1. Long-Term Follow-Up of Toric Intraocular Lens Implantation for Keratoconus Alejandro Navas, MD, MSc, Martha Jaimes, MD, Jesús Cabral, MD, Arturo Ramirez –Miranda, MD, Enrique O. Graue-Hernández, MD, MSc Institute of Ophthalmology “Conde de Valenciana”, Mexico City, Mexico dr.alejandro.navas@gmail.com

2. Financial Disclosure -AN: Carl Zeiss Meditec, Consultant (A); Alcon Laboratories, Consultant (B) and STAAR Surgical, Consultant (B). -AN: Carl Zeiss Meditec, Consultant (A). -MJ, JC & EOGH: No financial interest or relationship to disclose.

3. Purpose To report clinical characteristics and surgical outcomes at long-term follow-up of patients with keratoconus treated with implantation of in the bag toric intraocular lenses. Methods Retrospective review of medical records from patients diagnosed with keratoconus treated with in the bag toric intraocular lens implantation.

4. Age, preoperative and postoperative UDVA (uncorrected distance visual acuity) and CDVA (corrected distance visual acuity), objective and subjective refraction, spherical equivalent, total keratometric power, total astigmatism, axis, toric IOL model and power were analyzed. STATA 8.0 and paired t-test were used for statistical analysis. Please click on the link (View additional images/videos) for a video to expand surgical and patient selection methodology.

5. Results 21 eyes of 15 patients. 12 forme fruste keratoconus, 7 with frank keratoconus and 2 pellucid marginal degenerations were evaluated. Mean age was 50.61 ± 5.99 years. Mean follow-up was 45.42 ± 12.11 months (almost 4 years). Preoperative spherical equivalent was -7.11±6.06 and postoperative spherical equivalent was -0.50±1.02 (P<0.001). Preoperative cylinder was -3.85±1.26 and postoperatively -1.03±0.69 (P<0.001).

6. Results Preoperative UDVA was 1.37±0.35 (mean 20/468 Snellen) and postoperative UDVA was 0.25±0.17 (mean 20/35 Snellen) (p<0.001). 2 cases required Nd:YAG laser capsulotomies, 1 case underwent argon laser photocoagulation due to a peripheral retinal hole. No further complications or eventualities were found.

7. A) Topographic astigmatism, B) Scheimpflug images astigmatism. C) Sofware calculation astigmatism, D) Final surgical position. A B C D

8. A B C D

10. A) Clinical example of an Orbscan II keratometric map showing topographic irregular astigmatism. B) Toric IOL software calculation with suggested IOL position. C) Final postoperative IOL position; the IOL marks are in alignment according to the suggested position. ParameterPreoperativePostoperative UDVA1.38 + 0.33 logMAR0.28 + 0.23 logMAR CDVA0.25 + 0.42 logMAR0.03 + 0.05 logMAR Sphere-5.14 + 5.90 D0.01 + 0.97 D Cylinder3.91 + 1.26 D1.13 + 1.03 D Spherical equivalent-7.10 + 5.91 D-0.55 + 1.00 D

11. Clinical example of long-term stability: 3 years after toric IOL implantation, keratometry (A) and pachymetry (B) Scheimpflug images showing ectatic patterns. Toric IOL calculation (C) remained in alignment even after Nd:YAG laser capsolotomy (D).

12. Conclusions Toric intraocular lens implantation could be an effective therapeutic option at long-term follow- up in well selected patients with stable and non- progressive keratoconus. References 1) Jaimes M, Xacur-García F, Alvarez-Melloni D, Graue-Hernández EO, Ramirez-Luquín T, Navas A. Refractive Lens Exchange With Toric Intraocular Lenses in Keratoconus, J Refract Surg 2011;27:658-664. 2) Jhanji V, Sharma N, Vajpayee RB. Management of keratoconus: current scenario. Br J Ophthal 2011;95:1044-1050. 3) Sauder G, Jonas JB. Treatment of keratoconus by toric foldable intraocular lenses. Eur J Ophthalmol 2003; 13(6):577-579. 4 ) Leccisotti A. Refractive lens exchange in keratoconus. J Cataract Refract Surg 2006; 32:742-746. 5) Thebpatiphat N, Hammersmith KM, Rapuano CJ, Ayres BD, Cohen EJ. Cataract surgery in keratoconus. Eye Contact Lens 2007; 33(5):244-246. 6) Navas A, Suárez R. One-year follow-up of toric intraocular lens implantation in forme fruste keratoconus. J Cataract Refract Surg 2009;35:2024-2027. 7) Visser N, Gast ST, Bauer NJ, Nujits RM. Cataract surgery with toric intraocular lens implantation in keratoconus: a case report. Cornea 2011;30:720-723.