Transcript Rotation of Hydrophobic Acrylic Toric IOL

I have no financial interest in any devices or
techniques discussed in this presentation
Rotation of Hydrophobic
Acrylic Toric IOL
Jonathan M. Davidorf, M.D.
Los Angeles, CA
April, 2010
Case Report
Initial Evaluation
• 59 y.o. myopic male presents with
decreased vision OS
• Wears spherical soft CLs
• Current Spectacles (several yrs old)
OD: -5.50+0.25x168 = 20/60
OS: -6.50+0.25x163 = 20/60
• MR
OD: -7.50+0.50x170 = 20/25+
OS: -10.75+0.50x025 = 20/40--
Initial Evaluation
• 1+ nuclear sclerosis OD
2+ nuclear sclerosis OS
• PVD OS, no retinal pathology OU
• Patient desires cataract surgery OS only
(despite anisometropia), will wear conact
lens OD postoperatively until cataract OD
progresses
Keratometry (OS)
Flat
meridian
(D)
Steep
meridian
(D)
Steep
meridian
(degree)
Corneal
cylinder (D)
Auto Ks
41.75
42.25
058
0.50
Orbscan Sim Ks
42.2
43.0
076
0.8
IOLMaster Ks
42.35
42.88
078
0.53
Figure 1
IOL Selection (OS)
• Patient does not mind wearing reading
glasses (presbyopic IOLs discussed)
• Prefers minimizing spectacle/contact lens
dependence for distance vision
• Vector analysis using the AcrSofR Toric
IOL Calculator predicted residual
astigmatism of 0.51D at 099 degrees
using a spherical IOL (Figure 2)
(http://www.acrysoftoriccalculator.com)
Figure 2
Perioperative Course (OS)
• Standard clear corneal incision (2.4 mm),
topical, phacoemulsification performed
• 12.5D Aspheric hydrophobic acrylic IOL
(AcrySofR SN60WF) implanted
• Vsc postoperative day 1 = 20/25
• Developed significant posterior capsular
opacification, underwent YAG PC
• 7 months Postop
MR: 0.25+0.25x027= 20/20
Follow-up Evaluation
• Patient now has complaints of decreased
vision OD
• Corrected distance vision 20/50 OD
• 2+ NS, 1+PSC OD
• Patient desires cataract surgery OD
Keratometry (OD)
Flat
meridian
(D)
Steep
meridian
(D)
Steep
meridian
(degree)
Corneal
cylinder (D)
Auto Ks
42.00
43.25
126
1.25
Orbscan Sim Ks
43.00
43.9
110
0.9
IOLMaster Ks
42.56
43.60
115
1.04
Figure 3
IOL Selection (OD)
• Patient still does not mind wearing reading
glasses (presbyopic IOLs discussed)
• Still prefers minimizing spectacle/contact
lens dependence for distance vision
• Vector analysis using the AcrSofR Toric
IOL Calculator predicted residual
astigmatism of 0.39D at 109 degrees
using the lowest power toric IOL (Figure 4)
(http://www.acrysoftoriccalculator.com)
Figure 4
Operative Course (OD)
• Coaxial phacoemulsification (2.4mm CCI)
• 12.0D hydrophobic acrylic toric IOL
o
R
(AcrSof SN60T3) in the 109 meridian
(figure 5).
Good IOL alignment at the end of the procedure.
Gentian violet mark is at approximately 105 degrees.
Figure 5
Postoperative Course (OD)
• POD 1 Vsc 20/200 OD
MR: -1.50+1.00x107 = 20/30
• Toric IOL aligned at 47o (45o from intraoperative
placement; figure 6)
• POD 7
Vsc 20/40 OD
MR: -0.75+1.00x120 = 20/25+
• Vision has been stable, patient very happy and
desires no further intervention (ie: IOL rotation)
Figure 6
In image at left, the toric
IOL is seen aligned at
approximately 47o
With patient looking up
and left (right image), the
toric markings are easily
seen.
Discussion
•
•
•
•
•
•
While the hydrophobic acrylic toric IOL (AcrySofR Toric IOL) has good
documented rotational stability (1), significant rotation can occur.
Evaluation of the surgical video demonstrates absence of deliberate
viscoelastic removal from behind IOL optic.
Subsequent to this case, we now deliberately remove viscoelastic from
behind the toric IOL optic and have had no significant IOL rotations
identified (60 subsequent toric IOLs implanted)
It is estimated that each degree of rotation confers a 3.3% loss of effect, so
that with a 30 degree rotation, the toric IOL has no effect (2). Inasmuch as
a 90 degree IOL rotation confers a 100% induction of cylinder along the
preoperative meridian, it can be expected that there is essentially no toric
effect for rotations between 30 and 60 degrees. The 45 degree rotation
identified in our case with a subsequent residual refractive astigmatism of
1.00D supports this theory.
Objectively, the results in this case with a residual astigmatic refractive error
of 1D fell short of our expectations.
Subjectively, the patient tolerated the residual astigmatism well.
Conclusions
• While uncommon, hydrophobic acrylic IOLs can
rotate significantly within the first 24 hours of
surgery.
• Consider deliberately removing viscoelastic from
behind the toric IOL optic to minimize rotational
instability.
• For better or worse, a patient’s subjective
assessment trumps objective findings in
determining the patient’s level of happiness
following eye surgery.
References
• Mendicute J, Irigoyen C, Aramberri J, Ondarra A,
Monte´s-Mico´ R. Foldable toric intraocular lens for
astigmatism correction in cataract patients. J Cataract
Refract Surg 2008; 34:601–607
• Novis C. Astigmatism and toric intraocular lenses. Curr
Opin Ophthalmol 2000; 11:47–50