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Justin Charton, MD, Preston H. Blomquist, MD, Nalini K. Aggarwal, MD, James P. McCulley, MD University of Texas Southwestern Department of Ophthalmology.

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Presentation on theme: "Justin Charton, MD, Preston H. Blomquist, MD, Nalini K. Aggarwal, MD, James P. McCulley, MD University of Texas Southwestern Department of Ophthalmology."— Presentation transcript:

1 Justin Charton, MD, Preston H. Blomquist, MD, Nalini K. Aggarwal, MD, James P. McCulley, MD University of Texas Southwestern Department of Ophthalmology ** Dr. McCulley is an consultant for Alcon Labs

2  Cataract surgery technique and technology are evolving rapidly. New lens technologies allow us the ability to give patients a greater degree of spectacle independence.  Toric intraocular lens allow for intra-operative correction of astigmatism and multifocal lens allow for the correction of near vision in addition to distance vision.  These new technologies are rapidly being assimilated and are an important component of today’s comprehensive practice.  Each lens platform represents a different surgical technique to which the surgeon must adapt.  It is important to remember these technologies when considering current resident education. Use of these lens platforms during training will better equip residents for transition to their own practice.

3  A total of 17 eyes of 11 patients with more than 1.0 diopters of corneal astigmatism had placement of an Alcon AcrylSof Toric IOL. Preoperatively, informed consent was obtained, and the patients received a complete ophthalmic exam including slit lamp exam, applanation tonometry, slit lamp exam, best corrected visual acuity, keratometry and A-scan (IOLMaster), topography (Humphrey Atlas Eclipse), and dilated fundus exam. Patients with extensive retinal pathology, corneal surface abnormalities, and irregular astigmatism were excluded.  The AcrylSof Toric online calculator was used for determination of correct lens platform. The AcrylSof is supplied as a T3 (1.5 D), T4 (2.25 D), and T5 (3.00 D) lens. The steep and flat keratometry readings were placed into the calculator, and 0.4 D of surgically induced astigmatism was used. The placement of the main incision was varied to give the most desirable anticipated residual astigmatism. All incisions were 3.0 mm wounds. Lens spherical power was determined using IOL Master measurements in the SRK/T formula. The targeted spherical outcome was plano to -0.50 diopters.  The preoperative corneal markings were made with the patients sitting upright to negate any possible cyclotorsion in the supine position. An intraoperative toric axis marker was used for determination of actual axis placement. The surgeries were performed by senior residents who were completing their surgical chief rotation, and were completed using the divide and conquer technique. After injection, all IOLs were rotated 15-25 degrees from intended axis and the viscoelastic was then removed from posterior to the lens. The IOLs were then rotated to their final position to coincide with corneal axis markings.

4  The multifocal group consisted of a total of 8 eyes of 6 patients who requested correction of both near and distance vision. These patients had placement of the Alcon AcrySof ReSTOR SN6AD3 intraocular lens. Preoperatively, informed consent was obtained, and the patients received a complete ophthalmic exam including slit lamp exam, applanation tonometry, slit lamp exam, best corrected visual acuity, keratometry and A-scan (IOLMaster), topography (Humphrey Atlas Eclipse), and dilated fundus exam. Patients with extensive retinal pathology, corneal surface abnormalities, irregular astigmatism, and astigmatism greater then +0.75 diopters were excluded.  Lens spherical power was determined using IOL Master measurements in the SRK/T formula with a target refraction of plano to +0.25 diopters.  The surgeries were performed by senior residents who were completing their surgical chief rotation, and were completed using the divide and conquer technique. The IOLs were only placed if cases had a continuous curvilinear capsular rhexis. All patients in both groups were followed up at 1 day, 1 week, 1 month, and 6 month intervals. Only cases that retained follow-up through the 1 month appointment were included in the study.  All residents were given a questionnaire after completion of their surgical chief rotation. They were asked to respond to various questions and rate their responses with 1 being the lowest and 5 the highest. A total of 5 residents had completed the rotation at completion of this poster.

5  The mean age of toric patients was 66.4 years with the range being 48 to 70 years. The gender breakdown was 70.6% female / 29.4% male for the toric platform.  In the toric group, 76.5% of patients achieved an uncorrected visual acuity (VA) of 20/25 or better, and 94.1% of patients achieved an uncorrected VA of 20/30 or better. A total of 1 patient (5.9%) achieved uncorrected VA of 20/40 which is thought to be due to tear film abnormalities post-op. A total of 88.2% of patients had best corrected VA of 20/20 with 100% of patients having BCVA of 20/25 or better.  The residual postoperative cylinder for all toric patients was 0.41 +/- 0.34. The residual cylinder was 0.25 +/- 0.29, 0.6 +/- 0.38, and 0.34 +/- 0.27 for the T3, T4, and T5 platforms respectively. Two patients in the T4 group had residual astigmatism of +1.0 D for unknown reasons. These IOLs were on correct axis at dilated exam.  All toric lens had gross assessment of final alignment at 1 month follow-up with all but one IOL being stable in their alignment. One T5 lens was noted to have rotated 13 degrees s/p YAG capsulotomy.

6  The mean age of the multifocal group was 63.5 years with the range being 53 to 73 years of age. The gender breakdown was 50% female / 50% male for this group.  In the study, 87.5% of multifocal patients achieved an distance UCVA of 20/25 or better. One patient (12.5%) achieved an UCVA of 20/30. This was due to an unexpected myopic outcome. For near vision 87.5% of patients achieved uncorrected near VA of J1 with one patient having uncorrected vision of J4.  The mean pre-op cylinder for the multifocal group was 0.46 +/- 0.32.

7 NMean agePre-op refractive cylinder IOLMaster cylinder Topographic Cylinder Axial Length Mean IOL spherical power SN60T3466.75 +/- 12.5 2.25 +/- 0.46 1.57 +/- 0.24 1.31 +/- 0.16 23.37 +/- 1.06 19.5 +/- 3.49 SN60T4563.4 +/- 5.13 0.75 +/- 0.83 1.44 +/- 0.19 1.35 +/- 0.31 24.61 +/- 0.89 18.4 +/- 4.42 SN60T5868.13 +/- 5.36 1.96 +/- 0.37 2.75 +/- 1.07 2.47 +/- 1.34 23.67 +/- 1.30 20.0 +/- 3.15 Mean residual cylinder (refractive) UCVA 20/20 – 20/25 UCVA 20/30 UCVA < 20/30 BCVA 20/20 – 20/25 SN60T30.25 +/- 0.292 (50%) --4 (100%) SN60T40.6 +/- 0.384 (80%)1 (20%)--5 (100%) SN60T50.34 +/- 0.277 (87.5%)--1 (12.5%)8 (100%) Toric Intraocular Lens Measurements Outcomes

8 NMean ageIOLMaster cylinder Topographic Cylinder Axial Length Mean IOL spherical power SN6AD3 863.5 +/- 6.26 0.46 +/- 0.32 0.51 +/- 0.46 23.94 +/- 0.37 19.06 +/- 1.86 UCVA 20/20 – 20/25 UCVA 20/30 UCVA < 20/30 BCVA 20/20 – 20/25 BUCVA Near vision J1 BUCVA < J1 SN6AD3 7 (87.5%)1 (12.5%)08 (100%)7 (87.5%)1 (12.5%) Multifocal Intraocular Lens Measurements Outcomes

9 Rating from 1 (lowest) to 5 (highest) Knowledge with the pre-op workup needed for the multifocal IOLs. 4.8 Knowledge with the pre-op workup needed for the toric IOLs. 4.8 Knowledge of the surgical techniques needed for multifocal IOLs. 4.8 Knowledge of the surgical techniques needed for the toric IOLs. 4.8 To what degree will (multifocal/toric) IOLs impact your practice. 4.4 Will the resident personally utilize these IOLs in post residency practice? 4.4 Did this experience better prepare you for using the (multifocal/toric) IOLs in practice? 4.8 To what degree do you feel these lenses will provide spectacle independence for patients? 4.4 Results ** Total of 5 Residents Post rotation survey

10  The use of toric IOLs allows the surgeon to provide correction of astigmatism intra-op with the use of a lens platform. This provides the surgeon with more options for treating astigmatism.  The toric group of patients in our study compared favorably to prior studies with 76.5% of patients having a uncorrected visual acuity of 20/25 or better, and 100% of patients achieved a BCVA of 20/20.  The residual refractive error was 0.25, 0.60, 0.34 for the T3, T4, and T5 lenses respectively. The T4 group is skewed higher due to two patients with +1.0 D of residual astigmatism for unknown reasons.  In the multifocal group, results were also similar to prior studies. A total of 87.5% of patients achieved a distance UCVA of 20/25 or greater with 100% achieving distance BCVA of 20/25 or better. The only patient to have a UCVA of worse than 20/25 was due to an unexpected myopic outcome. All but one patient achieved near UCVA of J1.

11  The survey indicates that residents strongly feel that these lenses will be utilized frequently in their practice and experience with these lenses will better prepare them for future practice.  The opportunity to learn the pre-op, intra-op, and post-op management associated with these new technologies help prepare the residents for their future practices. Also, valuable experience is gained by residents in counseling patients about their personal goals and subsequent operative options.  Premium IOLs are an important component of today’s comprehensive ophthalmology practice, and residents can be taught to use these IOLs during their training with outcomes comparable to other published studies.

12 1. Horn J. Status of Toric Intraocular Lenses. Curr Opin Ophthalmol 2007;18:58-61 2. Souza C, Muccioli C, Soriano E, et al. Visual Performance of AcrySof ReSTOR Apodized Diffractive 3. IOL: A Prospective Comparative Trial. Am J Ophthalmol 1996;141:827-832 4. Baur N, Vries N, Webers C, et al. Astigmatism Management in Cataract Surgery with the AcrySof Toric Intraocular Lens. Cataract Refract Surg 2008;34:1483-1488 5. Mendicute J, Irigoyen C, Aramberri J. Foldable Toric Intraocular Lens for Astigmatism Correction in Cataract Patients. J Cataract refract Surg 2008;34:601-607 6. Kersey J, O’Donnell A, Illingworth C. Cataract Surgery with Toric Intraocular Lenses can Optimize Uncorrected Postoperative Visual Acuity in Patients with Marked Corneal Astigmatism. Am J Ophthalmol 1998:128:261 7. Wisotsky B, Magat-Gordon C, Puklin J. Vitreopapillary Traction as a Cause of Elevated Optic Nerve Head. Cornea 2007;26:133-135 8. Pepose J, Qazi M, Davies J, et al. Visual Performance of Patients with Bilateral vs Combination Crystalens, ReZoom, and ReSTOR Intraocular Lens Implants. AM J Ophthalmol 2007;144:347-357 9. Gills J, Van Der Karr M, Cherchio M. Combined Toric Intraocualr lens implantation and Relaxing Incisions to reduce High Prexisting Astigmatism. J Cataract Refract Surg 2002;28:1585-1588 10. Hill W, Potvin R. Monte Carlo Simulation of expected outcomes with the AcrySof Toric intraocular lens. BMC Ophthalmol 2008;8:1-9

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