intraoperative alignment procedure for toric … · posterior corneal astigmatism surgically...

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INTRAOPERATIVE ALIGNMENT PROCEDURE FOR TORIC INTRAOCULAR LENSES

TO YIELD OPTIMAL SUPPRESSION OF

ASTIGMATISMBarcelona - 2015/09/08

Dr. Andrea CantagalliPrivate Hospital,GSD Villa Erbosa, Bologna,Italy

The author has no financial or proprietary interest in any product mentioned.

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Intraoperative aberrometry:a guidance for toric IOL

Purpose:To demonstrate the efficacy of intraoperative wavefrontguidance to achieve best suppression of astigmatism without prior marking procedure.by using the intraoperative wavefront analyzer I-O-W-Afrom Eyesight & Vision GmbH, Nuremberg, Germany.


Intraoperative Wavefront Aberrometer

ADVANTAGES

1) SELECTING IOL( SPHERE AND CYLINDER)Confirm or revise the IOL selection(expecially for previous refractive surgery)

2) OPTIMIZING TORIC LENS LOCATION:Posterior corneal astigmatismSurgically induced astigmatismTilting or head misalignement during preoperative testing

3) TAILORING ARCUATE INCISIONS:LRI(limbal relaxing incisions)AK(arcuate keratotomy)ISAK ( intrastromal arcuate keratotomy)

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Measurement principles

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- A 2D Microscanner deflects a laserbeam over the cornea- The optical system of the eye generates a flying spot on the retina- The scattered light from the retina is displayed on a position detector PSD- The measured refraction of the eye is displayed binocular into microscope

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Measurement principles

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- The refraction of the eye is the difference (α – β) between the angle ofentrance α and the measured output angle β of the leaserbeam


Retinal image ‐> output angle

Corneal data ‐> angle of entrance

Processing192 data points

WavefrontZernike

RefractionS / C / Axis

IOL powerHaigis, Holladay, etc.

Evaluation of the measurement data

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Evaluation of the measurement data

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- A laserbeam scans the eye area-wide. - 192 points are sampled by the microprocessor.- The microprocessor calculates the wavefront for different optical zones.

for example optical zones of 4,0 mm or 2,3 mm diameter.

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Sarver, Sanders, Cooke JCRS 2013

MARKING PROCEDURE:

Influence ofcyclorotation ALSO

in orthostaticposition (+/-3°)

Toric IOLs: nailing the target axis

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VARIABILITY of the anterior intended axis

(autoker, biometry, topography,

Scheimpflug, OCT,LED topography)



NO MARKING PROCEDURE:

Eye trackinglinked to

morphologicalaspect



NO MARKING PROCEDURE:

Intraoperative WF linked to

functionalaspect



Pre-checked IOL Calculation

Toric IOL calculator(Ophtec Toric Calc, Soleko Toric Calc, Abbott Toric Calc)

Magnitude of cylinder with posterior corneal astigmatismcompensation (Scheimpflug,Total Corneal Power)

IN THIS STUDY THE INTRAOPERATIVE ABERROMETRY USED JUST FOR TUNING THE

FINAL POSITION OF THE TORIC IOL

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Work flow of optimal suppression ofastigmatism

Aphakicmeasurement

Cylinderminimum

?

Implantation of IOL

Pseudophakicmeasurement

Rotation of IOL

Final check

YES

NO

Intraop. measurement ofFUNCTIONAL cylinder & axis

Intraop. Check of FUNCTIONALcylinder & axis

Fine tuning

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Optimization of the pre-checked toric IOL


˝ Functional˝ aphakic axis

Intraoperative identification aphakic axis

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Case 1: intraoperative refraction aphakic eye

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Intraoperative refraction check - pseudophakic eye

FINE TUNING UNTIL THE LOWEST CYL VALUE!!!

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Case 1: intraoperative fine tuning of astigmatism

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Lens is rotated to minimize the cylinder

Rotates into wrong direction

check

Setting intraocular pressure

Rotates into right direction

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Intraoperative versus postop WF/ Subjective refraction

Intraoperative refractionI‐O‐W‐A

PostoperativeWavefront*

Postoperativ subjective refraction

IOL SE/dpt S/dpt C/dpt Axis SE/dpt S/dpt C/dpt Axis SE/dpt S/dpt C/dpt Axis

Precizon Toric 25,75 cyl 2,5 ‐0,71 ‐0,47 ‐0,48 118 ‐1,12 ‐0,87 ‐0,5 104 ‐0,5 0 ‐1 70

Soleko Toric 18,5 cyl 1,25 ‐0,53 0,1 ‐1,26 78 0,56 +1,0 ‐0,87 50 0,375 0,75 ‐0,75 80

Soleko Toric 20,25 cyl 1,5 0,01 0,24 ‐0,46 47 0,68 +1,37 ‐1,37 0 0 0 0 0

Tecnis Toric cyl 5,25 ‐0,86 ‐0,67 ‐0,38 74 ‐0,5 ‐0,25 ‐0,5 85 ‐0,5 0 ‐1 80

Soleko Toric 21,75 cyl 2 ‐0,32 ‐0,18 ‐0,29 109 ‐0,56 ‐0,25 ‐0,62 80 ‐0,5 ‐0,25 ‐0,5 80

Soleko Toric 18,75 cyl 2 ‐0,47 ‐0,44 ‐0,05 23 ‐0,5 ‐0,12 ‐0,75 101 ‐0,5 ‐0,5 0 0

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* HOYA iTrace™

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Results for toric IOLs

Postoperative refractionIOL SimK (IOL MASTER) SE/dpt. S/dpt. C/dpt. APrecizon Toric 25,75 cyl 2,5 1.79@92° ‐0,5 0 ‐075 70

Soleko Toric 18,5 cyl 1,25 0.70@3° 0,375 0,75 ‐0,75 80

Soleko Toric 20,25 cyl 1,5 1.04@94° 0 0 0 0

Tecnis Toric 22,0 cyl 5,25 3.45@113° ‐0,5 0 ‐1 80

Soleko Toric 22,5 cyl 2,75 2.04@179° +0,75 +0,75 0 0

Soleko Toric 18,5 cyl 2,75 1.77@88° 0 0 0 0

Soleko Toric 23,75 cyl 2,25 1.64@64° 0 0 0 0

Soleko Toric 21,75 cyl 2 0.95@157° ‐0,5 ‐0,25 ‐0,5 80

Soleko Toric 18,25 cyl 2 1.98@178° ‐0,5 ‐0,5 0 0

Soleko Toric 20,5 cyl 2 1.59@53° +0,25 +0,5 ‐0,5 6

Soleko Toric 23 cyl 2,5 1.48@6° ‐1,5 ‐1,5 0 0Soleko Toric 26 cyl 2 1.47@117° +0,5 +1,0 ‐1,0 55

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TOT N. 12 CASES (IOL PLANE):• ≥ 2.50 CYL N.6• < 2.50 CYL N.6

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Follow up results - alignement of torical IOL without preoperative marking

Corrected results if - IOL has rotated postoperatively and 1 day follow up confirmed intraop. cylinder- IOL cylinder << preop. cornea cylinder

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Reports

Patients were (2.4 times) more likely to have less than 0.5 D of residual refractive astigmatism with the use of the

aberrometry ̏ Hatch said.

Kathryn M. Hatch, M.D.

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Reports

Robert J. Cionni, M.D.

ORA systemwith VerifEye

(Alcon)or

preoperativemeasurement with a toric calculator

……the randomized, prospective, contralateral eyestudy included 111 eyes that underwent

intraoperative aberrometry with

89,2% of eyeshad astigmatism

of ≤ 0.5 D

76,7% of eyes hadastigmatism of ≤

0.5 D

1 month aftersurgery

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Summary

SUMMARY No prior marking procedure Identification of the “real“ astigmatic axis Optimization of the final position of the predetermined toric IOL Real time refractive analysis on the microscope (easy and fast

procedure)

QUESTION MARKS Is the intraoperative cornea THE SAME as the day after?? Does the IOL mantain the final intraoperative position? Is the intraoperative WF evaluation absolutely accurate?

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Conclusions

Intraoperative wavefront technology provides an easy way to align toric IOL

Realtime intraoperative wavefront technology equips the surgeon with a guidance tool to optimize the suppression of astigmatism without preoperative marking

High correlation between the intraoperative refraction and the follow-up examination results

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THANK YOU !

intraoperative alignment procedure for toric … · posterior corneal astigmatism surgically...

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