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Clinical Outcomes Post AcrySof Toric IOL Implantation In 231 Consecutive Eyes

Clinical Outcomes Post AcrySof Toric IOL Implantation In 231 Consecutive Eyes. Johnny L. Gayton, MD, FSEE Eyesight Associates 216 Corder Road Warner Robins, Georgia 31088 . The author is on the speaker’s bureau for Alcon Laboratories, Inc. Purpose.

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Clinical Outcomes Post AcrySof Toric IOL Implantation In 231 Consecutive Eyes

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  1. Clinical OutcomesPost AcrySof Toric IOL ImplantationIn 231 Consecutive Eyes Johnny L. Gayton, MD, FSEE Eyesight Associates 216 Corder Road Warner Robins, Georgia 31088 The author is on the speaker’s bureau for Alcon Laboratories, Inc.

  2. Purpose To compare visual outcomes ofgood candidates versus complex candidatesafter implantation of AcrySof Toric intraocular lenses (IOLs)in a large consecutive series of cataractous, astigmatic eyes • To isolate variables of interest, many AcrySof Toric studies1-3 excluded patients with • comorbid ocular conditions, including complicationsrelating to the retina, to the cornea, or to ocular pressure • a high degree of corneal astigmatism that would requireadditional limbal relaxing incisions (LRIs) • Real-world patients can be complex 1. AcrySof Toric Product Information. Fort Worth, TX: Alcon Laboratories, Inc., 2005. 2. Mendicute J, et al. J Cataract Refract Surg 2008;34:601-607. 3. Zuberbuhler B, et al. BMC Ophthalmol 2008;8:8.

  3. Methods:Consecutive Patient Enrollment • Prospectively enrolled 162 adults (231 eyes) with cataracts and regular corneal astigmatism (≥0.5 D with the rule or ≥1.0 D against the rule) • Patients categorized by ocular complexities (solid lines) and/or surgeries scheduled concurrently with IOL implantation (dashed lines) All eyes (n = 231) Good candidates (n = 121) Complex candidates (n = 110) Cataract-related(n = 12) Extra-ocular(n = 11) Angle/pressure(n = 23) Corneal(n = 10) Other(n = 2) Retinal/macular(n = 48) Dryeye(n = 9) Ocularsurgery(n = 26) Lateral rectus recession (n = 1) Punctal cautery(n = 1) Endolaser(n = 6) Any previous(n = 13) LRI with IOL(n = 13) +Kenalog(n = 2) Most prevalent complexities were angle/pressure, retinal/macular, and LRI with IOL.Angle/pressure complexities included open-angle glaucoma, narrow-angle glaucoma, ocular hypertension, narrow angles. Retinal/macular complexities included age-related macular degeneration, macular drusen, other macular changes.

  4. Methods:Lens Model Selection & LRI Inclusion • Each patient’s measurements entered into the AcrySof Toric Calculator (www.acrysoftoriccalculator.com) to determine lens model • All incisions temporal • Surgically induced astigmatism = 0.3 D • For against-the-rule astigmatism (steep axis within 30º of horizontal) • 1.0 D to 2.75 D, toric lens only • ≥2.75 D, toric lens + LRIs • For with-the-rule astigmatism (steep axis within 30º of vertical) • 0.5 D to 2.25 D, toric lens only • ≥2.25 D, toric lens + LRIs 1. AcrySof Toric Product Information. Fort Worth, TX: Alcon Laboratories, Inc., 2005.

  5. Methods:Surgical Procedures • With patient sitting up,eye marked at 0º & 180º • Self-sealing 2.2-mm temporal incision • Viscoelastic injected • DuoVisc, standard and Fuchs cases • DisCoVisc, floppy iris & endolaser cases • Continuous curvilinear capsulorhexis • Second entry with 15º slit blade • Nucleus removed usingcracking, chopping, hydrodissection • Axis marks placed on the eye • IOL injected & aligned I. gross alignment – while IOL was unfolding (see figure)II. stabilization – during OVD removal, preventing IOL rotationIII. fine alignment – rotated clockwise onto final intended axis

  6. Methods:Scheduling and Assessment • Assessment at intake • Snellen acuity at 4 m: uncorrected (UCDVA) and best-corrected (BCDVA) • IOLMaster • Manual keratometry • First eye surgery within 30 days of preoperative assessment;fellow eye surgery ≥7 days after the first operation (when applicable) • Follow-up assessment at ~6 weeks (average 44 ± 39 days) postoperatively • Snellen acuity at 4 m: UCDVA and BCDVA • Capsular haze assessment

  7. Results:Astigmatism and Its Correction • Toric lens generally effective at reducing astigmatism in all eye groups • Residual cylinder was larger and more variable in highly astigmatic eyeswhere adjunctive LRIs were needed *P < 0.05 versus good candidates

  8. Results:Residual Astigmatism by Model • Residual cylinder varied significantly by model • 0.24 ± 0.06 diopters for the T3 lens • 0.32 ± 0.07 diopters for the T4 lens • 0.71 ± 0.08 diopters for the T5 lens • 1.5 ± 1.7 D for eyes with adjunctive LRIs • 0.5 ± 0.4 D for eyes without LRIs

  9. Results:Average Distance Visual Acuity • Uncorrected (UCDVA) andbest-corrected (BCDVA) • BCDVA preop and postop worse in retinal/macular group;contributed to poorer values in complex group overall • Postoperative BCDVA and UCDVA worse in LRI group;contributed to poorer values in complex group overall Preoperative Postoperative 20/20 20/20 all all good good * complex complex eye candidate type * * eye candidate type * LRI LRI * angle/pressure angle/pressure retinal/macular retinal/macular * * -0.5 0.0 0.5 1.0 1.5 0 1 2 3 visual acuity, decimal visual acuity, decimal *P < 0.05 versus good candidates

  10. Results:Percent of Eyes at 20/20 or 20/40 • Snellen visual outcomes: 20/20 or better20/40 or better • UCDVA of 20/20 or better attained by lower proportions ofcomplex candidates (15%) than good candidates (26%) • UCDVA of 20/40 or better attained by high proportions of all eye types • 81% of good candidates, 75% of complex candidates (not statistically different) • 70% of eyes with LRIs, P = 0.02 versus good candidates Uncorrected Best-corrected all all good good * * complex complex Eye candidate type Eye candidate type * * LRI LRI angle/pressure angle/pressure * retinal/macular retinal/macular 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% Eyes at visual acuity level Eyes at visual acuity level *P < 0.05 versus good candidates

  11. Results:Capsular Haze • Capsular haze was observed in 14% of eyes • haze tended to be trace (9% of eyes) or mild (3% of eyes) • 2% had moderate or dense haze, or haze cleared by laser capsulotomy • Capsular haze equally likely in good or complex eyes • moderate, dense, capsulotomy casesmore common in complex candidates (P = 0.01)

  12. Conclusions • AcrySof Toric IOLs can provide good UCDVA (20/40 or better) to a majority of patients with astigmatic, cataractous eyes even in complex cases • Adding adjunctive LRIs in cases of high astigmatism can yield less predictable and suboptimal outcomes  adjunctive LRIs on a high-cylinder eye are not as straightforward as LRIs on a lower-cylinder eye  an AcrySof IOL model with stronger cylinder power would be useful

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