1. Cataract Surgery Using Biaspheric IOLs in Patients With Corneal Irregularities James P. Gills, MD St. Luke’s Cataract & Laser Institute Tarpon Springs FL Financial Disclosure: Dr. Gills is a stockholder In Lenstec, Allergan, Alcon and Abbott Medical.

2. Purpose To present case reports of patients with pre-existing corneal irregularities who underwent routine cataract surgery with an aberration free, biaspheric IOL between May and October 2010.

3. What is Paraxial Focus? Why is it important to the biaspheric lens design? The strategy of the lens design is to reduce spherical aberrations by controlling the paraxial ray of light so that it intersects at the paraxial focal point instead of in front or behind it.

4. Case 1: Keratoconus Surgical Status  Uncomplicated surgery on 7/19/2010  9.0 D Softec HD IOL  2mm CRI @ 7:30 in 8 mm optical zone (1/2 the usual correction) Presentation  1-2+ cortical spoke cataract  Keratoconus OS  Diabetic with no evidence of BDR  Manifest Refraction: -4.50 -5.25 x 140 → 20/40  Pachymetry: 492 µm  Cell Count: 1761 cells/m 2  Axial Length: 28.39 mm 2 Month Postoperative Outcome (9/22/10) UCVA: 20/20 J10 Ref: Plano → 20/20 Imp: Less astigmatism correction required; patient’s awareness of glare was minimized

5. Case 2: Hexagonal Keratotomy Surgical History 1993 Hexagonal Keratotomy OD Surgical Status  Uncomplicated surgery on 5/25/2010  14.0 D Softec HD IOL Presentation  2+ nuclear cataract  Pachymetry: 607µm  Axial Length: 23.56 mm  Manifest refraction: - 2.25 - 2.00 x 130 → 20/30 3 Month Postoperative Outcome (8/25/10) UCVA: 20/25 J1 Ref: - 0.25 - 0.75 x 150 → 20/25 Imp: Less astigmatism correction required; patient’s awareness of glare was minimized

6. Case 3: LASIK Surgical History Bilateral LASIK Surgical Status  Uncomplicated surgery  11.5 D Softec HD IOL Presentation  Cataract OD  Axial Length: OD: 27.88 mm Manifest Refraction: OD: -10.25 – 0.25 x 10 5 Month Postoperative Outcome UCVA: 20/40 J8 Ref: 0.50 – 0.50 x 35 → 20/30 Imp: Patient’s awareness of glare was minimized despite extremely irregular cornea

7. Case 4: ABMD Presentation  Bilateral cataract  ABMD with Corneal Scarring  Amblyopia OS  Normal macula  Pachymetry: OS: 546 µm  Biometry: OS: 21.98 mm  Manifest Refraction: OS: +3.25 – 0.75 x 105 Slide 1 of 2

8. Case 4: ABMD Continued Surgical Status  Planned monovision: -2.0 D Target with 30.0 D Softec HD IOL OS  Uncomplicated surgery  LRIs: OS: 7 mm @ 4:45 OS: 5 mm @ 10:30 and 4:30 enhancement Postoperative Outcome 3 Month Postoperative OS UCVA: 20/200 J1+ Ref: -2.50 – 0.75 x 10 → 20/25 Imp: Patient’s awareness of glare was minimal; improved quality of vision post-operatively despite corneal irregularities

9. Case 5: Radial Keratotomy Surgical History  Radial Keratotomy in 1990’s 24 cut OD / 20 cut OS  Cataract Removal OD ReSTOR +4 with piggyback lens Presentation (6/15/10)  Pseudophakic OD / Cataract OS  Anterior surface pigment piggyback (OD)  Cobblestone OS  Cell Count: 1618 cells/m 2 OD / 2625 cells/m 2 OS  Pachymetry: 478 µm OD / 673 µm OS  Biometry: 25.57 mm OD / 24.90 mm OS  Manifest Refraction: OD: +1.75 – 0.75 x 135 OS: +0.50 – 1.25 x 150 Slide 1 of 2 (Performed elsewhere)

10. Case 5: Radial Keratotomy Surgical Status  OD (7/16/10) Exchanged both IOLs -1.25 D Target with 21.0 D Softec HD IOL Scleral incision 6 mm @ 9:00 9-0 nylon suture at 2:30  OS (6/25/10) -2.00 D Target with 28.0 D Softec HD IOL Scleral incision 2.75 mm @ 2:30 Postoperative Outcomes 5 Month Postoperative OD UCVA: 20/40 J10 Ref: +1.50 – 1.50 x 30 → 20/25 5 Month Postoperative OS UCVA: 20/100 J1+ Ref: -3.00 – 1.00 x 165 → 20/25 OD OS Imp: Biaspheric IOLs improved paraxial focus by reducing spherical aberrations resulting in marked improvement in VA

11. Conclusion  As demonstrated, the aberration free, biaspheric IOL is preferred for patients with corneal irregularities.  Compared with conventional spherical IOL cases, those presented here require approximately half as much astigmatic correction and reported little or no glare.  This phenomena may be attributed to the aberration free, biaspheric optic of the reported IOL.  The paraxial focus that is associated with this IOL appears to primarily use the central cornea.  This paraxial focus appears to reduce spherical and optical aberrations, thus improving pseudophakic vision.