Modified Malyugin ring technique for optimized toric intraocular lens alignment in small-pupil cataract surgery

A simple optimization for toric intraocular lens (IOL) alignment in cataract surgery using the Malyugin ring is described. Traditionally, the Malyugin ring is removed before ophthalmic viscosurgical device evacuation, which frequently leads to pupillary constriction toward or smaller than its preplacement diameter and compromises visualization of the toric axis markings, making it difficult to ensure accurate lens alignment. In this modified technique, ophthalmic viscosurgical device is removed from the capsular bag while the Malyugin ring remains in place, preserving pupillary dilation for toric IOL alignment under irrigation. Once alignment is finalized, a small amount of ophthalmic viscosurgical device (Provisc) is reinjected into the anterior chamber to facilitate safe removal of the ring. The approach adds minimal surgical time and maximizes visualization of the toric markings after ophthalmic viscosurgical device evacuation. By maintaining accurate visualization throughout the procedure, this modification provides cataract surgeons with a practical and reproducible method for achieving more accurate toric IOL alignment.