Noel Bauer

Astigmatism management in cataract surgery with the AcrySof toric intraocular lens.

PURPOSE: To present clinical data from a single‐center prospective clinical trial of the AcrySof toric intraocular lens (IOL). SETTING: Academic Hospital Maastricht, Maastricht, The Netherlands. METHODS: Fifty‐three eyes (43 patients) had implantation of an AcrySof toric IOL. Three toric models were evaluated in cylinder powers of 1.50 diopters (D) (SN60T3; T3 group, n = 16), 2.25 D (SN60T4; T4 group, n = 14), and 3.00 D (SN60T5; T5 group, n = 23) at the IOL plane. The T5 group was subdivided into eyes that could be fully corrected (T5a, n = 13) and eyes that could be partially corrected (T5b, n = 10). RESULTS: Four months postoperatively, the mean uncorrected visual acuity (UCVA) was 0.77 ± 0.23 in the T3 group, 0.93 ± 0.23 in the T4 group, 0.82 ± 0.15 in the T5a group, and 0.47 ± 0.13 in the T5b group. More than 90% of the combined eyes in the T3, T4, and T5a groups achieved a UCVA of 20/40 or better, and almost 80% achieved a UCVA of 20/25 or better. Residual refractive astigmatism of less than 0.75 D was achieved in 74% of eyes and of less than 1.00 D in 91%. The mean IOL misalignment was 2.5 ± 2.1 degrees in the T3 group, 3.5 ± 2.3 degrees in the T4 group, and 4.1 ± 3.5 degrees in the T5 group. CONCLUSION: Implantation of the AcrySof toric IOL proved to be an effective, safe, and predictable method of managing corneal astigmatism in cataract patients.

Dissatisfaction after implantation of multifocal intraocular lenses

PURPOSE: To analyze the symptoms, etiology, and treatment of patient dissatisfaction after multifocal intraocular lens (IOL) implantation. SETTING: Department of Ophthalmology, Maastricht University Medical Center, The Netherlands. DESIGN: Case series. METHODS: In this retrospective chart review, the main outcome measures were type of complaints, uncorrected and corrected distance visual acuities, uncorrected and distance‐corrected near visual acuities, refractive state, pupil diameter and wavefront aberrometry measurements, and type of treatment. RESULTS: Seventy‐six eyes of 49 patients were included. Blurred vision (with or without photic phenomenon) was reported in 72 eyes (94.7%) and photic phenomena (with or without blurred vision) in 29 eyes (38.2%). Both symptoms were present in 25 eyes (32.9%). Residual ametropia and astigmatism, posterior capsule opacification, and a large pupil were the 3 most significant etiologies. Sixty‐four eyes (84.2%) were amenable to therapy, with refractive surgery, spectacles, and laser capsulotomy the most frequent treatment modalities. Intraocular lens exchange was performed in 3 cases (4.0%). CONCLUSION: The cause of dissatisfaction after implantation of a multifocal IOL can be identified and effective treatment measures taken in most cases. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

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.

The KIDROP model of combining strategies for providing retinopathy of prematurity screening in underserved areas in India using wide-field imaging, tele-medicine, non-physician graders and smart phone reporting

Aim: To report the Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity (KIDROP) program for retinopathy of prematurity (ROP) screening in underserved rural areas using an indigenously developed tele-ROP model. Materials and Methods: KIDROP currently provides ROP screening and treatment services in three zones and 81 neonatal units in Karnataka, India. Technicians were trained to use a portable Retcam Shuttle (Clarity, USA) and validated against ROP experts performing indirect ophthalmoscopy. An indigenously developed 20-point score (STAT score) graded their ability (Level I to III) to image and decide follow-up based on a three-way algorithm. Images were also uploaded on a secure tele-ROP platform and accessed and reported by remote experts on their smart phones (iPhone, Apple). Results: 6339 imaging sessions of 1601 infants were analyzed. A level III technician agreed with 94.3% of all expert decisions. The sensitivity, specificity, positive predictive value and negative predictive value for treatment grade disease were 95.7, 93.2, 81.5 and 98.6 respectively. The kappa for technicians to decide discharge of babies was 0.94 (P < 0.001). Only 0.4% of infants needing treatment were missed. The kappa agreement of experts reporting on the iPhone vs Retcam for treatment requiring and mild ROP were 0.96 and 0.94 (P < 0.001) respectively. Conclusions: This is the first and largest real-world program to employ accredited non-physicians to grade and report ROP. The KIDROP tele-ROP model demonstrates that ROP services can be delivered to the outreach despite lack of specialists and may be useful in other middle-income countries with similar demographics.

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.

Comparison of a trifocal intraocular lens with a +3.0 D bifocal IOL: results of a prospective randomized clinical trial.

Purpose To compare visual outcomes in patients with cataract surgery and bilateral implantation of a trifocal or bifocal intraocular lens (IOL). Setting University Eye Clinic Maastricht, the Netherlands. Design Prospective randomized clinical trial. Methods Eyes with cataract and less than 1.0 diopter (D) of corneal astigmatism were randomized to receive bilateral implantation of Finevision Micro F trifocal IOLs or Acrysof IQ Restor +3.0 bifocal IOLs. Outcome measures were monocular and binocular uncorrected distance (UDVA), uncorrected intermediate (UIVA), and uncorrected near (UNVA) visual acuities; refractive outcomes; binocular defocus curve; contrast sensitivity; reading speed; patient satisfaction; and spectacle independence. Results Six months postoperatively, the mean binocular UDVA, UIVA, and UNVA in 56 eyes of 28 patients were 0.01 logMAR ± 0.11 (SD), 0.32 ± 0.15 logMAR, and 0.15 ± 0.13 logMAR in the trifocal group (n = 15) and 0.00 ± 0.09 logMAR, 0.28 ± 0.08 logMAR, and 0.12 ± 0.08 logMAR in the bifocal group (n = 13), respectively. The trifocal group showed a more continuous defocus curve and better results at −1.0 D of defocus (P < .01). The mean mesopic contrast sensitivity was higher in the bifocal group (P = .02). Complete spectacle independence was reported by 80% of trifocal patients and 50% of bifocal patients. There were no significant differences in refractive outcomes, reading speed, or patient satisfaction. Conclusion This study showed noninferiority of visual outcomes with the trifocal IOL compared with the bifocal IOL, although the defocus curve was better at an intermediate distance with the trifocal IOL. Financial Disclosure Dr. Bauer received study grants from Alcon Laboratories, Inc., Carl Zeiss Meditec AG, and Physiol S.A. and a lecture fee from Alcon Surgical, Inc. Dr. Nuijts is a consultant to Alcon Surgical, Inc., Théa Pharma GmbH, and ASICO LLC; he has received study grants from Acufocus, Inc., Alcon Surgical, Inc., Carl Zeiss Meditec AG, Ophtec BV, and Physiol S.A. No other author has a financial or proprietary interest in any material or method mentioned.

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.