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Limbal relaxing incisions during phacoemulsification: 6-month results
2081
CORRESPONDENCE
IOLs. A future prospective randomized trial is needed to confirm these results. REFERENCES 1. Apple DJ, Solomon KD, Tetz MR, Assia EI, Holland EY, Legler UFC, Tsai JC, Castaneda VE, Hoggatt JP, Kostick AMP. Posterior capsule opacification. Surv Ophthalmol 1992; 37: 73–116 2. Findl O, Buehl W, Bauer P, Sycha T. Interventions for preventing posterior capsule opacification. Cochrane Database System Rev 2010; Issue 2, Art. No. CD003738. DOI: 10.1002/14651858.CD003738.pub3. Summary available at: http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003738/ frame.html. Accessed June 14, 2011 3. Can _I, Takmaz T, Bayahn HA, Bostanci Ceran B. Aspheric microincision intraocular lens implantation with biaxial microincision cataract surgery: efficacy and reliability. J Cataract Refract Surg 2010; 36:1905–1911 JL, Pin ~ero DP, Ortiz D, Montalba n R. Clinical outcomes and 4. Alio postoperative intraocular optical quality with a microincision aberration-free aspheric intraocular lens. J Cataract Refract Surg 2009; 35:1548–1554 5. Khandwala MA, Marjanovic B, Kotagiri AK, Teimory M. Rate of posterior capsule opacification in eyes with the Akreos intraocular lens. J Cataract Refract Surg 2007; 33:1409–1413 6. Prakash P, Kasaby HE, Aggarwal RK, Humfrey S. Microincision bimanual phacoemulsification and ThinoptxÒ implantation through a 1.70 mm incision. Eye 2007; 21:177–182. Available at: http://www.nature.com/eye/journal/v21/n2/pdf/6702153a.pdf. Accessed June 14, 2011 € u € u € Sivrikaya H, Ag ca A, €rker ZK, Ozt €rker C, Yas‚ar O, 7. Kaya V, Ozt € ThinOptX vs AcrySof: comparison of visual and reYilmaz OF. fractive results, contrast sensitivity, and the incidence of posterior capsule opacification. Eur J Ophthalmol 2007; 17:307–314 8. Cleary G, Spalton DJ, Hancox J, Boyce J, Marshall J. Randomized intraindividual comparison of posterior capsule opacification between a microincision intraocular lens and a conventional intraocular lens. J Cataract Refract Surg 2009; 35:265–272
Limbal relaxing incisions during phacoemulsification: 6-month results Sunil Ganekal, MS, Syril Dorairaj, MD, Vishal Jhanji, MD Limbal relaxing incisions (LRIs) are one of the more commonly performed adjunctive procedures with phacoemulsification to correct preexisting astigmatism, primarily because of the cost effectiveness
and the predictable surgical profile.1–3 We conducted a prospective interventional study to evaluate the effect and stability of LRIs in reducing preexisting astigmatism at the time of phacoemulsification. PATIENTS AND METHODS Patients with preexisting keratometric astigmatism of 1.0 diopter (D) or higher were included in the study. The LRI nomogram described by Nichamin2 was used to determine the extent of the incision arc. The steep meridian was identified by aligning a fixation ring (Koch Mendez ring, Mastel Precision) with previously placed orientation marks. A diamond blade with an empirical blade setting of 600 mm was used. Limbal relaxing incisions were made at the most peripheral extent of the clear cornea, just inside the true surgical limbus, after achieving good globe fixation. Phacoemulsification was then performed through an astigmatically neutral temporal incision. A foldable intraocular lens (Acrysof SA60AT, Alcon Laboratories, Inc.) was implanted in the capsular bag. Postoperative antibiotics and corticosteroid eyedrops (prednisolone acetate 1%) were continued for 4 weeks. The main outcome measures at the last follow-up included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manual keratometric astigmatism.
RESULTS Two hundred eyes of 200 patients were studied. The mean age of the 115 men and 85 women was 58 years G 11.5 (SD) (range 30 to 89 years). The mean preoperative astigmatism was 1.58 G 0.55 D. The mean postoperative astigmatism was 0.50 G 0.29 D at 1 week and 0.44 G 0.25 D at 6 months. The change in the amount of astigmatism from the preoperative value was statistically significant at all postoperative intervals (P!.001) (Table 1). The astigmatism reduction tended to be higher in the older age group (PZ.246); however, there was no statistically significant difference in the astigmatism reduction based on age or preoperative astigmatism (Table 2). At the last follow-up (6 months), the UDVA and CDVA were 6/12 or better in 94.5% of eyes and 99.5% of eyes, respectively (Table 3). Both UDVA (PZ.000) and CDVA (PZ.000) showed statistically significant improvement compared with preoperative levels.
Table 1. Comparison of astigmatism before and after LRIs combined with cataract surgery. Postoperative Astigmatism
Preoperative
1 Week
6 Weeks
6 Months
Total (D) WTR (D) ATR (D)
1.585 G 0.55 1.578 G 0.48 1.587 G 0.57
0.5094 G 0.29 0.5154 G 0.25 0.5141 G 0.3
0.479 G 0.26 0.493 G 0.25 0.475 G 0.2
0.448 G 0.25 0.456 G 0.22 0.446 G 0.26
ATR Z against the rule; LRI Z limbal relaxing incision; WTR Z with the rule astigmatism All values are mean G standard deviation
J CATARACT REFRACT SURG - VOL 37, NOVEMBER 2011
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CORRESPONDENCE
Table 2. Amount of preoperative and postoperative astigmatism after LRIs and cataract surgery. Postoperative Astigmatism (D) Age Group/Astigmatism Age group (y) 30–49 50–69 70–90 Astigmatism (D) 1.0–2.0 2.1–3.0 3.1–4.0
N
Preoperative Astigmatism (D)
1 Week
6 Weeks
6 Months
59 107 34
1.477 G 0.38 1.594 G 0.56 1.745 G 0.69
0.490 G 0.22 0.495 G 0.26 0.584 G 0.46
0.482 G 0.21 0.472 G 0.26 0.501 G 0.35
0.436 G 0.22 0.458 G 0.26 0.438 G 0.29
169 27 4
1.402 G 0.324 2.462 G 0.266 3.437 G 0.239
0.436 G 0.243 0.865 G 0.180 1.187 G 0.314
0.414 G 0.223 0.812 G 0.184 1.037 G 0.149
0.393 G 0.221 0.726 G 0.181 0.917 G 0.117
LRI Z limbal relaxing incision; N Z number of eyes All values are mean G standard deviation
Table 3. Visual acuity results before and after LRIs and cataract surgery. UDVA, n (%)
CDVA, n (%)
Acuity
1 Week
6 Weeks
6 Months
1 Week
6 Weeks
6 Months
R6/6 6/9 6/12 6/18 6/24 6/36
69 (34.5) 87 (43.5) 26 (13.0) 11 (5.5) 6 (3.0) 1 (0.5)
83 (41.5) 72 (36.0) 34 (17.0) 9 (4.5) 2 (1.0) 0
74 (37.0) 79 (39.5) 36 (18.0) 8 (4.0) 3 (1.5) 0
195 (97.5) 3 (1.5) 1 (0.5) 0 1 (0.5) 0
197 (98.5) 1 (0.5) 1 (0.5) 1 (0.5) 0 0
197 (98.5) 1 (0.5) 1 (0.5) 1 (0.5) 0 0
CDVA Z corrected distance visual acuity; LRI Z limbal relaxing incision; UDVA Z uncorrected distance visual acuity
Intraoperative extensions of the LRIs and immediate postoperative foreign-body sensation were noted in 4 patients (2%) and 21 patients (10.5%), respectively. DISCUSSION Limbal relaxing incisions provide a viable option for correcting preexisting astigmatism at the time of cataract surgery.4–7 In our study, the use of LRIs during phacoemulsification significantly reduced preoperative astigmatism. Additionally, the astigmatic correction with LRIs stabilized early and remained stable over 6 months with no regression noted. The CDVA of 6/9 or better was achieved in 99.5% of cases at the last follow-up. Most complications after LRIs were mild and clinically nonsignificant. The major limitations of the study are the absence of a comparison group and vector analysis of astigmatism. However, our study represents one of the largest series reported to date for the correction of preexisting astigmatism using LRIs. Although toric IOLs are increasingly used to manage preexisting astigmatism,8 LRIs remain a potentially useful, economical, and effective option.
REFERENCES 1. Duke-Elder S, Abrams D. System of Ophthalmology. Vol. 5. Ophthalmic Optics and Refraction. St. Louis, MO, Mosby, 1970; 671–674 2. Nichamin LD. Astigmatism control. Ophthalmol Clin North Am 2006; 19(4):485–493 3. Talley-Rostov A. Patient-centered care and refractive cataract surgery. Curr Opin Ophthalmol 2008; 19:5–9 4. Kaufmann C, Peter J, Ooi K, Phipps S, Cooper P, Goggin M, for the Queen Elizabeth Astigmatism Study Group. Limbal relaxing incisions versus on-axis incisions to reduce corneal astigmatism at the time of cataract surgery. J Cataract Refract Surg 2005; 31:2261–2265 5. Arraes JC, Cunha F, Azevedo Arraes T, Cavalvanti R, Ventura M. ~ es relaxantes limbares durante a cirurgia de catarata: resulInciso s seguimento de um ano [Limbal relaxing incisions tados apo during cataract surgery: one-year follow-up]. Arq Bras Oftalmol 2006; 69:361–364. Available at: http://www.scielo.br/pdf/abo/ v69n3/30787.pdf. Accessed July 23, 2011 6. Budak K, Friedman NJ, Koch DD. Limbal relaxing incisions with cataract surgery. J Cataract Refract Surg 1998; 24:503–508 7. Poll JT, Wang L, Koch DD, Weikert MP. Correction of astigmatism during cataract surgery: toric intraocular lens compared to peripheral corneal relaxing incisions. J Refract Surg 2011; 27:165–171 8. Sun X-Y, Vicary D, Montgomery P, Griffiths M. Toric intraocular lenses for correcting astigmatism in 130 eyes. Ophthalmology 2000; 107:1776–1781; discussion by RM Kershner, 1781–1782
J CATARACT REFRACT SURG - VOL 37, NOVEMBER 2011
CORRESPONDENCE
IOLs. A future prospective randomized trial is needed to confirm these results. REFERENCES 1. Apple DJ, Solomon KD, Tetz MR, Assia EI, Holland EY, Legler UFC, Tsai JC, Castaneda VE, Hoggatt JP, Kostick AMP. Posterior capsule opacification. Surv Ophthalmol 1992; 37: 73–116 2. Findl O, Buehl W, Bauer P, Sycha T. Interventions for preventing posterior capsule opacification. Cochrane Database System Rev 2010; Issue 2, Art. No. CD003738. DOI: 10.1002/14651858.CD003738.pub3. Summary available at: http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003738/ frame.html. Accessed June 14, 2011 3. Can _I, Takmaz T, Bayahn HA, Bostanci Ceran B. Aspheric microincision intraocular lens implantation with biaxial microincision cataract surgery: efficacy and reliability. J Cataract Refract Surg 2010; 36:1905–1911 JL, Pin ~ero DP, Ortiz D, Montalba n R. Clinical outcomes and 4. Alio postoperative intraocular optical quality with a microincision aberration-free aspheric intraocular lens. J Cataract Refract Surg 2009; 35:1548–1554 5. Khandwala MA, Marjanovic B, Kotagiri AK, Teimory M. Rate of posterior capsule opacification in eyes with the Akreos intraocular lens. J Cataract Refract Surg 2007; 33:1409–1413 6. Prakash P, Kasaby HE, Aggarwal RK, Humfrey S. Microincision bimanual phacoemulsification and ThinoptxÒ implantation through a 1.70 mm incision. Eye 2007; 21:177–182. Available at: http://www.nature.com/eye/journal/v21/n2/pdf/6702153a.pdf. Accessed June 14, 2011 € u € u € Sivrikaya H, Ag ca A, €rker ZK, Ozt €rker C, Yas‚ar O, 7. Kaya V, Ozt € ThinOptX vs AcrySof: comparison of visual and reYilmaz OF. fractive results, contrast sensitivity, and the incidence of posterior capsule opacification. Eur J Ophthalmol 2007; 17:307–314 8. Cleary G, Spalton DJ, Hancox J, Boyce J, Marshall J. Randomized intraindividual comparison of posterior capsule opacification between a microincision intraocular lens and a conventional intraocular lens. J Cataract Refract Surg 2009; 35:265–272
Limbal relaxing incisions during phacoemulsification: 6-month results Sunil Ganekal, MS, Syril Dorairaj, MD, Vishal Jhanji, MD Limbal relaxing incisions (LRIs) are one of the more commonly performed adjunctive procedures with phacoemulsification to correct preexisting astigmatism, primarily because of the cost effectiveness
and the predictable surgical profile.1–3 We conducted a prospective interventional study to evaluate the effect and stability of LRIs in reducing preexisting astigmatism at the time of phacoemulsification. PATIENTS AND METHODS Patients with preexisting keratometric astigmatism of 1.0 diopter (D) or higher were included in the study. The LRI nomogram described by Nichamin2 was used to determine the extent of the incision arc. The steep meridian was identified by aligning a fixation ring (Koch Mendez ring, Mastel Precision) with previously placed orientation marks. A diamond blade with an empirical blade setting of 600 mm was used. Limbal relaxing incisions were made at the most peripheral extent of the clear cornea, just inside the true surgical limbus, after achieving good globe fixation. Phacoemulsification was then performed through an astigmatically neutral temporal incision. A foldable intraocular lens (Acrysof SA60AT, Alcon Laboratories, Inc.) was implanted in the capsular bag. Postoperative antibiotics and corticosteroid eyedrops (prednisolone acetate 1%) were continued for 4 weeks. The main outcome measures at the last follow-up included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manual keratometric astigmatism.
RESULTS Two hundred eyes of 200 patients were studied. The mean age of the 115 men and 85 women was 58 years G 11.5 (SD) (range 30 to 89 years). The mean preoperative astigmatism was 1.58 G 0.55 D. The mean postoperative astigmatism was 0.50 G 0.29 D at 1 week and 0.44 G 0.25 D at 6 months. The change in the amount of astigmatism from the preoperative value was statistically significant at all postoperative intervals (P!.001) (Table 1). The astigmatism reduction tended to be higher in the older age group (PZ.246); however, there was no statistically significant difference in the astigmatism reduction based on age or preoperative astigmatism (Table 2). At the last follow-up (6 months), the UDVA and CDVA were 6/12 or better in 94.5% of eyes and 99.5% of eyes, respectively (Table 3). Both UDVA (PZ.000) and CDVA (PZ.000) showed statistically significant improvement compared with preoperative levels.
Table 1. Comparison of astigmatism before and after LRIs combined with cataract surgery. Postoperative Astigmatism
Preoperative
1 Week
6 Weeks
6 Months
Total (D) WTR (D) ATR (D)
1.585 G 0.55 1.578 G 0.48 1.587 G 0.57
0.5094 G 0.29 0.5154 G 0.25 0.5141 G 0.3
0.479 G 0.26 0.493 G 0.25 0.475 G 0.2
0.448 G 0.25 0.456 G 0.22 0.446 G 0.26
ATR Z against the rule; LRI Z limbal relaxing incision; WTR Z with the rule astigmatism All values are mean G standard deviation
J CATARACT REFRACT SURG - VOL 37, NOVEMBER 2011
2082
CORRESPONDENCE
Table 2. Amount of preoperative and postoperative astigmatism after LRIs and cataract surgery. Postoperative Astigmatism (D) Age Group/Astigmatism Age group (y) 30–49 50–69 70–90 Astigmatism (D) 1.0–2.0 2.1–3.0 3.1–4.0
N
Preoperative Astigmatism (D)
1 Week
6 Weeks
6 Months
59 107 34
1.477 G 0.38 1.594 G 0.56 1.745 G 0.69
0.490 G 0.22 0.495 G 0.26 0.584 G 0.46
0.482 G 0.21 0.472 G 0.26 0.501 G 0.35
0.436 G 0.22 0.458 G 0.26 0.438 G 0.29
169 27 4
1.402 G 0.324 2.462 G 0.266 3.437 G 0.239
0.436 G 0.243 0.865 G 0.180 1.187 G 0.314
0.414 G 0.223 0.812 G 0.184 1.037 G 0.149
0.393 G 0.221 0.726 G 0.181 0.917 G 0.117
LRI Z limbal relaxing incision; N Z number of eyes All values are mean G standard deviation
Table 3. Visual acuity results before and after LRIs and cataract surgery. UDVA, n (%)
CDVA, n (%)
Acuity
1 Week
6 Weeks
6 Months
1 Week
6 Weeks
6 Months
R6/6 6/9 6/12 6/18 6/24 6/36
69 (34.5) 87 (43.5) 26 (13.0) 11 (5.5) 6 (3.0) 1 (0.5)
83 (41.5) 72 (36.0) 34 (17.0) 9 (4.5) 2 (1.0) 0
74 (37.0) 79 (39.5) 36 (18.0) 8 (4.0) 3 (1.5) 0
195 (97.5) 3 (1.5) 1 (0.5) 0 1 (0.5) 0
197 (98.5) 1 (0.5) 1 (0.5) 1 (0.5) 0 0
197 (98.5) 1 (0.5) 1 (0.5) 1 (0.5) 0 0
CDVA Z corrected distance visual acuity; LRI Z limbal relaxing incision; UDVA Z uncorrected distance visual acuity
Intraoperative extensions of the LRIs and immediate postoperative foreign-body sensation were noted in 4 patients (2%) and 21 patients (10.5%), respectively. DISCUSSION Limbal relaxing incisions provide a viable option for correcting preexisting astigmatism at the time of cataract surgery.4–7 In our study, the use of LRIs during phacoemulsification significantly reduced preoperative astigmatism. Additionally, the astigmatic correction with LRIs stabilized early and remained stable over 6 months with no regression noted. The CDVA of 6/9 or better was achieved in 99.5% of cases at the last follow-up. Most complications after LRIs were mild and clinically nonsignificant. The major limitations of the study are the absence of a comparison group and vector analysis of astigmatism. However, our study represents one of the largest series reported to date for the correction of preexisting astigmatism using LRIs. Although toric IOLs are increasingly used to manage preexisting astigmatism,8 LRIs remain a potentially useful, economical, and effective option.
REFERENCES 1. Duke-Elder S, Abrams D. System of Ophthalmology. Vol. 5. Ophthalmic Optics and Refraction. St. Louis, MO, Mosby, 1970; 671–674 2. Nichamin LD. Astigmatism control. Ophthalmol Clin North Am 2006; 19(4):485–493 3. Talley-Rostov A. Patient-centered care and refractive cataract surgery. Curr Opin Ophthalmol 2008; 19:5–9 4. Kaufmann C, Peter J, Ooi K, Phipps S, Cooper P, Goggin M, for the Queen Elizabeth Astigmatism Study Group. Limbal relaxing incisions versus on-axis incisions to reduce corneal astigmatism at the time of cataract surgery. J Cataract Refract Surg 2005; 31:2261–2265 5. Arraes JC, Cunha F, Azevedo Arraes T, Cavalvanti R, Ventura M. ~ es relaxantes limbares durante a cirurgia de catarata: resulInciso s seguimento de um ano [Limbal relaxing incisions tados apo during cataract surgery: one-year follow-up]. Arq Bras Oftalmol 2006; 69:361–364. Available at: http://www.scielo.br/pdf/abo/ v69n3/30787.pdf. Accessed July 23, 2011 6. Budak K, Friedman NJ, Koch DD. Limbal relaxing incisions with cataract surgery. J Cataract Refract Surg 1998; 24:503–508 7. Poll JT, Wang L, Koch DD, Weikert MP. Correction of astigmatism during cataract surgery: toric intraocular lens compared to peripheral corneal relaxing incisions. J Refract Surg 2011; 27:165–171 8. Sun X-Y, Vicary D, Montgomery P, Griffiths M. Toric intraocular lenses for correcting astigmatism in 130 eyes. Ophthalmology 2000; 107:1776–1781; discussion by RM Kershner, 1781–1782
J CATARACT REFRACT SURG - VOL 37, NOVEMBER 2011