Transcript Slide 1

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
To compare visual outcomes of
good candidates versus complex candidates
after 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 complications
relating to the retina, to the cornea, or to ocular pressure
– a high degree of corneal astigmatism that would require
additional 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.
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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)
Extraocular
(n = 11)
Lateral
rectus
recession
(n = 1)
Complex candidates (n = 110)
Corneal
(n = 10)
Angle/
pressure
Cataractrelated
Ocular
surgery
(n = 23)
(n = 12)
(n = 26)
Endolaser
Other
(n = 2)
(n = 6)
Any
previous
LRI with
IOL
+Kenalog
(n = 13)
(n = 13)
Dry
eye
Retinal/
macular
(n = 9)
(n = 48)
Punctal
cautery
(n = 1)
(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.
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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
Cylinder power, D1
Model
Corneal astigmatism
correction ranges, D
at IOL plane
at corneal plane
SN60T3, or “T3”
1.50
1.03
0.90 – 1.50
SN60T4, or “T4”
2.25
1.55
1.50 – 2.00
SN60T5, or “T5”
3.00
2.06
2.00 – 2.50
• 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.
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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 using
cracking, 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 rotation
III. fine alignment – rotated clockwise onto final intended axis
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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
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Results:
Astigmatism and Its Correction
Eyes
Complex candidate subgroups
All
eyes
Good
candidates
Complex
candidates
LRI with IOL
Angle/pressure
Retinal/macular
231
121
110
13
23
48
37%
7%
56%
41%
4%
55%
32%
10%
58%
62%
0%
38%
50%
5%
45%
22%
9%
70%
1.9 ± 1.0
1.7 ± 0.7
2.1 ± 1.2*
3.9 ± 1.2*
1.9 ± 0.8
1.9 ± 1.2
45%
29%
26%
52%
30%
18%
38%
27%
35%
--100%
23%
45%
32%
52%
28%
20%
0.4 ± 0.6
0.3 ± 0.4
0.5 ± 0.8*
1.5 ± 1.7*
0.3 ± 0.5
0.4 ± 0.5
79%
84%
75%
61%*
84%
79%
Preop astigmatism
With the rule
Oblique
Against the rule
Magnitude, D
IOL model
T3
T4
T5
Postop astigmatism, D
Astigmatism reduced
• Toric lens generally effective at reducing astigmatism in all eye groups
• Residual cylinder was larger and more variable in highly astigmatic eyes
where adjunctive LRIs were needed
*P < 0.05 versus good candidates
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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
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Results:
Average Distance Visual Acuity
• Uncorrected (UCDVA) and best-corrected (BCDVA)
Preoperative
Postoperative
20/20
all
eye candidate type
eye candidate type
20/20
good
complex
*
LRI
angle/
pressure
retinal/
macular
*
-0.5
0.0
0.5
1.0
1.5
all
good
*
complex
*
LRI
angle/
pressure
retinal/
macular
*
*
*
0
visual acuity, decimal
1
2
3
visual acuity, decimal
• 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
*P < 0.05 versus good candidates
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Results:
Percent of Eyes at 20/20 or 20/40
• Snellen visual outcomes:
20/20 or better
20/40 or better
Uncorrected
Best-corrected
all
good
*
complex
LRI
*
angle/
pressure
retinal/
macular
0%
20%
40%
60%
80% 100%
Eyes at visual acuity level
Eye candidate type
Eye candidate type
all
good
*
complex
LRI
angle/
pressure
retinal/
macular
0%
*
*
20% 40% 60%
80% 100%
Eyes at visual acuity level
• UCDVA of 20/20 or better attained by lower proportions of
complex 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
*P < 0.05 versus good candidates
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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 cases
more common in complex candidates (P = 0.01)
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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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