GENTILINO, 14 novembre 2019 Francesco Failla, MD

SAoO Congresso Satellite 2019

Preoperative Evaluation in

Premium Toric Iol’s

GOOD RESULTS

Systematic Approach

Knowledge

Surgical Skill

📱📱 Question 1

How often do you implant toric IOL’s ?

A Never (not interested)

B Occasionally

C Regularly

D I’m interested but I don’t dare

📱📱 Question 2

How often do you implant multifocal IOL’s ?

A Never (not interested)

B Occasionally

C Regularly

D I’m interested but I don’t dare

☑📱📱 Summary

→ Patient evaluation/examination

→ Patient selection

→ Astigmatism evaluation

→ IOL calculation

→ Pre-operative setup

→ Surgical technique

☑📱📱 Patient evaluation

→ Done by the Optometrist

→ First discussion

→ Understand the problem

→ Understand the needs/wishes

→ Primary information

☑📱📱 Patient examination

→ Done by the Optometrist (first part)

→ Subjective Refraction

→ Keratometry + Topography

→ Biometry

→ Fundus Imaging (can avoid surprises)

☑📱📱 Patient selection

→ Done by the Ophthalmologist

→ Check all the measurements

→ Complete the medical examination

→ Discussion with the patient

→ Understand the needs/wishes

→ Discuss the different options

☑📱📱 Patient selection

Understanding needs & wishes

→ Ophthalmological / Psychological approach

→ Functional needs

→ Refractive needs

→ Refractive wishes (overestimated expectations !)

Downgrade Expectations !

☑📱📱 Patient selection

Discussion about different options

→ Aggressively suggest TORIC IOL’s (if corneal cylinder ≥ 1.5D) 🙂🙂 Low risk of visual complications

📱📱 IOL calculation, surgical skill

→ Carefully suggest MULTIFOCAL IOL’s 🙂🙂 Standard surgery

📱📱 Potential risk of visual complications (halos, glare, contrast sensitivity, luminosity)

Acceptance very variable (disappointment)

Impossible to test or simulate preoperatively

🙂🙂 If MF then aggressively suggest TORIC MF (cyl. ≥ 1.0D)

☑📱📱 IOL Calculation

→ MULTIFOCAL IOL’s - Target emmetropia

- Different Additions

→ TORIC & MF-TORIC IOL’s - Evaluation of Astigmatism

- Use Toric IOL Calculator

- Company made calculators

- Independent calculators

Astigmatism Evaluation

Astigmatism of the eye

Cornea Lens Retina

Astigmatism Evaluation

Astigmatism of the cornea

Astigmatism Evaluation

Astigmatism of the cornea

anterior corneal

astigmatism

posterior corneal

astigmatism

40/45 D -6/-8 D

Total corneal astigmatism (TCA) = ACA + PCA

Astigmatism Evaluation

Anterior Corneal Astigmatism (ACA)

MOST IMPORTANT

Different measurement methods

Manual Keratometry

Automatic Keratometry

Topography

Biometry

All measurements done @ 3 mm zone ➪ interpolation🙂🙂🙂🙂

All methods based on reflecting light (🙂🙂🙂🙂 corneal surface)

🙂🙂🙂🙂 All measurements give different values 🙂🙂🙂🙂

Astigmatism Evaluation

Anterior Corneal Astigmatism (ACA)

How to make the right choice?

1) Determine steep meridian by drawing a line manually through the

steepest axis of central 3mm zone off topographic map and reed

the value

2) The instrument that got the axis in agreement with observed axis

on the topography is the one to use for power

73°

Astigmatism Evaluation

Posterior Corneal Astigmatism (PCA)

Difficult to be measured

Low refractive index difference aqueus/cornea

Low value

Only few devices available Pentacam

Galilei

IOL Master 700

Author Year Eyes Device Percentage Vertical PCA

Ho 2009 493 Pentacam 96.1%

Koch 2012 715 Galilei 86.6%

Miyake 2015 608 Pentacam HR 91.0%

LaHood 2018 1098 IOLMaster 700 73.3%

Percentage of Vertical Posterior Corneal Astigmatism

J Refract Surg. LaHood et al. 2018;34(5):331-336

Most PCA (75-90%) are WRA independently of ACA

J Refract Surg. LaHood et al. 2018;34(5):331-336

WRA ARA ARA

WRA

ARA

ARA

How does the posterior astigmatism act:

WRACA

How does the posterior astigmatism act:

WRACA + WRPCA TCA

How does the posterior astigmatism act:

ARACA

How does the posterior astigmatism act:

ARACA + WRPCA TCA

What are the options for using

Posterior Corneal Astigmatism in Toric IOL calculation

Individual measurement - Ideal option measure TCA

- Can be incorporated in some Calculators

Population Statistics (estimation) - Integrated in some Calculators

- Used in Nomogram Adjustments

- 🙂🙂🙂🙂There can be outliers🙂🙂🙂🙂

- Incorporating PCA in IOL calculation gives better results

- No need to adjust large cylinders (>2.5 D)

- Either use a Nomogram or a Calculator 🙂🙂🙂🙂 DON’T double adjust 🙂🙂🙂🙂

How does a Nomogram Adjustment work

To Calculator

Different Toric IOL Calculators

Dr Ben LaHood

📱📱 Question 3

The Posterior Corneal Surface is…

A A week positive refractive surface

B A strong positive refractive surface

C A week negative refractive surface

D A strong negative refractive surface

📱📱 Question 4

In case of corneal WRA, the PCA mostly…

A Increases the TCA

B Decreases the TCA

C Does not affect TCA

D None of the above is correct

📱📱 Question 5

How do you consider posterior corneal astigmatism?

A I always take PCA in account

B It is new for me and I will consider it from now on

C I let the calculator do the job

D Nice to know but I don’t see the interest

☑📱📱 Preoperative setup

→ Check the IOL Chart

→ Check the IOL Labels

☑📱📱 Preoperative setup

→ Axis alignment

☑📱📱 Preoperative setup

→ Axis alignment - Making the “Zero Axis”

☑📱📱 Preoperative setup

→ Axis alignment - Making the “Zero Axis”

☑📱📱 Preoperative setup

→ Axis alignment - Making the “Zero Axis”

☑📱📱 Preoperative setup

→ Axis alignment - Making the “Zero Axis”

@ Slit lamp

☑📱📱 Preoperative setup

→ Axis alignment - Making the “Zero Axis”

@ Slit lamp

☑📱📱 Intraoperative IOL alignment

→ Making the “Final Axis”

☑📱📱 Intraoperative IOL alignment

→ Capsular Tention Ring

☑📱📱 Intraoperative IOL alignment

→ IOL Alignment

Take at home message

Take care of the quality of the measurement

Consider posterior corneal astigmatism in IOL calculation

Use updated calculators/nomograms

Take care of axis marking and IOL alignment

doc@failla.ch