Transcript Resident Experience with Toric and Multifocal IOLs in a

RESIDENT EXPERIENCE WITH
TORIC AND MULTIFOCAL IOLS
IN A PUBLIC COUNTY HOSPITAL
M. Allison Roensch, MD, Preston H. Blomquist, MD, Nalini K
Aggarwal, MD, James P. McCulley, MD
Department of Ophthalmology
University of Texas Southwestern Medical Center
*Dr. McCulley is a consultant for Alcon Laboratories
Introduction
 Recent advancements in cataract surgery technology allow
physicians to give patients a greater degree of spectacle
independence.
 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, as well as unique pre- and
post-operative management and patient counseling.
 Current resident education should take these new
technologies into account. Use of these lens platforms
during training will better equip residents for transition to
their own practice.
Methods: Toric IOLs

A total of 73 eyes of 55 patients with more than 1.0 diopter of corneal
astigmatism had placement of an Alcon AcrylSof Toric IOL. Preoperatively,
informed consent was obtained, and patients received a complete ophthalmic
exam including slit lamp exam, applanation tonometry, visual acuity, refraction,
keratometry, optical coherence biometry (IOLMaster), topography (Humphrey
Atlas Eclipse), and dilated fundus exam. Patients with corneal surface
abnormalities, irregular astigmatism, and extensive retinal pathology were
excluded.

The AcrylSof Toric online calculator was used for determination of correct lens
platform, either T3 (1.5 D), T4 (2.25 D), and T5 (3.00 D). 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 possible cyclotorsion in the supine position. An intraoperative toric
axis marker was used for determination of actual axis placement. The
surgeries were performed by senior residents who were completing their
surgical chief rotation. After injection, all IOLs were rotated 15-25 degrees from
intended axis and the viscoelastic was then removed. The IOLs were then
rotated to their final position to coincide with corneal axis markings.
Methods: Multifocal IOLs

The multifocal group consisted of a total of 15 eyes of 9 patients who requested
correction of both near and distance vision. These patients had placement of
the Alcon AcrySof ReSTOR SN6AD1 or SN6AD3 intraocular lens.

Preoperatively, informed consent was obtained, and the patients received a
complete ophthalmic exam including slit lamp exam, applanation tonometry,
best corrected visual acuity, keratometry, optical coherence biometry
(IOLMaster), topography (Humphrey Atlas Eclipse), and dilated fundus exam.

Patients with extensive retinal pathology, corneal surface abnormalities,
irregular astigmatism, and corneal astigmatism greater than +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 +0.25D. The surgeries were
performed by senior residents who were completing their surgical chief rotation.

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 14 residents have completed the survey.
Results: Toric IOLs

Mean length of follow-up was 3.9 months. Patient age ranged from 2282 with a mean of 56.95 years. 67% were female.

Uncorrected visual acuity: 56% were 20/25 or better, 88% were 20/40 or
better
 Best corrected visual acuity: 92% were 20/25 or better
 Mean refractive cylinder decreased from 1.67 D pre-op to 0.45 D post-op

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
 Outliers: one patient had amblyopia, 3 developed diabetic retinopathy
limiting vision, 1 had limited vision from dry AMD
 3 eyes also received LRIs due to corneal astigmatism greater than that
correctable by the T5 IOL
Results: Toric IOLs
All
Age
Axial Length (mm)
IOL spherical power
56.95 +/- 13.31
23.95 +/- 1.17
19.64 +/- 3.36
N
(eyes)
Pre-op
IOLMaster
cylinder
Pre-op
topographic
cylinder
Pre-op
refractive
cylinder
Post-op
refractive
cylinder
Spherical
Equivalent
T3
12
1.34 +/- 0.30
1.30 +/- 0.34
1.42 +/- 0.88
0.21 +/- 0.20
-0.38 +/- 0.43
T4
24
1.62 +/- 0.38
1.76 +/- 0.64
1.18 +/- 0.79
0.40 +/- 0.49
-0.40 +/- 0.59
T5
37
2.84 +/- 1.05
2.84 +/- 1.12
2.04 +/- 1.40
0.58 +/- 0.69
-0.44 +/- 0.52
All
73
2.19 +/- 1.03
2.22 +/- 1.09
1.67 +/- 1.22
0.45 +/- 0.59
-0.42 +/- 0.53
UCVA
20/20-30
UCVA
20/40
UCVA
<20/40
BCVA
20/20-25
BCVA
<20/25
T3
11 (91.7%)
0
1 (8.3%)
12 (100%)
0
T4
20 (83.3%)
1 (4.2%)
3 (12.5%)
21 (87.5%)
3 (12.5%)
T5
25 (67.6%)
7 (18.9%)
5 (13.5%)
34 (91.9%)
3 (8.1%)
All
56 (76.7%)
8 (11%)
9 (12.3%)
67 (91.8%)
6 (8.2%)
Refraction
unreliable in 4
patients in T4
group and 2 in the
T5 group pre-op
due to dense
cataract
Results: Multifocal IOLs
 Patients ranged in age from 53-80. 44% were male.
 Mean length of follow-up was 1.73 months +/- 1.34
 66.7% of eyes were 20/25 or better and 93.3% were 20/40 or
better uncorrected at distance.
 Near vision: 40% were J1 or better uncorrected. 86.7% were
J3 or better.
 One lens was explanted due to a non-continuous
capsulorrhexis and was replaced with a sulcus ReSTOR 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. 1 patient had BCVA of 20/30 due to an
epiretinal membrane.
Results: Multifocal IOLs
N
(eyes)
SN6AD1&3
SN6AD1&3
15
Age
(years)
67.93
+/- 7.91
Refractive
Cylinder
IOLMaster
cylinder
0.75
+/- 0.61
UCVA
20/2025
UCVA
20/30 –
20/40
UCVA
<20/40
10
(66.7%)
4
(26.7%)
1
(6.7%)
0.47
+/- 0.36
BCVA
20/20 –
20/25
14
(93.3%)
Topography
Cylinder
Axial
Length
Mean IOL
power
0.40
+/- 0.30
23.67
+/- 0.55
20.47
+/- 1.83
Near
UCVA J1
or better
6
(40%)
Near
UCVA
J2-J3
7
(46.7%)
Spherical
equivalent
Refractive
cylinder
-0.02
+/- 0.40
0.33
+/- 0.35
Results: Resident Survey
Ratings from 1 (lowest) to 5 (highest)
Knowledge of pre-operative workup for multifocal IOLs
4.3
Knowledge of pre-operative workup for toric IOLs
4.6
Knowledge of surgical techniques for multifocal IOLs
4.7
Knowledge of surgical techniques for toric IOLs
4.6
Degree that premium IOLs will impact your future practice
4.3
Will you personally utilize premium IOLs in future?
4.4
Did this experience better prepare you for using premium IOLs in your future practice?
4.9
To what degree do you feel these lenses will provide spectacle independence for your patients?
4.3
Discussion
 Toric IOLs permit astigmatism correction intra-
operatively, improving post-operative refractive
results.
 In our study, toric lenses compared favorably with previous
studies. 87.7% of patients receiving toric lenses had UCVA of
20/40 or better. 91.8% 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 1.67 D pre-op
to 0.45 D post-op, with best results in the T3 group. 74% 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.
Discussion
 Multifocal lenses allow better vision at a range of
distances, both near and far, after cataract
surgery
 Outcomes were similar to prior studies with multifocal
IOLs. 67% of eyes achieved an UCVA of 20/25 or better.
93% achieved UCVA of 20/40 or better.
 93% of eyes achieved a BCVA of 20/25 or better. One
eye had a BCVA of 20/30 due to an ERM.
 40% of eyes achieved uncorrected near vision of 20/25
or better, while 87% were 20/40 or better.
Discussion
 Premium IOLs are an important
component of today’s comprehensive
ophthalmology practice.
 Outcomes in a public county hospital with
surgeries performed by residents are
comparable to other published studies.
 Residents strongly feel that experience
with these lenses will better prepare them
for practice after residency.
References

Souza, CE, et al. Visual performance of AcrySof ReSTOR apodized 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 AcrySof toric 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. Curr Opin Ophthalmol. 2007 Feb;18(1):58-61.

Statham, M, Apel, A, Stephensen, D. Comparison of the AcrySof SA60 spherical intraocular lens
and the AcrySof Toric 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 AcrySof toric
or spherical control intraocular lenses. J Refract Surg. 2009 Oct;25(10):899-901

Dardzhikova, A, Shah, CR, Gimbel, HV. Early experience with the AcrySof toric IOL for the
correction of astigmatism in cataract surgery. Canadian J Ophthalmol. 2009 Jun;44(3):269-73.