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Evaluation & Surgical Correction of Astigmatism. Jean Luc Febbraro MD Rothschild Foundation Paris France. [email protected] Evaluation & Surgical Correction of Astigmatism. Financial disclosure Alcon Laboratories: C, Croma: C Bausch & Lomb Surgical: C,L.

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Evaluation surgical correction of astigmatism
Evaluation & Surgical Correction of Astigmatism

Jean Luc Febbraro MD

Rothschild Foundation

Paris

France

[email protected]


Evaluation surgical correction of astigmatism1
Evaluation & Surgical Correction of Astigmatism

Financial disclosure

Alcon Laboratories: C, Croma: C

Bausch & Lomb Surgical: C,L


Surgical correction of astigmatism
Surgical Correction of Astigmatism

  • Evaluation & Principles

  • Prevalence & Evolution

  • Cataract incisions SIA


Evaluation of astigmatism
Evaluation of Astigmatism

  • K-readings

    • 2mm central

  • Topography

    • Placido, Scheimflug (cornea > 2mm)

    • Aberrometers (cornea, internal)

  • Refraction

    • Total astigmatism (subjective, objective)


Evaluation of astigmatism1
Evaluation of Astigmatism

  • Topography (placido)

    • Precise measurement

      • Magnitude, axis

      • Symmetry

      • Regularity

      • Detection

        • K. fruste

        • Pellucid Deg.


Evaluation of astigmatism2
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 astigmatism3
Evaluation of Astigmatism

  • Refraction (Subjective, objective)

    • Perfect match required

      • Subjective

        • (Sph, cyl)

      • Objective

        • (Sph, cyl & HOA)

      • Enable WF ablation


Astigmatic correction cataract patients
Astigmatic Correction & Cataract Patients

  • Surgical options:

    • Incisional techniques

      • LRI, AK

    • Toric IOLs

    • Laser vision correction

      • PRK, LASIK


Astigmatic correction incisional techniques
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 techniques1
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 techniques2
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
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 lri1
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
Astigmatic Correction: LRI / AK

  • LRI: pros

    • Less irregular astigmatism

    • Less chance of perforation

    • Convenient technique

      • Easy to perform

      • Intraoperatively


Astigmatic correction lri ak1
Astigmatic Correction: LRI / AK

  • LRI: cons

    • Limited astigmatic correction

    • Regression

    • Variability of results


Astigmatic correction lri
Astigmatic Correction: LRI

  • Instruments: simple kit

    • Axis marker

    • 0.12-caliber forceps

    • Diamond knife

      • Preset (600 microns)

      • Micrometer


Study
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
Results:Astigmatism pre / postop

Corneal Astigmatism (D)


Lris tips tricks
LRIs: Tips & Tricks

Placement of incisions

  • Axis

    • 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
Astigmatic Correction withToric IOLs

  • Reduction of Astigmatism

    • SN60T3 = 1.5D (1D)

    • SN60T4 = 2.25D (1.5D)

    • SN60T5 = 3.0D (2D)


Astigmatic correction withtoric iols1
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
Astigmatic Correction with Laser

  • Laser Vision Correction:

    • Precise correction of astigmatism

    • Correction of spherical component

    • Check MR and WF refraction


Astigmatic correction with laser1
Astigmatic Correction with Laser

n=340

n=206

n=139

Netto et al, AJO 2006;141:360-368


Laser astigmatic vision correction
Laser Astigmatic Vision Correction

  • Refractive patients: primary choice

    • PRK

    • LASIK

    • Excellent accuracy (sphere & cylinder)

    • Constant technological improvements


Laser astigmatic vision correction1
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



Iris Recognition

ACE

SRET DRET

Static Rotational ET Dynamic Rotational ET

Compensation between Intraoperative compensation

upright / supine position

Texte



Results
Results

Cyclotorsion:

Static (SRET) / Dynamic (DRET)

Fondation A. de Rothschild

Paris

Jean-Luc Febbraro MD


ACE

Mean Static (SRET) / Dynamic (DRET)

N:70

%

Cyclotorsion

Fondation A. de Rothschild

Paris

Jean-Luc Febbraro MD


ACE

Mean Absolute Amplitude (DRET)

DRET Amplitude (°)

Fondation A. de Rothschild

Paris

Jean-Luc Febbraro MD


Conclusion
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

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
To evaluate Astigmatism Distribution and Evolution in Adult Patients

STUDY

  • Retrospective study

  • 500 eyes of 276 patients

  • Autorefractometer refraction & keratometry measurements

  • Mean interval: 8.37 +/-2.92 y (min 5-16 max)


RESULTS Patients


RESULTS Patients

Astigmatism Distribution


RESULTS Patients

Astigmatism Evolution

visit1

visit2

-0.02

OCULAR AST.

CORNEAL AST.

SPHERE


Astigmatism evolution
Astigmatism Evolution Patients

RESULTS

ATR shift over 8 years

0.26 D


Astigmatism evolution1
Astigmatism Evolution Patients

* E. Gudmundsdottir, A. Arnarsson, F. Jonasson. Five-year refractive changes in an adult population; Reykjavik Eye Study. Ophthalmology 2005;112, 672–677.


Astigmatism in Patients

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
Cataract Incisions Patients 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
Cataract Incisions Patients 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 Patients 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 Patients Astigmatic Effects

Standard 3-3.5-mm on axis CCI PKE

Long D. et al. Ophthalmology 1996; 103:226-232

Texte


Cataract Incisions Patients Astigmatic Effects

Standard 3.2-mm on axis / temp. CCI PKE

Borasio E. et al. JCRS 2006; 32:565-572

Texte


Cataract Incisions Patients Astigmatic Effects

3-3.5-mm Incision & SIA Range

Literature Summary

Texte


Cataract incisions 3 5 2 8 mm cci clinical implications
Cataract incisions Patients 3.5-2.8-mm CCIClinical Implications

Choice of Incision Location

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
Comparison Patients 3.0 / 2.2-mm Temporal CCI

Masket S. et al. JRS 2009; 25:21-2424

Texte


Comparison 1 8 mm c mics 1 7 mm b mics
Comparison Patients 1.8-mm C-MICS / 1.7-mm B-MICS

Wilczynski M. et al. JCRS 2009; 35:1563-69

Texte


Study evaluate sia cataract incisions
STUDY Patients 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
Study Patients Results

Vector Analysis


Cataract incisions
Cataract Incisions Patients

  • 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 incisions1
Cataract Incisions Patients

  • 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


Fondation A. de Rothschild Patients

Paris

Jean-Luc Febbraro MD

Thank you

for your attention

Texte


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