1. In-the-Bag Toric IOL for Correction of Astigmatism in Keratoconus and after Corneal Surgery Bart T.H. van Dooren, M.D., Ph.D Ilse E.M.A. Mol, M.D. Department of Ophthalmology, Amphia Hospital, Breda, The Netherlands Correspondence: bvandooren@amphia.nl The above mentioned author and co-author both have no financial interests in the subject matter of this poster B.T.H. van Dooren WCCVII 2015

2. Background and purpose Purpose: results of phacoemulsification with toric IOL implantation (in the capsular bag) for high, (fairly) regular corneal astigmatism and visually significant cataract in 3 corneal conditions: Keratoconus Post-keratoplasty Post-pterygium surgery Design: retrospective analysis of 17 eyes (16 patients) 2 B.T.H. van Dooren WCCVII 2015

3. Methods 3 B.T.H. van Dooren WCCVII 2015

4. Methods Inclusion criteria –Fairly regular cylinder Pentacam: - total refractive corneal power analysis - bow-tie pattern –Astigmatism correctable with glasses –Stable corneal astigmatism Keratoconus: minimal risk for progression (age and multiple stable Pentacam examinations) Post-keratoplasty: sutures out Post-pterygium surgery: stability on repeat Pentacam-imaging –Visually significant cataract –Medical indication (not on a patient-pay basis) 4 B.T.H. van Dooren WCCVII 2015

5. Methods 5 B.T.H. van Dooren WCCVII 2015

6. Results (1) Preoperative versus ‘late’ (12±5 months) postoperative BCVA 6 B.T.H. van Dooren WCCVII 2015

7. Results (2) Changes in BCVA (Snellen chart) during follow-up (12±5 months) * 7 *co-morbity: macular pucker with metamorphopsia (postoperative BCVA 0,6) B.T.H. van Dooren WCCVII 2015

8. Results (3) Preoperative versus ‘late’ (12±5 months) postoperative refractive cylinder in diopters (D) 8 B.T.H. van Dooren WCCVII 2015

9. Scatter plot of the astigmatic vectors (J 0 and J 45 ) during follow-up (12±5 months) Results (4) Reference: E.L. Mertens, toric phakic implantable collamer lens for correction of astigmatism: 1-year outcomes (review), Clinical Ophthalmology, 01/2011; 5:369-75 Manifest refractions (S [sphere], C [cylinder], α [axis]) were converted to power vector coordinates by the following formulas: J 0 = (−C/2)*cos (2α) J 45 = (−C/2)*sin (2α) The value (0,0) represents an eye free of astigmatism. 9 B.T.H. van Dooren WCCVII 2015

10. Results (5) No surgical complications: - No off-axis alignment or decentration of toric IOL - No intra- or post-operative complications Patient satisfaction: - Overall fairly good - Less satisfaction in 3 patients because of: - Comorbidity: macular pucker (n=1) - Conversion from myopia to slight hypermetropia (SE + 1.0 D; target was emmetropia; n=1) - Additional need for a scleral contact lens (residual astigmatism/anisometropia) (n=1) 10 B.T.H. van Dooren WCCVII 2015

11. Discussion and conclusions Safe and effective procedure Good improvement in BCVA and refractive parameters Overall fairly high patient satisfaction Case and IOL selection are crucial! –Strict and thorough preoperative Pentacam evaluation, repeated measurements –Previously mentioned inclusion criteria 11 B.T.H. van Dooren WCCVII 2015

12. Discussion and conclusions Recommendations: To optimize patient satisfaction, just like in usual toric IOL implantation: –Prevent postoperative hyperopisation in myopes, and extensively discuss a wish for postoperative emmetropic target refraction. –Provide optimal cylindrical correction by choosing the optimal IOL for the purpose (i.e. different IOL manufacturers may be necessary). But remain on the conservative side in these corneal cases: –Especially in keratoconus, postoperative target refraction calculation usually errs somewhat towards more hyperopic outcomes. –High residual astigmatism is undesirable, but both slight residual astigmatism and postoperative spectacle correction were well tolerated in our cohort. –Especially since a reading add is often necessary anyway (don’t use multifocal IOLs in these corneal cases). Correspondence: bvandooren@amphia.nl 12 B.T.H. van Dooren WCCVII 2015