What is the main target for all phaco surgeons?

(1)

CORRECTION OF

CO

C O

O

CO

C O

O

ASTIGMATISM DURING

CATARACT SURGERY

d ll h d ll h Abdallah

Abdallah K. K. HassounaHassouna, M.D., M.D. Sherein

Sherein S. S. WahbaWahba, M.D., M.D. Ain

Ain Shams UniversityShams University 2009

(2)

Main target

What is the main target for

ll h

?

(3)

Main Target

Removal

Removal ofof thethe crystallinecrystalline lenslens (( whetherwhether Removal

Removal ofof thethe crystallinecrystalline lenslens (( whetherwhether cataractous

cataractous oror notnot )) withwith properproper IOLIOL implantation

implantation combinedcombined withwith otherother proceduresprocedures to

to correctcorrect preoperativepreoperative astigmatismastigmatism toto

to

to correctcorrect preoperativepreoperative astigmatismastigmatism toto achieve

(4)

Astigmatism

l di ib i f i i l di ib i f i i

Astigmatism

Natural distribution of astigmatism Natural distribution of astigmatism

00 -- 11 DD 4545%% 11..2511..2525 -- 22..55 D25 22..55 DD 45D 4545%45%%% >> 22..55 DD 1010%%

Value of minimizing astigmatism Value of minimizing astigmatism

ToTo achieveachieve bestbest UCVAUCVA

PrePre--requisiterequisite forfor multifocalmultifocal && accommodativeaccommodative PrePre requisiterequisite forfor multifocalmultifocal && accommodativeaccommodative

IOLs IOLs

(5)

Methods of correction of astigmatism

at the time of cataract surgery

Wound placementWound placementpp

Opposite clear corneal incisionsOpposite clear corneal incisions

Astigmatic keratotomy Astigmatic keratotomy

Astigmatic keratotomyAstigmatic keratotomy

LimbalLimbal relaxing incisions (LRIs)relaxing incisions (LRIs) LASIKLASIK

(6)

Astigmatism

Preoperative evaluation of corneal astigmatism Preoperative evaluation of corneal astigmatism

Astigmatism

Preoperative evaluation of corneal astigmatism Preoperative evaluation of corneal astigmatism

9

9 Use KeratometryUseUseUse KeratometryKeratometry,, IOLKeratometry,, IOLIOL masterIOL mastermaster ormaster oror elevationor elevationelevation basedelevation basedbasedbased

topography topography

XX NotNot:: refractionrefraction (Corneal(Corneal && lenticularlenticular astigmatism)astigmatism) XX NotNot:: refractionrefraction (Corneal(Corneal && lenticularlenticular astigmatism)astigmatism)

neither

neither PlacidoPlacido basedbased topographytopography (tilt,(tilt, errorerror inin calculation)

(7)

Astigmatism

< 1 D Steep meridian incision

2 D Opposite clear corneal i i i

incision

< 3.5 D Limbal relaxing incisions 1.4- 2.3 D Staar toric IOL

1- 2 D AcrySof toric IOL (T3-T5) 2.5 – 4 D AcrySof toric IOL (T6-T9) Up to 12 D Combinations and

b k piggybacking

(8)

Toric Intraocular Lenses

(9)

Toric

Toric IOLs

IOLs

Toric

Toric IOLs

IOLs

Advantages: Advantages: Advantages: Advantages:

No additional surgical stepsNo additional surgical steps

Predictable Predictable

PredictablePredictable

Minimal cataract woundMinimal cataract wound

Ideal candidate: Ideal candidate:

Regular astigmatismRegular astigmatism

(10)

Staar Toric AcrySof Toric

Plate Silicon Hapticp Single piece hydrophobic acrylicg p y p y

Anterior toric Posterior toric

24 % > 10° rotation Average 4° rotation

Usually stabilize within 48h Usually stabilize after OVD

removal

Corrects: 1.4 or 2.3 D @ Corrects: 1.03, 1.55 or 2.06 D

Corrects: 1.4 or 2.3 D @

corneal plane Corrects: 1.03, 1.55 or 2.06 D @ corneal plane

Calculator: no SIA compensation Calculator: SIA compensation

(11)

Complications

pp

Decentration

Decentration SublaxationSublaxation Decentration

(12)

Rotational stability

Generally , for every 1Generally , for every 1°° of rotation, 3.3% of rotation, 3.3%

of the IOL cylinder power is lost of the IOL cylinder power is lost

3030°° of rotation may completely negate of rotation may completely negate yy pp yy gg

cylinder power correction of a

cylinder power correction of a torictoric IOLIOL

Further rotation potentially increases Further rotation potentially increases

visual problems for the patients visual problems for the patientspp pp

(13)

Fi t

Fi t T i

T i IOL

IOL

First

First Toric

Toric IOL

IOL

ThreeThree--piecepiece (PMMA)(PMMA)

ToricToric curvecurve onon thethe concaveconcave backback surfacesurface ToricToric curvecurve onon thethe concaveconcave backback surfacesurface ImplantedImplanted throughthrough aa 55..77 mmmm cornealcorneal

incision incision

((SchimizuSchimizu etet alal 19921992)) ((SchimizuSchimizu,, etet alal 19921992))

(14)

Second

Second Toric

Toric IOL

IOL

OneOne--piecepiece PMMAPMMA lenslens

OverOver lengthlength ofof 1212..55 mmmm

Modified

Modified CC looploop hapticshaptics

ModifiedModified CC--looploop hapticshaptics 55..2525 mmmm roundround opticopticpp

(15)

Fi t F ld bl IOL

First Foldable IOL

Staar

Staar Toric

Toric IOL

IOL

Staar

Staar Toric

Toric IOL

IOL

PlatePlate hapticPlatePlate haptichaptichaptic

FoldableFoldable siliconsilicon

BiconvexBiconvex 66 mmmm opticoptic

hh l dl d ll ff

SpheroSphero--cylindricalcylindrical anterioranterior surfacesurface SphericalSpherical posteriorSphericalSpherical posteriorposterior surfaceposterior surfacesurfacesurface

(16)

Id l

did

Ideal

Ideal candidate

candidate

RegularRegular astigmatismastigmatism

AstigmatismAstigmatism betweenbetween 11..55-- 33..55 DD

Prerequisites

TheThe cataractcataract woundwound shouldshould bebe astigmaticallyastigmatically

neutral neutral

Advantages

Predictable Predictable PredictablePredictable

minimalminimal cataractcataract woundwound

dd l

dd l ll

(17)

Complications

DecentrationDecentration SublaxationSublaxation SublaxationSublaxation

LensLens rotationrotation andand axisaxis shiftshift::

1010°° results in cylinder reduction of 2/3results in cylinder reduction of 2/3

1010 results in cylinder reduction of 2/3results in cylinder reduction of 2/3

2020°° results in cylinder reduction of 1/3results in cylinder reduction of 1/3

(18)

2003

2003 –– 2005

2005

2003

2003 2005

2005

Staar

Staar Toric

Toric

Staar

Staar Toric

Toric

OUR AIM

To study the best way of reducing

PEA during cataract surgery

(19)

2003

2003 ‐‐ 2005

2005

2003

2003 2005

2005

comparing between construction

of the wound in the steep

meridian, LRIs, and

meridian, LRIs, and toric

,

toric IOLs

IOLs

as regards the efficacy, predictability, stability, and as regards the efficacy, predictability, stability, and

safety safety

(20)

Patients and Methods

45 45

This study included

This study included 45 eyes 45 eyes of 42 patients with a mean of 42 patients with a mean age 53.9 years divided into 3 parts:

age 53.9 years divided into 3 parts:

P t

P t II I l d dI l d d 1515 dd tt tt tt

¾

¾ PartPart II:: IncludedIncluded 1515 eyeseyes underwentunderwent cataractcataract surgerysurgery

with

with thethe incisionincision sitesite onon thethe steepsteep meridianmeridian

¾

¾ PartPart IIII:: IncludedIncluded 1515 eyeseyes underwentunderwent LRIsLRIs duringduring ¾

¾ PartPart IIII:: IncludedIncluded 1515 eyeseyes underwentunderwent LRIsLRIs duringduring

cataract

cataract surgerysurgery

¾

¾ PartPart IIIIII:: IncludedIncluded 1515 eyeseyes underwentunderwent cataractcataract surgerysurgery ¾

¾ PartPart IIIIII:: IncludedIncluded 1515 eyeseyes underwentunderwent cataractcataract surgerysurgery

with

(21)

Calculation of the

Calculation of the Toric

Toric IOL Power

IOL Power

ff

Staar

(22)

Staar

Staar Toric

Toric IOL

IOL

Staar

Staar Toric

Toric IOL

IOL

Inserted through an injector (2.8Inserted through an injector (2.8--3.0 mm)Inserted through an injector (2.8Inserted through an injector (2.8 3.0 mm)3.0 mm)3.0 mm) Has two marks on should be aligned with Has two marks on should be aligned with

h i

the steep axis the steep axis

(23)

(24)

(25)

Vi

l O

Vi

l O

Visual Outcome

Mean % of change of UCVA

4.42 7.57 Part I Part II 4.54 Part II Part III

Comparison between the three parts as regards the mean Comparison between the three parts as regards the mean

percentage of change of UCVA percentage of change of UCVA

(26)

Keratometric

Keratometric astigmatism

astigmatism

2.5 2.38 1 98 1 1.5 2 1.86 1.98 1.36 1.67 1.83 Keratometric Astigmatism 0 0.5

Part I Part II Part III

Study groups

Preop k.astigmatism Postop k.astigmatism 3m

Comparisons between the mean

Comparisons between the mean preoppreop. . keratometrickeratometric

ti ti d

ti ti d tt kk tt t it i astigmatism, and mean

astigmatism, and mean postoppostop. . keratometrickeratometric astigmatism at 3 months among the study groups astigmatism at 3 months among the study groups

(27)

Steep meridian

LRIs

Toric IOL

Preoperative

(28)

Refractive astigmatism

2.11 2.63 2.22 2 2.5 3 0.970.93 1.181.23 0.480.48 0.5 1 1.5 Refractive Astigm atism 0 0.5

Part I Part II Part III

Study groups

Preop R.Astigmatism Postop R.Astigmatism 3m Postop R.Astigmatism 9m

Comparisons between the mean preop refractive astigmatism and mean postop Comparisons between the mean preop. refractive astigmatism, and mean postop.

(29)

Astigmatism reducing effect

Mean % of change of postop. refractive

0.9 1 astigm atism 0.65 0.4 0.6 0.8 0 0.2 1.50-2.25 D 2.50-3.50 D

Comparison between the two astigmatism groups in part III as regards the mean percentage of change of postoperative refractive astigmatism

(30)

P

i

P

d

P

i

P

d

Postoperative Procedure

Orientation

Orientation ofof thethe axisaxis ofof thethe IOLIOL assessedassessed byby:: Orientation

Orientation ofof thethe axisaxis ofof thethe IOLIOL assessedassessed byby::

DilatedDilated pupilpupil onon SLSL examinationexamination

TheThe guideguide ofof thethe StaarStaar softwaresoftware programprogram TheThe guideguide ofof thethe StaarStaar softwaresoftware programprogram

Rotation

Rotation ofof IOLIOL

Five

Five IOLsIOLs werewere withinwithin 55 degreesdegrees ofof thethe intendedintended axisaxis

FiveFive IOLsIOLs werewere withinwithin 55 degreesdegrees ofof thethe intendedintended axisaxis SixSix IOLsIOLs rotatedrotated 1010 degreesdegrees

TwoTwo IOLsIOLs rotatedrotated 1515 degreesdegrees TwoTwo IOLsIOLs rotatedrotated 1515 degreesdegrees OneOne IOLIOL rotatedrotated 2020 degreesdegrees

In

In allall cases,cases, the,, the torictoric IOLIOL remainedremained withinwithin 3030 degreesdegreesgg of

(31)

2008

2008‐‐ 2009

2009

2008

2008 2009

2009

E l

i

f

E l

i

f

Evaluation of

AcrySof

AcrySof Toric

Toric IOL

IOL

AcrySof

AcrySof Toric

Toric IOL

IOL

As regards the efficacy, predictability, stability, As regards the efficacy, predictability, stability,

and safety and safety and safety and safety

(32)

Patients & Methods

This study included

This study included 12 eyes12 eyes of 12 patientsof 12 patients

This study included This study included 12 eyes 12 eyes of 12 patients of 12 patients

implanted with

implanted with AcrysofAcrysof ToricToric IOLIOL

Mean age of patients was 50 7 yearsMean age of patients was 50 7 years Mean age of patients was 50.7 yearsMean age of patients was 50.7 years

Male

Male Female 75% (3/1)Female 75% (3/1)

Male Male –– Female 75% (3/1)Female 75% (3/1)

(33)

AcrySof

AcrySof Toric

Toric IOL

IOL

Rotational stability Rotational stability

AcrySof

AcrySof Toric

Toric IOL

IOL

Rotational stability Rotational stability

STABLEFORCESTABLEFORCE haptichaptic designdesign

Adhesive properties of acrylic materialAdhesive properties of acrylic material Adhesive properties of acrylic materialAdhesive properties of acrylic material

(34)

Posterior Surface

Posterior Surface Toricity

Toricity

Posterior Surface

(35)

(36)

Corrective Cylinder options

(37)

(38)

(39)

(40)

(41)

(42)

(43)

AcrySof

AcrySof Toric

Toric

IOL calculator

(44)

Marking of the eye

g

y

(45)

Marking of the eye

(46)

(47)

Precise on

Precise on-- axis placement

axis placement

Precise on

Precise on axis placement

axis placement

Gross alignment of the IOLGross alignment of the IOL ViscoelasticViscoelastic removalremoval

ViscoelasticViscoelastic removalremoval

(48)

(49)

(50)

(51)

Visual Outcome

(52)

(53)

Postoperative complication

Rotation of IOL

Ten IOLs were within 5 degrees of the

intended axis intended axis

Two IOLs rotated 10 degrees

In all cases, the toric IOL remained within 30 degrees of rotation

(54)

Conclusion

These

These preliminary

preliminary results

results show

show

that

toric

IOLs

implantation

that

toric

IOLs

implantation

during

cataract

surgery

is

effective

and

aa

predictable

procedure

procedure in

in correction

correction of

of PEA

PEA

procedure

(55)

BUT

Cost ineffective

(EXPENSIVE)

(56)

2009

Opposite Clear Corneal

I i i

Incisions

(57)

2009

Opposite Clear Corneal Incisions

22 standard cataract incisions are madestandard cataract incisions are made 180180°°

22 standard cataract incisions are made standard cataract incisions are made 180180 apart along the steep meridian

(58)

Opposite Clear Corneal Incisions

Predictable

Predictable ?? andand effectiveeffective inin providingproviding

Opposite Clear Corneal Incisions

PredictablePredictable ?? andand effectiveeffective inin providingproviding

an

an enhancedenhanced effecteffect overover aa singlesingle CCICCI forfor correcting

correcting PEAPEA inin cataractcataract surgerysurgery correcting

correcting PEAPEA inin cataractcataract surgerysurgery

SteepSteep axisaxis markedmarked withwith thethe patientpatient

t d

t d tt thth litllitl seated

seated atat thethe slitlampslitlamp

22..7575 mmmm incisionincision forfor astigmatismastigmatism ofof 11..00

to

to 11..7575 DD

(59)

Opposite Clear Corneal Incisions

No need for special diamond knife No need for special diamond knife No need for expensive IOLNo need for expensive IOL

(60)

Opposite Clear Corneal Incisions

Lever

Lever andand DahanDahan reported a meanreported a mean

Opposite Clear Corneal Incisions

LeverLever andand DahanDahan reported a mean reported a mean

astigmatism correction of

astigmatism correction of 22..06 06 D with D with incisions ranging from

incisions ranging from 22 88 toto 33 55 mmmm incisions ranging from

incisions ranging from 22..8 8 to to 33..5 5 mmmm

In our hand up to In our hand up to 22D of astigmatism D of astigmatism

correction with

correction with 33..0 0 keratomekeratome

Stability ?

(61)