Managing the Managing the Refractive “Surprise” Refractive “Surprise” After Toric IOL After Toric IOL Placement Placement Brad H Feldman, Brad H Feldman, MD MD Derek DelMonte, Derek DelMonte, MD MD Alan N Carlson, Alan N Carlson, MD MD Authors have no financial interests Duke Eye Duke Eye Center Center Durham, NC Durham, NC
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Managing the Refractive “Surprise” After Toric IOL Placement Managing the Refractive “Surprise” After Toric IOL Placement Brad H Feldman, MD Derek DelMonte,
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Managing the Managing the Refractive “Surprise” Refractive “Surprise”
After Toric IOL PlacementAfter Toric IOL Placement Brad H Feldman, Brad H Feldman,
MDMDDerek DelMonte, Derek DelMonte,
MDMDAlan N Carlson, Alan N Carlson,
MDMD
Authors have no financial interests
Duke Eye Duke Eye CenterCenter
Durham, NCDurham, NC
Case PresentationCase Presentation53 year-old man referred to the Duke Eye 53 year-old man referred to the Duke Eye Center for 2nd opinion regarding residual Center for 2nd opinion regarding residual astigmatism after undergoing cataract astigmatism after undergoing cataract extraction with Toric IOL left eyeextraction with Toric IOL left eye
Patient originally chose Toric IOL on Patient originally chose Toric IOL on surgeon recommendation to achieve surgeon recommendation to achieve astigmatic neutrality and decrease astigmatic neutrality and decrease spectacle dependencespectacle dependence
Patient completely unsatisfied with Patient completely unsatisfied with outcome immediately after surgeryoutcome immediately after surgery
Surgeon indicated there was nothing more Surgeon indicated there was nothing more he could offer the patienthe could offer the patient
Prior Ocular HistoryPrior Ocular History
Note: patient underwent myopic Note: patient underwent myopic LASIK OU in 1999 with monovision LASIK OU in 1999 with monovision OSOS– Pre-LASIK OS MRx: -6.75 +1.25 x 080Pre-LASIK OS MRx: -6.75 +1.25 x 080– Post-LASIK OS MRx: -1.50 spherePost-LASIK OS MRx: -1.50 sphere
Cataract noted in August 2007 with Cataract noted in August 2007 with BCVA of 20/50 OSBCVA of 20/50 OS– OS MRx: -3.00 –1.25 x 170OS MRx: -3.00 –1.25 x 170
Prior History ContinuedPrior History ContinuedPre-Cataract Surgery Evaluation OS Pre-Cataract Surgery Evaluation OS
April 2008 (Still at Outside Facility)April 2008 (Still at Outside Facility)
– MRx: -2.75 -1.00 x 170 MRx: -2.75 -1.00 x 170 BCVA: 20/60BCVA: 20/60
– Orbscan Keratometry: Orbscan Keratometry: 42.90/43.70 x 098 42.90/43.70 x 098
+ 0.8D x 098+ 0.8D x 098
– IOL Master K Values: IOL Master K Values: 42.13/43.21 x 092 42.13/43.21 x 092
+1.1D x 092+1.1D x 092
– Manual KeratometryManual Keratometry 40.20/42.20 x 09840.20/42.20 x 098
+2.0D x 098+2.0D x 098– US PachymetryUS Pachymetry 479 microns479 microns
Astigmatism Power:Astigmatism Power:– Alcon AcrySof Toric Calculator UsedAlcon AcrySof Toric Calculator Used– Based on Manual K’s Based on Manual K’s
As per instructions of online calculatorAs per instructions of online calculatorNote difference in Note difference in powerpower of K axes of K axes between Orbscan, IOL Master, and between Orbscan, IOL Master, and Manual K’s (see prior slide)Manual K’s (see prior slide)
IOL IOL CalculationCalculation
ss
Postoperative CoursePostoperative CourseUCVAUCVA 20/60; plano –2.50 x 100 = 20/60; plano –2.50 x 100 = 20/2020/20ExaminationExamination– Axis flipped despite properly achieving the Axis flipped despite properly achieving the
intended axisintended axis– Position: asymmetric fixation, superior loop in Position: asymmetric fixation, superior loop in
sulcus, inferior loop in bag, optic decentered sulcus, inferior loop in bag, optic decentered superiorly and tiltedsuperiorly and tilted
Assessment:Assessment:– Pantoscopic tilt with optic decentration Pantoscopic tilt with optic decentration
making astigmatic correction by the IOL making astigmatic correction by the IOL overly effective, causing over correction and overly effective, causing over correction and axis flipaxis flip
Plan:Plan: Reposition lens for symmetric bag Reposition lens for symmetric bag fixationfixation– Please view attached video for detailsPlease view attached video for details
Our initial assessment in consultation Our initial assessment in consultation supported an improperly implanted IOL as supported an improperly implanted IOL as the culprit for the astigmatic axis flip.the culprit for the astigmatic axis flip.
The patient’s outcome after his second The patient’s outcome after his second surgery indicates the original IOL selection surgery indicates the original IOL selection error was based on using a post-LASIK error was based on using a post-LASIK manual “K” reading. Additional data manual “K” reading. Additional data revealed this was inconsistent with other revealed this was inconsistent with other astigmatism measurements.astigmatism measurements.
Patient remains frustrated and is now Patient remains frustrated and is now contemplating IOL exchange.contemplating IOL exchange.
DiscussionDiscussion
The differential diagnosis for a “surprise” The differential diagnosis for a “surprise” result after surgery includes:result after surgery includes:– Wrong astigmatic power calculation and IOL Wrong astigmatic power calculation and IOL
selectionselection– Incorrect astigmatic axis alignmentIncorrect astigmatic axis alignment– Incorrect Toric IOL location resulting from Incorrect Toric IOL location resulting from
decentration or optic tiltdecentration or optic tilt– Surgical or postoperative induction of Surgical or postoperative induction of
astigmatism related to wound healing or IOL astigmatism related to wound healing or IOL optic rotationoptic rotation
SummarySummary53 yo h/o LASIK unsatisfied due to astigmatism 53 yo h/o LASIK unsatisfied due to astigmatism following cataract surgery with Toric IOLfollowing cataract surgery with Toric IOL– Toric IOL was selected on the basis of manual “K” Toric IOL was selected on the basis of manual “K”
readings as recommended by IOL selection protocolreadings as recommended by IOL selection protocol– Original measurements were inconsistent:Original measurements were inconsistent:
Our error was attributing the initial surgical outcome entirely to faulty IOL fixation and position– There was optic tilt and decentration secondary to There was optic tilt and decentration secondary to
asymmetric capsular fixation from the original surgeryasymmetric capsular fixation from the original surgery
Astigmatism remained despite proper Astigmatism remained despite proper repositioning repositioning – This suggests the original surgeon used manual “K” This suggests the original surgeon used manual “K”
readings which were incorrect after previous LASIK readings which were incorrect after previous LASIK surgerysurgery
ConclusionConclusion
Measuring corneal astigmatism after Measuring corneal astigmatism after refractive surgery requires multiple methods refractive surgery requires multiple methods and more critical analysis for consistency and more critical analysis for consistency before recommending astigmatism-before recommending astigmatism-correcting Toric IOLs.correcting Toric IOLs.
Critical analysis and caution are warranted Critical analysis and caution are warranted when considering a Toric IOL in cases having when considering a Toric IOL in cases having discrepancies between different methods of discrepancies between different methods of “K” readings“K” readings