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Refractive Correction with Multifocal Intraocular Lenses After Radial Keratotomy

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Refractive Correction with Multifocal Intraocular Lenses After Radial Keratotomy Eye (2019) 33:1000–1007 https://doi.org/10.1038/s41433-019-0364-8 ARTICLE Refractive correction with multifocal intraocular lenses after radial keratotomy 1 1,2 1 3 Bárbara Martín-Escuer ● José F. Alfonso ● Luis Fernández-Vega-Cueto ● Alberto Domíngez-Vicent ● Robert Montés-Micó3 Received: 28 August 2018 / Revised: 10 December 2018 / Accepted: 19 December 2018 / Published online: 15 February 2019 © The Royal College of Ophthalmologists 2019 Abstract Purpose To assess visual and refractive results of multifocal intraocular lens (IOLs) implantation for refractive correction after radial keratotomy (RK). Methods In a retrospective non-comparative interventional case series, we analyzed the outcomes of multifocal IOL implantation performed in the context of cataract or refractive lens exchange surgery following RK. A total of 17 eyes from nine patients were included in the study. IOL power calculation was done using the Double-K formula. Refractive error was used to assess predictability, and distance-corrected visual acuity (DCVA) and uncorrected distance visual acuity (UDVA) ’ fi 1234567890();,: 1234567890();,: values were used to assess the surgical procedure sef cacy and safety. Distance-corrected near visual acuity (DCNVA) was also determined. Results Phacoemulsification and multifocal IOL implantation was successful in all cases, with neither complications nor adverse events. At 6 months postoperatively, monocular UDVA, DCVA, and DCNVA were 0.51 ± 0.39, 0.20 ± 0.30, and 0.11 ± 0.11, respectively (logMAR scale). More specifically, 35.29% of the eyes had DCVA ≥20/20 and 52.94% showed DCVA ≥20/25. Regarding pre- vs. post-operative changes, 52.94% had lost one line of DCVA, 23.53% showed no changes, 11.76% had gained one line of DCVA, 5.88% had gained two lines, and 5.88% had gained three or more lines. The efficacy and safety indexes were 0.56 and 0.98, respectively. As for near vision surgical outcomes, 29.41% of the eyes had DCNVA ≥20/20 and 64.71% had DCNVA ≥20/25. As for surgical accuracy, 29% of the eyes were within ±0.50 D of the target refraction, whereas 65% were within ±1.00 D. Conclusions Multifocal IOL implantation following radial keratotomy (RK) does not result in good distance visual per- formance, at least after 6 months of follow-up. Thus, this surgical approach has to be considered with only limited expectations. Introduction conducted an assessment of this technique prospectively in 1994 [2]. This study followed up on 693 eyes to evaluate Radial keratotomy (RK), introduced by Fyodorov and the long-term (10 years) safety and efficacy outcomes of Durnev [1], was in the past one of the most important this technique and concluded that RK eliminates the need refractive surgery techniques for myopia correction. The for distance optical correction in 70% of the patients with a prospective evaluation of radial keratotomy (PERK) group reasonable level of safety, but they also reported a hyperopic shift of the refractive error, being progressive [2]. RK used declined with the advent of excimer laser-based techniques [3]. * José F. Alfonso We are now seeing patients who have undergone RK and [email protected] are now presenting with cataract or want to become 1 Fernández-Vega Ophthalmological Institute, Oviedo, Spain spectacle-free again. Intraocular len (IOL) power calcula- 2 Surgery Department, School of Medicine, University of Oviedo, tion has been one of the main challenges that we have faced Oviedo, Spain with these patients due to the above-mentioned hyperopic fi 3 Optics and Optometry and Vision Sciences Department, Faculty of shift, and the dif cult determination of the effective lens Physics, University of Valencia, Valencia, Spain position and true corneal curvature [4, 5]. Ma et al. [6] Refractive correction with multifocal intraocular lenses after radial keratotomy 1001 studied the accuracy of several IOL formulas in RK eyes slit-lamp examination, corneal topography, anterior cham- and concluded that IOL power calculations require further ber depth measurement and pachymetry (Orbscan II; enhancements when it comes to this type of patients. A Bausch & Lomb, Rochester, NY), ocular biometry (Ocus- recent study by Zhang et al. [7] encompassing 30 eyes and a can; Alcon, USA and IOLMaster 500/700; Carl Zeiss 3-year follow-up period concluded that phacoemulsification Meditec, Jena, Germany), and indirect ophthalmoscopy. and IOL implantation with clear corneal incision were associated with good surgical outcomes. Surgical technique Despite the intrinsic difficulties of IOL power calcula- tions in these patients (mainly in presbyopia correction Surgery was carried out under peribulbar anesthesia. The surgery) and the resulting impact upon visual and refractive main incision was performed on clear cornea provided that surgical outcomes, several case reports focusing on pres- the RK radii were at least 3.2 mm apart, so that enough byopia correction have been published [8–10]. Gupta et al. space was left to make the incision and to modulate its size, [8] reported the outcomes for two eyes implanted with depending on the amount of astigmatism that was to be hybrid monovision AcrySof IQ ReSTOR IOLs, concluding corrected. Alternatively, scleral access was used when that their approach was an excellent option for patients corneal entry was not feasible. Capsulorhexis (under cohe- aiming to be cataract and spectacle free. sive viscoelastic) and phacoemulsification (assisted by dis- Kim et al. [9] concluded, after refractive lens exchange persive viscoelastic) were then performed. Prior to lens with bilateral implantation of a rotationally asymmetric implantation, a capsular tension ring was inserted in all refractive multifocal IOL in two eyes from two unilateral cases. To finish the surgery, an intracameral miotic solution RK patients, that this approach may benefit presbyopic (acetylcholine) was injected. For infection prophylaxis, 5% patients. Moreover, Nuzzi et al. [10] also showed that the and 10% iodine solution was applied onto the eyes and the implantation of a customized toric multifocal IOL leads to skin, respectively, prior to the intervention, and 1 mg/ml of good visual outcomes without regressions. All three case cefuroxime solution was injected into the anterior chamber reports (Gupta’s, Kim’s, and Nuzzi’s) concluded that mul- once the surgical procedure was completed. tifocal IOL implantation might be a feasible approach to achieve presbyopia correction in RK patients. These studies IOLs power calculation and lenses used are promising indeed, but larger samples are required for a thorough procedure evaluation. The double-K [11] formula was employed to calculate the In this context, the purpose of the present study was to power of the IOL to be implanted, based on the values report visual and refractive outcomes in a larger sample of yielded by the OcuScan and the IOLMaster 500/700. Pre- RK patients who underwent cataract or refractive lens and post-RK keratometry values were also fed into this exchange surgery involving multifocal IOL implantation. formula for IOL power calculation. In all cases, the target was fixed at –1.00 D. Each eye included in this study had implanted one of the following seven multifocal IOL Methods models: the Symfony ZXROO (Johnson & Johnson, USA), the AcrySof ReSTOR SN6AD1 (Alcon, USA), the AcrySof We retrospectively examined 17 eyes from nine consecutive ReSTOR SN60D3 (Alcon, USA), the Tecnis ZMBOO patients who underwent cataract or refractive lens exchange (Johnson & Johnson, USA), the FineVision (Physiol SA, surgery involving multifocal IOL implantation and who had Belgium), the Acri.LISA 366D (Carl Zeiss Meditec, Ger- also previously undergone RK surgery at the Fernández- many), and the AT LISA tri 839MP (Carl Zeiss Meditec, Vega Ophthalmological Institute (Oviedo, Spain) between Germany). November 2004 and July 2016. In this most recent surgical procedure, we aimed to correct both refractive error and Outcome indicators presbyopia in all patients. Informed consent was obtained from all patients once the nature and possible consequences Pre-operative and post-operative visual acuity was eval- of the study were explained to them. uated and the occurrence of any adverse events or compli- cations was recorded. The efficacy index (defined as the Pre-operative assessment ratio between post-operative UDVA and pre-operative DCVA given in Snellen decimal notation) and the safety Before IOL implantation, patients underwent a compre- index (defined as the ratio between post-operative and pre- hensive ophthalmologic examination. The examination operative DCVA) were also calculated. Snellen decimal included uncorrected distance visual acuity (UDVA), visual acuity values were turned into logMAR values for distance-corrected visual acuity (DCVA) and refraction, statistical purposes. Distance-corrected near visual acuity 1002 B. Martín-Escuer et al. (DCNVA) was also measured since one of the goals of this Efficacy and safety surgical approach was to provide spectacle-free functional near vision. All patients were followed up throughout a 6- Mean monocular UDVA and DCVA were (logMAR nota- month period. For data analysis, we relied on Matlab soft- tion) 0.51 ± 0.39 (about 20/63) and 0.20 ± 0.30 (about 20/ ware (MathWorks, Boston, USA). Normality was checked 32), respectively, at the 6-month follow-up. There were no by means of the Kolmogorov–Smirnov test. A non- statistically significant pre- vs. post-surgery changes neither parametric Wilcoxon test was used to assess differences for UDVA (p = 0.143), nor for DCVA (p = 0.58P8). For between post- and pre-operative outcomes. Differences near vision, DCNVA was (logMAR notation) 0.11 ± 0.11 were considered statistically significant when the corre- (about 20/25). sponding p value was smaller than 0.05. Figure 1a shows cumulative frequency graphs for monocular UDVA (top) and DCVA (bottom). The percen- tage of eyes with better UDVA was higher before surgery Results (black bars) than after surgery (white bars); after surgery only 11.76% of the eyes (two) were 20/25 or better and Seventeen eyes of nine patients (six males and three 35.29% of eyes (six) was 20/32 or better.
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