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Multifocal and Toric IOLs: An Update on the Resident Experience

Multifocal and Toric IOLs: An Update on the Resident Experience. M. Allison Roensch , MD, Preston H. Blomquist , MD, Nalini K Aggarwal , MD, Justin W. Charton , MD, James P. McCulley , MD University of Texas Southwestern Department of Ophthalmology

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Multifocal and Toric IOLs: An Update on the Resident Experience

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  1. Multifocal and Toric IOLs: An Update on the Resident Experience M. Allison Roensch, MD, Preston H. Blomquist, MD, Nalini K Aggarwal, MD, Justin W. Charton, MD, James P. McCulley, MD University of Texas Southwestern Department of Ophthalmology *Dr. McCulley is a consultant for Alcon Laboratories Supported by Research to Prevent Blindness

  2. Introduction • Cataract surgery technique and technology are evolving rapidly, allowing physicians to give patients a greater degree of spectacle independence. • These new technologies are an important component of today’s comprehensive practice. • Toric intraocular lenses allow for intra-operative correction of astigmatism. Multifocal lenses allow for the correction of near vision, as well as distance vision. • Each lens platform represents a different surgical technique to which the surgeon must adapt. • Current resident education should take into account new technology. Use of these lens platforms during training will better equip residents for transition to their own practice.

  3. Methods: Toric IOLs • A total of 45 eyes of 35 patients with more than 1.0 diopter of corneal astigmatism had placement of an Alcon AcrylSofToric IOL. 8 eyes were in the prospective arm of the study and 37 eyes in the restrospective arm. Preoperatively, informed consent was obtained, and the patients received a complete ophthalmic exam including slit lamp exam, applanationtonometry, slit lamp exam, best corrected visual acuity, keratometry and A-scan (IOLMaster), topography (Humphrey Atlas Eclipse), and dilated fundus exam. Patients with corneal surface abnormalities, irregular astigmatism, and extensive retinal pathology were excluded. • The AcrylSofToric 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 intraoperativetoric 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. Methods: Multifocal IOLs • The multifocal group consisted of a total of 10 eyes of 6 patients who requested correction of both near and distance vision. These patients had placement of the Alcon AcrySofReSTOR SN6AD1 or SN6AD3 intraocular lens.Preoperatively, informed consent was obtained, and the patients received a complete ophthalmic exam including slit lamp exam, applanationtonometry, 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.. 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. • Resident Survey: • 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 8 residents had finished the rotation at completion of this poster.

  5. Results: Toric IOLs • Mean age of patients in the Toric group was 61 with a range of 35-78. 63% were female and 37% male. Mean length of follow-up was 3.4 months. • Uncorrected visual acuity: 51% of eyes were 20/25 or better, 71% were 20/30 or better; 89% were 20/40 or better • Best corrected visual acuity: 87% of eyes were 20/25 or better • Mean post-op cylinder was 0.56D +/- 0.7, with 79.5% of all eyes achieving a post-op refractive cylinder of <0.75D. Mean post-op cylinder in the T3 group was 0.22D+/-0.23, T4 group was 0.5D+/-0.52, and the T5 group was 0.78D +/- 0.9. • Mean spherical equivalent for all groups was -0.41D +/- 0.56 • 3 patients were noted to have lens rotation post-op: 1 lens rotated 13 degrees s/p YAG capsulotomy, resulting in a change from 0.5 residual cylinder to 1.75 of cylinder. 1 patient had 5 degrees of rotation resulting in 1.25 of residual cylinder. 1 patient had 3 degrees of rotation with 0.75D of residual cylinder • 1 eye had amblylopia and LRIs were used during surgery for a pre-op corneal astigmatism of 5D. 1 eye was noted to have AMD post-op. 1 patient developed CSME and another NVG several months post-op.

  6. Results: Toric IOLs *Pre-op refraction unavailable for 3 eyes. Data unreliable due to severity of cataract *Pre-op topography data unavailable for 2 eyes in T5 group *BCVA data unavailable for one eye in T5 group

  7. Results: Multifocal IOLs • Mean age of patients receiving multifocal IOLs was 64.2 with a range of 53-73. 50% were male and 50% female. Mean length of follow-up was 2.3 months. • Uncorrected visual acuity: 70% of eyes were 20/25 or better, and 90% were 20/40 or better • Best corrected visual acuity: 70% of eyes were 20/20, and 100% were 20/25 or better • Near vision was J1 or better in 60% of eyes • Mean post-op spherical equivalent was 0.08D +/- 0.37 with a mean post-op cylinder of 0.45D +/- 0.35 • One lens was explanted due to a non-continuous capsulorrhexis and was replaced with a sulcusReSTOR IOL. This patient’s UCVA was 20/70 post-op. 2 eyes had UCVA of 20/40 due to an unexpected myopic outcome with mild astigmatism.

  8. Results: Multifocal IOLs Pre-op: Post-op:

  9. Results: Resident Survey

  10. Discussion • Toric IOLs allow the surgeon to correct astigmatism intra-operatively, thereby improving post-operative refractive results. • In our study, toric lenses compared favorably with previous studies. 88.9% of patients receiving toric lenses had UCVA of 20/40 or better. 88.6% of patients had a BCVA of 20/25 or better. Several eyes had limited visual potential secondary to retinal pathology or amblyopia. • Refractive cylinder decreased from a mean of 1.52 pre-op to 0.56 post-op. 70% of all eyes had a residual cylinder of 0.50D or less. There was little post-op lens rotation with only one patient having rotation >5 degrees. • Multifocal lenses allow patients to see at near as well as distance after cataract surgery. • In the multifocal group, outcomes were also similar to prior studies. 70% of eyes achieved an UCVA of 20/25 or better. 90% achieved UCVA of 20/40 or better. • 100% of eyes achieved a BCVA of 20/25 or better. • 60% of eyes achieved uncorrected near vision of 20/25 or better.

  11. Discussion • Residents strongly feel that these lenses will be utilized frequently in their future practices and that experience with these lenses will better prepare them for practice after residency. • The opportunity to learn the pre-op, intra-op, and post-op management associated with these new technologies helps prepare residents for the future. Residents gain valuable experience 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. References • Souza, CE, et al. Visual performance of AcrySofReSTORapodized diffractive IOL: A prospective comparative trial. Am J Ophthalmol. 2006 May;141(5):827-832. • Zhao G, et al. Visual function after monocular implantation of apodized diffractive multifocal or single-piece monofocal intraocular lens. J Cataract Refract Surg. 2010 Feb;36(2):282-5. • De Vries, NE, et al. Long-term follow-up of a multifocal apodized diffractive intraocular lens after cataract surgery. J Cataract Refract Surg. 2008 Sep;34(9):1476-82. • Bauer, NJC, et al. Astigmatism management in cataract surgery with the AcrySoftoric intraocular lens. J Cataract Refract Surg. 2008 Sep;34(9):1483-8. • Mendicute, J, et al. Foldable toric intraocular lens for astigmatism correction in cataract patients. J Cataract Refract Surg. 2008 Apr;34(4):601-7. • Horn, JD. Status of toric intraocular lenses. CurrOpinOphthalmol. 2007 Feb;18(1):58-61. • Statham, M, Apel, A, Stephensen, D. Comparison of the AcrySof SA60 spherical intraocular lens and the AcrySofToric SN60T3 intraocular lens outcomes in patients with low amounts of corneal astigmatism. Clin Experiment Ophthalmol. 2009 Nov;37(8):775-9. • Lane, SS, et al. Comparison of clinical and patient-reported outcomes with bilateral AcrySoftoric or spherical control intraocular lenses. J Refract Surg. 2009 Oct;25(10):899-901 • Dardzhikova, A, Shah, CR, Gimbel, HV. Early experience with the AcrySoftoric IOL for the correction of astigmatism in cataract surgery. Canadian J Ophthalmol. 2009 Jun;44(3):269-73.

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