© Eyesight&Vision GmbH© Villa Erbosa
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.
© Eyesight&Vision GmbH© Villa Erbosa 2
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.
© Eyesight&Vision GmbH© Villa Erbosa 3
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)
© Villa Erbosa
Measurement principles
4
- 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
© Villa Erbosa
Measurement principles
5
- The refraction of the eye is the difference (α – β) between the angle ofentrance α and the measured output angle β of the leaserbeam
© Eyesight&Vision GmbH© Villa Erbosa 6
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
© Villa Erbosa
Evaluation of the measurement data
7
- 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.
© Villa Erbosa
Sarver, Sanders, Cooke JCRS 2013
MARKING PROCEDURE:
Influence ofcyclorotation ALSO
in orthostaticposition (+/-3°)
Toric IOLs: nailing the target axis
8
© Eyesight&Vision GmbH© Villa Erbosa 9
VARIABILITY of the anterior intended axis
(autoker, biometry, topography,
Scheimpflug, OCT,LED topography)
Toric IOLs: nailing the target axis
© Eyesight&Vision GmbH© Villa Erbosa 10
NO MARKING PROCEDURE:
Eye trackinglinked to
morphologicalaspect
Toric IOLs: nailing the target axis
© Eyesight&Vision GmbH© Villa Erbosa 11
NO MARKING PROCEDURE:
Intraoperative WF linked to
functionalaspect
Toric IOLs: nailing the target axis
© Eyesight&Vision GmbH© Villa Erbosa 12
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
© Villa Erbosa
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
13
Optimization of the pre-checked toric IOL
© Eyesight&Vision GmbH© Villa Erbosa 14
˝ Functional˝ aphakic axis
Intraoperative identification aphakic axis
© Villa Erbosa
Case 1: intraoperative refraction aphakic eye
15
© Eyesight&Vision GmbH© Villa Erbosa 16
Intraoperative refraction check - pseudophakic eye
FINE TUNING UNTIL THE LOWEST CYL VALUE!!!
© Villa Erbosa
Case 1: intraoperative fine tuning of astigmatism
17
Lens is rotated to minimize the cylinder
Rotates into wrong direction
check
Setting intraocular pressure
Rotates into right direction
© Villa Erbosa
Case 1: final intraoperative refraction check
18
© Villa Erbosa
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
19
* HOYA iTrace™
© Villa Erbosa
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
20
TOT N. 12 CASES (IOL PLANE):• ≥ 2.50 CYL N.6• < 2.50 CYL N.6
© Villa Erbosa 21
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
© Eyesight&Vision GmbH© Villa Erbosa
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.
22
© Eyesight&Vision GmbH© Villa Erbosa 23
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
© Villa Erbosa
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?
24
© Villa Erbosa
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
25
26
THANK YOU !