Comparison of manual, image-guided, and femtosecond laser-assisted marking techniques for toric intraocular lens alignment

• Precise alignment of toric intraocular lenses (IOLs) is crucial for optimal astigmatism correction. • Femtosecond laser-assisted capsulotomy marking achieved the best visual outcomes and the most accurate toric IOL alignment. • The CALLISTO Eye image-guided system showed better performance than manual marking. • Postoperative residual astigmatism and IOL misalignment were significantly associated with visual outcomes. To compare the visual outcomes and the accuracy of three axial marking techniques for toric intraocular lenses (IOLs): manual marking, the CALLISTO eye image-guided system and femtosecond laser-assisted capsulotomy marking. A total of 105 eyes of 105 patients were enrolled in this retrospective comparative study. According to different axial marking methods, patients were assigned to the manual marking group (MM group), CALLISTO Eye image-guided system group (CE group) and femtosecond laser-assisted capsulotomy marking group (CM group). Uncorrected distant visual acuity (UCDVA), best corrected distant visual acuity, residual astigmatism, toric IOL misalignment, and modulation transfer function were measured and compared preoperatively and one month and three months postoperatively. Postoperative UCDVA and residual astigmatism were significantly lower in the CM group than in the MM group and CE group both at one month and three months postoperatively. IOL misalignment in the CM group was significantly less than that in the other two groups, and the CE group also performed better than the MM group. The AR values in the CE group and CM group were significantly higher than those in the MM group. Further correlation analysis found that postoperative UCDVA was positively correlated with residual astigmatism and IOL misalignment and negatively correlated with AR value. Postoperative residual astigmatism was positively correlated with IOL misalignment and negatively correlated with AR value. Femtosecond laser-assisted capsulotomy marking provided the best visual outcomes and accurate alignment for toric IOLs. The CALLISTO eye image-guided marking performed moderately but slightly better than manual marking.