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1.  Implantation of a customized toric intraocular lens for correction of post-keratoplasty astigmatism 
Eye  2013;27(4):531-537.
Purpose
To report visual and refractive outcomes, and endothelial cell loss following primary and secondary ‘piggyback' toric intraocular lens (IOL) implantation in patients with high post-penetrating keratoplasty (PK) astigmatism.
Methods
Prospective case series. Nine eyes of nine patients with post-PK astigmatism were consecutively recruited for implantation of a customized toric IOL. Six underwent simultaneous phacoemulsification (PE) and three pseudophakic eyes had a secondary ‘piggyback' toric IOL implanted in the ciliary sulcus. Mean follow-up time was 17.2±7.7 months. Pre- and post-operative uncorrected (UDVA) and best-corrected (BDVA) distance visual acuities and refractive errors were collected for comparison. Cartesian astigmatic vectors were calculated to identify a change in the magnitude of astigmatism pre- compared to postoperatively. Pre- and post-operative endothelial cell counts were also collected for analysis.
Results
UDVA (logMAR) improved from 1.13±0.51 preoperatively to 0.48±0.24 postoperatively (P-value=0.003). There was no significant change in BDVA (P-value=0.905) from 0.31±0.27 to 0.26±0.19. Corneal astigmatism preoperatively was 6.57±4.40 diopters (D). Post-operative refractive cylinder was 0.83±1.09 D compared to 3.89±4.01 D preoperatively (P=0.039). Analysis of astigmatic Cartesian x and y coordinates found a significant reduction postoperatively compared to preoperatively (P=0.005 and P=0.002), respectively. Mean endothelial cell loss was 9.9%.
Conclusion:
Implantation of a customized primary or secondary ‘piggyback' toric IOL serves as an effective modality in treating patients with high post-PK astigmatism.
doi:10.1038/eye.2012.300
PMCID: PMC3626004  PMID: 23348728
penetrating keratoplasty; astigmatism; toric intraocular lens
2.  Descemet stripping endothelial keratoplasty for a failed penetrating keratoplasty graft in a pseudophakic patient with a toric intraocular lens: a case report 
BMC Ophthalmology  2013;13:64.
Background
To report a patient with penetrating keratoplasty (PKP) graft endothelial failure implanted with toric intraocular lens (IOL) who was treated with Descemet stripping endothelial keratoplasty (DSAEK).
Case presentation
A 40 year old male patient implanted with toric intraocular lens for the treatment of post PKP astigmatism, presented for the treatment of graft endothelial failure’. The patient had uncorrected distance visual acuity (UDVA) 20/200 not correcting with manifest refraction. The patient reported excellent visual acuity after cataract surgery and toric IOL implantation. DSAEK was performed in order to minimally affect keratometry and retain correspondence of the anterior cornea astigmatism with the toric IOL astigmatic power. Three months postoperatively the cornea was clear with no edema. UDVA was 20/40 and corrected distance visual acuity was 20/25 with +1.50-1.00 × 20.
Conclusions
This report describes a unique case of DSAEK for treatment of a failed PKP in a patient previously implanted with a toric IOL. DSAEK was an effective alternative of PKP in this patient for the preservation of the toric IOL’s effect.
doi:10.1186/1471-2415-13-64
PMCID: PMC3871011  PMID: 24171843
Descemet stripping automated endothelial keratoplasty; Post penetrating keratoplasty astigmatism; Toric intraocular lens
3.  Combined 23-gauge microincisonal vitrectomy surgery and phacoemulsification with AcrySof toric intraocular lens implantation: a comparative study 
Eye  2011;25(10):1327-1332.
Aim
To compare AcrySof toric intraocular lens (IOL) and non-toric IOL in patients who had combined 23-gauge microincisional vitrectomy surgery (MIVS) and phacoemulsification for vitreoretinal diseases and cataract with pre-existing corneal astigmatism.
Methods
This is a prospective comparative study comprised of 30 patients (30 eyes) who had combined 23-gauge MIVS and phacoemulsification for vitreoretinal diseases and cataract with pre-existing regular corneal astigmatism greater than 1 diopters (D). In all, 15 eyes had AcrySof toric IOL (Alcon Laboratories) and 15 eyes had non-toric IOL (Akreos AO MI60; Bausch & Lomb) implantation. Main outcome measures were uncorrected visual acuity (UCVA), refractive cylinder, surgically induced astigmatism (SIA), and IOL misalignment during 6 months.
Results
The mean UCVA of the toric IOL group was better than the non-toric IOL group at postoperative months 1, 3, and 6 (P<0.001, respectively). The mean absolute residual refractive cylinder of the toric IOL group at postoperative week 1, and months 1, 3, and 6 was less than the non-toric IOL group (P=0.008, <0.001, <0.001, and <0.001, respectively). There was no difference in the mean SIA between the two groups (P>0.05, respectively). The mean toric IOL axis rotation was 3.52±2.75°, which was within 5° in 66.7% of the toric IOL group and within 10° in 100%.
Conclusions
Combined 23-gauge MIVS and phacoemulsification with AcrySof toric IOL implantation is an effective method of correcting vitreoretinal diseases and cataract and pre-existing corneal astigmatism, and the toric IOL showed good rotational stability, even in vitrectomized eyes for 6 months.
doi:10.1038/eye.2011.168
PMCID: PMC3194321  PMID: 21760624
toric intraocular lens; corneal astigmatism; IOL rotation; phacovitrectomy
4.  Agreement analysis of LENSTAR with other techniques of biometry 
Eye  2011;25(6):717-724.
Purpose
To assess the agreement of the optical low-coherence reflectometry (OLCR) device LENSTAR LS900 with partial coherence interferometry (PCI) device IOLMaster and applanation and immersion ultrasound biometry.
Methods
We conducted the study at the Ophthalmology Clinic, University of Malaya Medical Center, Malaysia. Phakic eyes of 76 consecutive cataract patients were measured using four different methods: IOLMaster, LENSTAR and A-scan applanation and immersion ultrasound biometry. We assessed the method agreement in the LENSTAR-IOLMaster, LENSTAR-applanation, and LENSTAR-immersion comparisons for axial length (AL) and intraocular lens (IOL) power using Bland–Altman plots. For average K, we compared LENSTAR with IOLMaster and the TOPCON KR-8100 autorefractor-keratometer. SRK/T formula was used to compute IOL power, with emmetropia as the target refractive outcome.
Results
For all the variables studied, LENSTAR agreement with IOLMaster is strongest, followed by those with immersion and applanation. For the LENSTAR-IOLMaster comparison, the estimated proportion of differences falling within 0.33 mm from zero AL and within 1D from zero IOL power is 100%. The estimated proportion of differences falling within 0.5 D from zero average K is almost 100% in the LENSTAR-IOLMaster comparison but 88% in the LENSTAR-TOPCON comparison. The proportion of differences falling within 0.10 mm (AL) and within 1D (IOL power) in the LENSTAR-IOLMaster comparison has practically significant discrepancy with that of LENSTAR-applanation and LENSTAR-immersion comparisons.
Conclusions
In phakic eyes of cataract patients, measurements of AL, average K, and IOL power calculated using the SRK/T formula from LENSTAR are biometrically equivalent to those from IOLMaster, but not with those from applanation and immersion ultrasound biometry.
doi:10.1038/eye.2011.28
PMCID: PMC3178124  PMID: 21394115
LENSTAR; IOL Master; biometry
5.  Results of the AcrySof Toric intraocular lenses implantation 
Summary
Background
The expectations of post-removal cataract surgery patients are extremely high, and best vision acuity is expected. The best refractive results are influenced by two factors – cataract surgical removal and the corneal astigmatism correction. Currently, the two most often applied corneal astigmatism removal methods are laser surgery and toric intraocular lens implantation, with the latter method being both more stable and more reversible. This study aimed to estimate the surgical astigmatism correction efficiency after AcrySof Toric intraocular lens implantation in patients with corneal astigmatism.
Material/Methods
We used the AcrySof Toric IOL 1-part hydrophobic acrylic lenses. The retrospective research covered 30 eyeballs in 28 cataract and corneal astigmatism patients, with the AcrySof Toric lens implanted by one surgeon.
Results
In our test group 92.31% of post-surgical patients (phacoemulsification and toric lenses implantation) gained the best uncorrected visual acuity, range 0.6–1.0; and in 7.69% of patients the acuity was 0.4–0.6. Lens rotation was examined three weeks after the surgical procedure and a 3.24±3.41 degree axial displacement was observed; however, this lens rotation was clinically unimportant.
Based on the analysis of post-surgical results, the corneal astigmatism was 84.2% lower than before the procedure.
Conclusions
We noticed clinically and statistically important vision acuity improvement in the corneal astigmatism patients. The patients’ high satisfaction was conditioned by proper pre-surgery qualification. Astigmatism correction by cataract removal surgery is a safe and effective surgical solution. In the future, we expect the use of toric intraocular lenses will become widespread and significant.
doi:10.12659/MSM.882182
PMCID: PMC3560683  PMID: 22207126
cataract; corneal astigmatism; toric intraocular lenses
6.  Comparison of patient outcomes after implantation of Visian toric implantable collamer lens and iris-fixated toric phakic intraocular lens 
Eye  2011;25(11):1409-1417.
Purpose
We compared visual and refractive outcomes after implantation of Visian toric implantable collamer lenses (toric ICLs) and iris-fixated toric pIOLs (toric Artisans).
Patients and methods
A comparative retrospective analysis was performed. Toric ICLs were implanted into 30 eyes of 18 patients, and toric Artisans into 31 eyes of 22 recipients. We measured the logarithms of the minimum angle of resolution of uncorrected visual acuity (logMAR UCVA), logMAR of best spectacle-corrected corrected VA (logMAR BSCVA), MR, SE, and astigmatism (by the power vector method) before surgery and 1, 3, and 6 months thereafter. Differences between patients receiving each type of lens were compared by using a mixed model of repeated measures.
Results
Visual improvements were evident after operation in both groups. By comparing the attempted to the achieved SE values, we were able to confirm that correction of refractive error was similar in both groups. However, the logMAR UCVA was significantly higher in the toric ICL group at all postoperative time points. Although manifest cylinder power and astigmatism (calculated by using the power vector method) gradually decreased in the toric ICL group, cylinder power 1 month postoperatively increased from −2.62 to −2.75 D; astigmatism was also increased at this time in the toric Artisan group.
Conclusion
The two tested toric pIOLs were similar in terms of the ability to correct refractive error, as assessed 3 months postoperatively. However toric ICLs corrected astigmatism more rapidly and safely. Notably, the large difference in astigmatism level between the two groups 1 month postoperatively indicates that toric ICLs are more effective when used to correct astigmatism.
doi:10.1038/eye.2011.176
PMCID: PMC3213644  PMID: 21852802
Visian toric implantable collamer lens; iris-fixated toric phakic intraocular lens; Verisys intraocular lens; phakic intraocular lens; correction of astigmatism
7.  Long-Term Efficacy and Rotational Stability of AcrySof Toric Intraocular Lens Implantation in Cataract Surgery 
Purpose
To evaluate the long-term efficacy and rotational stability of the AcrySof toric intraocular lens (IOL) in correcting preoperative astigmatism in cataract patients.
Methods
This prospective observational study included 30 eyes from 24 consecutive patients who underwent implantation of an AcrySof toric IOL with micro-coaxial cataract surgery between May 2008 and September 2008. Outcomes of visual acuity, refractive and keratometric astigmatism, and IOL rotation after 1 day, 1 month, 3 months, and long-term (mean, 13.3±5.0 months) follow-up were evaluated.
Results
At final follow-up, 73.3% of eyes showed an uncorrected visual acuity of 20/25 or better. The postoperative keratometric value was not different from the preoperative value; mean refractive astigmatism was reduced to -0.28±0.38 diopter (D) from -1.28±0.48 D. The mean rotation of the toric IOL was 3.45±3.39 degrees at final follow-up. One eye (3.3%) exhibited IOL rotation of 10.3 degrees, the remaining eyes (96.7%) had IOL rotation of less than 10 degrees.
Conclusions
Early postoperative and long-term follow-up showed that implantation of the AcrySof toric IOL is an effective, safe, and predictable method for managing corneal astigmatism in cataract patients.
doi:10.3341/kjo.2010.24.4.207
PMCID: PMC2916101  PMID: 20714383
Astigmatism; Cataract surgery; Toric intraocular lens
8.  High-cylinder toric intraocular lens implantation versus combined surgery of low-cylinder intraocular lens implantation and limbal relaxing incision for high-astigmatism eyes 
Clinical outcomes were compared between high-cylinder toric intraocular lens (IOL) implantation and the combined surgery of low-cylinder toric IOL implantation and limbal relaxing incision (LRI) for correcting preexisting high-amplitude corneal astigmatism. Fifty-seven eyes with preexisting corneal astigmatism of 2.5 diopter (D) or greater were divided into the following two groups: (1) eyes that underwent Alcon AcrySof® IQ Toric T6, T7, T8, or T9 IOL implantation (toric group); and (2) eyes that underwent the combined surgery of AcrySof® IQ Toric T5 IOL implantation and LRI (LRI group). Uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), manifest, refractive and corneal cylinder (MC, RC, CC), were compared postoperatively. Corneal and ocular higher-order aberrations (HOA) were also compared. At 1 day postoperative, UCVA was significantly better and MC and RC were significantly less in the toric group, however, at 1 and 6 months postoperative, there was no significant difference in those parameters. Postoperative corneal and ocular HOA were significantly greater in the LRI Group. For correcting astigmatism in eyes with a high amount of preexisting astigmatism, high-cylinder toric IOL implantation achieves better clinical outcomes, especially in the early postoperative period, than the combined procedure of moderate-cylinder toric IOL implantation and LRI.
doi:10.2147/OPTH.S61373
PMCID: PMC3976238
toric intraocular lens; limbal relaxing incision; high-cylinder astigmatism; cataract surgery
9.  Which Keratometer is Most Reliable for Correcting Astigmatism with Toric Intraocular Lenses? 
Purpose
To evaluate the accuracy of preoperative keratometers used in cataract surgery with toric intraocular lens (IOL).
Methods
Twenty-five eyes received an AcrySof toric IOL implantation. Four different keratometric methods, a manual keratometer, an IOL master, a Pentacam and an auto keratometer, were performed preoperatively in order to evaluate preexisting corneal astigmatism. Differences between the true residual astigmatism and the anticipated residual astigmatism (keratometric error) were compared at one and three months after surgery by using a separate vector analysis to identify the keratometric method that provided the highest accuracy for astigmatism control.
Results
The mean keratomeric error was 0.52 diopters (0.17-1.17) for the manual keratometer, 0.62 (0-1.31) for the IOL master, 0.69 (0.08-1.92) for the Pentacam, and 0.59 (0.08-0.94) for the auto keratometer. The manual keratometer was the most accurate, although there was no significant difference between the keratometers (p > 0.05). All of the keratometers achieved an average keratometric error of less than one diopter.
Conclusions
Manual keratometry was the most accurate of the four methods evaluated, although the other techniques were equally satisfactory in determining corneal astigmatism.
doi:10.3341/kjo.2012.26.1.10
PMCID: PMC3268162  PMID: 22323879
Astigmatism; Cataract; Keratometer; Keratometric error; Toric intraocular lenses
10.  Acrylic toric intraocular lens implantation: a single center experience concerning clinical outcomes and postoperative rotation 
Purpose:
To present clinical results of toric intraocular lens (IOL) implantation for preexisting astigmatism correction and determine the time of any postoperative rotation.
Patients and methods:
Twenty-nine eyes of 19 patients underwent uncomplicated phacoemulsification and were implanted with an Acrysof © toric IOL. Uncorrected visual acuity, residual astigmatism, and postoperative rotation of the IOL were estimated one and six months after the operation.
Results:
Uncorrected visual acuity was ≥0.5 in 26 of 29 eyes (89.7%) and ≥0.8 in 19 of 29 patients (65.5%). The mean toric IOL axis rotation was 2.2 ± 1.5° (range 0.6–7.8°) one month postoperation and 2.7 ± 1.5° (range 0.9–8.4°) six months postoperation.
Conclusion:
Implantation of one-piece hydrophobic acrylic toric IOLs appears to have acceptable stability, which encourages visual outcome and emerges as an attractive alternative for correction of refractive astigmatism.
PMCID: PMC2850825  PMID: 20390033
astigmatism; cataract; stability; implantation
11.  Successful toric intraocular lens implantation in a patient with induced cataract and astigmatism after posterior chamber toric phakic intraocular lens implantation: a case report 
Introduction
We report the case of a patient in whom simultaneous toric phakic intraocular lens removal and phacoemulsification with toric intraocular lens implantation were beneficial for reducing pre-existing astigmatism and acquiring good visual outcomes in eyes with implantable collamer lens-induced cataract and astigmatism.
Case presentation
A 53-year-old woman had undergone toric implantable collamer lens implantation three years earlier. After informed consent was obtained, we performed simultaneous toric implantable collamer lens removal and phacoemulsification with toric intraocular lens implantation. Preoperatively, the manifest refraction was 0, -0.5 × 15, with an uncorrected visual acuity of 0.7 and a best spectacle-corrected visual acuity of 0.8. Postoperatively, the manifest refraction was improved to 0, -0.5 × 180, with an uncorrected visual acuity of 1.2 and a best spectacle-corrected visual acuity of 1.5. No vision-threatening complications were observed.
Conclusion
Toric intraocular lens implantation may be a good surgical option for the correction of spherical and cylindrical errors in eyes with implantable collamer lens-induced cataract and astigmatism.
doi:10.1186/1752-1947-6-109
PMCID: PMC3349471  PMID: 22507132
12.  Visual outcome and rotational stability of open loop toric intraocular lens implantation in Indian eyes 
Indian Journal of Ophthalmology  2013;61(11):626-629.
Purpose:
To assess the visual outcome and rotational stability of single-piece open loop toric Intra Ocular Lens (IOL) in a clinical setting.
Materials and Methods:
In a prospective study, 122 eyes of 77 patients were followed up for a period of 12 months after cataract surgery with toric open loop IOL implantation. The pre-operative markings for the position of incision and IOL placement were done under slit lamp by anterior stromal puncture. The visual acuity, refraction, and IOL position were assessed at day 1, 1 week, 1 month, 3 months, 6 months, and 12 months after surgery.
Results:
The mean age of the cohort was 56 yrs (S.D. 13.88; range 16 to 87 years). The mean pre-operative cylinder of corneal astigmatism was 1.37 D. (SD 0.79, range 1.0 to 5.87 D). Mean post-operative refractive cylinder was 0.36 D (SD 0.57, range 0 to 1.50 D) at 12 months. Ninety-seven percent of the eyes were within 1 D of residual astigmatism. Ninety-four percent of patients had uncorrected visual acuity of 20/30 or better. Four eyes required IOL repositioning due to rotation. At 12 months, 96.7% of the IOLs were within 10 degrees of the target axis. There was no rotation seen after 6 months.
Conclusion:
Toric IOLs are very effective and consistent in correcting astigmatism during the cataract surgery. IOL rotation happens mostly within a month of surgery, and if significant, requires early repositioning.
doi:10.4103/0301-4738.123142
PMCID: PMC3959075  PMID: 24343593
Astigmatism; cataract surgery; toric lens; toric intraocular lens
13.  Visual and Refractive Outcomes after Cataract Surgery with Implantation of a New Toric Intraocular Lens 
Case Reports in Ophthalmology  2013;4(2):48-56.
Purpose
The aim of this study was to evaluate and report the visual, refractive and aberrometric outcomes of cataract surgery with implantation of the new aspheric Tecnis ZCT toric intraocular lens (IOL) in eyes with low to moderate corneal astigmatism.
Methods
We conducted a prospective study of 19 consecutive eyes of 17 patients (mean age: 78 years) with a visually significant cataract and moderate corneal astigmatism [higher than 1 diopter (D)] undergoing cataract surgery with implantation of the aspheric Tecnis ZCT toric IOL (Abbott Medical Optics). Visual, refractive and aberrometric changes were evaluated during a 6-month follow-up. Ocular aberrations as well as IOL rotation were evaluated by means of the OPD-Station II (Nidek).
Results
The six-month postoperative spherical equivalent and power vector components of the refractive cylinder were within ±0.50 D in all eyes (100%). Postoperative logMAR uncorrected and corrected distance visual acuities (UDVA/CDVA) were 0.1 (about 20/25) or better in almost all eyes (94.74%). The mean logMAR CDVA improved significantly from 0.41 ± 0.23 to 0.02 ± 0.05 (p < 0.01). No significant changes were found in corneal astigmatism (p = 0.73). The mean IOL rotation was 3.33 ± 1.94°. This parameter did not correlate with higher-order aberrations (r = −0.09, p = 0.73). A significant improvement in the Strehl ratio was also observed (p < 0.01), which was consistent with the significant reduction in higher-order aberrations (p = 0.02).
Conclusion
Cataract surgery with implantation of the aspheric Tecnis ZCT IOL is a predictable and effective procedure for visual rehabilitation in eyes with cataract and low to moderate corneal astigmatism, providing an excellent postoperative ocular optical quality.
doi:10.1159/000353389
PMCID: PMC3724128  PMID: 23898293
Tecnis ZCT; Aspheric toric intraocular lens; Cataract surgery; Higher-order aberrations
14.  Postoperative Astigmatic Outcomes Based on the Haptic Axis of Intraocular Lenses Inserted in Cataract Surgery 
Purpose
This study was conducted to compare post-operative astigmatic outcomes of two groups, with-the-rule (WTR) and against-the-rule (ATR) astigmatism patients, according to the haptic axis of intraocular lenses (IOLs) inserted in cataract surgery.
Methods
Seventy-two eyes with WTR astigmatism and 79 eyes with ATR astigmatism had cataract surgery through a clear corneal temporal incision. These two groups of eyes were then each divided into 2 groups based on whether the haptic axis of the inserted IOL was at 180° or 90°. For ATR patients, the outcomes were analyzed according to the three types of IOLs.
Results
There was no difference in corneal astigmatism, but WTR patients with a 180° haptic axis of the inserted IOL and ATR patients with a 90° hepatic axis of the inserted IOL had a significant decrease in postoperative refractive astigmatism (p < 0.05). The changes in ATR astigmatism according to the IOL type were more effective in single-piece acrylic IOLs than in the three-piece polymethylmethacrylate haptic IOL group.
Conclusions
Insertion of the IOL at the 180° haptic axis in WTR patients and at 90° in ATR patients during cataract surgery may have an effect in reducing pre-existing astigmatism. This observed effect was not consistent among the different types of IOLs.
doi:10.3341/kjo.2011.25.1.22
PMCID: PMC3039190  PMID: 21350690
Cataract; Clear corneal temporal incision; Haptic axis of inserted intraocular lens; Ocular residual astigmatism
15.  Three-Year Follow-Up of Posterior Chamber Toric Phakic Intraocular Lens Implantation for Moderate to High Myopic Astigmatism 
PLoS ONE  2013;8(2):e56453.
Purpose
To assess the 3-year clinical outcomes of toric phakic intraocular lens (Visian ICL™; STAAR Surgical) implantation for moderate to high myopic astigmatism.
Methods
This retrospective study evaluated fifty eyes of 28 patients who underwent toric ICL implantation for the correction of moderate to high myopic astigmatism and who regularly returned for postoperative examination. Before, and 1, 3, and 6 months after, and 1, 2, and 3 years after surgery, we assessed the safety, efficacy, predictability, stability, and adverse events of the surgery in eyes undergoing toric ICL implantation.
Results
The logarithm of the minimal angle of resolution (LogMAR) uncorrected visual acuity and LogMAR best spectacle-corrected visual acuity were –0.10 (corresponding to Snellen equivalents 20/16) ± 0.16 and –0.20 (corresponding to 20/12.5) ± 0.07, 3 years postoperatively, respectively. The safety and efficacy indices were 1.16 ± 0.20 and 0.94 ± 0.28. At 3 year, 82% and 98% of the eyes were within 0.5 and 1.0 D, respectively, of the targeted correction. Manifest refraction changes of –0.15 ± 0.31 D occurred from 1 month to 3 year. No vision-threatening complications occurred during the observation period.
Conclusions
On the basis of the clinical results of this study, toric ICL implantation was good in all measures of safety, efficacy, predictability, and stability for the correction of moderate to high myopic astigmatism throughout a 3-year observation period.
doi:10.1371/journal.pone.0056453
PMCID: PMC3568037  PMID: 23409187
16.  Toric phakic implantable collamer lens for correction of astigmatism: 1-year outcomes 
Purpose:
The purpose of this study was to assess predictability, efficacy, safety and stability in patients who received a toric implantable collamer lens to correct moderate to high myopic astigmatism.
Methods:
Forty-three eyes of 23 patients underwent implantation of a toric implantable collamer lens (STAAR Surgical Inc) for astigmatism correction. Mean spherical refraction was −4. 98 ± 3.49 diopters (D) (range: 0 to −13 D), and mean cylinder was −2.62 ± 0.97 D (range: −1.00 to −5.00 D). Main outcomes measures evaluated during a 12-month follow-up included uncorrected visual acuity (UCVA), refraction, best-corrected visual acuity (BCVA), vault, and adverse events.
Results:
At 12 months the mean Snellen decimal UCVA was 0.87 ± 0.27 and mean BCVA was 0.94 ± 0.21, with an efficacy index of 1.05. More than 60% of the eyes gained ≥1 line of BCVA (17 eyes, safety index of 1.14). The treatment was highly predictable for spherical equivalent (r2 = 0.99) and astigmatic components: J0 (r2 = 0.99) and J45 (r2 = 0.90). The mean spherical equivalent dropped from −7.29 ± 3.4 D to −0.17 ± 0.40 D at 12 months. Of the attempted spherical equivalent, 76.7% of the eyes were within ±0.50 D and 97.7% eyes were within ±1.00 D, respectively. For J0 and J45, 97.7% and 83.7% were within ±0.50 D, respectively.
Conclusion:
The results of the present study support the safety, efficacy, and predictability of toric implantable collamer lens implantation to treat moderate to high myopic astigmatism.
doi:10.2147/OPTH.S7259
PMCID: PMC3065582  PMID: 21468348
phakic intraocular lens; toric implantable collamer lens; astigmatism
17.  Functional and refractive results after one month of AcrySof toric intraocular lens implantation 
Journal of Optometry  2011;4(2):63-68.
Purpose
To describe the functional and refractive results obtained with the implantation of toric intraocular lens (IOL) in a private clinic, and verify and compare these results with other similar studies.
Methods
Retrospective evaluation of patients implanted with SN60AT toric IOL. Patients undergoing cataract surgery and corneal astigmatism (CA) higher than 0.75 D were included in the study. Preoperative and postoperative uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), subjective refraction and preoperative keratometry were recorded and analyzed statistically.
Results
The study included 68 eyes (52 patients). Thirty eyes were implanted with SN60T3, 11 with SN60T4 and 28 with SN60T5. Mean BCVA gain was of 1.9 ± 1.67 logMAR lines. Comparing the preoperative BCVA versus postoperative UCVA, the improvement was of 0.89 ± 2 logMAR lines. The postoperative refractive astigmatism was −0.37 ± 0.37 D; 75.5% of the eyes had a refractive astigmatism lower than 0.50 D and 98.6% lower than 1.00 D. The expected cylinder supplied by the manufacturer showed a good agreement with the postoperative subjective results (−0.03 ± 0.47 D).
Conclusions
The implantation of SN60T toric IOL in patients with CA higher than 0.75 D is a safe, predictable and effective way of reducing refractive astigmatism in patients undergoing cataract surgery.
doi:10.1016/S1888-4296(11)70043-7
PMCID: PMC3974402
AcrySof toric intraocular lens; Functional and refractive results; Lente intraocular tórica AcrySof; Resultados funcionales y refractivos
18.  Toric Intraocular Lens Implantation for Correction of Astigmatism in Cataract Patients with Corneal Ectasia 
Case Reports in Ophthalmology  2013;4(3):219-228.
Our purpose was to examine the long-term efficacy of toric intraocular lens (IOL) implantation in cataract patients with high astigmatism due to corneal ectasia, who underwent phacoemulsification cataract surgery. Five eyes of 3 cataract patients with topographically stable keratoconus or pellucid macular degeneration (PMD), in which phacoemulsification with toric IOL implantation was used to correct high astigmatism, are reported. Objective and subjective refraction, visual acuity measurement and corneal topography were performed in all cases before and after cataract surgery. In all cases, there was a significant improvement in visual acuity, as well as refraction, which remained stable over time. Specifically, in subjective refraction, all patients achieved visual acuity from 7/10 to 9/10 with up to −2.50 cyl. Corneal topography also remained stable. Postoperative follow-up was 18–28 months. Cataract surgery with toric IOL implantation seems to be safe and effective in correcting astigmatism and improving visual function in cataract patients with topographically stable keratoconus or PMD.
doi:10.1159/000356532
PMCID: PMC3843926  PMID: 24348406
Phacoemulsification; Keratoconus; Pellucid marginal degeneration; Toric intraocular lens; Intraocular lens; Astigmatism
19.  Current Approaches for Management of Postpenetrating Keratoplasty Astigmatism 
Journal of Ophthalmology  2011;2011:708736.
A successful corneal graft requires both clarity and an acceptable refraction. A clear corneal graft may be an optical failure if high astigmatism limits visual acuity. Intraoperative measures to reduce postkeratoplasty astigmatism include round and central trephination of cornea with an adequate size, appropriate sutures with evenly distributed tension, and perfect graft-host apposition. Suture manipulation has been described for minimising early postoperative astigmatism. If significant astigmatism remains after suture removal, which cannot be corrected by optical means, then further surgical procedures containing relaxing incisions, compression sutures, laser refractive surgery, insertion of intrastromal corneal ring segments, wedge resection, and toric intraocular lens implantation can be performed. When astigmatism cannot be reduced using one or more abovementioned approaches, repeat penetrating keratoplasty should inevitably be considered. However, none of these techniques has emerged as an ideal one, and corneal surgeons may require combining two or more approaches to exploit the maximum advantages.
doi:10.1155/2011/708736
PMCID: PMC3147001  PMID: 21811668
20.  Artiflex Toric Phakic Intraocular Lens Implantation in Congenital Nystagmus 
Case Reports in Ophthalmology  2011;2(2):273-278.
Case
A 44-year-old woman with congenital nystagmus and myopic astigmatism in both eyes who was submitted to phakic intraocular lens (pIOL) implantation.
Methods
Full ophthalmologic examination including refractive status, corrected (CDVA) and uncorrected (UCVA) monocular and binocular visual acuities, ocular motility, slit-lamp evaluation, tonometry and fundoscopy before and after implantation of toric pIOLs (Artiflex; Ophtec BV, The Netherlands) in both eyes.
Results
Preoperative logMAR CDVA were 0.699 and 0.420 in the right and left eye, respectively. Three months after surgery, logMAR UCVA were 0.398 and 0.182, reaching binocular logMAR UCVA of 0.132. There were no changes in nystagmus characteristics after surgery.
Conclusions
pIOL implantation may be a safe and suitable treatment to correct high refractive errors in patients with congenital nystagmus. Significant improvement in CDVA and UCVA can be achieved.
doi:10.1159/000331115
PMCID: PMC3177809  PMID: 21941505
Nystagmus; Refractive surgery; Toric phakic intraocular lens
21.  Artisan iris-fixated toric phakic intraocular lens for the correction of high astigmatism after deep anterior lamellar keratoplasty 
Summary
We report the refractive correction of high astigmatism in one eye of a 23-year-old woman following deep anterior lamellar keratoplasty (DALK) using an Artisan iris-fixated, toric, phakic intraocular lens (IOL). One year after implantation, uncorrected and corrected distance visual acuities were both 20/25, refraction was −1.00 D cylinder, and the endothelial cell count was 1827 cells/mm2. Iris-fixated phakic IOLs are not recommended for every postkeratoplasty patient with high refractive error; however, this procedure can offer good outcomes in carefully selected cases of previous DALK.
doi:10.5693/djo.02.2013.04.001
PMCID: PMC3790592  PMID: 24109249
22.  Intraocular lens exchange through a 3.2-mm corneal incision for opacified intraocular lenses 
Aim:
The aim was to evaluate visual and refractive results and complications of intraocular lens (IOL) exchange through a 3.2 mm corneal incision for opacified IOLs.
Materials and Methods:
This retrospective study comprised 33 eyes of 32 patients with IOL opacification requiring an IOL exchange between July 2003 and March 2007. Exchange surgery was performed through a 3.2-mm temporal clear corneal incision followed by implantation of a new foldable hydrophobic IOL. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), topographical astigmatism, and refractive cylinder were evaluated. Surgically induced astigmatism (SIA) was calculated and complications were recorded.
Results:
Opacification was observed in 25 eyes (76%) with Aqua-Sense, 3 eyes (9%) with Hydroview, 3 eyes (9%) with MemoryLens IOLs, and 2 eyes (6%) with DgR. The mean follow-up period was 36.54 months. An uneventful IOL exchange was achieved in 18 eyes (55%). Zonular dehiscence occurred in 9 eyes (27%), and posterior capsule tear developed in 4 eyes (12%). The mean preoperative BSCVA (mean ± standard deviation, decimal scale) was 0.13 ± 0.08 (mean: 20/150, range 20/2000 to 20/60) and improved to 0.63 ± 0.18 (mean: 20/32, range 20/60 to 20/20, P < 0.001). The mean SIA was 0.70 D. Seven eyes (21%) had 0.5 D or lower SIA.
Conclusion:
IOL exchange is a technically challenging procedure with potential risks of reversing the advantages of a prior small-incision cataract surgery. The use of a small corneal incision for IOL exchange could preserve the advantages of modern phacoemulsification surgery with acceptable SIA related to the procedure.
doi:10.4103/0301-4738.73713
PMCID: PMC3032237  PMID: 21157067
Intraocular lens opacification; small corneal incision; intraocular lens exchange; postsurgical outcomes
23.  Distance vision after bilateral implantation of AcrySof toric intraocular lenses: a randomized, controlled, prospective trial 
AIM
To evaluate the distance vision of Chinese patients with cataracts and corneal astigmatism after implantation of bilateral AcrySof toric intraocular lens (IOL) versus bilateral AcrySof spherical IOL.
METHODS
This study randomized 60 patients into equal groups to receive toric IOL or spherical IOL. IOL powers targeting emmetropia were selected for 93% of toric IOL patients and for 90% of spherical IOL patients. Assessments included monocular and binocular distance vision, with and without best correction. Patients also completed surveys about their distance vision.
RESULTS
Preoperatively, the two study groups were similar in age, in distance visual acuity, and in the magnitude of corneal astigmatism. At 6 months postoperative, binocular uncorrected distance vision was 0.06±0.14 logMAR in the AcrySof toric IOL group, significantly better than the 0.14±0.11 logMAR in the spherical IOL group (P<0.05). For eyes with emmetropia as a target, the equivalent of 20/20 uncorrected vision was more likely (P<0.001) in the toric IOL group (36% of eyes) than in the spherical IOL group (4% of eyes). No patients in the emmetropia/toric IOL group used distance glasses, as compared to 52% of patients in the emmetropia/spherical IOL group. All patients were satisfied or highly satisfied. Quality of distance vision was rated higher by toric IOL patients than by spherical IOL patients (P<0.05).
CONCLUSION
Bilateral AcrySof toric IOL is superior to bilateral spherical IOL in providing uncorrected distance vision to cataract patients with corneal astigmatism.
doi:10.3980/j.issn.2222-3959.2011.02.13
PMCID: PMC3340696  PMID: 22553636
astigmatism; cataract extraction; lenses, intraocular; pseudophakia
24.  Predicting the necessity of LASIK enhancement after cataract surgery in patients with multifocal IOL implantation 
Purpose
To investigate if the parameters measured routinely prior to cataract surgery with multifocal intraocular lens (IOL) implantation can predict the necessity of additional laser in situ keratomileusis (LASIK) to improve visual outcome.
Methods
Records of patients undergoing cataract surgery between January 2008 and December 2009 were reviewed. Individuals satisfied with visual outcome of cataract surgery and not satisfied were grouped (group 1 and 2, respectively). Preoperative data of refractive error, axial length, corneal astigmatism, intraocular pressure, and postoperative uncorrected visual acuity were recorded. Data was available for 62 patients (104 eyes), of which LASIK enhancement was deemed necessary in 21 eyes (20%; group 2). The receiver operator characteristic curves were used to discriminate between the groups and linear regression analysis was performed to predict the postoperative visual outcome.
Results
The astigmatism measured preoperatively using manifest refraction had an accuracy of 64% in discriminating between the groups. Age, spherical component of refraction, axial length, corneal astigmatism, and intraocular pressure were very close to chance prediction 59%, 57%, 56%, 51%, and 51%, respectively. The postoperative uncorrected visual acuity had an accuracy of 79% in discriminating the groups. Individuals with uncorrected visual acuity worse than 20/40 after cataract surgery were most likely to undergo LASIK enhancement; however, approximately 20% of group 2 underwent LASIK enhancement despite having visual acuity of 20/30 or better. When combined, preoperative visual acuity accounted for just 7% of variance in postoperative uncorrected visual acuity.
Conclusion
Requirement of LASIK enhancement after cataract surgery with multifocal IOL implant is complex in nature, and parameters routinely measured before surgery cannot successfully identify the group requiring LASIK enhancement or predict postoperative uncorrected visual acuity.
doi:10.2147/OPTH.S23345
PMCID: PMC3180499  PMID: 21966202
refractive error; axial length; corneal astigmatism; intraocular pressure; uncorrected visual acuity; visual outcome; multivariate analysis; LASIK enhancement
25.  Surgically induced astigmatism after 3.0 mm temporal and nasal clear corneal incisions in bilateral cataract surgery 
Indian Journal of Ophthalmology  2013;61(11):645-648.
Aims:
To compare the corneal refractive changes induced after 3.0 mm temporal and nasal corneal incisions in bilateral cataract surgery.
Materials and Methods:
This prospective study comprised a consecutive case series of 60 eyes from 30 patients with bilateral phacoemulsification that were implanted with a 6.0 mm foldable intraocular lens through a 3.0 mm horizontal clear corneal incision (temporal in the right eyes, nasal in the left eyes). The outcome measures were surgically induced astigmatism (SIA) and uncorrected visual acuity (UCVA) 1 and 3 months, post-operatively.
Results:
At 1 month, the mean SIA was 0.81 diopter (D) for the temporal incisions and 0.92 D for nasal incisions (P = 0.139). At 3 months, the mean SIA were 0.53 D for temporal incisions and 0.62 D for nasal incisions (P = 0.309). The UCVA was similar in the 2 incision groups before surgery, and at 1 and 3 months post-operatively.
Conclusion:
After bilateral cataract surgery using 3.0 mm temporal and nasal horizontal corneal incisions, the induced corneal astigmatic change was similar in both incision groups. Especially in Asian eyes, both temporal and nasal incisions (3.0 mm or less) would be favorable for astigmatism-neutral cataract surgery.
doi:10.4103/0301-4738.119341
PMCID: PMC3959080  PMID: 24145563
Nasal incision; surgically induced astigmatism; temporal incision

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