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Predicting Refractive Aniseikonia After Cataract Surgery in Anisometropia

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Predicting Refractive Aniseikonia After Cataract Surgery in Anisometropia ARTICLE Predicting refractive aniseikonia after cataract surgery in anisometropia Laure Gobin, PhD, Jos J. Rozema, PhD, Marie-Jose´ Tassignon, MD, PhD, FEBO PURPOSE: To propose a comprehensive classification of anisometropia, a method to calculate the theoretical related aniseikonia (objective aniseikonia) and a purpose-designed eikonometer to measure aniseikonia psychophysically (subjective aniseikonia). SETTING: University Hospital Antwerp, Department of Ophthalmology, Edegem, Belgium. METHODS: The occurrence of anisometropia was evaluated in 263 patients scheduled for cataract surgery. Subjective aniseikonia was evaluated in 77 healthy patients. The theoretical model was validated to calculate objective aniseikonia by implementing data from the literature. Ultimately, an aniseikogram was developed and its practical use illustrated by 4 clinical cases of anisometropia. RESULTS: In a population of 263 patients, the total incidence of anisometropia was 7.6%, with a dominance of axial anisometropia. Subjective aniseikonia between 2% and 4% was found in 3.0% to 7.5% of the cases, depending on the refractive error. The correlation coefficient between objective and subjective aniseikonia was good (R2 Z 0.82). Analysis of 4 clinical cases illustrated the calculated preoperative and postoperative aniseikonia in 4 types of anisometropia planned for lens removal. CONCLUSIONS: Anisometropia is not a rare condition and should be assessed before cataract sur- gery. A comprehensive method to calculate the objective aniseikonia and to measure the subjective aniseikonia in anisometropia was proposed. If cataract surgery is considered in anisometropic patients, a postoperative aniseikonia of 4% or more may be induced in the case of emmetropization. A method to calculate the intraocular lens power resulting in an acceptable postoperative aniseiko- nia, especially in axial anisometropic patients, is also proposed. J Cataract Refract Surg 2008; 34:1353–1361 Q 2008 ASCRS and ESCRS Aniseikonia occurs when ‘‘the images presented to the anisometropia.4 In the past few decades, aniseikonia cortex from the 2 eyes are abnormally unequal in size, related to high anisometropia, such as unilateral apha- shape or luminance.’’1 The brain is able to compensate kia, has been well described.5 Aniseikonia up to 35% for a certain degree of image inequality, including has been reported.6,7 With the advent of contact lenses oblique aniseikonia.2 However, in the case of severe im- and the development of a large number of intraocular age inequality, impairment of stereoacuity will occur.3 lenses (IOLs), aniseikonia could be avoided in most Although aniseikonia is not necessarily the cause of cases. amblyopia, it is often associated with congenital Due to the growing popularity of refractive surgery, aniseikonia has again caught the attention of ophthal- mologists. Troutman8 warned corneal and cataract surgeons about the risk for inducing aniseikonia in Accepted for publication April 12, 2008. the case of anisometropia. Ha¨ring et al.9 reported From the Department of Ophthalmology, University Hospital near-vision aniseikonia in up to 12% (mean 2.4%) of Antwerp, Edegem, Belgium. patients implanted with the very first generation of multifocal IOLs. In patients with unilateral pseudo- No author has a financial or proprietary interest in any material or phakia, Kramer et al.10 found up to 10% aniseikonia method mentioned. (mean 4.1%). In a population of pseudophakic pa- Corresponding author: L. Gobin, University Hospital Antwerp, tients, he reported subjective complaints attributable Wilrijkstraat 10, 2650, Edegem, Belgium. E-mail: gobin.laure@ to aniseikonia in 40.2%. Huber and Binkhorst11 ex- gmail.com. pressed concern about aniseikonia after implantation Q 2008 ASCRS and ESCRS 0886-3350/08/$dsee front matter 1353 Published by Elsevier Inc. doi:10.1016/j.jcrs.2008.04.023 1354 PREDICTING ANISEIKONIA IN ANISOMETROPIA Z n of anterior chamber IOLs for severe anisometropia. Paxial These numbers show that aniseikonia is not a marginal L À IPP problem and thus should be considered in any case of where L is the ocular AL (mm); n Z 1336, the refractive index Z 19 anisometropia, particularly in anisometropic patients of the vitreous; and IPP 1.6 mm, the estimated position of the image principal plane in the Gullstrand eye model. seeking lenticular refractive correction.12,13 14 According to Knapp’s law, axial anisometropia Lenticular Anisometropia Lenticular anisometropia is the can be corrected with spectacles without inducing difference between the crystalline lens power in both eyes. aniseikonia. However, this law does not seem to be The lenticular power Plens can be estimated from the AL 14–18 and the keratometry using an IOL power calculation formula clinically confirmed. The explanation was formu- 20 21 22 17 (eg, SRK II, SRK/T, Holladay ) or ray-tracing calcula- lated by Awaya and von Noorden, who stated that tion.23 When an IOL power formula is used, the spherical pure axial anisometropia is a rare condition because equivalent (SE) of the best spectacle refraction should be it is often combined with refractive anisometropia used for the targeted refraction R. (corneal or lenticular). Spectacle Anisometropia In this paper, we propose a comprehensive ap- Spectacle anisometropia is the difference between the SEs of both spectacles. It can also be proach to aniseikonia to (1) define the refractive defined as the difference between the axial anisometropia balance of the eye, (2) define the type of anisometropia, and the sum of corneal and lenticular anisometropia. (3) measure aniseikonia in the normal population, (4) calculate the theoretical aniseikonia, (5) predict post- Mixed Anisometropia Mixed anisometropia is the combi- operative aniseikonia in the case of preoperative aniso- nation of 2 or more pure types of anisometropia. It can thus be corneal and axial; corneal and lenticular; axial and metropia, and (6) validate the proposed method. lenticular; or corneal, axial, and lenticular. To measure the optical balance of the eye, the following parameters are needed5,19,23,24: best spectacle-corrected re- PATIENTS AND METHODS fraction, corneal power, ocular AL, and anterior chamber depth (ACD) (endothelium to anterior lens capsule) in both Defining a Patient’s Refractive Balance eyes. Table 1 shows all required parameters to calculate the To obtain a patient’s refractive balance, the 4 pure types of theoretical anisometropia. For the vertex distance, an esti- anisometropia should be defined. mated distance of 12.0 mm is generally accepted. Defining the Type of Anisometropia Corneal Anisometropia Corneal anisometropia is the difference between the corneal powers in the left eye and Using this anisometropic assessment, the type and rate of the right eye. This can be directly derived from both kerato- anisometropia in a population of 263 patients planned for metric values obtained by topographical devices. cataract surgery were analyzed. The parameters studied The difference between the axial powers in both eyes is were best subjective spectacle correction in both eyes with called axial anisometropia. Axial power can be accurately estimated vertex distance at 12.0 mm, AL, keratometry, estimated by measuring the axial length (AL) (obtained by and ACD. The last 3 parameters were determined using biometry measurement) using the following formula19: the IOLMaster (Zeiss). Table 1. Anisometropia assessment form (ocular parameters from which the theoretical aniseikonia will be derived). Eye Parameter Source of Parameter Right Left Spectacle spherical equivalent R Subjective refraction .. D .. D Mean corneal power K Keratometry .. D .. D Axial length L Biometry .. mm .. mm Anterior chamber depth* Biometry .. mm .. mm Z 1336 .. .. Axial power Paxial LÀ1:6 D D Z .. Axial anisometropia aA PaxialOD À PaxialOS D Z K .. .. Effective corneal power Keff 1À0:0016ÂK D D Z .. Corneal anisometropia aC KeffOD À KeffOS D Z .. .. Lens power Plens 119 À 2:5 Â L À 0:9 Â K À Reff D D Effective lenticular power P Z Plens .. D .. D eff lens 1À0:001ðACDÀ1:6ÞPlens Z .. Lenticular anisometropia aL Peff lensOD À Peff lensOS D Z R .. .. Effective spectacle spherical equivalent power Reff 1À0:0136ÂR D D Z .. Spectacle anisometropia aS ReffOD À ReffOS D *Distance between endothelium and anterior lens capsule J CATARACT REFRACT SURG - VOL 34, AUGUST 2008 PREDICTING ANISEIKONIA IN ANISOMETROPIA 1355 Measuring Aniseikonia in the Normal Population are developed. In these cases, the calculation of aniseikonia can be significantly reduced to the ratio of both ALs. Few eikonometers are commercially available. In collabo- ration with Metrovision, the authors developed a direct-com- parison eikonometer consisting of liquid crystal spectacles, a computer screen, and software technology. The patient Validating the Proposed Method was asked to wear liquid crystal spectacles on top of his/ To validate this theoretical approach, data available from her corrective spectacles and to look at a computer screen. the literature were implemented. The reference paper is by These liquid crystal glasses were configured in such a way Winn et al.16 In this article, the authors published the full that both sides change between transparent and opaque at refractive assessment of 18 patients, which they correlated a high frequency in opposite phase with each other. Mean- with the subjective aniseikonia assessed with an eikonome- while, the computer screen was synchronized with these ter of their design. After the parameters of these
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