Nienke Visser

Toric intraocular lenses: historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications.

&NA; We present an overview of currently available toric intraocular lenses (IOLs) and multifocal toric IOLs. Relevant patient selection criteria, IOL calculation issues, and surgical techniques for IOL implantation are discussed. Clinical outcomes including uncorrected visual acuity, residual refractive astigmatism, and spectacle independency, which have been reported for both toric IOLs and multifocal toric IOLs, are reviewed. The incidence of misalignment, the most important complication of toric IOLs, is determined. Finally, future developments in the field of toric IOLs are discussed. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Cataract surgery with toric intraocular lens implantation in keratoconus: a case report.

Purpose: We report 2 cases in which cataract extraction with a foldable acrylic toric intraocular lens (IOL) implantation was used to correct (irregular) corneal astigmatism in patients with keratoconus and cataract. Methods: Case 1 was a 78-year-old man with cataract and keratoconus in the left eye. He underwent phacoemulsification with a toric IOL [Acrysof SN60T9; cylinder power: 6.0 diopters (D)] implantation. Case 2 was a 64-year-old woman with bilateral cataract and keratoconus. She underwent phacoemulsification with toric IOL implantation in the right (Acrysof SN60T9; cylinder power: 6.0 D) and left eyes (Acrysof SN60T5; cylinder power: 3.0 D). Postoperative follow-up in both cases was 6 months. Results: In case 1, the uncorrected visual acuity increased from 20/400 to 20/50. The refractive cylinder decreased from −6.0 to −1.5 D, which is a reduction of 75%. In case 2, the uncorrected visual acuity increased from 20/400 to 20/130 in the right eye and from 20/400 to 20/30 in the left eye. Refractive astigmatism decreased by 70% in both eyes. No IOL misalignment or other complications occurred. Conclusions: Cataract extraction with toric IOL implantation can be used to correct (irregular) astigmatism and to improve visual functioning in patients with mild to moderate amounts of stable keratoconus and cataract.

Cataract surgery with toric intraocular lens implantation in patients with high corneal astigmatism

PURPOSE: To evaluate the visual and refractive outcomes after toric intraocular lens (IOL) implantation in patients with high amounts of corneal astigmatism. SETTING: University Eye Clinic, Maastricht, The Netherlands; Oftalvist Centro Integral Ocular and Fundación Oftalmológica del Mediterráneo, Valencia, Spain. DESIGN: Cohort study. METHODS: This study comprised eyes with cataract and more than 2.25 diopters (D) of corneal astigmatism who had toric Acrysof SN60T6, SN60T7, SN60T8, or SN60T9 IOL implantation. The uncorrected (UDVA) and corrected (CDVA) distance visual acuities, visual potential index (ratio of postoperative UDVA to postoperative CDVA), residual refractive cylinder, IOL misalignment, and surgically induced astigmatism (SIA) were evaluated. RESULTS: The mean follow‐up in this study of 67 eyes (45 patients) was 6.3 months. Postoperatively, the mean UDVA was 0.61 ± 0.26 (SD) and the mean CDVA, 0.81 ± 0.21. The UDVA of 20/40 was better in 83% of eyes and 20/30 or better in 50% of eyes. The mean visual potential index was 0.78. The residual refractive cylinder was less than 0.75 D in 62% of eyes and less than 1.00 D in 81% of eyes. The mean IOL misalignment was 3.2 ± 2.8 degrees. The mean SIA was −0.40 ± 0.60 D with a superior incision and −0.19 ± 0.78 D with a temporal incision (P=.034). CONCLUSION: Implantation of the toric IOL during cataract surgery was effective and safe in correcting high amounts of corneal astigmatism. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Visual outcomes and patient satisfaction after cataract surgery with toric multifocal intraocular lens implantation

PURPOSE: To evaluate visual outcomes and patient satisfaction after toric multifocal intraocular lens (IOL) implantation in patients with cataract and corneal astigmatism. SETTING: University Eye Clinic Maastricht, The Netherlands. DESIGN: Cohort study. METHODS: Patients with cataract, corneal astigmatism, and a motivation for spectacle independency had cataract surgery with implantation of a toric diffractive multifocal IOL (AT Lisa). Three months postoperatively, the uncorrected distance (UDVA), intermediate (UIVA), and near (UNVA) visual acuities; corrected distance, intermediate, and near visual acuities; residual refractive astigmatism; defocus curve; contrast sensitivity; and patient satisfaction were evaluated. RESULTS: Forty‐five eyes of 25 patients were enrolled. Postoperatively, the mean UDVA was 0.04 logMAR ± 0.15 (SD) and 98% of eyes achieved a UDVA of 20/40 or better. The mean UNVA was 0.20 ± 0.16 logMAR and the mean UIVA (at 60 cm), 0.40 ± 0.16 logMAR. Residual refractive astigmatism of −1.00 diopter or less was achieved in approximately 90% of eyes. Contrast sensitivity levels were high. Approximately 50% of patients reported moderate glare, halos, and starburst symptoms. Spectacle independency for distance and near vision was achieved by 95% of patients and 79% of patients, respectively. CONCLUSIONS: Toric IOL implantation in patients with cataract and corneal astigmatism provided good distance and near visual outcomes and acceptable intermediate visual outcomes, allowing patients with considerable amounts of corneal astigmatism to achieve spectacle independence at distance and near. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Vector Analysis of Corneal and Refractive Astigmatism Changes Following Toric Pseudophakic and Toric Phakic IOL Implantation

PURPOSE To determine the efficacy of the astigmatism correction following toric intraocular lens (IOL) and toric phakic IOL (pIOL) implantation in eyes with no previous ocular surgery and in postkeratoplasty (PKP) eyes. In addition, changes in corneal astigmatism were determined. METHODS Astigmatism was analyzed in 35 eyes with an AcrySof toric IOL, 35 eyes with an Artiflex toric pIOL, 50 eyes with an Artisan toric pIOL, and 40 PKP eyes with an Artisan toric pIOL. Refractive astigmatism was analyzed by using Alpins method. Surgically induced corneal astigmatism (SICA) was determined following a superior 2.2-mm, 3.4-mm, or 5.4-mm incision. Follow-up was 12 months. RESULTS Following toric IOL implantation, the index of success was 0.14 and overall residual astigmatism, 0.37 diopter (D). Following toric pIOL implantation, the index of success was 0.32 (Artiflex) and 0.18 (Artisan), and overall residual astigmatism was approximately 0.60 D. In PKP eyes, Artisan pIOLs resulted in an index of success of 0.28 and overall residual astigmatism of 1.56 D. The SICA, following 2.2-mm, 3.4-mm, 5.4-mm (normal eyes), and 5.4-mm (PKP eyes) incisions, was -0.25 ± 0.42 D (P = 0.108), -0.31 ± 0.43 D (P < 0.001), -0.48 ± 0.55 D (P < 0.001), and -0.49 ± 1.48 D (P = 0.035), respectively. CONCLUSIONS Toric IOLs and pIOLs provide an effective astigmatism correction. Incorporating the SICA into the toric IOL power calculation may further increase their effectiveness. Therefore, incorporation of 0 D, -0.30 D, or -0.50 D of SICA for a 2.2-, 3.4-, or 5.4-mm superior incision, respectively, is recommended.

Toric vs Aspherical Control Intraocular Lenses in Patients With Cataract and Corneal Astigmatism: A Randomized Clinical Trial

IMPORTANCE Spectacle independence is becoming increasingly important in cataract surgery. Not correcting corneal astigmatism at the time of cataract surgery will fail to achieve spectacle independency in 20% to 30% of patients. OBJECTIVE To compare bilateral aspherical toric with bilateral aspherical control intraocular lens (IOL) implantation in patients with cataract and corneal astigmatism. DESIGN, SETTING, AND PARTICIPANTS A multicenter, hospital-based, randomized clinical trial was conducted. The participants included 86 individuals with bilateral cataract and bilateral corneal astigmatism of at least 1.25 diopters (D) who were randomized to receive either bilateral toric (n = 41) or bilateral control (n = 45) IOL implantation. INTERVENTIONS Bilateral implantation of an aspherical toric IOL or an aspherical control IOL. MAIN OUTCOMES AND MEASURES Spectacle independency for distance vision, uncorrected distance visual acuity, refractive astigmatism, contrast sensitivity, wavefront aberrations, and refractive error-related quality-of-life questionnaire. RESULTS Preoperatively, mean (SD) corneal astigmatism was 2.02 (0.95) D and 2.00 (0.84) D in the toric and control groups, respectively. Four patients (5%) were lost to follow-up. At 6 months postoperatively, 26 (70%) of the patients in the toric group achieved an uncorrected distance visual acuity of 20/25 or better compared with 14 (31%) in the control group (P < .001; odds ratio, 5.23; 95% CI, 2.03-13.48). Spectacle independency for distance vision was achieved in 31 patients (84%) in the toric group compared with 14 patients (31%) in the control group (P < .001; odds ratio, 11.44; 95% CI, 3.89- 33.63). Mean refractive astigmatism was -0.77 (0.52) D and -1.89 D (1.00) D, respectively. Vector analysis of toric IOLs showed a mean magnitude of error of +0.38 D, indicative of overcorrection. No significant differences were found in contrast sensitivity, higher-order aberrations, or refractive error-related quality of life. CONCLUSIONS AND RELEVANCE In patients with cataract and corneal astigmatism, bilateral toric IOL implantation results in a higher spectacle independency for distance vision compared with bilateral control IOL implantation. No significant differences were identified in contrast sensitivity, higher-order aberrations, or refractive error-related quality of life following both treatments. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01075542.

Residual Astigmatism Following Toric Intraocular Lens Implantation Related to Pupil Size

PURPOSE To present two patients with residual astigmatism following toric intraocular lens (IOL) implantation. METHODS Case reports. RESULTS A 58-year-old woman underwent toric IOL implantation (spherical power 29.50 diopters [D], cylinder power 3.00 D; SN60T5, Alcon Laboratories Inc) to correct 2.33 D @ 80° of corneal astigmatism. Postoperatively, uncorrected distance visual acuity (UDVA) was 20/30 and corrected distance visual acuity (CDVA) was 20/22 (0 -1.75 × 95), indicating an overcorrection of astigmatism. Slit-lamp examination demonstrated no IOL misalignment. Wavefront aberrometry showed a large pupil diameter (>6 mm) and a lower corneal astigmatism in a 6-mm zone (-1.40 D @ 174°) compared to a 4-mm zone (-2.21 D @ 171°). The second patient, a 60-year-old man, underwent multifocal toric IOL implantation (spherical power 22.50 D, cylinder power 2.25 D; SND1T4, Alcon Laboratories Inc) to correct 1.51 D @ 173° of corneal astigmatism. Postoperatively, UDVA was 20/50 and CDVA was 20/20 (+0.25 -1.00 × 102), indicating an undercorrection of astigmatism. Slit-lamp examination showed no misalignment. CONCLUSIONS Both cases indicate that unexplained residual astigmatism following toric IOL implantation may be the result of multiple factors: the effect of the spherical power and anterior chamber depth on toric IOL calculations, the effect of posterior corneal astigmatism, and the effect of a large pupil size. The first two issues may be compensated for by improving toric IOL calculations. The latter indicates that pupillometry is indicated in relatively young patients who undergo toric IOL implantation.

Visual acuity and refraction with a diffractive multifocal toric intraocular lens

Purpose To evaluate clinical outcomes and optical performance of the AT Lisa 909M diffractive multifocal toric intraocular lens (IOL). Setting Multicenter study. Design Cohort study. Methods The measured outcomes included refractive error; distance, near (40 cm), and intermediate (60 cm and 80 cm) visual acuities; defocus curve; rotational stability; and monocular and binocular photopic and mesopic contrast sensitivity. Astigmatism was evaluated by Alpins vector analysis. Results The multifocal toric IOL was implanted in 284 eyes of 142 patients. At 6 months, 89.4% of eyes were within ±1.00 diopter (D) of emmetropia. The mean refractive cylinder decreased from −2.39 D ± 1.48 (SD) to −0.49 ± 0.53 D; it was lower than 1.00 D in 80.9% of eyes. The mean visual acuities (logMAR) were monocular uncorrected distance 0.16 ± 0.22, monocular corrected distance 0.04 ± 0.15, binocular corrected distance −0.00 ± 0.09; monocular uncorrected near 0.21 ± 0.22, monocular corrected near 0.08 ± 0.16, binocular distance‐corrected near 0.07 ± 0.14; intermediate at 60 cm (80 cm): monocular uncorrected 0.16 ± 0.21 (0.09 ± 0.21), monocular distance corrected 0.13 ± 0.19 (0.07 ± 0.20), and binocular distance corrected 0.07 ± 0.17 (0.00 ± 0.18). At 3 months and 6 months, 95.8% of IOLs showed no rotation over 5 degrees. Conclusions This is the largest study yet on the first commercially available diffractive multifocal toric IOL. Results confirm its efficacy, predictability, and safety in restoring distance, near, and intermediate vision and allowing patients with significant levels of corneal astigmatism to achieve spectacle independence. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.