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In-the-Bag Toric IOL for Correction of Astigmatism in Keratoconus and
after Corneal Surgery
Bart T.H. van Dooren, M.D., Ph.D
Ilse E.M.A. Mol, M.D.
Department of Ophthalmology, Amphia Hospital, Breda, The Netherlands
Correspondence: [email protected]
The above mentioned author and co-author both have no financial interests in the subject matter of this poster
B.T.H. van Dooren WCCVII 2015
Background and purpose
• Purpose: results of phacoemulsification with toric IOL implantation (in the capsular bag) for high, (fairly) regular corneal astigmatism and visually significant cataract in 3 corneal conditions:
• Keratoconus • Post-keratoplasty• Post-pterygium surgery
• Design: retrospective analysis of 17 eyes (16 patients)
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B.T.H. van Dooren WCCVII 2015
Methods
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B.T.H. van Dooren WCCVII 2015
Methods• Inclusion criteria
– Fairly regular cylinder• Pentacam: - total refractive corneal power analysis
- bow-tie pattern
– Astigmatism correctable with glasses– Stable corneal astigmatism
• Keratoconus: minimal risk for progression (age and multiple stable Pentacam examinations)
• Post-keratoplasty: sutures out• Post-pterygium surgery: stability on repeat Pentacam-imaging
– Visually significant cataract– Medical indication (not on a patient-pay basis)
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B.T.H. van Dooren WCCVII 2015
Methods
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B.T.H. van Dooren WCCVII 2015
Results (1)
< 0,1 0,1+ 0,2+ 0,3+ 0,4+ 0,5+ 0,6+ 0,7+ 0,8+ 0,9+0
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Preoperative
Postoperative
Nu
mb
er
of
ey
es
(n
)
Best corrected distance visual acuity (BCVA)
Preoperative versus ‘late’ (12±5 months) postoperative BCVA
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B.T.H. van Dooren WCCVII 2015
Results (2)Changes in BCVA (lines)Number of eyes (n)
Changes in BCVA (Snellen chart) during follow-up (12±5 months)
*
Lost 1 UnchangedGained 1 Gained 2 Gained 3 Gained 4 Gained 5 Gained 6 Gained 7 Gained 80
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Changes in BCVA (lines)
7*co-morbity: macular pucker with metamorphopsia (postoperative BCVA 0,6)
B.T.H. van Dooren WCCVII 2015
Results (3)
< 0.5 < 1.00 < 2.00 < 3.00 < 4.00 < 5.00 < 6.00 6+0
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Preoperative
Postoperative
Manifest refractive cylinder (D)
Nu
mb
er
of
ey
es
(n
)
Preoperative versus ‘late’ (12±5 months) postoperative refractive cylinder in diopters (D)
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B.T.H. van Dooren WCCVII 2015
Scatter plot of the astigmatic vectors (J0 and J45) during follow-up (12±5 months)
-6 -4 -2 0 2 4 6
-4
-3
-2
-1
0
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Preoperative
Postoperative
J45 (D)
J0
(D
)Results (4)
Reference: E.L. Mertens, toric phakic implantable collamer lens for correction of astigmatism: 1-year outcomes (review), Clinical Ophthalmology, 01/2011; 5:369-75
Manifest refractions (S [sphere], C [cylinder], α [axis]) were converted to power vector coordinates by the following formulas:
J0 = (−C/2)*cos (2α) J45 = (−C/2)*sin (2α)
The value (0,0) represents an eye free of astigmatism.
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B.T.H. van Dooren WCCVII 2015
Results (5)
• No surgical complications:- No off-axis alignment or decentration of toric IOL
- No intra- or post-operative complications
• Patient satisfaction:- Overall fairly good
- Less satisfaction in 3 patients because of:- Comorbidity: macular pucker (n=1)
- Conversion from myopia to slight hypermetropia (SE + 1.0 D; target was emmetropia; n=1)
- Additional need for a scleral contact lens (residual astigmatism/anisometropia) (n=1)
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B.T.H. van Dooren WCCVII 2015
Discussion and conclusions
• Safe and effective procedure• Good improvement in BCVA and refractive
parameters• Overall fairly high patient satisfaction
• Case and IOL selection are crucial!– Strict and thorough preoperative Pentacam
evaluation, repeated measurements– Previously mentioned inclusion criteria
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B.T.H. van Dooren WCCVII 2015
Discussion and conclusionsRecommendations:To optimize patient satisfaction, just like in usual toric IOL implantation:
– Prevent postoperative hyperopisation in myopes , and extensively discuss a wish for postoperative emmetropic target refraction.
– Provide optimal cylindrical correction by choosing the optimal IOL for the purpose (i.e. different IOL manufacturers may be necessary).
But remain on the conservative side in these corneal cases: – Especially in keratoconus, postoperative target refraction calculation usually
errs somewhat towards more hyperopic outcomes.– High residual astigmatism is undesirable, but both slight residual
astigmatism and postoperative spectacle correction were well tolerated in our cohort.
– Especially since a reading add is often necessary anyway (don’t use multifocal IOLs in these corneal cases).
Correspondence: [email protected]
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B.T.H. van Dooren WCCVII 2015
