Evaluating the Need for both Aphakic and Pseudophakic Intraoperative Aberrometry in Toric IOL Implantation

My name is Dr. Satish Modi. I am an ophthalmologist in private practice in New York’s Hudson Valley region and an Assistant Clinical Professor of Ophthalmology at Albert Einstein College of Medicine. I specialize in refractive cataract surgery and advanced LASIK surgical techniques. I recently conducted an investigator-initiated trial to evaluate outcomes after toric intraocular lens implantation based on measurements using the ORA® intraoperative aberrometer. More specifically, the study was designed to compare refractive outcomes when ORA® was used to collect measurements just in the aphakic state, versus both the aphakic and pseudophakic states, i.e. once the lens was put in. This prospective study enrolled cataract patients who were candidates for bilateral toric IOL implantation and also had regular anterior corneal astigmatism between 1.0 and 5.0 D in both eyes. For each patient, eyes were randomized to one of two intraoperative aberrometry protocols. In the first eye, only the aphakic measurements were collected. In the second eye, both aphakic and pseudophakic measurements were taken. All eyes were implanted with an AcrySof® IQ Toric IOL, and data were analyzed for 70 eyes from 35 patients. The mean age in the study population was just over 73 years and 19 of the 35 patients were male. One month after second eye surgery was done, eyes in both groups had good refractive outcomes, with 94% of them having residual refractive astigmatism of 0.50D or lower. The data also revealed no significant differences with respect to mean refractive and keratometric outcomes. There was only one eye, which underwent both the aphakic and pseudophakic measurement, which had a residual refractive cylinder greater than 1.0 D. When aphakic plus pseudophakic measurements were collected, the IOL orientation suggested by the pseudophakic measurement was within a mere five degrees of that suggested by the aphakic measurement in 83% of eyes, and within ten degrees in 91% of eyes. Finally, measurement time was significantly longer in the aphakic plus pseudophakic measurement group. The median number of captures of the pseudophakic eye was three and mean time for a single pseudophakic capture was 71 seconds, which was significantly longer than the mean time for an aphakic capture, which was 56 seconds in eyes with just that aphakic measurement. So, achieving desired post-operative outcomes after toric IOL implantation depends not only on lens design, but also the ability to select the right IOL power based on accurate measurements of the eye. With the ORA® intraoperative aberrometer, surgeons can obtain measurements with the eye in the aphakic and pseudophakic state, with really good refractive outcomes overall.1-3 One drawback though of obtaining both aphakic and pseudophakic measurements, however, is the additional time required versus an aphakic measurement only. As a result, it is important to evaluate whether this additional time actually provides an incremental clinical benefit. The data from this study suggest that pseudophakic measurements after aphakic measurements are not associated with improved refractive outcomes when implanting toric IOLs following intraoperative aberrometry with the ORA® System. Put another way, the additional time required to collect pseudophakic measurements did not have a clear clinical benefit. Surgeons can therefore feel comfortable relying on aphakic measurement with ORA® alone to achieve excellent refractive outcomes. © 2022 Alcon Inc. US-ORA-2200015