Toric or No Toric: That is the Question ASTIGMATISM CORRECTION IN ABNORMAL CORNEAS

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

Astigmatism Correction Tools

1 – 4.11 D

Kiawah 2013

Kristiana D. Neff, MD

4

Not all astigmatism is created equal… THUS, NOT ALL PATIENTS WITH CORNEAL ASTIGMATISM SHOULD BE TREATED WITH A TORIC IOL

Kiawah 2013

Kristiana D. Neff, MD

Identify Corneal Disease  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

Kiawah 2013

Kristiana D. Neff, MD

 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

All may cause variable changes which can effect topography and IOL calculations

 Ectasia

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:

2 weeks of CTL holiday:

OD cyl: 1.67 at 81 SE = 42.61 Lens choice: 17 D SN6AT4

OD cyl: 2.10 at 86 SE = 43.24 Lens choice: 16.5 D SN6AT5

OS cyl: 3.25 D at 94 SE=43.13 Lens choice: 10.5 D SN6AT8

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 Vroman, MD

David T. Carolina Cataract & Laser

Post Super K  normalized topography

IOL Master - EBMD after scrape with normal topography OS cyl = 2.20D at 103 SE = 45.39

OS cyl = 0.93 at 99 SE = 44.30

Lens choice: 18.0D SN6AT5

Lens choice: 19.0D SN60WF

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

Kiawah 2013

K1: 43.28 x 16 K2: 43.08 x 106 Cyl = 0.20 x 16

Kristiana D. Neff, MD

Standard IOL

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