Optimizing Refractive

Outcomes of Cataract
Surgery
PRESENTER : DR MWALIMU NASSORO
SUPORVISOR: DR SARAH KWEKA
OUTLINE

 INTRODUCTION
 TYPES OF INTRAOCULAR LENS
 PRESBYOPIA CORRECTION
 Pseudophakia monovision
 Accommodating IOLs
 Multifocal IOLs
 Extended depth of focus IOLs
 Postoperative adjustment of IOLs
 MODIFICATION OF PREEXISTING ASTIGMATISM
 Corneal relaxing incision
 Toric IOLs
INTRODUCTION

 Optimizing Refractive Outcomes is the process of attain

targeted postoperative visual function.
 Achieving optimal refractive outcomes after cataracts surgery
involves precise preoperative measurement, selecting the
right IOL power and addressing astigmatism.
 It involves improvement in the preoperative biometry, surgical
techniques and instrumentation, intraocular lens (IOL)
technology and calculations, and postoperative enhancement
options
 TYPES OF INTRAOCULAR LENS

 Intraocular lenses (IOLs) are permanent artificial lenses that replace

the eye's natural lens to restoring vision.
 They consist of an optic (central refracting element) and haptics
(arms or loops for stable positioning).
 There are two types based on foldability:
I. Rigid IOLs
II. Flexible IOLs
 Rigid IOLs

 They are made of polymethylmethacrylate (PMMA), lack foldability

and require a sizable incision, usually around 5 mm for insertion.
 PMMA lenses are associated with higher rates of posterior capsule
opacification (PCO) compared to silicone and acrylic.
 In specific cases, surgeons may prefer heparin-coated IOLs for
uveitic eyes, especially in pediatric patients.
Flexible IOL

 There three types of foldable IOL

I. Silicone IOL
II. Acrylic IOLs
III. Collamer IOLs
 Silicone IOLs come in loop haptic (1- or 3-piece) and plate haptic
(1-piece) forms, potentially offering greater biocompatibility with
less inflammatory reaction than hydrophobic acrylic counterparts.
 However, they may be more susceptible to significant silicone
deposition in silicone oil-filled eyes.
Flexible IOL……………….

 Acrylic IOLs, there 3-piece or 1-piece, can be hydrophobic

(water content <1%) or hydrophilic.
 Hydrophobic lenses having a higher refractive index and tending to cause
more reaction in uveitic eyes.
 Hydrophilic acrylic (hydrogel) theoretically provides superior
biocompatibility, though it may have higher rates of posterior capsular
opacification (PCO).
 Collamer, composed of collagen and poly-HEMA, it has high
biocompatibility.
Characteristics of flexible Intraocular
Lens
 They are foldable and injectable
 They are made from either silicone or acrylic
materials
 They have a biconvex aspheric optic with a square
posterior edge
 They are either single- piece or 3- piece
Modern IOL Characteristics

Characteristic Benefit
Foldable Allows for a smaller incision
Injectable Minimizes exposure of IOL to ocular
surface contamination
Aspheric optic Improves contrast sensitivity by
minimizing spherical aberration
Square posterior optic edge Minimizes PCO
Biconvex optic Allows for a thinner optic (and a
smaller incision)
Characteristics of flexible
IOL…………….

 Foldable IOLs enable smaller incisions, reducing surgically

induced corneal astigmatism and postoperative wound
complications.
 Injectable IOLs, manually loaded or preloaded, minimize IOL
exposure to ocular surface contamination.
 Silicone IOLs may face adherence issues with silicone oil,
making alternative IOL materials preferable for patients
anticipating vitrectomy with silicone oil injection, such as
those with proliferative diabetic retinopathy or retinal
detachment in the fellow eye.
Characteristics of flexible IOL…………….

IOL optic geometry

 Sharp and square-edged optics are significantly associated
with a lower rate of PCO compared with round-edged optics.
 Lens material seems to have a less important effect than
shape on PCO.
 Square posterior optic edge design has reduced posterior
capsular opacification (PCO) by blocking cell migration behind
the optic
Characteristics of flexible
IOL…………….
Aspheric optics
 Most corneas have some degree of positive spherical aberration.
 Newer IOLs are aspheric, with varying degrees of zero or
negative spherical aberration (ranging from 0 to −0.27 μm) to
offset any positive spherical aberration of the cornea and thus
improve contrast sensitivity.

 The designs of older types of IOLs were spherical, adding positive spherical
aberration to the optical system of the eye, thereby decreasing contrast
sensitivity.
Characteristics of flexible
IOL…………….
Blue light filters
 Most modern IOLs include ultraviolet (UV)-absorbing
chromophores to shield the retina from UV radiation.
 Some IOLs have blue-light filtering to diminish blue-wavelength
light which they provide added protection to the macula against
blue-light exposure.
 Presbyopia Correction

 Patients who undergo cataract surgery are corrected for

emmetropia with monofocal IOLs and rely on spectacles for their
intermediate- and near- vision tasks
 Surgical strategies for correcting presbyopia include:
I. Pseudophakic monovision,
II. Accommodating IOLs,
III. Multifocal IOLs, and
IV. Extended depth of focus IOLs (EDOF IOLs)
Pseudophakic Monovision

 Pseudophakic monovision refers to a vision correction technique where one

eye has a lens implant adjusted for distance vision, while the other eye is
adjusted for near vision.
 This helps reduce the need for reading glasses post-surgery.
 Pseudophakic monovision is a surgical technique in which different
refractive targets are set for each eye.
 Typically, the dominant eye is targeted for emmetropia. The fellow eye is
targeted for some degree of myopia.
 Modified monovision (or mini- monovision) refers to a milder myopic target
(eg, −0.50 to −1.50 diopters [D]), compared with “traditional” monovision
(−1.50 to −2.50 D).
Accommodating IOLs
 The accommodating lens was designed to improve distance, intermediate, and
near acuity via the movement of its hinged haptics during the accommodative
process.
 The accommodating IOL provides some degree of improved intermediate vision

 This IOL provides some pseudoaccommodative depth of focus, because there is

no clear clinical evidence that these “accommodating” IOLs change axial
position in the eye during near- vision tasks.
 Accommodative IOLs attempt to flex and thereby alter focal length but in
practice the amplitude of accommodation is slight.
 Pseudoaccommodative IOLs achieve their purpose by refractive or diffractive
means.
Accommodating IOLs
Multifocal IOLs

 Multifocal IOLs (MFIOLs) achieve

both distance and intermediate/near
vision by dividing light into 2 or
more focal points.
 This is achieved by either refractive
or diffractive optics, or a
combination of the two.
Multifocal IOLs……………………

 The advantage of MFIOLs is reduced dependence on spectacles.

 Disadvantages include
I. diminished contrast sensitivity,
II. glare,
III. halos, and
IV. the perception of multiple images.
Multifocal IOLs……………………

 Patients with preoperative hyperopia may experience fewer visual

aberrations than those with myopia.
 MFIOLs are most suitable for patients with excellent ocular health,
as they can lead to suboptimal outcomes in individuals with ocular
pathologies.
 Bilateral implantation and minimal postoperative astigmatism
enhance MFIOL effectiveness.
Extended Depth of Focus IOLs

 EDOF IOLs create an elongated focal range instead of 2

distinct focal points.
 They provide a range of vision from distance through
intermediate, with a low level of dysphotopsias such as glare
and halos.
Extended Depth of Focus
IOLs………………
 Some surgeons employ mini- monovision with EDOF IOLs, setting
the nondominant eye for mild residual myopia (eg, −0.50 D) and
the dominant eye for emmetropia.
 These adjustments can enable the EDOF IOL to provide better
near vision in the nondominant eye.
 The advantages and disadvantages of EDOF IOLs are similar to
those of MFIOLs including some loss of contrast sensitivity.
Extended Depth of Focus
IOLs………………
Postoperative Adjustment of
Intraocular Lenses
 The ability to adjust IOL power after implantation to minimize postoperative
refractive error.
 This 3- piece silicone IOL can be irradiated with UV light postoperatively to
change its spherocylindrical power.
 Refractive indexing is a technique in which a specialized femtosecond laser
system is used to change the refractive index of a material (eg, an acrylic IOL),
thereby changing its optical power.
 This technique would enable the surgeon to adjust the IOL’s spherocylindrical
power postoperatively.
Modification of Preexisting
Astigmatism
 Residual astigmatism after cataract surgery can impact visual
function and patient satisfaction.
 Approximately 40% of cataract patients have 1.00 D or more of
preoperative keratometric astigmatism.
 Therefore, correction of regular astigmatism during cataract
surgery has increasingly become a priority for both patients and
surgeons
 Refractive astigmatism is a combination of total corneal astigmatism and
lenticular astigmatism.
 Lenticular astigmatism is eliminated during cataract surgery.
 Total corneal astigmatism comprises both anterior and posterior corneal
astigmatism.

 Anterior corneal astigmatism tends to drift from with- the- rule (steeper
vertical meridian) toward against- the- rule (steeper horizontal median) with
increasing age.
 Posterior corneal astigmatism does not tend to change with age
 Anterior corneal astigmatism can be measured by
 keratometry (manual or automated),
 topography,
 Scheimpflug imaging,
 optical coherence tomography (OCT).
 It is best to combine keratometry with other imaging methods, because irregular
corneal astigmatism or ectatic disease may not be apparent without the use of
topography or tomography.
 Different regression formulas used to account unmeasured effect of the posterior
cornea, such as the
 Abulafia- Koch formula, or
 Barrett toric calculator,
 It is important to considering surgically induced astigmatism (SIA) in
preoperative planning for astigmatism correction during cataract surgery.
 The SIA, particularly associated with corneal incisions, can be quantified using a
centroid value.
 For instance, a 2.4-mm temporal clear corneal incision typically induces
approximately 0.10 D of flattening, but actual SIA can vary.

 Surgeons may use online toric calculators with centroid values or opt for
personally calculated values based on their experience.
 Choosing incision placement, especially across the steeper meridian for larger
incisions, is suggested to minimize preoperative astigmatism.
Corneal Relaxing Incisions

 It is technique for modification of preexisting astigmatism

 Corneal relaxing incisions include the use of both astigmatic (or arcuate)
keratotomies and limbal relaxing incisions.
 Both of these techniques employ partial-thickness arcuate incisions to reduce
regular corneal astigmatism without altering the spherical equivalent power of
the cornea.

 These incisions decrease the curvature of the incised steep meridian and
increase the curvature of the meridian 90° away (a phenomenon known as
coupling).
 Corneal relaxing incisions are most commonly used for treating lower
amounts of astigmatism, and toric IOLs are used for treating higher amounts
of astigmatism.
Corneal Relaxing Incisions
Astigmatic (arcuate) keratotomy

 Astigmatic (or arcuate) keratotomies (AKs) can be single or

paired.
 They are typically placed 7-10mm from optical zone on the
steep meridian of the cornea.

 If they are placed too close to the visual axis, can cause glare
and irregular astigmatism.
 AKs can be performed with a diamond blade or with a
femtosecond laser platform.
Astigmatic (arcuate)
keratotomy………….
 Femtosecond lasers can create AKs of a specified arc length,
optical zone, and depth.

 Laser- created AKs that are placed to penetrate anteriorly can be

manually opened later, if necessary, to “titrate” the astigmatic
effect.

 Alternatively, the laser can also create intrastromal AKs (ie, AKs
that do not penetrate the epithelial surface).
Limbal relaxing incisions

 Limbal relaxing incisions (LRIs) are placed near the limbus in the peripheral cornea and
can be single or paired.
 They are more peripheral than arcuate keratotomy (AK), to minimizing the risk of glare
or irregular astigmatism.
 However, LRIs need to be longer than AKs for an equivalent astigmatic effect due to
their peripheral location.
 Surgeons may use a diamond blade for these incisions, and some may integrate cataract
incision within one of the paired LRIs, while others opt for a separate location.
 LRIs can also be performed postoperatively.
Toric IOLs

 Toric IOLs are intraocular lenses used during cataract surgery to correct corneal
astigmatism.
 They come in optical powers ranging from 1.00 D to 4.00 D.
 Accommodative IOLs, MFIOLs, and EDOF IOLs also utilize toric platforms.

 Precise preoperative measurements, including total corneal astigmatism

calculated with a toric calculator, are crucial.
 Topography or tomography aids in identifying unsuitable candidates for toric
IOLs or corneal relaxing incisions, such as those with irregular astigmatism or
corneal ectatic disease.
Toric IOLs………………………….

 During cataract surgery, the surgeon marks the cornea preoperatively in

the upright position to avoid misalignment due to potential eye
cyclotorsion when the patient is supine.
 These reference marks guide the alignment of toric IOLs.
 Various tools, including marking devices, smartphone apps, and
intraoperative alignment systems, assist in this process.
 The toric IOL is inserted into the capsular bag and rotated to align with the
calculated steep corneal meridian.
Toric IOLs…………………………..

 Postoperative rotation can reduce astigmatism correction, with

each degree away from the optimal meridian decreasing
correction by 3.3%.
 Misalignments beyond 30° may worsen astigmatic refractive
error.
 If needed, an early postoperative procedure can correct toric
IOL rotation before capsular fibrosis and strong capsular
adherence occur.
Thank you for
listening