Evaluation & Surgical Correction of Astigmatism Jean Luc Febbraro MD Rothschild Foundation Paris France jeanluc@febbraro.net

Evaluation & Surgical Correction of Astigmatism Financial disclosure Alcon Laboratories: C, Croma: C Bausch & Lomb Surgical: C,L

Surgical Correction of Astigmatism Evaluation & Principles Prevalence & Evolution Cataract incisions SIA

Evaluation of Astigmatism K-readings 2mm central Topography Placido, Scheimflug (cornea > 2mm) Aberrometers (cornea, internal) Refraction Total astigmatism (subjective, objective)

Evaluation of Astigmatism Topography (placido) Precise measurement Magnitude, axis Symmetry Regularity Detection K. fruste Pellucid Deg.

Evaluation of Astigmatism Aberrometers (Hartman-Shack, OPD) Precise measurement Lower order ab. (Sph, cyl.) Higher order ab. (coma, trefoil, sph. aberrations) Distinction Total, internal

Evaluation of Astigmatism Refraction (Subjective, objective) Perfect match required Subjective (Sph, cyl) Objective (Sph, cyl & HOA) Enable WF ablation

Astigmatic Correction & Cataract Patients Surgical options: Incisional techniques LRI, AK Toric IOLs Laser vision correction PRK, LASIK

Astigmatic Correction & Incisional Techniques Principles: The cornea flattens over an incision Transverse incisions increase the radius of curvature in one meridian only The flattening effect increases as incisions approach the visual axis

Astigmatic Correction & Incisional Techniques Coupling: The flattening effect of a transverse incision is associated with a steepening effect 90° away. Coupling ratio tend to be one to one. The spherical equivalent remains unchanged.

Astigmatic Correction & Incisional Techniques Principles: Incisions are always placed on the steep meridian. The longer and deeper the incision the greater the effect. The older the patient the greater the effect.

Astigmatic Correction with LRI LRI / PRI Placed on the steepest meridian Located at the limbus (9.0-11.0-mm OZ) 44 42

Astigmatic Correction with LRI Principles Flatten the steepest meridian Steepen the axis at 90° Coupling ratio 1:1 42 43 44 43

Astigmatic Correction: LRI / AK LRI: pros Less irregular astigmatism Less chance of perforation Convenient technique Easy to perform Intraoperatively

Astigmatic Correction: LRI / AK LRI: cons Limited astigmatic correction Regression Variability of results

Astigmatic Correction: LRI Instruments: simple kit Axis marker 0.12-caliber forceps Diamond knife Preset (600 microns) Micrometer

STUDY 46 eyes, 30 patients (age: 72 + 10 A) 3.2 mm CCI, Steep axis Preset 600 µ diamond knife Limbal relaxing incisions Preop Corneal Astig.: 1.66 + 0.65 D (0.75 to 3) Follow up: 6 M

Results: Astigmatism pre / postop Corneal Astigmatism (D)

LRIs: Tips & Tricks Placement of incisions Axis Constant orientation 10° off: -33% 15° off: -52% Constant orientation Constant depth Preset 600µ knife Micrometer knife set at 90% thinnest pachymetry Steep axis +++

Astigmatic Correction withToric IOLs Reduction of Astigmatism SN60T3 = 1.5D (1D) SN60T4 = 2.25D (1.5D) SN60T5 = 3.0D (2D)

Astigmatic Correction withToric IOLs FDA Data 92% 20/40 or better Mean residual astigmatism: 0.60 D 50% less than 0.5D of residual postop astigmatism 97.6% rotated less than 15 degrees

Astigmatic Correction with Laser Laser Vision Correction: Precise correction of astigmatism Correction of spherical component Check MR and WF refraction

Astigmatic Correction with Laser Netto et al, AJO 2006;141:360-368

Laser Astigmatic Vision Correction Refractive patients: primary choice PRK LASIK Excellent accuracy (sphere & cylinder) Constant technological improvements

Laser Astigmatic Vision Correction All types of regular astigmatisms Simple, compound myopic astig. Flatten the steepest meridian Simple, compound hyperopic astig. Steepen the flattest meridian Mixed astig. Combine both principles

Cyclotorsion & Astigmatic Correction

ACE Iris Recognition SRET DRET Static Rotational ET Dynamic Rotational ET Compensation between Intraoperative compensation upright / supine position Texte

Cyclotorsion Study Eyes Mean Degree Movement Other Febbraro et al. JCRS, 2010 70 3.4 + 2.7º up to 14º Swami, Steinert et al, AJO, 2002 240 4.1º + 3.7º 8% with over 10º of movement Smith, Talamo, Assil, JCRS, 1994 50 - 25% over 7º of movement (up to 16º)

Results Cyclotorsion: Static (SRET) / Dynamic (DRET) ACE SRET DRET Mean 3.08 + 2.68 ° 3.39 + 2.94° Range -7 - +14.1° -10.3 - +13.5° Fondation A. de Rothschild Paris Jean-Luc Febbraro MD

ACE Mean Static (SRET) / Dynamic (DRET) Fondation A. de Rothschild % Cyclotorsion Fondation A. de Rothschild Paris Jean-Luc Febbraro MD

ACE Mean Absolute Amplitude (DRET) Fondation A. de Rothschild DRET Amplitude (°) Fondation A. de Rothschild Paris Jean-Luc Febbraro MD

Fondation A. de Rothschild Conclusion Surgical correction of astigmatism is a reality Mandatory to optimize uncorrected vision Refractive and cataract patients Numerous surgical options Fondation A. de Rothschild Paris Jean-Luc Febbraro MD

Prevalence and evolution Of astigmatism Clinical significance Accurate eye care IOL manufacturers (SA , Cyl.) Valuable information for cataract & refractive surgeons

Prevalence and evolution Of astigmatism Astigmatism evolution with age Age / Ast. 2654 patients % Mean 20-30 years 40% 1.20 D 70-80 years 72% 1.30 D Prevalence of astig. increases with age. Ferrer-Blasco T. et al. JCRS 2008; 34:424-432

To evaluate Astigmatism Distribution and Evolution in Adult Patients STUDY To evaluate Astigmatism Distribution and Evolution in Adult Patients Retrospective study 500 eyes of 276 patients Autorefractometer refraction & keratometry measurements Mean interval: 8.37 +/-2.92 y (min 5-16 max)

RESULTS Mean ocular astigmatism 0.95 +/- 0.77 Mean corneal astigmatism Mean age 60.11 +/- 11.39 Age min- Age max 37-90 Gender: Male / Female 182 M / 318 F Mean sphere -0.02 +/- 3.20 Sphere min-max -14.75 - + 7.5 Mean ocular astigmatism 0.95 +/- 0.77 Ocular astig. min-max 0.25 - 6.75 Mean corneal astigmatism 1.14 +/- 0.40 Corneal astig. min-max 0 - 6.5 Mean flat K (K1) 43.10 +/- 1.39 Mean steep K (K2) 44.11 +/- 1.48 Nous avons etudie 500 yeux…

RESULTS Astigmatism Distribution Magnitude ≤0.5D 35.8% 33.8% 0.75 - 1D Ocular Astig. Corneal Astig. ≤0.5D 35.8% 33.8% 0.75 - 1D 36.6% 33.4% 1.25 - 2D 20.8% 23.8% > 2D 6.8% 8.2% Distribution de lastig total et corneenselon sa puissance , on voit que le 1 tiers des ….

RESULTS Astigmatism Evolution visit 1 visit 2 -0.02 OCULAR AST. CORNEAL AST. SPHERE L evaluation de la sph du cyl total et corneen lors de la 2eme visite montre que…. -0.02

Astigmatism Evolution RESULTS Astigmatism Evolution Age Groups Cylinder Axis < 50 0.19 +/- 0.64D 6 +/- 17° 50-59 0.24 +/- 0.71D 12 +/- 20° 60-69 0.31 +/- 0.75D 6 +/-17° > 70 0.28 +/- 0.89D 5 +/- 15° ATR shift over 8 years 0.26 D

Astigmatism Evolution Age Groups Study 500 eyes Reykjavic Eye Study* 757 eyes < 50 0.19 +/- 0.64 D 50-59 0.24 +/- 0.71D 0.09 +/- 0.41 D 60-69 0.31 +/- 0.75D 0.13 +/- 0.45 D > 70 0.28 +/- 0.89D 0.22+/- 73° All Groups O.26 D over 8 years 0.13 D over 5 years * E. Gudmundsdottir, A. Arnarsson, F. Jonasson. Five-year refractive changes in an adult population; Reykjavik Eye Study. Ophthalmology 2005;112, 672–677.

Astigmatism in Cataract Patients Knowledge of prevalence and evolution of astigmatism is valuable information 35% negligible astig. 35% 0.75 – 1 D 30% > 1 D 7% 2 D Mean magnitude +/- 1 D in adults, tends to increase with age ATR axis shift (0.13 – 0.26 D) over time, particularly in older patients

Cataract Incisions Introduction Trend Size Standard 3-mm incision Mini + 2.5-mm incision Micro sub 2-mm incision Placement Scleral to limbal / clear corneal incision Superior to temporal approach Texte

Cataract Incisions Choice Factors Size IOL implantation Monofocal, Multifocal, Accomodative, Toric IOLs Phaco platform Phaco and I/A probes & sleeves Location Scleral to limbal / clear corneal incision Superior to temporal approach Texte

Cataract Incisions Astigmatic Effects Astigmatic change Incision size Distance from visual axis Axis placement Astigmatic change evaluation Algebraic method (magnitude of ast.) Vector Analysis (magnitude & axis of ast.) Texte

Cataract Incisions Astigmatic Effects Standard 3-3.5-mm on axis CCI PKE n: 172 Sup. Incision Temp. Incision SIA 0.93 + 0.54 D 0.62 + 0.47 D Long D. et al. Ophthalmology 1996; 103:226-232 Texte

Cataract Incisions Astigmatic Effects Standard 3.2-mm on axis / temp. CCI PKE n: 62 On Axis Incision Temporal Incision SIA 7 w PO 0.63 D 0.34 D * Borasio E. et al. JCRS 2006; 32:565-572 Texte

Cataract Incisions Astigmatic Effects 3-3.5-mm Incision & SIA Range Literature Summary Incision Location Superior Oblique On Axis Temporal SIA (D) 0.60 – 1.50 0.60 – 1.29 0.60 – 0.90 0.09 – 0.44 * Texte

Cataract incisions 3.5-2.8-mm CCI Clinical Implications Choice of Incision Location Temporal Inc. Nasal Inc. Superior Inc. 1996 Kohnen T, Koch D.1 ATR 0.75-1.25 D WTR 2005 Tejedor J, Murube J.2 ATR < 0.75 D ATR > 0.75 D WTR >1.25 D 2009 Tejedor J, Perez J.3 Negligible Ast. 1 Kohnen T, Koch D. Curr Opin Ophthalmol. 1996; 7:75-80 2 Tejedor J, Murube J. Am J Ophthalmol. 2005; 139:767-776 3 Tejedor J, Perez-Rodriguez J. IOVS. 2009; 50:989-994 Texte

Comparison 3.0 / 2.2-mm Temporal CCI SIA 0.67 + 0.48 D 0.35 + 0.21 D * Masket S. et al. JRS 2009; 25:21-2424 Texte

Comparison 1.8-mm C-MICS / 1.7-mm B-MICS SIA 0.23 + 0.29 D 0.23 + 0.22 D Wilczynski M. et al. JCRS 2009; 35:1563-69 Texte

STUDY Evaluate SIA Cataract Incisions Nonrandomized prospective series 191 eyes Group 1: 60 eyes PKE 3.2-mm sup. CCI Group 2: 68 eyes PKE 2.2-mm sup. CCI Group 3: 63 eyes PKE 1.8-mm sup. CCI Two-plane incision with precalibrated metal knife Unenlarged wound for IOL implantation Group 1: SN60WF / Akreos AO IOLs Group 2: SN60WF / Akreos MICS IOLs Group 3: Akreos MICS IOL Texte

Study Results Vector Analysis 3.2-mm 2.2-mm 1.8-mm Group Arithmetic Mean Vector Mean 3.2-mm 1.02 + 0.39 D 0.77 at 10° 2.2-mm O.60 + 0.20 D 0.26 at 20° 1.8-mm O.48 + 0.10 D 0.16 at 13°

Cataract Incisions Texte Desirable to know astigmatic effect of CCI SIA depends on incision size and location. Significant less SIA with 1.8 / 2.2 / + 3.0-mm CCI. SIA very limited with + 2.0-mm CCI. Texte

Cataract Incisions Texte Desirable to know astigmatic effect of CCI SIA depends on incision size and location. Significant less SIA with 1.8 / 2.2 / + 3.0-mm CCI. SIA very limited with + 2.0-mm CCI. Clinical implications To minimize SIA & optimize visual rehabilitation. Customized incision size and location (>2.8-mm) based upon preop. astig. Optimize UCVA with monofocal & premium IOLs. Texte

Thank you for your attention Fondation A. de Rothschild Paris Jean-Luc Febbraro MD Texte