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Evaluation & Surgical Correction of Astigmatism Jean Luc Febbraro MD Rothschild Foundation Paris...
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Transcript of Evaluation & Surgical Correction of Astigmatism Jean Luc Febbraro MD Rothschild Foundation Paris...
![Page 1: Evaluation & Surgical Correction of Astigmatism Jean Luc Febbraro MD Rothschild Foundation Paris France jeanluc@febbraro.net.](https://reader036.fdocuments.in/reader036/viewer/2022062407/56649da95503460f94a95d1d/html5/thumbnails/1.jpg)
Evaluation & Surgical Correction of Astigmatism
Jean Luc Febbraro MDRothschild Foundation
Paris France
[email protected]@febbraro.net
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Evaluation & Surgical Correction of Astigmatism
Financial disclosureAlcon Laboratories: C, Croma: C
Bausch & Lomb Surgical: C,L
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Surgical Correction of Astigmatism
Evaluation & Principles
Prevalence & EvolutionPrevalence & Evolution
Cataract incisions SIA Cataract incisions SIA
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Evaluation of Astigmatism
• K-readings– 2mm central
• Topography– Placido, Scheimflug (cornea > 2mm)– Aberrometers (cornea, internal)
• Refraction– Total astigmatism (subjective, objective)
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Evaluation of Astigmatism
Topography (placido) Precise measurement
Magnitude, axis Symmetry Regularity Detection
K. fruste Pellucid Deg.
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Evaluation of Astigmatism
Aberrometers (Hartman-Shack, OPD)
Precise measurement Lower order ab. (Sph, cyl.) Higher order ab. (coma,
trefoil, sph. aberrations) Distinction
Total, internal
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Evaluation of Astigmatism
• Refraction (Subjective, objective)
– Perfect match required• Subjective
– (Sph, cyl)• Objective
– (Sph, cyl & HOA)• Enable WF ablation
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Astigmatic Correction & Cataract Patients
Surgical options: • Incisional techniques
• LRI, AK• Toric IOLs• Laser vision correction
• PRK, LASIK
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Astigmatic Correction & Incisional Techniques
Principles: • The cornea flattens over an incision
• Transverse incisions increase the radius of curvature in one meridian only
• The flattening effect increases as incisions approach the visual axis
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Astigmatic Correction & Incisional Techniques
Coupling: The flattening effect of a transverse incision is
associated with a steepening effect 90° away.
• Coupling ratio tend to be one to one.
• The spherical equivalent remains unchanged.
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Astigmatic Correction & Incisional Techniques
Principles: Incisions are always placed on the steep
meridian.
• The longer and deeper the incision the greater the effect.
• The older the patient the greater the effect.
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Astigmatic Correction with LRI
LRI / PRI Placed on the steepest meridian Located at the limbus (9.0-11.0-mm OZ)
4242
4444
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Astigmatic Correction with LRI
Principles Flatten the steepest meridian Steepen the axis at 90° Coupling ratio 1:1
4444
42424343
4343
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Astigmatic Correction: LRI / AK
LRI: pros Less irregular astigmatism Less chance of perforation Convenient technique
Easy to perform Intraoperatively
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Astigmatic Correction: LRI / AK
LRI: cons Limited astigmatic correction Regression Variability of results
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Astigmatic Correction: LRI
Instruments: simple kit Axis marker 0.12-caliber forceps Diamond knife
Preset (600 microns)Micrometer
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STUDY
46 eyes, 30 patients (age: 72 + 10 A)• 3.2 mm CCI, Steep axis• Preset 600 µ diamond knife• Limbal relaxing incisions• Preop Corneal Astig.: 1.66 + 0.65 D (0.75 to 3)• Follow up: 6 M
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Results:Astigmatism pre / postop
Corneal Astigmatism (D)Corneal Astigmatism (D)
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LRIs: Tips & Tricks
Placement of incisions• Axis
– 10° off: -33%– 15° off: -52%
• Constant orientation• Constant depth• Preset 600µ knife• Micrometer knife set at 90%
thinnest pachymetry • Steep axis +++
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Astigmatic Correction withToric IOLs
Reduction of Astigmatism
SN60T3 = 1.5D (1D) SN60T4 = 2.25D (1.5D) SN60T5 = 3.0D (2D)
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Astigmatic Correction withToric IOLs
FDA Data
92% 20/40 or better Mean residual astigmatism: 0.60 D 50% less than 0.5D of residual postop astigmatism 97.6% rotated less than 15 degrees
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Astigmatic Correction with Laser
Laser Vision Correction: Precise correction of astigmatismCorrection of spherical componentCheck MR and WF refraction
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Astigmatic Correction with Laser
n=206n=139
n=340
Netto et al, AJO 2006;141:360-368Netto et al, AJO 2006;141:360-368
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Laser Astigmatic Vision CorrectionRefractive patients: primary choice
PRK LASIK Excellent accuracy (sphere & cylinder) Constant technological improvements
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Laser Astigmatic Vision CorrectionAll types of regular astigmatisms
Simple, compound myopic astig. Flatten the steepest meridian
Simple, compound hyperopic astig. Steepen the flattest meridian
Mixed astig. Combine both principles
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Angle Error (Degrees)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
0 1 2 3 4 5 6 7 8 9 10
Angle Error (Degrees)
Undercorrection in Astigmatism
Cyclotorsion & Astigmatic Correction
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ACE
SRET DRETStatic Rotational ET Dynamic Rotational ETCompensation between Intraoperative compensationupright / supine position
Iris Recognition
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Cyclotorsion
Study EyesMean Degree Movement
Other
Febbraro et al.JCRS, 2010
70 3.4 + 2.7º up to 14º
Swami, Steinert et al, AJO, 2002
240 4.1º + 3.7º8% with over 10º of movement
Smith, Talamo, Assil, JCRS, 1994
50 - 25% over 7º of movement (up to 16º)
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ACEACE SRETSRET DRETDRET
MeanMean 3.08 3.08 + 2.68 ° 2.68 ° 3.39 3.39 + 2.94° 2.94°
RangeRange -7 - +14.1°-7 - +14.1° -10.3 - +13.5°-10.3 - +13.5°
Results
Fondation A. de Fondation A. de RothschildRothschild
ParisParis
Jean-Luc Febbraro Jean-Luc Febbraro MDMD
Cyclotorsion:
Static (SRET) / Dynamic (DRET)
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ACE
%%
Cyclotorsion Cyclotorsion
Mean Static (SRET) / Dynamic (DRET)
Fondation A. de Fondation A. de RothschildRothschild
ParisParis
Jean-Luc Febbraro Jean-Luc Febbraro MDMD
N:70 N:70
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ACEMean Absolute Amplitude (DRET)
Fondation A. de Fondation A. de RothschildRothschild
ParisParis
Jean-Luc Febbraro Jean-Luc Febbraro MDMD
DRET Amplitude (°)DRET Amplitude (°)
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Conclusion
• Surgical correction of astigmatism is a reality – Mandatory to optimize uncorrected vision– Refractive and cataract patients– Numerous surgical options
Fondation A. de Fondation A. de RothschildRothschild
ParisParis
Jean-Luc Febbraro Jean-Luc Febbraro MDMD
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• Clinical significance– Accurate eye care
– IOL manufacturers (SA , Cyl.)
– Valuable information for cataract & refractive surgeons
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Astigmatism evolution with age
Age / Ast.2654 patients
% Mean
20-30 years 40% 1.20 D
70-80 years 72% 1.30 D
Prevalence of astig. increases with age.
Ferrer-Blasco T. et al. Ferrer-Blasco T. et al. JCRS 2008; 34:424- JCRS 2008; 34:424-432432
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To evaluate Astigmatism Distribution and Evolution in Adult Patients
Retrospective study 500 eyes of 276 patients Autorefractometer refraction & keratometry
measurements Mean interval: 8.37 +/-2.92 y (min 5-16 max)
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Mean age 60.11 +/- 11.39
Age min- Age max 37-90
Gender: Male / Female 182 M / 318 F
Mean sphere -0.02 +/- 3.20
Sphere min-max -14.75 - + 7.5
Mean ocular astigmatism 0.95 +/- 0.77
Ocular astig. min-max 0.25 - 6.75
Mean corneal astigmatism 1.14 +/- 0.40
Corneal astig. min-max 0 - 6.5
Mean flat K (K1) 43.10 +/- 1.39
Mean steep K (K2) 44.11 +/- 1.48
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Magnitude Ocular Astig. Corneal Astig.
≤0.5D 35.8% 33.8%
0.75 - 1D 36.6% 33.4%
1.25 - 2D 20.8% 23.8%
> 2D 6.8% 8.2%
Astigmatism DistributionAstigmatism Distribution
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-0.02-0.02
Astigmatism Evolution
OCULAR OCULAR AST.AST.
visitvisit 11 visitvisit 22
CORNEAL CORNEAL AST.AST.
SPHERESPHERE
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Astigmatism Evolution Age Groups Cylinder Axis
< 50 0.19 +/- 0.64D 6 +/- 17°
50-59 0.24 +/- 0.71D 12 +/- 20°
60-69 0.31 +/- 0.75D 6 +/-17°
> 70 0.28 +/- 0.89D 5 +/- 15°
ATR shift over 8 yearsATR shift over 8 years
0.26 D0.26 D
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Astigmatism Evolution
Age GroupsAge Groups Study Study 500 eyes500 eyes
Reykjavic Eye Reykjavic Eye Study* 757 eyesStudy* 757 eyes
< 50 0.19 +/- 0.64 D
50-59 0.24 +/- 0.71D 0.09 +/- 0.41 D
60-69 0.31 +/- 0.75D 0.13 +/- 0.45 D
> 70 0.28 +/- 0.89D 0.22+/- 73°
All Groups O.26 D over 8 years 0.13 D over 5 years
* E. Gudmundsdottir, A. Arnarsson, F. Jonasson. Five-year refractive * E. Gudmundsdottir, A. Arnarsson, F. Jonasson. Five-year refractive changes in an adult population; Reykjavik Eye Study. changes in an adult population; Reykjavik Eye Study. Ophthalmology 2005;112, 672–677.Ophthalmology 2005;112, 672–677.
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Knowledge of prevalence and evolution of astigmatism is valuable information 35% negligible astig. 35% 0.75 – 1 D 30% > 1 D 7% 2 D
Mean magnitude +/- 1 D in adults, tends to increase with age
ATR axis shift (0.13 – 0.26 D) over time, particularly in older patients
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• Trend Size
Standard 3-mm incision Mini + 2.5-mm incision Micro sub 2-mm incision
Placement Scleral to limbal / clear corneal incision Superior to temporal approach
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• Size IOL implantation
Monofocal, Multifocal, Accomodative, Toric IOLs Phaco platform
Phaco and I/A probes & sleeves
• Location Scleral to limbal / clear corneal incision Superior to temporal approach
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• Astigmatic change Incision size Distance from visual axis Axis placement
• Astigmatic change evaluation Algebraic method (magnitude of ast.) Vector Analysis (magnitude & axis of ast.)
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Standard 3-3.5-mm on axis CCI PKE
n: 172 Sup. Incision Temp. Incision
SIA 0.93 + 0.54 D 0.62 + 0.47 D
Long D. et al. Ophthalmology 1996; 103:226-232Long D. et al. Ophthalmology 1996; 103:226-232
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Standard 3.2-mm on axis / temp. CCI PKE
n: 62On Axis Incision
Temporal Incision
SIA7 w PO
0.63 D 0.34 D *
Borasio E. et al. JCRS 2006; 32:565-572Borasio E. et al. JCRS 2006; 32:565-572
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3-3.5-mm Incision & SIA RangeLiterature Summary
Incision Location
Superior Oblique On Axis Temporal
SIA (D) 0.60 – 1.50 0.60 – 1.29 0.60 – 0.90 0.09 – 0.44 *
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Choice of Incision Location
1 Kohnen T, Koch D. Curr Opin 1 Kohnen T, Koch D. Curr Opin Ophthalmol. 1996; 7:75-80Ophthalmol. 1996; 7:75-80
Temporal Inc. Nasal Inc. Superior Inc.
1996Kohnen T, Koch D.1
ATR 0.75-1.25 D
WTR 0.75-1.25 D
2005Tejedor J, Murube
J.2
ATR < 0.75 D ATR > 0.75 D WTR >1.25 D
2009Tejedor J, Perez J.3 Negligible Ast. ATR WTR
2 Tejedor J, Murube J. Am J Ophthalmol. 2005; 139:767-7762 Tejedor J, Murube J. Am J Ophthalmol. 2005; 139:767-776
3 Tejedor J, Perez-Rodriguez J. IOVS. 2009; 50:989-9943 Tejedor J, Perez-Rodriguez J. IOVS. 2009; 50:989-994
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n: 44 3.0-mm 2.2-mm
SIA 0.67 + 0.48 D 0.35 + 0.21 D *
Masket S. et al. JRS 2009; 25:21-2424Masket S. et al. JRS 2009; 25:21-2424
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n: 108 C-MICS B-MICS
SIA 0.23 + 0.29 D 0.23 + 0.22 D
Wilczynski M. et al. JCRS 2009; 35:1563-69Wilczynski M. et al. JCRS 2009; 35:1563-69
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STUDYEvaluate SIA Cataract Incisions
• Nonrandomized prospective series 191 eyes • Group 1: 60 eyes PKE 3.2-mm sup. CCI• Group 2: 68 eyes PKE 2.2-mm sup. CCI• Group 3: 63 eyes PKE 1.8-mm sup. CCI
• Two-plane incision with precalibrated metal knife
• Unenlarged wound for IOL implantation• Group 1: SN60WF / Akreos AO IOLs• Group 2: SN60WF / Akreos MICS IOLs• Group 3: Akreos MICS IOL
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Group Arithmetic Mean Vector Mean
3.2-mm 1.02 + 0.39 D 0.77 at 10°
2.2-mm O.60 + 0.20 D 0.26 at 20°
1.8-mm O.48 + 0.10 D 0.16 at 13°
Vector Analysis Vector Analysis
StudyResults
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• Desirable to know astigmatic effect of CCI• SIA depends on incision size and location.
• Significant less SIA with 1.8 / 2.2 / + 3.0-mm CCI.• SIA very limited with + 2.0-mm CCI.
![Page 54: Evaluation & Surgical Correction of Astigmatism Jean Luc Febbraro MD Rothschild Foundation Paris France jeanluc@febbraro.net.](https://reader036.fdocuments.in/reader036/viewer/2022062407/56649da95503460f94a95d1d/html5/thumbnails/54.jpg)
• Desirable to know astigmatic effect of CCI• SIA depends on incision size and location.
• Significant less SIA with 1.8 / 2.2 / + 3.0-mm CCI.
• SIA very limited with + 2.0-mm CCI.
• Clinical implications• To minimize SIA & optimize visual rehabilitation.• Customized incision size and location (>2.8-mm) based upon preop.
astig.• Optimize UCVA with monofocal & premium IOLs.
![Page 55: Evaluation & Surgical Correction of Astigmatism Jean Luc Febbraro MD Rothschild Foundation Paris France jeanluc@febbraro.net.](https://reader036.fdocuments.in/reader036/viewer/2022062407/56649da95503460f94a95d1d/html5/thumbnails/55.jpg)
Fondation A. de Fondation A. de RothschildRothschild
ParisParis
Jean-Luc Febbraro Jean-Luc Febbraro MDMD
Thank youfor your attention