Impact of intraocular lens haptic design and orientation on decentration and tilt

Pendahuluan

Cataract surgery has transitioned from being a treatment for visual rehabilitation to also being a refractive procedure with aim of gaining visual function comparable to non cataract elderly eye Aspheric IOL compensate for spherical abberation of cornea and contrast sensitivity

Multifocal IOL decrease spectacle dependence Toric Iol correct corneal astigmatism and uncorrected distance vision IOL performance highly depends on the position of IOL in the optical system Holladay et al asperic IOL should be decentered < 0.4 mm and tilted < 7

Piers et al critical decentration 0.8 mm and 10 as critical tilt point Decentration and tilt can be assessed with slitlamp, retroillumination photography, Scheimpflug imaging, and Purkinje reflections. Purkinje images provide qualitative information about IOL alignment and more accurate than Scheimpflug imaging The aim of this study: to compared the effet of IOL haptic orientation and haptic-loop design on IOL centration and tilt using a Purkinje meter.

Patients and method

Prospective randomized study with intraindividual comparison comprised patient with age-related cataract Exclusion criteria: - age < 21 years old - pseudoexfoliation syndrome - pigment dispersion syndrome - history of ocular trauma or other ocular comorbidity that could affect IOLs position

method

Study consisted of 2 parts Part 1 comparation of tilt and decentration between horizontal and vertical orientation of a plate-style IOL One eye was oriented with its haptic horizontal or vertical orientation according randomization, and contralateral eye get the alternate orientation

Part 2 comparation between hydrophobic acrylic 1-piece IOL with the same haptic material and 3-piece IOL with PMMA haptic One eye get a 1-piece open loop or a 3-piece open-loop IOL according to randomization, contralateral eye get the alternate IOL haptic design both of them were vertically oriented and centered on the pupil

Postop evaluation are 1 month and 3 month postoperative Recorded variables: - visual acuity - Purkinje meter images

Results

30 patients were recruited Mean age of 15 patients in part 1: 75 years Mean age of 15 patients in part 2: 77 years Mean IOL power: 21.5 D (part 1) and 21.6 D (part 2)

Decentration & tilt at 3 month follow up (part 1): - nasal decentration: vertical 8 (57%) horizontal 11 (77%) - upward decentration: vertical 12 (79%) horizontal all - temporal tilted : vertical 12 (79%) horizontal 9 (62%) - downward tilted: all IOLs

Decentration & tilt at 3 month follow up (part 2) - nasal decentration: 1 piece IOL 10 (67%) 3 piece IOL 10 (67%) - upward decentration was measured in most IOLs in both group,2 IOLs in each group decenterd downward - temporal tilted: 1 piece IOL7 (45%) 3 piece IOL 8 (57%) - downward tilted: most of IOLs; 1 IOL in 1-piece and 2 IOLs in 3-piece group were tilted upward - no statistically significant about differrences in decentration and tilt between 2 groups IOL

Discussion

The first study to compare IOL axis orientation and to use Purkinje meter The patient numbers may have been too small to detect the effect of small or less relevant differences between the groups In part 1 tendency toward nasal and upward decentration on both groups & horizontal oriented IOL to decenter upward,especially at 3months fu

Because these findings, the IOL implant in part 2 was oriented vertically In part 2 most IOLs were tilted downward & slightly nasal De Castro et al mostly nasal & upward decentration & nasally tilted Mester et al: - 1-piece IOL nasal decentration & almost no vertical displacement - crystalline lens temporal & downward displaced - both significantly up & temporal tilted

Schaefel: temporal & inferior decentration; and significantly upward & temporal tilt This study is slightly different with previous study ( Mester et al & Schaefel) in image acquisition and image-analysis algorithm Taketani et al didnt find differences in decentration between 1-piece & 3-piece acrylic IOL But the Scheimpflug imaging showed statistically significant difference , where 3-piece tilted more

Hayashi et al didnt find differences between decenration & tilt of 1-piece & 3-piece PMMA IOLs using anterior eye segment analysis 3-piece IOLs have tendencey to decenter & tilt more than 1-piece IOL The reason : - production process of 3-piece IOLs, where during the PMMA haptic are placed into optic with hand than machine - because the haptic is PMMA, which is known to lose its memory within few days under compresion - haptic may be deformed during implantation procedure, causing slight kinking of the haptic

In this study: - minimize the mechanical stress on haptics by enlarging wound in cases of high powered IOL with greater optic thickness & not maneuvering IOL by touching / grasping haptic with forceps - the IOL were position on the bag by pushing on the optic

conclusion

Axis orientation of a plate-haptic IOL in the bag seemed to have no clinical impact because there is no differences in decentration and tilt in this study Single-piece IOL maybe more predictable than multipiece IOLs in terms of tilt and decentration confirm with a larger trial