toric or no toric: that is the...
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A S T I G M A T I S M C O R R E C T I O N I N A B N O R M A L C O R N E A S
Toric or No Toric: That is the Question
Kristiana D. Neff, MD Charleston & Ladson, SC
Financial Disclosure
I do have an industry relationship with Alcon Laboratories (Speaker).
Kiawah 2013 Kristiana D. Neff, MD
Why manage astigmatism?
Astigmatism is a leading cause of poor vision before and after cataract surgery
1. Patients request and expect better outcomes. 2. Patients can understand astigmatism and methods of correction. 3. Astigmatism is COMMON (approximately 50% of patients have 0.75 D or greater).
Kiawah 2013 Kristiana D. Neff, MD
4
Astigmatism Correction Tools
1 – 4.11 D
Kiawah 2013 Kristiana D. Neff, MD
THUS, NOT A LL PA TIENTS WITH
CORNEA L A STIGMATISM SHOULD
BE TREA TED WITH A TORIC IOL
Not all astigmatism is created equal…
Kiawah 2013 Kristiana D. Neff, MD
Identify Corneal Disease
Kiawah 2013 Kristiana D. Neff, MD
Proper evaluation and treatment of corneal conditions affecting astigmatism before cataract surgery is essential When possible, eliminate all variables to determine true
corneal shape Only when this is accomplished can a lens be selected and a
proper surgical plan formulated which may include Toric IOL
Identify corneal conditions where surgical astigmatism management should be used with caution or not at all Some astigmatism can not or should not be addressed at the time of cataract surgery
Kiawah 2013 Kristiana D. Neff, MD
Conditions to Identify
Dry Eye Contact lens wear EBMD Subepithelial fibrosis Salzmann’s nodules Scars Pterygia Ectasia
All may cause variable
changes which can effect
topography and IOL calculations
Kiawah 2013 Kristiana D. Neff, MD
Contact Lens Warpage
Can affect the astigmatism values and IOL power Guidelines the same as excimer laser surgery
1-2 weeks out for SCL Repeat calcs and topos monthly until stable for RGPs
Kiawah 2013 Kristiana D. Neff, MD
Immediately after taking CTL out: OD cyl: 1.67 at 81 SE = 42.61 Lens choice: 17 D SN6AT4 OS cyl: 3.25 D at 94 SE=43.13 Lens choice: 10.5 D SN6AT8
2 weeks of CTL holiday: OD cyl: 2.10 at 86 SE = 43.24 Lens choice: 16.5 D SN6AT5 OS cyl: 3.02 D at 92 SE = 43.02 Lens choice: 10.5 D SN6AT7
Kiawah 2013 Kristiana D. Neff, MD
EBMD
Can be very subtle!! Superficial keratectomy if concerned about
topography Wait 6 weeks following Super-K for repeat IOL
calculations
Kiawah 2013 Kristiana D. Neff, MD
Kiawah 2011 David T. Vroman, MD Carolina Cataract & Laser
Post Super K normalized topography
OS cyl = 2.20D at 103 SE = 45.39 Lens choice: 18.0D SN6AT5
OS cyl = 0.93 at 99 SE = 44.30 Lens choice: 19.0D SN60WF
IOL Master - EBMD after scrape with normal topography
Kiawah 2013 Kristiana D. Neff, MD
Salzmann’s Nodule in patient with 2-3+ NSC
K1: 43.67 x 171 K2: 39.81 x 81 Cyl = 4.55 x 171
SN6AT7
K1: 43.28 x 16 K2: 43.08 x 106 Cyl = 0.20 x 16 Standard IOL
Kiawah 2013 Kristiana D. Neff, MD
PRE Superficial Keratectomy POST Superficial Keratectomy
• Reduction of 4 D cyl to 0.69 D x 158 • BCVa improved from 20/40 to 20/20
Kiawah 2013 Kristiana D. Neff, MD
Salzmann’s Nodules and Subepithelial Fibrosis
Can be subtle or massive Scrape can improve topography Scarring can result if left too long Wait 6 weeks after scrape to repeat IOL calculations
and topography
Kiawah 2013 Kristiana D. Neff, MD
Kiawah 2013 Kristiana D. Neff, MD
Post superficial keratectomy and nodule removal, topographies normalized, and patient underwent
successful phaco with multifocal IOL
Kiawah 2013 Kristiana D. Neff, MD
Extensive Bilateral Salzmann’s Nodules
Kiawah 2013 Kristiana D. Neff, MD
Extensive bilateral Salzmann’s nodules
after superficial keratectomy
and nodule removal
Persistent corneal scarring and irregularity
Pterygia
Can induce high levels of astigmatism Removal significantly changes corneal power and
astigmatism ALWAYS remove pterygia first for patients desiring best post cataract refractive outcome
Kiawah 2013 Kristiana D. Neff, MD
Pre pterygium excision: 6.84D
topographic astigmatism
Post pterygium excision: 1.09D topographic
astigmatism
Unilateral Corneal Scar
POM #1: 20/20- sc Very happy with vision quality
Kiawah 2013 Kristiana D. Neff, MD
Remember…
Even if corneal disease has been stabilized, not all astigmatism can or should be addressed surgically with Toric IOLs
Care to avoid unrealistic expectations Care to avoid doing harm
Kiawah 2013 Kristiana D. Neff, MD
Astigmatism Addressed with Caution –
Irregular astigmatism Keratoconus Pellucid Terriens RK PK STABLE
and REALISTIC
Kiawah 2013 Kristiana D. Neff, MD
There are other ways to correct astigmatism!
Glasses RGP’s or scleral lenses for patients with corneal
distortion Patients who plan to wear scleral lenses or hard contact lenses
postoperatively Dry eye patients in scleral lenses Long time ectasia patients happy in hard lenses When wearing contacts, the toric IOL induces astigmatism
LRI Excimer ablation
Kiawah 2013 Kristiana D. Neff, MD
Pearls for Success: Toric in Abnormal Corneas
Patient must have realistic expectations Magnitude and axis of cylinder agree between
topography, biometry, and refraction Reasonable vision potential Rule out meridonial amblyopia Consider anisometropia Be mindful of posterior cornea contribution to cylinder
Consider effect of incision Treat the cornea aggressively before cataract surgery
to eliminate variables affecting astigmatism and corneal power
Kiawah 2013 Kristiana D. Neff, MD
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