ORIGINALARTICLE

Residual Astigmatism After Toric IOL Implantation/Berdahl et al

The Effect of Lens Sphere and Cylinder

calculator limitations have also been documented that
Power
were collected; early versions
of the program did not may reduce the predictability of results. Preopera- include 7-9

onanatomical
Residual Astigmatism and Its Resolution
details such as the date of the calculation or the tive and intraoperative marking errors and
intended orientation. A preliminary data

Afterreduce Toric Intraocular Lens tors thatImplantation

review was characteristics of eyes with longer axial lengths are fac-
the likelihood of erroneous and/or
conducted to
might negatively affect the correct
alignment multiple calculations; this included removing
apparent
John P. of MD;
Berdahl, toric David
lenses;R.
in Hardten,
highly myopic eyes, larger
MD; Brent capsular
A. Kramer, duplicate
BS; Richard Potvin,records,
OD
records that were related to research, bag size, zonular laxity, or dehiscence may be poten-
and data that were outside normal clinical

C
ranges (eg, tial causes for poor lens alignment.10-12 corneal cylinder greater than 10.00
orneal astigmatism of a magnitude16,17 likely to
D). Previous manu- Some studies suggest that the IOL sphere and cyl- scripts have
ABSTRACT be vi- sually significant may be found in
described the process of filtering and inder power may affect the amount of toric lens mis-
one-third of the population presenting for
PURPOSE: To analyze correlations between qualifying1 the data in more detail.
tation theof cataract
toric surgery.
intraocular Implan-(IOLs)
lenses re- is one of the
residual Additional
refractive cylinderanalyti- alignment
(and and increase
its correction likelihood of significant cal
variables,
through both entation)
lens reori- numeric with and thecategorical,
sphere most suc- cessful methods
were calcu- sidual refractive error. of reducing
13,14 the effect
However, these of
2
and cylinder power
factors have of the toric intraocular lens this astigmatism on the postoperative
lated from the raw data. This included refraction.
(IOL)categorizing
implanted. IOL not been extensively However, studied. significant
One study levels suggested of re- sidual refractive sphere
astigmatism
and cylinder powers and calculating the differ- low sphere power IOLs are after toric IOL implantation
thinner, which maymay be
METHODS: An online toric back-calculator present in some patients and intended,
reduce uncorrected
make
(www. astigmatismfix.com) allows users to ence vectors between actual, and
vision. After toric IOL implantation, the optimal percentIOL of
input toric IOL planning data, along with
them more IOL
postoperative likely to rotate;
orienta- tion andthis
eyes
may also be a func-
refractive
with residual astigmatism greater
orientations where possible. than 0.50
results;
tion of a theselongerdataeye are orused to de- capsular
a larger termine bag. diopters
13
Results(D) may Thebe dataas highextracted
as 47%, but fromis morethe
3
the
onlineoptimalweborientation
site were of from
the IOL to reduce
another typically in the 20% to 30%
study indicated that the percentage of available in a range. Under- standing
refractive astigmatism. This was a the with
reasons for such
comma-delimited
retrospective data
text file. The aggregate
analysis;
data were eyes greater than residual
0.50 D of refractive astigmatism
residual astigmatism
imported data into were
an Access database may help improve outcomes after toric IOL
historical extracted from thisfor data checking, may be slightly higher in eyes with
higher IOL implantation.
calculator to cylin-
investigate collation, and preliminary
the relationship be- analysis (Microsoft Corpo- der powers than
those residual
tween with lower IOL cylinder
refractive astigmatism pow- Reasons for
ration, Redmond,
and IOL WA).residual
Statistical astigmatism
analyses that were were per-
cylinder
ers. Aand
14
thirdsphere
study power. previously ex- plored
suggested that both groups of toric formed using the STATISTICA data included preoperative
analysis software IOLs (high and low cylinder measurement
powers) provided or calculation
a simi- er-system rors, operative
(version toric12;
RESULTS: A total of 12,812 records, 4,619 of
StatSoft, Inc., Tulsa, OK). Statisti- lar lens
magnitude misalignment,
of mean and
residual postoperative
astigmatism. to- ric lens
However, cal
which included IOL sphere power, were rotation. It is important to understand the residual
impact
testing was performed using
available for analysis. There was no significant analysis of variance they further suggest that
astigmatism thatvariables
each of these and has on refractive witherror after toric
effect of sphereinpowereyes on(ANOVA)
residu- alon continuous
refractive appropriate lower cylinder
power toric (P
astigmatism IOLs is likely
= .25), related
but lower IOL non-parametric
cylinder IOL implan- tation so that corrective
tests on categorical data. Statistical more methods can be
powers were associated with
to measurement or calculation errors, whereas re- significantly applied effectively. The impact
significance was set at a P value of .05. of preoperative
lower
sidualresidual
astigmatismrefractive in astigmatism
higher cylinder (P < .05). measurements,
power toric IOLs mostly in the form of the corneal
The difference between the intended and ideal
is likely related more to misalignment or lens rotation curvature readings from the RESULTSanterior and pos- terior
orientation15 was higher in the lower IOL corneal surfaces, has been explored extensively in
errors. power
cylinder These resultsgroups suggest(P < that.01).both the sphere and A total of 35,846 raw
the literature and they are believed to play an
data records
Overcorrection were available
of astigmatism cylinder powers of toric IOLs may be important factors
was significantly
more likely with higher IOL cylinder power (P < . important role in the amount of residual astigmatism
from the web site; these calculation requests
01),were
but not with in
from sphere
the power (P
occurrence of residual after toric IOLs.4-6
astigmatism Toric
after toric an estimated
= .33). Reorientation to correct residual
3,000 different surgeons. On completion IOL implantation. of the data validation
refractive cylin- der to less than 0.50 diopters
(D) and
was filtering process,with a total of This analysis was Thompson
initiated Vision,
to determine whether 12,812
From Vance Sioux Falls, South Dakota (JPB);
more successful IOL cylinder Minnesota Eye Consultants, Minnetonka, Minnesota (DRH);
records were available for
powers of 1.50 D or less (P < .01); IOL sphere analysis. All records the IOL sphere or cylinder power
University of Iowa Carver College of Medicine, Iowa City, Iowa reported by
power hadusers no of
apparent effect. contained the IOL cylinder
(BAK); and Science in Vision, Akron, New York (RP). power at the
corneal plane, a toric back-calculation web site had
Submitted: Augustany29, correlation
2016; Accepted: December although8, 2016only
CONCLUSIONS:
later softwareThere were significant
versions recorded effects
the with the residual refractive cylinder reported by these
of IOL cylinder power on residual refractive Supported by an investigator-initiated research grant to Ocular
sphere
astigmatism, the difference between intended Surgical Data, LLC, power
from Alcon of (Fort
the Worth,
IOL. Limiting
TX). data to a
range of users or with
and ideal orientation, the likelihood ofany of the potential contributing vari- 6.00 to 36.00 D, there
Drs. Berdahl and Hardten are owners of Ocular Surgical Data,
overcorrection, and the likelihood of astig- LLC, makers of astigmatismfix.com. Dr. Berdahl valid
were 4,619 records with is a
ables collected
matism reduction with on the lenssite. The effect
reorientation. IOLof the implanted
consultant to Alcon, IOL sphere
AMO, power
and Bausch & provided.
Lomb. Dr. Hardten is
sphere powerand
IOL sphere appeared
cylinder topower
have on no suchwhether a reorienta-
consultant to AMO, ESI,After and reviewing
TLCVision. Dr. Potvin is a
a histogram
effects. of the data, cylinder tion could correct consultant to Alcon, Haag-Streit, Imprimis, and Ocular
any residual
Therapeutix. refractive
Mr. Kramer has no cylinder wasor power
financial was
proprietary
categorized into four groups using the IOL also investigated.
interest in the materials presented cylinder power at the corneal
herein.
[J Refract Surg. 2017;33(3):157-162.]
Journal of Refractive planeSurgery
(input by Vol. the web
33, No. site user): 1.50 D or less, greater than 1.50 D to 2.50 157
3, 2017 D
15 Copyright SLACK Incorporated
8
 Residual Astigmatism After Toric IOL Implantation/Berdahl et al

TABLE 1
Distribution of IOL Sphere and Cylinder Powers
IOL Cylinder Power at the Corneal Plane (D)
IOL Sphere Power (D) 1.50 > 1.50 and 2.50 > 2.50 and 3.50 > 3.50 Total
No data 1,628 3,172 1,850 1,543 8,193
12.00 38 141 130 85 394
> 12.00 and 18.00 201 542 351 170 1,264

> 18.00 and 24.00 551 1,002 538 365 2,456

> 24.00 89 193 103 120 505
Total 2,507 5,050 2,972 2,283 12,812
IOL = intraocular lens; D = diopters

Figure 2. Percentage of calculation records related to

orientation that Figure 1. Residual refractive astigmatism by intraocular lens (IOL) sphere was as intended (by lens
manufacturer and intraocular lens [IOL] cylin- and cylinder categories. D = diopters der power category). D = diopters

plane. Detailed lens use data were not available, so the that was reported to be within 5 of the
intended ori- relative incidence of back-calculation by IOL sphere entation was considered to
be implanted as intended, and cylinder category could not be determined. with no
significant postoperative rotation.
There was a weak, but statistically significant, in- Figure 2 shows the
percentage of lenses implanted verse correlation between IOL sphere power and cyl-
that were oriented as intended by cylinder
category inder power (-0.04, P < .01), indicating slightly more and IOL
manufacturer (AcrySof Toric, Alcon, Fort cylinder power was observed in the IOLs with
lower Worth, TX; Tecnis Toric, AMO, Santa Ana,
CA; Tru- sphere power. This was not considered clinically sig- lign Toric, Bausch +
Lomb Surgical, Rancho Cucamon- nificant; the mean cylinder difference between 6.00
ga, CA: Staar Toric, STAAR Surgical,
Monrovia, CA). and 36.00 D sphere lenses was 0.30 D. Note that higher cylinder
power toric IOLs were not Figure 1 shows the ANOVA of the reported residual available
from STAAR Surgical or Bausch & Lomb. refractive cylinder by sphere and cylinder
categories. In fact, with fewer than 200 records for
each, overall There was no statistically significant effect of IOL sphere back-calculation
data for these two manufacturers are power (P = .25), but higher cylinder powers, perhaps
limited. A higher percentage of lenses were
oriented not surprisingly, were associated with higher levels of as intended at the
lowest IOL cylinder power rela- residual refractive astigmatism reported (P < .05).
Journal of Refractive Surgery Vol. 33, No. 3, 2017 159

Residual Astigmatism After Toric IOL Implantation/Berdahl et al

Figure 3. Absolute angular difference between intended and ideal orien- Figure 4. Percentage of cases overcorrected, by
cylinder category and tation. D = diopters intraocular lens manufacturer. D = diopters

tended and ideal orientation, by IOL cylinder

category, is shown in Figure 3. There was a
statistically signifi- cant difference by
cylinder category (P < .01), with a larger
difference between the intended and ideal
orien- tations in the lower IOL cylinder power
groups.
After the toric back-calculation was
completed, the determination of whether an
IOL in the eye was over- correcting or
undercorrecting was determined. This was
based on whether the expected residual
cylin- der was within 10 of being in line
with, or orthogo- nal to, the ideal orientation
of the IOL. Due to some early rounding
effects in the calculation algorithm, there
were 7% of cases outside this range; for the
pur- poses of this analysis, they were
excluded. There was no statistically
significant difference in the percentage
Figure 5. Percentage of expected residual refractive cylinder < 0.50
16 of cases overcorrected by sphere
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0
Residual Astigmatism After Toric IOL Implantation/Berdahl et al
calculated by IOL cylinder category. Figure 5 shows a erage angular difference between the
intended orienta- histogram of the percentages by IOL cylinder category. tion and the ideal
orientation was significantly higher The percentage was statistically significantly different at
lower IOL cylinder powers. This is presumably a by category (chi-square test, P < .01),
with the highest function of errors in preoperative calculation, such percentage correction in the
lowest cylinder group. as not accounting for posterior corneal astigmatism or There was no
statistically significant difference by surgically induced astigmatism effects. Research has
sphere category (P = .07). An ANOVA of the percentage shown that both factors appear to affect
lower cylinder reduction in cylinder expected with lens reorientation, power calculations more
than higher cylinder power by cylinder category, showed a statistically significant calculations
because the relative vector effects are larg- difference (P = .02). These differences were
considered er.19,20 The findings here indicate that toric IOL power clinically insignificant, with a
range of 44.5% to 48% by calculation is a significant factor in the occurrence of group. Similarly,
there was a statistically significant dif- residual astigmatism, as a result of the actual formula,
ference in the percentage reduction in residual refrac- variability in preoperative keratometry,
consideration tive cylinder expected with lens reorientation by sphere of posterior corneal
astigmatism effects, and/or ac- category (P < .01), but again with a clinically insignifi- tual
versus expected surgically induced astigmatism cant difference in range (48.0% to 52.7%).
changes.
Figure 4 shows the relative percentage of overcor-
DISCUSSION rections by manufacturer. The IOL cylinder
powers are Results based on data collected from an online toric presumed to have been
calculated with the relevant back-calculator indicate that greater residual refractive
toric calculators associated with each lens.
(This may astigmatism is associated with higher cylinder powers, not be as certain in
future because more nonlens- as expected. These results are consistent with previ-
specific calculators have been developed and
are now ously reported results where 20% fewer eyes in a high- in use.) The AcrySof
calculator is more conservative, er cylinder group had residual refractive error within
never suggesting an IOL that would overcorrect
astig-
0.50 D when compared to those in a lower cylinder matism (ie, flip the axis). This appears to
bias the low- group.14 However, another study noted that the magni- er power cylinder results
toward undercorrection, but tude of mean residual astigmatism in both lower and the effect is
less apparent with higher cylinder powers, higher cylinder groups was approximately 0.35 D. 15
where the percentage of overcorrection approaches Results from the current study are not
directly compa- 50%.
rable because of the nature of the web site; it is used Finally, Figure 5
shows the likelihood of achieving by surgeons only when a case with significant residual
a residual refractive cylinder of 0.50 D or less
after lens cylinder is encountered. reorientation. This likelihood is
significantly higher A previous study reported that a lower cylinder with lower
cylinder power IOLs, an interesting result. group was more often overcorrected and a higher
cyl- Although the overall corneal cylinder in these
eyes is inder group was more often undercorrected.15 This is presumably lower,
which would suggest that the result in contrast to the findings here, but the overcorrections
here is as expected, the relative effects of IOL
rotation and undercorrections in the current data set were de- are also much lower,
which might suggest it would be termined after the lens was rotated to the ideal orienta-
harder to reduce astigmatism through IOL
rotation. It tion. It is more difficult to determine overcorrection or appears that when
there is residual refractive cylinder undercorrection when the orientation of the residual
with higher cylinder powers, there is a higher
likeli- astigmatism is not with, or orthogonal to, the orienta- hood of a secondary
procedure such as a lens exchange tion of the cylinder power of the IOL. or
Journal of Refractive Surgery Vol. 33, No. 3, 2017 161

Residual Astigmatism After Toric IOL Implantation/Berdahl et al

tometry, formula limitations, and/or variability in sur- rection with toric intraocular lenses. J Cataract
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DRH) Shimizu K. Long-term
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