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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.

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evaluation surgical correction of astigmatism
Evaluation & Surgical Correction of Astigmatism

Jean Luc Febbraro MD

Rothschild Foundation

Paris

France

jeanluc@febbraro.net

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
slide27

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

slide30
ACE

Mean Static (SRET) / Dynamic (DRET)

N:70

%

Cyclotorsion

Fondation A. de Rothschild

Paris

Jean-Luc Febbraro MD

slide31
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

slide33

Prevalence and evolution

Of astigmatism

  • Clinical significance
    • Accurate eye care
    • IOL manufacturers (SA , Cyl.)
    • Valuable information for cataract & refractive surgeons
slide34

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)
slide37

RESULTS

Astigmatism Distribution

slide38

RESULTS

Astigmatism Evolution

visit1

visit2

-0.02

OCULAR AST.

CORNEAL AST.

SPHERE

astigmatism evolution
Astigmatism Evolution

RESULTS

ATR shift over 8 years

0.26 D

astigmatism evolution1
Astigmatism Evolution

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

slide41

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
Cataract IncisionsIntroduction
  • 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 IncisionsChoice 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

slide44

Cataract IncisionsAstigmatic 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

slide45

Cataract IncisionsAstigmatic Effects

Standard 3-3.5-mm on axis CCI PKE

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

Texte

slide46

Cataract IncisionsAstigmatic Effects

Standard 3.2-mm on axis / temp. CCI PKE

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

Texte

slide47

Cataract IncisionsAstigmatic Effects

3-3.5-mm Incision & SIA Range

Literature Summary

Texte

cataract incisions 3 5 2 8 mm cci clinical implications
Cataract incisions 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
Comparison3.0 / 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
Comparison1.8-mm C-MICS / 1.7-mm B-MICS

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

Texte

study evaluate sia cataract incisions
STUDYEvaluate 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
StudyResults

Vector Analysis

cataract incisions
Cataract Incisions
  • 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
  • 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

slide55

Fondation A. de Rothschild

Paris

Jean-Luc Febbraro MD

Thank you

for your attention

Texte