성모병원 안센터 CHANGES IN ASTIGMATISM RELATIVE TO IOL HAPTIC INSERTION AXIS IN WITH-THE-RULE AND AGAINST-THE-RULE ASTIGMATISM PATIENTS Hyun Seung Kim, M.D.

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성모병원 안센터 CHANGES IN ASTIGMATISM RELATIVE TO IOL HAPTIC INSERTION AXIS IN WITH-THE-RULE AND AGAINST-THE-RULE ASTIGMATISM PATIENTS Hyun Seung Kim, M.D. Department of Ophthalmology, St. Mary’s hospital, The Catholic University of Korea Authors have no financial interest.

Purpose To compare astigmatic outcomes caused by axis change of inserted IOL haptic during clear corneal temporal incision cataract surgery for patients with WTR and ATR astigmatism IOL haptic insertion at 180° vs. 90° axis IOL haptic insertion at 180° axis at 90° axis

Materials and Methods 138 patients (151 eyes) with LOCS III, No 2-3 cataract Phacoemulsification cataract extraction + PCL insertion through 3 mm temporal clear corneal incision by one surgeon. No suture was done. Pupil dilatation was done at POD # 1 month : When IOL rotation was detected from original axis (out of 180±10° or 90±10°), the patient was excluded from the study. Patient selection criteria (at pre-, and post-operative state) WTR astigmatism : Steep axis range 90±20° ATR astigmatism : Steep axis range 180±20°

Materials and Methods Patients divided into 4 groups according to preoperative astigmatism axis (WTR or ATR) and IOL inserted axis (Haptic in 180° or 90°). Group I : preoperative WTR astigmatism + IOL haptic axis at 180° (38 eyes) Group II : preoperative WTR astigmatism + IOL haptic axis at 90° (34 eyes) Group III : preoperative ATR astigmatism + IOL haptic axis at 180° (36 eyes) Group IV : preoperative ATR astigmatism + IOL haptic axis at 90° (43 eyes) 3 types of IOLs (Alcon acrySof SA60AT; Rayner C-flex™; AMO Tecnis ZA9003) were inserted in the bag. Astigmatic changes were compared by Autorefractor (BK-F1, Canon) and Topography (Orbscan II, Orbtek) at preoperative and postoperative 1 day, 1 week, 1 month, 2 months.

Results ; Astigmatisms in WTR & ATR groups Haptic 180° (Group I) Haptic 90° (Group II) P-value Autorefractor Preoperative Postoperative 1 week Postoperative 1 month Postoperative 2 months 1.32±1.17 1.00±0.73 1.01±0.77 1.01±0.81 1.46±1.09 1.34±1.09 1.49±1.11 1.53±1.30 0.971 0.051 0.050 0.048 Topography 1.20±1.14 1.34±0.88 1.42±0.95 1.29±0.97 1.30±0.79 1.56±1.11 1.61±1.07 1.65±1.05 0.321 0.129 0.585 ATR Haptic 180° (Group III) Haptic 90° (Group IV) P-value Autorefractor Preoperative Postoperative 1 week Postoperative 1 month Postoperative 2 months 1.23±0.85 1.20±0.51 1.21±0.56 1.22±0.40 1.34±0.76 1.18±0.63 0.97±0.56 0.91±0.53 0.338 0.607 0.046 0.034 Topography 1.41±0.48 1.32±0.17 1.25±0.09 1.19±0.10 1.26±1.09 1.12±0.63 0.99±0.57 1.06±0.54 0.310 0.291 0.170 0.302

Results ; Astigmatisms in WTR & ATR groups Refractive Astigmatism by Autorefractor Corneal Astigmatism by Topography WTR Group I & II WTR Group I & II Refractive Astigmatism by Autorefractor Corneal Astigmatism by Topography ATR Group III & IV ATR Group III & IV

Vector Analysis of Mean Refractive Astigmatism WTR Haptic 180° (Group I) Haptic 90° (Group II) P-value Autorefractor Postoperative 1 day Postoperative 1 week Postoperative 1 month Postoperative 2 months 1.17±0.94 1.00±1.01 1.02±0.87 0.96±0.77 1.35±1.21 1.12±0.98 1.32±0.95 1.49±1.10 0.321 0.217 0.049 0.017 Topography 1.05±1.15 1.07±1.23 1.15±1.10 0.90±1.04 0.97±1.11 1.04±0.75 0.766 0.723 0.667 ATR Haptic 180° (Group III) Haptic 90° (Group IV) P-value Autorefractor Postoperative 1 day Postoperative 1 week Postoperative 1 month Postoperative 2 months 1.54±0.91 1.47±0.67 1.49±0.54 1.35±0.76 1.29±0.96 1.37±0.85 1.10±0.75 1.06±1.02 0.255 0.170 0.046 0.029 Topography 0.95±0.85 0.62±0.72 0.62±0.93 1.01±0.88 0.72±0.83 0.74±0.577 0.752 0.699 0.532

Vector Analysis of Mean Refractive Astigmatism In WTR Patients In ATR Patients WTR Group I & II ATR Group III & IV

Refractive Astigmatism Mean Astigmatism Change According to IOL Type in ATR Patients IOL Type Refractive Astigmatism Corneal Astigmatism Single-piece hydrophobic acrylic IOL (Alcon acrySof SA60AT) hydrophilic acrylic IOL (Rayner C-flex™) Three-piece acrylic optic with PMMA haptic IOL (AMO Tecnis ZA9003)

Summary WTR astigmatism group with Haptic axis 180° Topography : Corneal Astigmatism ↑ Autorefractor : Total Astigmatism ↓ May be a net effect of Ocular residual astigmatism ↓(IOL effect ?) ATR astigmatism group with Haptic axis 90° Topography : Corneal Astigmatism ↓ Autorefractor : Total Astigmatism ↓↓ May be a net effect of Ocular residual astigmatism ↓ (IOL effect ?)

Our Hypothesis of IOL Effect Inserting the IOL in the bag Capsule bag diameter < Total IOL length → Angulation of IOL, Stretching of posterior capsule → More astigmatism perpendicular to IOL haptic axis Development of With-the-Rule effect

Conclusions When performing cataract surgery by clear corneal temporal incision, inserting IOL axis parallel to preoperative astigmatism axis could minimize the surgically induced astigmatism. The effect was greater with one-piece acrylic IOL than three-piece PMMA haptic IOL. Considering the ocular residual astigmatism after cataract surgery may be important when inserting toric, aspheric and multifocal IOLs. And the possibility that IOL haptic insertion axis may affect the ocular residual astigmatism should be considered when performing cataract surgery.