1. M. Allison Roensch, MD, Preston H. Blomquist, MD, Nalini K Aggarwal, MD, James P. McCulley, MD Department of Ophthalmology University of Texas Southwestern Medical Center *Dr. McCulley is a consultant for Alcon Laboratories

2. Introduction  Recent advancements in cataract surgery technology allow physicians to give patients a greater degree of spectacle independence.  Toric intraocular lenses allow for intra-operative correction of astigmatism. Multifocal lenses allow for the correction of near vision, as well as distance vision.  Each lens platform represents a different surgical technique to which the surgeon must adapt, as well as unique pre- and post-operative management and patient counseling.  Current resident education should take these new technologies into account. Use of these lens platforms during training will better equip residents for transition to their own practice.

3. Methods: Toric IOLs  A total of 73 eyes of 55 patients with more than 1.0 diopter of corneal astigmatism had placement of an Alcon AcrylSof Toric IOL. Preoperatively, informed consent was obtained, and patients received a complete ophthalmic exam including slit lamp exam, applanation tonometry, visual acuity, refraction, keratometry, optical coherence biometry (IOLMaster), topography (Humphrey Atlas Eclipse), and dilated fundus exam. Patients with corneal surface abnormalities, irregular astigmatism, and extensive retinal pathology were excluded.  The AcrylSof Toric online calculator was used for determination of correct lens platform, either T3 (1.5 D), T4 (2.25 D), and T5 (3.00 D). The steep and flat keratometry readings were placed into the calculator, and 0.4 D of surgically induced astigmatism was used. The placement of the main incision was varied to give the most desirable anticipated residual astigmatism. All incisions were 3.0 mm wounds. Lens spherical power was determined using IOL Master measurements in the SRK/T formula. The targeted spherical outcome was plano to -0.50 diopters.  The preoperative corneal markings were made with the patients sitting upright to negate possible cyclotorsion in the supine position. An intraoperative toric axis marker was used for determination of actual axis placement. The surgeries were performed by senior residents who were completing their surgical chief rotation. After injection, all IOLs were rotated 15-25 degrees from intended axis and the viscoelastic was then removed. The IOLs were then rotated to their final position to coincide with corneal axis markings.

4. Methods: Multifocal IOLs  The multifocal group consisted of a total of 15 eyes of 9 patients who requested correction of both near and distance vision. These patients had placement of the Alcon AcrySof ReSTOR SN6AD1 or SN6AD3 intraocular lens.  Preoperatively, informed consent was obtained, and the patients received a complete ophthalmic exam including slit lamp exam, applanation tonometry, best corrected visual acuity, keratometry, optical coherence biometry (IOLMaster), topography (Humphrey Atlas Eclipse), and dilated fundus exam.  Patients with extensive retinal pathology, corneal surface abnormalities, irregular astigmatism, and corneal astigmatism greater than +0.75 diopters were excluded.  Lens spherical power was determined using IOL Master measurements in the SRK/T formula with a target refraction of plano to +0.25D. The surgeries were performed by senior residents who were completing their surgical chief rotation.  Resident Survey:  Residents were given a questionnaire after completion of their surgical chief rotation. They were asked to respond to various questions and rate their responses with 1 being the lowest and 5 the highest. A total of 14 residents have completed the survey.

5. Results: Toric IOLs  Mean length of follow-up was 3.9 months. Patient age ranged from 22- 82 with a mean of 56.95 years. 67% were female.  Uncorrected visual acuity: 56% were 20/25 or better, 88% were 20/40 or better  Best corrected visual acuity: 92% were 20/25 or better  Mean refractive cylinder decreased from 1.67 D pre-op to 0.45 D post-op  3 patients were noted to have lens rotation post-op: 1 lens rotated 13 degrees s/p YAG capsulotomy, resulting in a change from 0.5 residual cylinder to 1.75 of cylinder. 1 patient had 5 degrees of rotation resulting in 1.25 of residual cylinder. 1 patient had 3 degrees of rotation with 0.75D of residual cylinder  Outliers: one patient had amblyopia, 3 developed diabetic retinopathy limiting vision, 1 had limited vision from dry AMD  3 eyes also received LRIs due to corneal astigmatism greater than that correctable by the T5 IOL

6. Results: Toric IOLs AgeAxial Length (mm)IOL spherical power All56.95 +/- 13.3123.95 +/- 1.1719.64 +/- 3.36 N (eyes) Pre-op IOLMaster cylinder Pre-op topographic cylinder Pre-op refractive cylinder Post-op refractive cylinder Spherical Equivalent T3121.34 +/- 0.30 1.30 +/- 0.341.42 +/- 0.880.21 +/- 0.20-0.38 +/- 0.43 T4241.62 +/- 0.381.76 +/- 0.641.18 +/- 0.790.40 +/- 0.49-0.40 +/- 0.59 T5372.84 +/- 1.052.84 +/- 1.122.04 +/- 1.400.58 +/- 0.69-0.44 +/- 0.52 All732.19 +/- 1.032.22 +/- 1.091.67 +/- 1.220.45 +/- 0.59-0.42 +/- 0.53 UCVA 20/20-30 UCVA 20/40 UCVA <20/40 BCVA 20/20-25 BCVA <20/25 T311 (91.7%)01 (8.3%)12 (100%)0 T420 (83.3%)1 (4.2%)3 (12.5%)21 (87.5%)3 (12.5%) T525 (67.6%)7 (18.9%)5 (13.5%)34 (91.9%)3 (8.1%) All56 (76.7%)8 (11%)9 (12.3%)67 (91.8%)6 (8.2%) Refraction unreliable in 4 patients in T4 group and 2 in the T5 group pre-op due to dense cataract

7. Results: Multifocal IOLs  Patients ranged in age from 53-80. 44% were male.  Mean length of follow-up was 1.73 months +/- 1.34  66.7% of eyes were 20/25 or better and 93.3% were 20/40 or better uncorrected at distance.  Near vision: 40% were J1 or better uncorrected. 86.7% were J3 or better.  One lens was explanted due to a non-continuous capsulorrhexis and was replaced with a sulcus ReSTOR IOL. This patient’s UCVA was 20/70 post-op. 2 eyes had UCVA of 20/40 due to an unexpected myopic outcome with mild astigmatism. 1 patient had BCVA of 20/30 due to an epiretinal membrane.

8. Results: Multifocal IOLs N (eyes) Age (years) Refractive Cylinder IOLMaster cylinder Topography Cylinder Axial Length Mean IOL power SN6AD1&31567.93 +/- 7.91 0.75 +/- 0.61 0.47 +/- 0.36 0.40 +/- 0.30 23.67 +/- 0.55 20.47 +/- 1.83 UCVA 20/20- 25 UCVA 20/30 – 20/40 UCVA <20/40 BCVA 20/20 – 20/25 Near UCVA J1 or better Near UCVA J2-J3 Spherical equivalent Refractive cylinder SN6AD1&310 (66.7%) 4 (26.7%) 1 (6.7%) 14 (93.3%) 6 (40%) 7 (46.7%) -0.02 +/- 0.40 0.33 +/- 0.35 Results: Resident Survey Ratings from 1 (lowest) to 5 (highest) Knowledge of pre-operative workup for multifocal IOLs4.3 Knowledge of pre-operative workup for toric IOLs4.6 Knowledge of surgical techniques for multifocal IOLs4.7 Knowledge of surgical techniques for toric IOLs4.6 Degree that premium IOLs will impact your future practice4.3 Will you personally utilize premium IOLs in future?4.4 Did this experience better prepare you for using premium IOLs in your future practice?4.9 To what degree do you feel these lenses will provide spectacle independence for your patients?4.3

9. Discussion  Toric IOLs permit astigmatism correction intra- operatively, improving post-operative refractive results.  In our study, toric lenses compared favorably with previous studies. 87.7% of patients receiving toric lenses had UCVA of 20/40 or better. 91.8% of patients had a BCVA of 20/25 or better. Several eyes had limited visual potential secondary to retinal pathology or amblyopia.  Refractive cylinder decreased from a mean of 1.67 D pre-op to 0.45 D post-op, with best results in the T3 group. 74% of all eyes had a residual cylinder of 0.50D or less.  There was little post-op lens rotation with only one patient having rotation >5 degrees.

10. Discussion  Multifocal lenses allow better vision at a range of distances, both near and far, after cataract surgery  Outcomes were similar to prior studies with multifocal IOLs. 67% of eyes achieved an UCVA of 20/25 or better. 93% achieved UCVA of 20/40 or better.  93% of eyes achieved a BCVA of 20/25 or better. One eye had a BCVA of 20/30 due to an ERM.  40% of eyes achieved uncorrected near vision of 20/25 or better, while 87% were 20/40 or better.

11. Discussion  Premium IOLs are an important component of today’s comprehensive ophthalmology practice.  Outcomes in a public county hospital with surgeries performed by residents are comparable to other published studies.  Residents strongly feel that experience with these lenses will better prepare them for practice after residency.

12. References  Souza, CE, et al. Visual performance of AcrySof ReSTOR apodized diffractive IOL: A prospective comparative trial. Am J Ophthalmol. 2006 May;141(5):827-832.  Zhao G, et al. Visual function after monocular implantation of apodized diffractive multifocal or single-piece monofocal intraocular lens. J Cataract Refract Surg. 2010 Feb;36(2):282-5.  De Vries, NE, et al. Long-term follow-up of a multifocal apodized diffractive intraocular lens after cataract surgery. J Cataract Refract Surg. 2008 Sep;34(9):1476-82.  Bauer, NJC, et al. Astigmatism management in cataract surgery with the AcrySof toric intraocular lens. J Cataract Refract Surg. 2008 Sep;34(9):1483-8.  Mendicute, J, et al. Foldable toric intraocular lens for astigmatism correction in cataract patients. J Cataract Refract Surg. 2008 Apr;34(4):601-7.  Horn, JD. Status of toric intraocular lenses. Curr Opin Ophthalmol. 2007 Feb;18(1):58-61.  Statham, M, Apel, A, Stephensen, D. Comparison of the AcrySof SA60 spherical intraocular lens and the AcrySof Toric SN60T3 intraocular lens outcomes in patients with low amounts of corneal astigmatism. Clin Experiment Ophthalmol. 2009 Nov;37(8):775-9.  Lane, SS, et al. Comparison of clinical and patient-reported outcomes with bilateral AcrySof toric or spherical control intraocular lenses. J Refract Surg. 2009 Oct;25(10):899-901  Dardzhikova, A, Shah, CR, Gimbel, HV. Early experience with the AcrySof toric IOL for the correction of astigmatism in cataract surgery. Canadian J Ophthalmol. 2009 Jun;44(3):269-73.