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