LENS EXCHANGE WITH IMPLANTATION OF A BITORIC INTRAOCULAR LENS IN EYES WITH SIGNIFICANT ASTIGMATISM AFTER PREVIOUS CORNEAL SURGERIES Dimitrii Dementiev, MD, Anna Shipunova, MD, PhD Irina Ivanchikova, MD, Vera Veshchikova “ Blue Eye ” Centro di Chirurgia Oculare, Milano, Italy, “ International Center for Ophthalmology” Moscow, Russia Financial Interest
Purpose To evaluate refractive outcomes, rotational stability and safety after lens exchange for customized AT TORBI 709M (Carl Zeiss) IOL in eyes previously underwent PKP, RK and PRK
AT TORBI 709M • Bitoric, plate haptics, Hydrophilic Acrylic, (Carl Zeiss Meditec) one piece IOL • Aspheric (Aberration-neutral) MICS: Implantable trough 1.5 mm incision • 6.0 mm optical/ 11.0 mm total diameter • 118.3 A-Const • • In bag implantation • Individual calculation & manufacturing (customized) DIOPTER RANGE: High rotational stability after surgery • Sphere: -10.0 to +32.0 D, 0.5 D increments Easy rotation during surgery • Cylinder: +1.0 to +12.0 D, 0.5 D increments
Materials & Methods 34 eyes of 33 patients Preexisting induced corneal astigmatism of -3.0 to -12.0 D Keratoconus Myopia Post-RK ectasia 15 eyes 15 eyes 4 eyes PRK PKP RK 7 eyes 8 eyes 19 eyes
Materials & Methods Uncorrected distance visual acuity (UDVA) • • Best-corrected distance visual acuity (BDVA) Autorefractokeratometry (Tomey) • Slit-lamp examination with photo registration (Takagi, Japan), • • Software (Adobe Photoshop) Optical biometry, keratometry AC measuraments, WW size (Carl Zeiss IOL Master V.5.4.1, • Carl Zeiss Meditec) Pachymetry, AC depth & angle size (Visante OCT 3.0.1.8 Carl Zeiss Meditec) • • Corneal topography (ATLAS Revision 3.0.0.39 Carl Zeiss Meditec)
Materials & Methods Questionnaire: spectacle independence, visual disturbances, and satisfaction with vision (1 = completely unsatisfied; 10 = completely satisfied) The toric IOL was customized, calculated and ordered from manufacturers in all Guidance for STACY Alignment - IOL Implantation Axis 51 (18.04.62) cases (Carl Zeiss) Right Eye - OD AT TORBI ™ 709M(P) ° implantation axis Toric IOL Request Quotation Order Customer / Surgeon Patient *Name Dr. Dementiev, Dimitri *ID 2276_13 *Institute/Clinic Blue eye 51 (18.04.62) *Age Davidov, Leonid Piazza Fontana 6 Name Postop Refractive Target: sph - 1.0 AT TORBI ™ 709M(P) 20123 Milano IOL Type *Address IT Request / Order to Distributor- / CZM AG Fax / E-Mail Address demso.orderexport@meditec.zeiss.com *Tel./Fax Distributor / Acri.Tec Biometry / Input data preop (to be filled in by customer - * MANDATORY fields) Date: Surgery Date: right (OD) Surgery Date: left (OS) r [mm] P [D] *Axis [ ° ] r [mm] P [D] *Axis [ ° ] *K1 Refractive *K1 52,54 162 *K2 *K2 37,69 72 *n=1,332 *AL [mm] Visus sc *AL [mm] 24,20 Visus sc *n=1,336 *ACD [mm] Visus cc *ACD [mm] Visus cc *n=1,3375 Sphere Cylinder Axis Sphere Cylinder Axis [°] *n=1,338 [°] [D] [D] [D] [D] Eye Glasses Eye Glasses Refraction Refraction *Target Ref. *Target Ref. Topography attached (yes/no) Topography attached (yes/no) *Devices Surgery Incision site OD/OS (° ) / Effect of surgery on K1, K2, (OD/OS) / Comments Post-Keratoplasty Calculation (to be filled in by *CZM AG) Date: 30.04.2013 ASAS right (OD) left (OS) AT TORBI ™ Left Eye - OS 709M(P) 162 ° implantation axis Residual Refraction IOL Power Residual Refraction IOL Power Sph. Equ. Sphere Cylinder Sphere Cylinder Sph. Equ. Sphere Cylinder Cylinder Sphere [D] Nr. [D] [D] [D] [D] [D] Nr. [D] [D] [D] [D] 1 1 0,42 3,26 -5,68 9,50 12,00 2 2 0,06 2,92 -5,71 10,00 12,00 3 3 -0,30 2,57 -5,73 10,50 12,00 90 ° 90 ° 90 ° 90 ° Axis [ ° ] Axis [ ° ] 162 Axis Axis = IOL position in eye* = IOL position in eye* 0° 0° 0° 0° Marks Marks = plus-cylinder axis = plus-cylinder axis = min. / flat IOL-Meridian = min. / flat IOL-Meridian *Correct graphical display of the implantation axis requires Microsoft Office XP or later versions. Calculated with: Postop estimated ACD: OD= / OS= Corneal refractive index n' = 4,41 1,3375 Order (to be filled in by customer) IOL : right (OD) IOL : left (OS) Sphere Cylinder Delivery Sphere Cylinder Delivery No. [D] [D] Quantity date No. [D] [D] Quantity date STACY (reusable screen transparency) desired (yes/no) Order-No. (Customer) Date Sign Exclusion of liability: Carl Zeiss Meditec AG (CZM) provides a service for medical practices to calculate the recommended IOL refractive power. Calculation of these power recommendations will be made on the basis of the data of the patient using a proprietary calculation algorithm. The results of IOL calculation performed by CZM should be regarded as non-binding recommendations specifically matched to the CZM IOL product line. Note that these recommendations cannot replace the professional expertise of the health care specialist. Despite careful processing of the data transmitted, postoperative refractive errors cannot be excluded, since (a) prediction of the postoperative IOL position is based on the population mean and may significantly deviate in individual cases, (b) postoperative IOL dislocation (e.g. due to capsular phimosis etc.) cannot be predicted, (c) errors in the transmission of the biometric data cannot be excluded, and (d) accuracy of the biometric raw data cannot be verified by CZM. CZM shall not be liable for any potential postoperative refractive errors in connection with the IOL power recommendations submitted. Please send order to: Carl Zeiss Meditec AG, Gö schwitzer Strasse 51-52, D - 07745 Jena International Customer Service: Tel +33 5 46 44 85 50 Fax +33 5 46 44 09 24 email: demso.orderexport@meditec.zeiss.com IOL-Berechnung-V23-KW-17--30 04 2013_ASAS.xls Dr.Dementiev_Davidov Version 23 / 01/2012 / RB Date of print: 30.04.2013 IOL-Berechnung-V23-KW-17--30 04 2013_ASAS.xls
Patient Preparation MARKING 0 ° & 180 ° axis • Topic Anestesia (Lidocaine 2%) • Under Slit lamp in sit position • Just before the surgery to keep the marks visible
SURGICAL TECHNIQUE • Topic anestesia 2% Lidocain 20 min prior surgery Midriasis (Fenelefrin,Tropicamid1%, Deltamidrin) • • Clear Cornea self sealing incision of 2.4 mm MICS of 1.5 Viscoelastic in AC • Capsulorexis 5.0-6.0 mm • Facoimulsification I/A cortex removal • Viscoelastic injection in capsular bag • • IOL implantation • IOL positioning
SURGICAL TECHNIQUE IOL positioning according to steep corneal axis
Mean (SD) Preoperative data p-value Mean (SD) Postoperative data p-value Median (Range) Median (Range) PKP group PRK group RK group PKP group PRK group RK group 1.05 (0.32) 0.93 (0.52) 1.20 (0.30) 0.776 LogMAR UDVA 0.29 (0.21) 0.12 (0.03) 0.20 (0.07) 0.018 LogMAR UDVA 1.00 (0.40 to 1.52) 1.30 (0.20 to 1.30) 1.00 (1.00 to 1.80) 0.30 (0.05 to 1.00) 0.10 (0.10 to 0.17) 0.17 (0.10 to 0.30) -2.64 (2.57) 0.53 (2.03) -1.18 (3.65) 0.029 Manifest sphere (D) -1.41 (1.70) -0.09 (0.42) -0.39 (0.20) 0.132 Manifest sphere (D) -2.50 (-8.25 to 1.50) 1.25 (-4.00 to 2.25) -1.50 (-7.00 to 3.00) -0.50 (-5.00 to 0.50) 0.00 (-1.00 to 0.50) -0.50 (-0.50 to 0.00) -9.08 (1.92) -4.67 (1.36) -6.04 (1.21) <0.001 Manifest cylinder (D) -3.00 (1.60) -0.94 (0.73) -0.79 (0.17) 0.003 Manifest cylinder (D) -9.00 (-12.00 to -6.00) -5.00 (-6.00 to -2.50) -6.50 (-7.00 to -3.75) -3.00 (-6.00 to 0.00) -0.88 (-2.00 to -0.25) -0.75 (-1.00 to -0.50) Manifest SE (D) -7.18 (2.86) -1.80 (2.37) -4.20 (3.89) <0.003 Manifest SE (D) -2.91 (2.05) -0.56 (0.60) -0.79 (0.20) 0.004 -8.00 (-12.50 to -1.50) -0.75 (-7.00 to 0.075) -5.00 (-10.25 to 0.25) -2.75 (-7.50 to 0.00) -0.44 (-2.00 to -0.13) -0.88 (-1.00 to -0.50) 0.42 (0.21) 0.35 (0.21) 0.49 (0.04) 0.587 LogMAR CDVA LogMAR CDVA 0.07 (0.04) 0.01 (0.00) 0.08 (0.03) 0.088 0.50 (0.00 to 0.80) 0.50 (0.10 to 0.50) 0.50 (0.40 to 0.50) 0.10 (0.00 to 0.10) 0.01 (0.01 to 0.01) 0.10 (0.05 to 0.10) 34 eyes of 33 patients Mean age: 41.5 ± 6,4 years (31-51) Mean postoperative follow-up – 31.3 ± 8.1 months (22-55) The mean interval from previous surgery to toric IOL implantation 9.9 ± 6.1 years (3-22)
Efficacy 1,2 1 Mean UCVA (LogMAR) 0,8 0,6 PRK PKP 0,4 RK 0,2 0 pre op 1 month 6 months 12 months 24 months 30 months
EFFICACY
SAFETY
PREDICTABILITY
Scatter plot of polar astigmatic vectors Pre-operative corneal astigmatism Post RK Post PRK Post-operative refractive cylindrical error
Scatter plot of polar astigmatic vectors Pre-operative corneal astigmatism Post PKP Post-operative refractive cylindrical error
Stability RK pre op 1 month 6 months 12 months 24 months 30 months PKP 2 PRK Mean Manifest spherical 1,5 1 equivalent (D) 0,5 0 -0,5 -1 -1,5 -2
ROTATIONAL STABILITY ≤ 2° - 86% ≤ 5° - 100%
PATIENT SATISFACTION 1. Spectacle independence – 63, 7% 2. Visual disturbance (halo and glare) – 21,4%, 3. Satisfaction with vision: - 92,3%
CONCLUSION Customized Refractive Lens Exchange for AT TORBI Toric IOL (Carl Zeiss) • Effective • Safe • Predictable • Stable solution for correction of high level of induced corneal astigmatism in eyes that underwent corneal transplantation and corneal refractive procedures
THANK YOU Dimitrii Dementiev, MD Milano, Italy Moscow, Russia
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