Supplemental Toric Intraocular Lenses in the Ciliary Sulcus for Correction of Residual Refractive Astigmatism: A Review

PURPOSE

This study conducted a critical review of the peer-reviewed literature on the use of supplemental toric intraocular lenses (STIOL) in the ciliary sulcus to correct residual refractive astigmatism.

METHODS

This review used PubMed as a database from 1 January 2010 to 13 March 2023. According to the inclusion and exclusion criteria defined, 14 articles were selected for the current review.

RESULTS

The data of 155 eyes were analyzed. Most of the studies reviewed had a short follow-up and poor or limited design, including case reports, case series, and retrospective cohorts. The follow-up period ranged from 43 days to 4.5 years. STIOL rotation was the most frequently described complication in the literature, with a mean rotation of 30.48 ± 19.90°. These patients required repositioning in 50 of 155 eyes (32.25%). Moreover, four eyes (2.58%) required scleral fixation sutures and two eyes (1.29%) iris fixation. Other complications were high intraocular pressure (3 eyes, 1.93%), transient corneal edema (2 eyes, 1.29%), corneal decompensation (2 eyes, 1.29%), and pigment dispersion (1 eye, 0.64%). From the total, 57.41% of eyes (89 eyes from 155) achieved within ± 0.50D of target refractive astigmatism. It is important to highlight that at least 52 eyes out of the 155 (33.54%) had an abnormal cornea with irregular astigmatism.

CONCLUSION

STIOL seem to offer good visual and refractive outcomes. However, STIOL showed variable rotational stability, especially in some platforms. Further studies with a more robust design, methodology, and standardized analysis methods are needed to confirm these trends.

Reversible Multifocality Achieved Through Polypseudophakia

Simultaneous implantation of a monofocal or monofocal toric intraocular lens (IOL) into the capsular bag and a multifocal IOL into the ciliary sulcus, referred to as duet procedure, allows us to create multifocality that is more easily reversible than the implantation of a capsular bag-fixated multifocal IOL. The optical quality and results after the duet procedure are equivalent to those of a capsular bag-fixated multifocal IOL. Patients who cannot tolerate the side effects of multifocal optics or who develop an ocular condition leading to loss of function such as age-related macular degeneration (AMD) or glaucoma in the course of their lives may benefit from the reversibility of the procedure.

Novel custom designed toric piggyback intraocular lens for the correction of residual postoperative astigmatism

We report the outcomes of a custom-designed toric piggyback intraocular lens in a patient with high postoperative residual astigmatism. A 60-year-old male patient underwent customized toric piggyback IOL for postoperative residual astigmatism of 13 D, with follow-up examinations for IOL stability and refractive outcomes. The refractive error stabilized at two months and remained stable at one year, with a correction of nearly 9 D of astigmatism. The IOP remained within normal limits, and there were no postoperative complications. The IOL remained stable in the horizontal position. To our knowledge, this is the first case report of correction of unusually high astigmatism by a novel smart toric design of piggyback IOL.

Toric intraocular lens for astigmatism correction following keratoplasty in phakic and pseudophakic eyes

ABSTRACT

Residual astigmatism and anisometropia significantly impact patients' vision and quality of life even in clear grafts after corneal transplant. We reviewed and summarized the role of toric intraocular lens (IOL) in phakic and pseudophakic eyes after penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK) in correcting residual astigmatism. We included 342 eyes from 20 studies with iris-clipped toric IOL, ciliary sulcus toric implantable collamer lens, piggyback sulcus toric IOL, or posterior chamber toric IOL implantations for phakic, pseudophakic, or eyes undergoing cataract surgery after keratoplasty. Visual, refractive, and predictability outcomes were encouraging. Secondary re-alignment rate and complications were low. Endothelial cell loss secondary to phakic toric IOL might be a concern over the long-term, particularly in iris-clipped IOL in PKP eyes. Toric IOL represent a viable option in the treatment of residual astigmatism in post-keratoplasty eyes, resulting in improved visual acuity and reduced anisometropia.

Calculation of equivalent and toric power in AddOn lenses based on a Monte Carlo simulation

BACKGROUND

Additional lenses implanted in the ciliary sulcus (AddOn) are one option for permanent correction of refractive error or generate pseudoaccommodation in the pseudophakic eye. The purpose of this paper was to model the power and magnification behaviour of toric AddOn and to show the effect sizes with a Monte-Carlo simulation.

METHODS

Anonymized data of a cataractous population uploaded for formula constant optimization were extracted from the IOLCon platform. After filtering out data with refractive spherical equivalent (RSEQ) between -0.75 to 0.25 dpt and refractive cylinder (RCYL) lower than 0.75, for each of the N=6588 redcords a toric AddOn was calculated which transfers the refraction error from spectacle plane to AddOn plane using a matrix-based calculation strategy based on linear Gaussian optics. The equivalent (AddOnEQ) and toric (AddOnCYL) power of the AddOn and the overall lateral magnification change and meridional magnification was derived for the situations before and after AddOn implantation, and a linear modelling was fitted for all 4 parameters.

RESULTS

RSEQ is the dominant effect size in the prediction of AddOnEQ and overall change in magnification (ΔM) , whereas the lens position (LP), corneal thickness (CCT) and mean corneal radius (CPa) play a minor role. In a simplified model AddOnEQ can be estimated by 0.0179 + 1.4104 · RSEQ. RCYL and corneal radius difference (CPad) are the dominant effect sizes in the prediction of AddOnCYL and the change in meridional magnification (ΔMmer) , whereas LP, CCT, CPa and RSEQ play a minor role. In a simplified model AddOnCYL can be predicted by -0.0005+ 0.0328 · CPad + 1.4087 · RCYL. Myopic eyes gain in overall magnification whereas in hyperopic eyes we observe a loss. Meridional distortion could be in general reduced to 35% on average with a toric AddOn.

CONCLUSION

Our simulation shows that with a linear model the equivalent and toric AddOn power as well as overall change in magnification, meridional distortion before and after AddOn implantation as well as the reduction in meridional distortion can be easily predicted from the biometric data in pseudophakic eyes with moderate refractive error.

Clinical and Surgical Outcome of a Supplementary Multifocal Intraocular Lens Implanted with a Bag-In-the-Lens Intraocular Lens: 5-Year Follow-Up

INTRODUCTION

To assess the postoperative outcome and patient-reported satisfaction, spectacle independence, and dysphotopsia after implantation with the mutifocal Rayner Sulcoflex supplementary intraocular lens (sIOL).

MATERIALS AND METHODS

We analyzed the outcome of all patients implanted with a multifocal sIOL between 2009 and 2011. In all cases, the sIOL was the Rayner Sulcoflex IOL (type 653F) and the primary IOL was a bag-in-the-lens (BIL) IOL. The data were obtained through a retrospective analysis of the patient records and by means of a questionnaire, 5 years after sIOL implantation.

RESULTS

This study included 31 eyes of 20 patients. In 13 eyes, the sIOL needed explantation (n = 13, 41.94%). Dysphotopsia is a frequent complaint (12/15 patients: 80.0%) after sIOL implantation. In 13 out of 31 eyes (41.94%), pigment deposits were found on the sIOL with variable clinical complaints. Five eyes required additional surgery because of clinically significant deposits.

DISCUSSION/CONCLUSION

Patients with a multifocal sIOL in combination with a BIL implantation have a higher incidence of dysphotopsia compared to previously published studies. Dysphotopsia was the main complaint and reason for explantation. We encountered a high incidence of pigmented IOL deposits. The sIOLs can be safely removed even years after implantation.

Refractive and Visual Outcomes After Implantation of a Secondary Toric Sulcus Intraocular Lenses

Purpose

To evaluate the rotational stability, visual acuity and refractive error after sulcus implantation of a secondary toric IOL.

Setting

One clinical practice in Haugesund, Norway.

Design

Non-interventional single-arm diagnostic study.

Methods

Eligible subjects who had previous successful primary cataract or refractive lens exchange surgery in one or both eyes and the AddOn^® secondary toric IOL implanted in the sulcus were evaluated at a single postoperative diagnostic visit to measure visual outcomes. Subjects with surgical complications (either primary or secondary) or pathology that would affect best-corrected visual acuity (eg, amblyopia) were excluded. Clinical evaluations at the diagnostic visit included measurement of visual acuity, manifest refraction and IOL orientation.

Results

Eighteen eyes were evaluated. After secondary IOL implantation, mean residual refractive astigmatism was significantly reduced (1.66 ± 0.92 to 0.32 ± 0.25 D). There was no appreciable change in the spherical equivalent refraction. Sixteen of 18 eyes (89%) had residual refractive astigmatism ≤0.50D, and no eye had more than 0.75D after secondary IOL implantation. Mean UCVA was 0.00 ± 0.03 logMAR, with no eyes worse than 0.10. Mean BCVA was −0.05 ± 0.03 logMAR (20/20+2), with all eyes having BCVA of 0.00 logMAR. The mean change in orientation was near zero, with a mean absolute change of 4.9 ± 3.7 degrees. Sixteen of 18 eyes (89%) had a lens orientation ≤10 degrees from intended, with no eye oriented more than 13 degrees from intended.

Conclusion

The AddOn^® toric sulcus IOL significantly reduced postoperative refractive astigmatism in patients with high astigmatism after their primary cataract or RLE surgery, providing very good uncorrected distance vision.

Postoperative rotation of supplementary sulcus-supported toric intraocular lenses

We describe 7 cases in which supplementary sulcus-based toric intraocular lenses (IOLs) rotated postoperatively, requiring surgical realignment. The initial rotation was identified clinically between 3 months and 36 months postoperatively. All eyes had keratoconus, with and without prior keratoplasty, and 6 had longer than average axial lengths. No preceding trauma could be identified for 5 of the eyes. One eye had 3 episodes of postoperative IOL rotation, eventually requiring suture fixation to stabilize the IOL. This series indicates that postoperative rotation of a supplementary sulcus-based toric IOL may occur in eyes with or without preceding trauma. Eyes with keratoconus are at risk for postoperative rotation of the IOL, and suture fixation may be required to obtain stability.

Impact of ultrasound and optical biometry on refractive outcomes of cataract surgery after penetrating keratoplasty in keratoconus

AIM

To analyse the impact of ultrasound and optical intraocular lens (IOL) calculation methods on refractive outcomes of cataract phacoemulsification performed after penetrating keratoplasty (PK) in keratoconus.

METHODS

Phacoemulsification cataract surgery was performed on 42 eyes of 34 patients with keratoconus who had previously undergone PK. The IOL power was determined by using both standard and corneal topography-derived keratometry using the SRK/T formula. We used two independent methods-ultrasound biometry (UB) and interferometry [optical biometry (OB)] for IOL calculation. The analysed data from medical records included demographics, medical history, best corrected visual acuity (BCVA) on Snellen charts, technique of IOL calculation and calculation formula and its impact on final refractive result.

RESULTS

BCVA ranged from 0.01 to 0.4 (mean 0.09±0.19) before surgery and ranged from 0.2 to 0.7 (mean 0.38±0.14) at 1mo and from 0.2 to 1.0 (mean 0.56±0.16) (P<0.05) at 3mo, postoperatively. The refractive aim differed significantly from the refractive outcome in both the UB and OB groups (P<0.05). There was no statistically significant difference in the accuracy of the two biometry methods.

CONCLUSION

The refractive aim in keratoconus eyes post-PK is not achieved with either ultrasound or OB.

A review of results after implantation of a secondary intraocular lens to correct residual refractive error after cataract surgery

PURPOSE

The purpose of this study was to provide clinical outcomes data related to secondary intraocular lens (IOL) implantation for the correction of residual refractive error after cataract surgery.

PATIENTS AND METHODS

A chart review was conducted to identify all eyes implanted with the monofocal spherical or toric AddOn^® secondary IOL. Data were collated from charts where uncomplicated initial cataract surgery was completed. Measures of interest included the original IOL implanted, the postoperative refractive error (before secondary IOL implantation) and the associated corrected and uncorrected visual acuities (VAs). Postoperative data of interest included the residual refractive error, the best-corrected visual acuity (BCVA) and uncorrected visual acuity (UCVA).

RESULTS

Refractive and VA data from 1 week to 3 months post-surgery were available for 46 of 70 eyes implanted with a secondary IOL by one surgeon at one practice between 4/15 and 3/17. There was a statistically significant improvement in UCVA of about 2 lines after surgery (p<0.01), with no change in BCVA (p=0.94). No eyes lost a line of BCVA. There was a statistically significant reduction in the absolute magnitude of the residual spherical equivalent refractive error (p<0.01). In the 10 cases with a toric secondary IOL, there was a statistically significant reduction in refractive cylinder (p<0.01).

CONCLUSION

The secondary IOL studied here appears to be a viable surgical option to correct residual refractive error after primary IOL implantation.

Correction of High Astigmatism after Penetrating Keratoplasty with Toric Multifocal Intraocular Lens Implantation

After penetrating keratoplasty (PK), high astigmatism is often induced, being frequently about 4–6 dpt. According to the entity and typology of astigmatism, different methods of correction can be used. Selective suture removal, relaxing incisions, wedge resections, compression sutures, photorefractive keratectomy, and laser-assisted in situ keratomileusis can reduce corneal astigmatism and ametropia, but meanwhile they can cause a reduction in the corneal integrity and cause an over- or undercorrection. In case of moderate-to-high regular astigmatisms, the authors propose a toric multifocal intraocular lens (IOL) implantation to preserve the corneal integrity (especially in PK after herpetic corneal leukoma keratitis). We evaluated a 45-year-old patient who at the age of 30 was subjected to PK in his left eye due to corneal leukoma herpetic keratitis, which led to high astigmatism (7.50 dpt cyl. 5°). The patient was subjected to phacoemulsification and customized toric multifocal IOL implantation in his left eye. The correction of PK-induced residual astigmatism with a toric IOL implantation is an excellent choice but has to be evaluated in relation to patient age, corneal integrity, longevity graft, and surgical risk. It seems to be a well-tolerated therapeutic choice and with good results.

Clinical outcomes after implantation of a toric intraocular lens with a transitional conic toric surface

PURPOSE

To evaluate the postoperative outcomes after implantation of a hydrophilic toric intraocular lens (tIOL) with a transitional conic toric surface in patients with astigmatism undergoing refractive lens exchange (RLE) or cataract surgery.

METHODS

In this monocentric study, clinical outcomes following implantation of the hydrophilic Precizon toric IOL model 565 (Ophtec) were analysed. For intraoperative axis alignment, the Verion Image Guided System was used. Intended versus achieved refraction, IOL position, visual acuity outcomes and power vector analyses were evaluated 3 months postoperatively.

RESULTS

Forty-three eyes of 28 patients (40 eyes cataract, 3 eyes RLE) received a Precizon toric IOL with a cylindrical power between 1.0 and 7.5 D. Target refraction was emmetropia except for four eyes that had a myopic target. The median postoperative IOL rotation at slit lamp was 3° with a range from 0° to 16°. Uncorrected distance visual acuity (UDVA) increased from median 0.5 logMAR preoperatively to median 0.06 logMAR at 3 months postoperatively. Corrected distance visual acuity increased from 0.20 to -0.02 logMAR. Median preoperative subjective cylinder was 1.5 D and 3 months postoperatively 0.25 D.

CONCLUSION

Preoperative diagnostics, IOL selection and correct intraoperative positioning of tIOLs are essential for good outcomes and postoperative spectacle independence following cataract or RLE surgery. Visual acuities and rotational stability of the Precizon toric IOL showed very good outcomes and the subjective postoperative astigmatism could be reduced significantly.

[Toric add-on intraocular lenses for correction of high astigmatism after pseudophakic keratoplasty]

Perforating keratoplasty shows good morphological results with a clear cornea; however, a limiting factor is often the resulting astigmatism, which cannot be corrected with either glasses or contact lenses (CL) in up to 20% of the patients. We retrospectively investigated 15 patients after pseudophakic perforating keratoplasty, who received implantation of toric add-on intraocular lenses (IOL) to correct astigmatism. The mean preoperative astigmatism of 6.5 diopter (dpt) could be reduced to a mean postoperative value of 1.0 dpt. The mean visual acuity could be improved from a preoperative value of sc <0.05 (cc 0.6) to a postoperative value of sc 0.4 (cc 0.63). There were no complications except for one case of a lens extension tear. Based on our good experiences we now provide toric add-on IOL to all patients with pseudophakic perforating keratoplasty when this cannot be corrected or only insufficiently corrected by conservative methods.

Supplementary, Sulcus-Fixated Intraocular Lens in the Treatment of Spherical and Astigmatic Refractive Errors in Pseudophakic Eyes After Keratoplasty

PURPOSE

To evaluate the efficacy, refractive outcomes, and complications of supplementary intraocular lens (IOL) implantation in pseudophakic eyes after keratoplasty.

METHODS

This is a retrospective review of pseudophakic postkeratoplasty eyes after implantation of a custom-designed, sulcus-fixated, supplementary "piggyback" IOL to correct refractive errors. The outcome measures included preoperative and postoperative uncorrected distance visual acuity (UDVA), spectacle-corrected distance visual acuity (CDVA), refractive correction, and complications.

RESULTS

This study evaluated 10 eyes (10 patients) with previous penetrating or deep anterior lamellar keratoplasty with a mean follow-up period of 12.2 ± 10.7 months (range, 2-33 months). All eyes showed improved UDVA postoperatively with 70% achieving ≥20/40. Median UDVA (logarithm of the minimum angle of resolution) improved from 1.2 (20/280, range 20/70-20/2000) preoperatively to 0.3 (20/40, range 20/20-20/60) postoperatively at the latest follow-up visit (P < 0.01). Five eyes (50%) had improvement in CDVA by at least 1 line of Snellen acuity with all eyes achieving ≥20/40 and 70% achieving ≥20/25. Median CDVA (logarithm of the minimum angle of resolution) was 0.2 (20/30, range 20/20-20/50) preoperatively compared with 0.1 (20/25, range 20/20-20/40) postoperatively (P = 0.03). In 8 eyes that received toric secondary IOLs, the mean refractive astigmatism decreased by 84% from 5.7 diopters (D) (range, 4-9 D) to 0.9 D (range, 0.2-3.0 D) (P = 0.01). Postoperative refractive astigmatism was ±1 D of predicted astigmatism for 7 of 8 eyes. No eyes lost any lines of UDVA or CDVA, and there were no keratoplasty rejection/failure events.

CONCLUSIONS

Implantation of a supplementary, sulcus-based IOL is an effective approach to reduce spherical and astigmatic refractive errors in pseudophakic eyes after keratoplasty.

Clinical results with a supplementary toric intraocular lens for the correction of astigmatism in pseudophakic patients

PURPOSE

To evaluate the visual outcomes of pseudophakic patients who underwent supplementary toric intraocular lens (IOL) implantation to correct astigmatic refractive errors.

METHODS

Pseudophakic patients referred for the implantation of a supplementary toric IOL (Sulcoflex Toric 653T) were evaluated. Uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively), spherical equivalent (SE) refraction, rotational stability, higher order aberrations (HOA), and photopic glare and no-glare contrast sensitivity (CSV-1000, VectorVision) were evaluated.

RESULTS

A total of 10 eyes of 10 patients were included. The mean age was 56.42 ± 5.9 years (range 45-65 years). Mean follow-up was 6.99 ± 5.1 months (6-18 months). Postoperatively, UDVA improved to 0.10 ± 0.12 (0.3 to -0.1) (p = 0.004) and CDVA to 0.07 ± 0.12 (0.3 to -0.1) (p = 0.021). Mean SE was -0.30 ± 0.56 D (-1.00 to +0.75) (p = 0.001). Mean toric IOL axis rotation at 6-month follow-up was 3.0° ± 2.45° (0-6). Ocular aberrometry values decreased after surgery (for average HOA root mean square, p = 0.008). Photopic contrast sensitivity (for all spatial frequencies) showed a trend for improvement after surgery; however, this was not borne out from the analysis (p&gt;0.05).

CONCLUSIONS

The implantation of the Sulcoflex Toric IOL to correct astigmatism in pseudophakic patients provided excellent visual outcomes, predictability of refractive results, rotational stability, and optical performance. The implantation of this IOL is a safe and effective technique to correct pseudophakic cylindrical refractive errors and reduce spectacle dependence in these patients.

Add-on sulcus-based versus primary in-the-bag multifocal intraocular lens: intraindividual study

PURPOSE

To compare the clinical outcomes of add-on sulcus-based multifocal and standard in-the-bag multifocal intraocular lens (IOL) implantation.

METHODS

Twenty-one patients with unilateral monofocal pseudophakia underwent add-on sulcus-based Acri. LISA 536D multifocal IOL (Carl Zeiss Meditec, Jena, Germany) implantation (add-on multifocal IOL group) and contralateral phacoemulsification with in-the-bag Acri.LISA 376D multifocal IOL (Carl Zeiss Meditec) implantation (primary multifocal IOL group). Uncorrected distance visual acuity, uncorrected near visual acuity, corrected distance visual acuity, distance-corrected near visual acuity, photopic (90 cd/m(2)) distance, near contrast sensitivity, mesopic (5 cd/m(2)) distance contrast sensitivity with and without glare, wavefront aberrations, and complications were measured 6 months postoperatively.

RESULTS

Primary in-the-bag multifocal IOLs provided slightly but significantly better uncorrected distance visual acuity (0.08 ± 0.10 vs 0.17 ± 0.15 logMAR, P = .028), uncorrected near visual acuity (0.09 ± 0.17 vs 0.18 ± 0.11 logMAR, P = .005), and corrected distance visual acuity (0.01 ± 0.04 vs 0.04 ± 0.05 logMAR, P = .038). There were no significant differences in distance-corrected near visual acuity, photopic or mesopic contrast sensitivity under different conditions, and wavefront aberrations. Complications included pigment dispersion in one eye (4.8%) and pupillary capture in 2 eyes (9.5%) of the add-on multifocal IOL group.

CONCLUSIONS

The secondary add-on sulcus-based multifocal IOL provided useful pseudoaccommodation with vision quality similar to the primary in-the-bag multifocal IOL. The technique should be considered in patients diagnosed as having unilateral or bilateral monofocal pseudophakia seeking near spectacle independence.