Clinical Outcomes Post AcrySof Toric IOL Implantation In 231 Consecutive Eyes

1
Clinical OutcomesPost AcrySof Toric IOL
ImplantationIn 231 Consecutive Eyes

• Johnny L. Gayton, MD, FSEE
• Eyesight Associates
• 216 Corder Road
• Warner Robins, Georgia 31088

The author is on the speakers bureau for Alcon
Laboratories, Inc.
 
2
Purpose

• To compare visual outcomes ofgood candidates
  versus complex candidatesafter 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
  complicationsrelating to the retina, to the
  cornea, or to ocular pressure
• a high degree of corneal astigmatism that would
  requireadditional 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
200834601-607. 3. Zuberbuhler B, et al. BMC
Ophthalmol 200888.
3
MethodsConsecutive 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)
Complex candidates (n 110)
Cataract-related(n 12)
Retinal/macular(n 48)
Angle/pressure(n 23)
Corneal(n 10)
Extra-ocular(n 11)
Other(n 2)
Dryeye(n 9)
Ocularsurgery(n 26)
Lateral rectus recession (n 1)
Punctal cautery(n 1)
Endolaser(n 6)
Any previous(n 13)
LRI with IOL(n 13)
Kenalog(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.
4
MethodsLens Model Selection LRI Inclusion

• Each patients measurements entered into the
  AcrySof Toric Calculator (www.acrysoftoriccalculat
  or.com) to determine lens model
• All incisions temporal
• Surgically induced astigmatism 0.3 D
• 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.
5
MethodsSurgical 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 usingcracking, 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 rotationIII.
  fine alignment rotated clockwise onto final
  intended axis

6
MethodsScheduling 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
  assessmentfellow 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

7
ResultsAstigmatism and Its Correction

• Toric lens generally effective at reducing
  astigmatism in all eye groups
• Residual cylinder was larger and more variable in
  highly astigmatic eyeswhere adjunctive LRIs were
  needed

P lt 0.05 versus good candidates
8
ResultsResidual 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

9
ResultsAverage Distance Visual Acuity

• Uncorrected (UCDVA) and best-corrected (BCDVA)
• BCDVA preop and postop worse in retinal/macular
  groupcontributed to poorer values in complex
  group overall
• Postoperative BCDVA and UCDVA worse in LRI
  groupcontributed to poorer values in complex
  group overall

Preoperative
Postoperative
20/20
20/20
all
all
good
good

complex
complex
eye candidate type


eye candidate type

LRI
LRI

angle/pressure
angle/pressure
retinal/macular
retinal/macular


-0.5
0.0
0.5
1.0
1.5
0
1
2
3
visual acuity, decimal
visual acuity, decimal
P lt 0.05 versus good candidates
10
ResultsPercent of Eyes at 20/20 or 20/40

• Snellen visual outcomes 20/20 or better
  20/40 or better
• UCDVA of 20/20 or better attained by lower
  proportions ofcomplex 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

Uncorrected
Best-corrected
all
all
good
good


complex
complex
Eye candidate type
Eye candidate type


LRI
LRI
angle/pressure
angle/pressure

retinal/macular
retinal/macular
0
20
40
60
80
100
0
20
40
60
80
100
Eyes at visual acuity level
Eyes at visual acuity level
P lt 0.05 versus good candidates
11
ResultsCapsular 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 casesmore common in
  complex candidates (P  0.01)

12
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