validating two apps (toriCAM, iToric Patwardhan) in a clinical setting as adjunct tools for preoperative axis marking were identified. Phase II of our study screened 477 studies from PubMed, Medline and Google Scholar. Phase I of our study screened 2428 smartphone apps, of which six apps for toric IOL calculation and four apps for axis marking were eligible and were selected for quantitative analysis.
Included apps were objectively scored (phase III) by three independent reviewers using the mobile app rating scale (MARS), a validated tool that ranks the quality of mobile health apps using a calculated mean app quality (MAQ) score.
Keywords used in both searches included: “toric lens”, “toric IOL”, “refraction”, “astigmatism”, “ophthalmology”, “eye calculator”, “ophthalmology calculator” and “refractive calculator”.
A systematic literature review (phase II) was conducted to identify studies for included apps in phase I of our study. A review was conducted on four major app databases (phase I): National Health Service (NHS) Apps Library, Google Play Store, Apple App Store and Amazon Appstore. This review was divided into three phases. Our objective was to identify, review and objectively score smartphone apps applicable to toric IOL calculation and/or axis alignment. Smartphone apps are becoming increasingly popular in ophthalmology, one specific area of their application being toric intraocular lens (IOL) surgery for astigmatism correction.
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