- Email: [email protected]
Rotation stability of a toric intraocular lens with a second capsular tension ring
CASE REPORT
Rotation stability of a toric intraocular lens with a second capsular tension ring Oded Sagiv, MD, Dan Sachs, MD
An Acrysof toric intraocular lens (IOL) and a capsular tension ring (CTR) were implanted in the highly myopic eye of a 74-year-old white man during cataract surgery. On the first postoperative day, the IOL was found 90 degrees from the required position, with a consequent high amount of astigmatism. A second procedure was performed and because it was not possible to secure the toric IOL in the correct position, an additional in-the-bag CTR was inserted, with an immediate optimal outcome. The IOL remained stable up to the final follow-up examination. Co-implantation of a toric IOL and a single CTR has been reported. In our case, 2 CTRs were required to fixate the toric IOL in the correct position. This procedure is simple and safe and should be considered in cases of postoperatively misaligned toric IOLs. Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2015; 41:1098–1099 Q 2015 ASCRS and ESCRS
Toric intraocular lenses (IOLs) are considered among the most promising IOLs available, and their advantage in cataract surgery is indisputable. At the present time, toric IOLs are the perfect choice for the treatment of astigmatism in the course of cataract extraction and provide accurate and predictable results.1–3 Toric IOLs require precise positioning and must maintain this alignment over time. It has been reported that a small misalignment (dislocation or rotation) of the IOL in the capsular bag can significantly alter the refractive result.3 Several techniques to improve in-the-bag IOL stability have been described. The technique we use routinely is the insertion of an endocapsular tension ring (CTR) in the bag along with implantation of the IOL.A To our knowledge, we describe the first case in which a second CTR was inserted to fixate and stabilize a toric IOL that rotated after implantation during a prior procedure.
Submitted: November 9, 2014. Accepted: January 13, 2015. From the Goldschleger Eye Institute, Sackler Faculty of Medicine, Tel-Aviv University, Sheba Medical Center, Tel Hashomer, Israel. Corresponding author: Oded Sagiv, MD, Department of Ophthalmology, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, 52621, Israel. E-mail: [email protected].
1098
Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
CASE REPORT A 74-year-old man with nuclear sclerosis and posterior subcapsular cataract in both eyes had phacoemulsification and implantation of a toric IOL in the right eye. The eye was amblyopic and had no prior ocular surgery; the preoperative corrected distance visual acuity (CDVA) was 20/50. The preoperative refraction was 8.00 3.00 170 in the right eye and 1.25 2.50 12 in the left eye. The corneal topography in the right eye showed regular corneal astigmatism of 3.02 175 with keratometry readings of 44.12 @ 175/47.14 @ 85. The anterior chamber depth was 3.80 mm and the axial length (AL), 27.07 mm. After performing uneventful cataract phacoemulsification with a 5.0 mm anterior capsulorhexis diameter, the surgeon implanted a CTR (Hanita Lenses) and a toric IOL (Acrysof IQ SN6AT6, Alcon Laboratories, Inc.) that was dialed into the desired position. The ophthalmic viscosurgical device was removed completely; the IOL was centered, with a 360degree overlap of the anterior capsulorhexis margins on the IOL optic. At the 1-day postoperative examination, the IOL had rotated 90 degrees from the desired position and the refraction was C1.25 5.75 170. The patient was operated on again, and during the second procedure, the IOL seemed to move freely in the bag with good stability of the bag and zonular fibers. A second CTR was implanted in the bag with immediate stabilization of the IOL. The toric IOL was then rotated to the desired position. On follow-up examinations up to 3 months postoperatively, the IOL remained in the desired position. The refraction was 1.50 0.50 70 and the CDVA, 20/40.
DISCUSSION Misalignment of a toric IOL leads to residual astigmatism postoperatively. A rotation of 10 degrees is http://dx.doi.org/10.1016/j.jcrs.2015.04.004 0886-3350
CASE REPORT: ROTATIONAL STABILITY OF TORIC IOL WITH 2 CTRS
estimated to cause a 33% residual astigmatism error and is generally considered an indication for surgical repositioning.3,4 Toric IOLs have various rates of postoperative misalignment. A recently published review of the literature3 estimates the rate as 3% for the Acrysof toric IOL and up to 20% for the Staar toric IOL (Staar Surgical Co.).5 Surgical techniques to prevent IOL rotation postoperatively have been described.3 WileyA reported that the “IOLock technique,” which combines implantation of a CTR with the Staar plate–haptic silicone toric IOL, reduced the rate of surgical corrections required postoperatively due to macrorotations (more than 10 degrees). He did not report using this technique with the Acrysof acrylic hydrophobic toric IOL. The rationale for implanting a CTR to improve toric IOL stability is that it theoretically enforces symmetry on the bag, stretching the bag’s equator and thus flattening the bag in the anterior–posterior axis. The CTR may also increase friction on the IOL haptics and thus increase stability. For these reasons, we have been using this technique when implanting all types of toric IOLs. Our case presented the surgeon with a special challenge because a CTR had been implanted in the primary surgery. Since the IOL was clearly moving freely in the bag and had rotated 90 degrees, 2 options were considered: performing an IOL exchange or trying to enhance stability of the implanted toric IOL. (The options of laser correction or glasses were also available.) Techniques to increase toric IOL stability include suturing the IOL to a Cionni CTR in case of a traumatic cataract or megalocornea6,7 or simply dialing the IOL back to its proper position up to even 15 months after the primary operation.4 In our case, the clinical impression was that the bag was particularly large and had not flattened enough after implantation of the first CTR. The second CTR was therefore placed in the bag next to the first CTR. As reported, the effect was obtained immediately. The AL in our patient was greater than 27.0 mm. In a recent study, Shah et al.8 report an increased rate of toric IOL rotation with longer ALs. Although the effect was only shown for up to 3 degrees of rotation, and thus the clinical significance is not certain, it may imply that patients with high myopia are at increased risk for postoperative IOL misalignment. The co-implantation of a CTR with a toric IOL has not been shown to improve IOL stability in a
1099
randomized controlled trial. When considering the low rate of macrorotation of the Acrysof toric IOL, it is clear that a considerable number of patients will be required to show a significant benefit in all cases of microrotation. Nevertheless, we have found that implanting a CTR is logical and beneficial in highly myopic patients. In our case of significant toric IOL misalignment after CTR implantation in a stable bag, it was reasonable to insert a second CTR to secure the toric IOL. This is a safe and simple solution to align and fixate a rotated toric IOL. REFERENCES 1. Agresta B, Knorz MC, Donatti C, Jackson D. Visual acuity improvements after implantation of toric intraocular lenses in cataract patients with astigmatism: a systematic review. BMC Ophthalmol 2012; 12:41. Available at: http://www.bio medcentral.com/content/pdf/1471-2415-12-41.pdf. Accessed January 31, 2015 2. Sasaki H, Yoshida M, Manabe S, Yoshimura K, Hayashi K. Effects of the toric intraocular lens on correction of preexisting corneal astigmatism. Jpn J Ophthalmol 2012; 56:445–452 3. Visser N, Bauer NJC, Nuijts RMMA. Toric intraocular lenses: historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications. J Cataract Refract Surg 2013; 39:624–637 4. Brandlhuber U, Haritoglou C, Kreutzer TC, Kook D. Reposition of a misaligned Zeiss AT TORBI 709MÒ intraocular lens 15 months after implantation. Eur J Ophthalmol 2014; 24:800–802 5. Chang DF. Comparative rotational stability of single-piece openloop acrylic and plate-haptic silicone toric intraocular lenses. J Cataract Refract Surg 2008; 34:1842–1847 6. Kandar AK. Combined special capsular tension ring and toric IOL implantation for management of post-DALK high regular astigmatism with subluxated traumatic cataract. Indian J Ophthalmol 2014; 62:819–822. Available at: http://www.ncbi. nlm.nih.gov/pmc/articles/PMC4152657/?reportZprintable. Accessed January 31, 2015 zycki _ 7. Rekas M, Pawlik R, Klus A, Ro R, Szaflik JP, O1dak M. Phacoemulsification with corneal astigmatism correction with the use of a toric intraocular lens in a case of megalocornea. J Cataract Refract Surg 2011; 37:1546–1550 8. Shah GD, Praveen MR, Vasavada AR, Vasavada VA, Rampal G, Shastry LR. Rotational stability of a toric intraocular lens: influence of axial length and alignment in the capsular bag. J Cataract Refract Surg 2012; 38:54–59
OTHER CITED MATERIAL A. Wiley WF, “Combining a CTR with a Plate-Haptic Toric IOL,” Cataract & Refractive Surgery Today May 2012, pages 32–33. Available at: http://crstoday.com/pdfs/crst0512_cs2_wiley.pdf. Accessed January 31, 2015
J CATARACT REFRACT SURG - VOL 41, MAY 2015
Rotation stability of a toric intraocular lens with a second capsular tension ring Oded Sagiv, MD, Dan Sachs, MD
An Acrysof toric intraocular lens (IOL) and a capsular tension ring (CTR) were implanted in the highly myopic eye of a 74-year-old white man during cataract surgery. On the first postoperative day, the IOL was found 90 degrees from the required position, with a consequent high amount of astigmatism. A second procedure was performed and because it was not possible to secure the toric IOL in the correct position, an additional in-the-bag CTR was inserted, with an immediate optimal outcome. The IOL remained stable up to the final follow-up examination. Co-implantation of a toric IOL and a single CTR has been reported. In our case, 2 CTRs were required to fixate the toric IOL in the correct position. This procedure is simple and safe and should be considered in cases of postoperatively misaligned toric IOLs. Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2015; 41:1098–1099 Q 2015 ASCRS and ESCRS
Toric intraocular lenses (IOLs) are considered among the most promising IOLs available, and their advantage in cataract surgery is indisputable. At the present time, toric IOLs are the perfect choice for the treatment of astigmatism in the course of cataract extraction and provide accurate and predictable results.1–3 Toric IOLs require precise positioning and must maintain this alignment over time. It has been reported that a small misalignment (dislocation or rotation) of the IOL in the capsular bag can significantly alter the refractive result.3 Several techniques to improve in-the-bag IOL stability have been described. The technique we use routinely is the insertion of an endocapsular tension ring (CTR) in the bag along with implantation of the IOL.A To our knowledge, we describe the first case in which a second CTR was inserted to fixate and stabilize a toric IOL that rotated after implantation during a prior procedure.
Submitted: November 9, 2014. Accepted: January 13, 2015. From the Goldschleger Eye Institute, Sackler Faculty of Medicine, Tel-Aviv University, Sheba Medical Center, Tel Hashomer, Israel. Corresponding author: Oded Sagiv, MD, Department of Ophthalmology, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, 52621, Israel. E-mail: [email protected].
1098
Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
CASE REPORT A 74-year-old man with nuclear sclerosis and posterior subcapsular cataract in both eyes had phacoemulsification and implantation of a toric IOL in the right eye. The eye was amblyopic and had no prior ocular surgery; the preoperative corrected distance visual acuity (CDVA) was 20/50. The preoperative refraction was 8.00 3.00 170 in the right eye and 1.25 2.50 12 in the left eye. The corneal topography in the right eye showed regular corneal astigmatism of 3.02 175 with keratometry readings of 44.12 @ 175/47.14 @ 85. The anterior chamber depth was 3.80 mm and the axial length (AL), 27.07 mm. After performing uneventful cataract phacoemulsification with a 5.0 mm anterior capsulorhexis diameter, the surgeon implanted a CTR (Hanita Lenses) and a toric IOL (Acrysof IQ SN6AT6, Alcon Laboratories, Inc.) that was dialed into the desired position. The ophthalmic viscosurgical device was removed completely; the IOL was centered, with a 360degree overlap of the anterior capsulorhexis margins on the IOL optic. At the 1-day postoperative examination, the IOL had rotated 90 degrees from the desired position and the refraction was C1.25 5.75 170. The patient was operated on again, and during the second procedure, the IOL seemed to move freely in the bag with good stability of the bag and zonular fibers. A second CTR was implanted in the bag with immediate stabilization of the IOL. The toric IOL was then rotated to the desired position. On follow-up examinations up to 3 months postoperatively, the IOL remained in the desired position. The refraction was 1.50 0.50 70 and the CDVA, 20/40.
DISCUSSION Misalignment of a toric IOL leads to residual astigmatism postoperatively. A rotation of 10 degrees is http://dx.doi.org/10.1016/j.jcrs.2015.04.004 0886-3350
CASE REPORT: ROTATIONAL STABILITY OF TORIC IOL WITH 2 CTRS
estimated to cause a 33% residual astigmatism error and is generally considered an indication for surgical repositioning.3,4 Toric IOLs have various rates of postoperative misalignment. A recently published review of the literature3 estimates the rate as 3% for the Acrysof toric IOL and up to 20% for the Staar toric IOL (Staar Surgical Co.).5 Surgical techniques to prevent IOL rotation postoperatively have been described.3 WileyA reported that the “IOLock technique,” which combines implantation of a CTR with the Staar plate–haptic silicone toric IOL, reduced the rate of surgical corrections required postoperatively due to macrorotations (more than 10 degrees). He did not report using this technique with the Acrysof acrylic hydrophobic toric IOL. The rationale for implanting a CTR to improve toric IOL stability is that it theoretically enforces symmetry on the bag, stretching the bag’s equator and thus flattening the bag in the anterior–posterior axis. The CTR may also increase friction on the IOL haptics and thus increase stability. For these reasons, we have been using this technique when implanting all types of toric IOLs. Our case presented the surgeon with a special challenge because a CTR had been implanted in the primary surgery. Since the IOL was clearly moving freely in the bag and had rotated 90 degrees, 2 options were considered: performing an IOL exchange or trying to enhance stability of the implanted toric IOL. (The options of laser correction or glasses were also available.) Techniques to increase toric IOL stability include suturing the IOL to a Cionni CTR in case of a traumatic cataract or megalocornea6,7 or simply dialing the IOL back to its proper position up to even 15 months after the primary operation.4 In our case, the clinical impression was that the bag was particularly large and had not flattened enough after implantation of the first CTR. The second CTR was therefore placed in the bag next to the first CTR. As reported, the effect was obtained immediately. The AL in our patient was greater than 27.0 mm. In a recent study, Shah et al.8 report an increased rate of toric IOL rotation with longer ALs. Although the effect was only shown for up to 3 degrees of rotation, and thus the clinical significance is not certain, it may imply that patients with high myopia are at increased risk for postoperative IOL misalignment. The co-implantation of a CTR with a toric IOL has not been shown to improve IOL stability in a
1099
randomized controlled trial. When considering the low rate of macrorotation of the Acrysof toric IOL, it is clear that a considerable number of patients will be required to show a significant benefit in all cases of microrotation. Nevertheless, we have found that implanting a CTR is logical and beneficial in highly myopic patients. In our case of significant toric IOL misalignment after CTR implantation in a stable bag, it was reasonable to insert a second CTR to secure the toric IOL. This is a safe and simple solution to align and fixate a rotated toric IOL. REFERENCES 1. Agresta B, Knorz MC, Donatti C, Jackson D. Visual acuity improvements after implantation of toric intraocular lenses in cataract patients with astigmatism: a systematic review. BMC Ophthalmol 2012; 12:41. Available at: http://www.bio medcentral.com/content/pdf/1471-2415-12-41.pdf. Accessed January 31, 2015 2. Sasaki H, Yoshida M, Manabe S, Yoshimura K, Hayashi K. Effects of the toric intraocular lens on correction of preexisting corneal astigmatism. Jpn J Ophthalmol 2012; 56:445–452 3. Visser N, Bauer NJC, Nuijts RMMA. Toric intraocular lenses: historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications. J Cataract Refract Surg 2013; 39:624–637 4. Brandlhuber U, Haritoglou C, Kreutzer TC, Kook D. Reposition of a misaligned Zeiss AT TORBI 709MÒ intraocular lens 15 months after implantation. Eur J Ophthalmol 2014; 24:800–802 5. Chang DF. Comparative rotational stability of single-piece openloop acrylic and plate-haptic silicone toric intraocular lenses. J Cataract Refract Surg 2008; 34:1842–1847 6. Kandar AK. Combined special capsular tension ring and toric IOL implantation for management of post-DALK high regular astigmatism with subluxated traumatic cataract. Indian J Ophthalmol 2014; 62:819–822. Available at: http://www.ncbi. nlm.nih.gov/pmc/articles/PMC4152657/?reportZprintable. Accessed January 31, 2015 zycki _ 7. Rekas M, Pawlik R, Klus A, Ro R, Szaflik JP, O1dak M. Phacoemulsification with corneal astigmatism correction with the use of a toric intraocular lens in a case of megalocornea. J Cataract Refract Surg 2011; 37:1546–1550 8. Shah GD, Praveen MR, Vasavada AR, Vasavada VA, Rampal G, Shastry LR. Rotational stability of a toric intraocular lens: influence of axial length and alignment in the capsular bag. J Cataract Refract Surg 2012; 38:54–59
OTHER CITED MATERIAL A. Wiley WF, “Combining a CTR with a Plate-Haptic Toric IOL,” Cataract & Refractive Surgery Today May 2012, pages 32–33. Available at: http://crstoday.com/pdfs/crst0512_cs2_wiley.pdf. Accessed January 31, 2015
J CATARACT REFRACT SURG - VOL 41, MAY 2015