Managing residual postoperative error
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1 Managing residual postoperative error Michael Amon Academic Teaching Hospital of St. John Vienna Sigmund Freud Private University Vienna Financial disclosure: Alcon Bausch&Lomb Bayer Johnson&Johnson Morcher Rayner Zeiss Meditec
2 Potential causes of biometrical surprise: preop. assessment (biometry, axis, ant./post. K, marking) formulas, IOL (labeling, ) intraoperative alignment (toric IOL) postoperative rotation (early, late) tilt/decentration of IOL surgically induced astigmatism ocular pathology (forme fruste keratoconus, )
3 Preop assessment amount of corneal astigmatism (regular, irregular) manifest refraction position of IOL (tilt, decentration) kind of implant (toric, multifocal, EDOF, ) status of patient (complaints, VA, monovision, ) pathology of the eye (keratoconus, PKP, )
4 Pseudoaccommodative optical effects Astigmatism: Sturm`s conoid Higher Order Aberrations Monovision
5 Options of refractive correction Corneal surgery IOLs (exchange, add-on IOL, rotation, reposition)
6 IOL - Cornea IOL: Pros: high predictability, reversible, stable (tissue independant), corrects high astigmatism, early intervention possible Cornea: Pros: no implant needed, no intraocular surgery, irregular treatment
7 Regular astigmatism +/- ametropia with a/spheric IOL Manifest refraction Corneal astigmatism IOL position (tilt, decentration)
8 Corneal surgery sub-2mm CCI: +/- neutral plus-2mm CCI on steep axis: 0.5 dpt contralateral incision: 1.0 dpt limbal relaxing incisions: 4 dpt corneal relaxing incisions: > 4 pt intracorneal segments refractive laser surgery
9 IOLs IOL in the bag Sutured or irisfixated IOL Add on IOL
10 IOL-exchange capsular surgery with risk of vitreous loss toric IOL in the bag sutured or irisfixated toric IOL
11 Additive IOLs
12 Platform: Rayner Sulcoflex, Cristalens Reverso, 1 st Q Optic: 6/6.5mm diameter: round edge: concave post. surface: Haptic: 13.5/14mm diameter: angulation: IOL overlap, avoid iris/optic-capture less dysphotopsia no hyperopic defocus centration, rot. stability uveal clearence
13 IOLs available Cristalens Reverso Rayner Sulcoflex 1 st Q
14 IOL calculation for secondary implantation R-vergence formula: sph. equivalent of ametropia, K-values, ACD software provided by company postop ametropia within +/- 7 D: hyperopia: sph. equivalent x 1.5 myopia: sph. equivalent x 1.2 M. Amon; 2018
15 Surgery limbal marks or intraop. projection temp mm CCI OVD injector/forceps positioning of IOL aspiration of OVD alignment antibiotic M. Amon; 2018
16 Reversibility: Explantation/exchange M. Amon; 2018
17 Toric Study 1 st Q A4W : 10% rotation viable method to correct residual refractive error after primary IOL implantation 90% residual error below 0.5dpt no intra- and postoperative complication retrospective study A REVIEW OF RESULTS AFTER IMPLANTATION OF A SECONDARY INTRAOCULAR LENS TO CORRECT RESIDUAL REFRACTIVE ERROR AFTER CATARACT SURGERY: K. GUNDERSEN ET AL.; CLINICAL OPHTHALMOLOGY; 11, ; 2017 M. Amon; 2018
18 Results Rayner Sulcoflex positive iris-distance: 100% positive optic-distance: 100% optic capture: 0 pupil ovalisation: 0 M. Amon; 2018
19 Rotational stability: rotation > 10 o in 10% 1 day 7 days 12 months M. Amon; 2018
20 Indications PRIMARY IMPLANTATION (Duet Implantation) High Ametropia High Astigmatism Multifocal (Toric) Duet (reversible: > Indications) De-Conversion From Multifocal to Monofocal SECONDARY IMPLANTATION Spherical Correction Astigmatic Correction Conversion from Monofocal to Multifocal (Toric) Dysphotopsia M. Amon; 2015
21 Conclusion add on IOLs surgery: safe and easy; less trauma than IOL-exchange correction at any time, same incision/lasik? calculation based on refraction (no misslabeling issue) higher amount of correction with toric IOL potential of rotation: suturing reversible procedure M. Amon
22 Regular astigmatism with toric IOL Manifest refraction Corneal astigmatism Axis of toric IOL, type of IOL Preop astigmatism AC
23 Calculation for toric IOL rotation vectoranalysis software provided by company astigmatismfix.com M. Amon; 2018
24 Regular astigmatism with toric IOL Manifest refraction Corneal astigmatism Axis of toric IOL Preop astigmatism AC
25 Surgery limbal marks or intraop. projection paracenthesis 2x OVD preparation rotation (both sides) complete aspiration of OVD (bimanuel) no air bubble hydration antibiotic final alignment
26 Irregular Astigmatism Corneal domain Laser, X-linking, ring segments, Stenopaeic hole IOLs
27 Monofocal IOLs: depth of focus Miosis Capsular phimosis
28 Stenopaeic hole IOL (hydrophobic): extended depth of focus-iols for irregular astigmatism New pinhole sulcus implant for the correction of irregular corneal astigmatism: C. Trinidade et al J.Cat. Refract.Surgery; Vol. 13/10, ; 2017
29 Conclusion: both corneal- or IOL-surgery may lead to favourable results individual selection of surgical technique is mandatory refractive laser treatment good option add on IOLs represent an excellent, reversible alternative pros: no induced rotation by capsular contraction, reversible, adjustable, early treatment cons: rotation issue (option to suture)
30 zentrale Öffnung: 1,36 mm ermöglicht die IOL eine kontinuierliche Tiefenschärfe von 2,0 bis 3,0 D Nichtdominantes Auge Zielrefraktion: -0,75 dpt (Monovision) Extended depth of focus (EDOF- IOL): IC-8 30
31 Spherical, chromatic aberrations of the IOL
32 Spherical, chromatic aberrations of the IOL
33 Tiefenschärfe und Pupillendurchmesser
34 Extended depth of focus-iols (additiv)
35 Surgery limbal marks or projection 2.75mm temp. CCI OVD implantation complete aspiration of OVD no air bubble hydration antibiotic final alignment
36 Results Rayner Sulcoflex multifocal/toric Preop: 2.94cyl/175; 2.39cyl/179 Surgery: Duet Implantation No complication VA sc 20/20 ou M. Amon; 2014
37 Specific indications: dynamic refraction : keratoplasty (adjustable) keratoconus/globus pediatric cataract M. Amon; ESCRS 09
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