**7. Surgical techniques**

Success in cataract surgery with premium IOLs lies in performing every step precisely and predictably. The surgeon team should check the patient's information, the surgical device and material availability.

Surgeons must pay attention to preexisting or surgically induced astigmatism, because it can have a huge impact on visual outcomes with a multifocal IOL. The magnitude of astigmatism and axis should be checked by more than two device such as topography, IOLMaster, Lenstar and so on. For less than 1.0D astigmatism, the incision at steep axis is the better approach. When preoperative astigmatism is up to1.5 diopter, the limbal relaxing incisions (LRIs) can be considerable [65]. At higher levels of astigmatism than 1.5D, the best solution is toric multifocal IOLs [66]. Whether LRI or toric IOLs, the corneal limbal mark should be made before surgery. Many manual method or device had been developed, and computerized automated axis marking system also can been chosen [67].

**Figure 9.** *Trifocal IOL (Panoptix, Alcon) implantation with 5.0 mm FLACS capsulotomy.*

A 5.0–5.5 mm perfectly round and centered capsulorhexis is preferred for premium IOLs surgery. The right size capsulorhexis will completely cover the optic of IOLs, let the lens center over the visual axis to get the best visual results. The capsulorhexis size depends on the different IOLs design. The precise size will be customed when femtosecond laser is available, which led to less intraocular aberration postoperatively [68, 69] (**Figure 9**).

The Healon or other viscous ophthalmic viscoelastic device (OVD) can protect the endothelium cells during the procedure. It also can flat the anterior capsule to make capsulorhexis more controlled. The OVD should be removed completely when surgery finished to prevent intraocular pressure from increasing. If the toric multifocal IOLs used, the OVD should be totally removed behind lens to avoid the accident rotation after surgery [67].
