Journal of Refractive Surgery

Original Article Supplemental Data

Refractive and Visual Outcomes and Rotational Stability of Toric Intraocular Lenses in Eyes With and Without Previous Ocular Surgeries: A Longitudinal Study

Osama M. Mustafa, MD; Christina Prescott, MD, PhD; Fares Alsaleh, MD, MPH; Daliya Dzhaber, MD; Yassine J. Daoud, MD, FACS

Abstract

PURPOSE:

To evaluate visual and refractive outcomes and rotational stability of toric intraocular lens (IOL) implantation in eyes with previous ocular surgeries.

METHODS:

This controlled, longitudinal cohort study included a total of 133 eyes (59 study cases with a history of corneal, vitreoretinal, and/or glaucoma surgery and 74 randomly selected controls without a history of ocular surgery) that had cataract and corneal astigmatism treated with toric IOL implantation. Postoperative outcomes were recorded at postoperative 1 month and 3 to 12 months.

RESULTS:

Refractive prediction errors were within ±1.00 diopter (D) of target in 93.5% and 88.4% of the study cases at postoperative 1 month and 3 to 12 months, respectively. They were within ±0.50 D of target in 56.5% and 60.5% of the cases during the same follow-up intervals, respectively. Study cases showed statistically significantly inferior uncorrected distance visual acuity (UDVA) compared to controls at 1 month postoperatively (0.27 ± 0.24 and 0.17 ± 0.21 logMAR, respectively, P = .027) but not during the later follow-up (0.19 ± 0.19 and 0.16 ± 0.19 logMAR, respectively, P = .431). Corrected distance visual acuity (CDVA) was slightly lower in the study cases than in controls at 1 month postoperatively (0.13 ± 0.16 and 0.07 ± 0.14, respectively, P = .005) and subsequent follow-up months (0.10 ± 0.13 and 0.03 ± 0.10, respectively, P < .001). Of the examined study cases, 93.9% and 88.4% had IOL axes within 5° of intended axis at postoperative 1 month and 3 to 12 months, respectively.

CONCLUSIONS:

Toric IOLs provided significant and sustained improvement in visual acuity and refraction in eyes with a history of prior ophthalmic surgery. Refractive outcomes achieved postoperatively were comparable to those in eyes without a prior history of ophthalmic surgery, although the rate of visual recovery may be different.

[J Refract Surg. 2019;35(12):781–788.]

Abstract

PURPOSE:

To evaluate visual and refractive outcomes and rotational stability of toric intraocular lens (IOL) implantation in eyes with previous ocular surgeries.

METHODS:

This controlled, longitudinal cohort study included a total of 133 eyes (59 study cases with a history of corneal, vitreoretinal, and/or glaucoma surgery and 74 randomly selected controls without a history of ocular surgery) that had cataract and corneal astigmatism treated with toric IOL implantation. Postoperative outcomes were recorded at postoperative 1 month and 3 to 12 months.

RESULTS:

Refractive prediction errors were within ±1.00 diopter (D) of target in 93.5% and 88.4% of the study cases at postoperative 1 month and 3 to 12 months, respectively. They were within ±0.50 D of target in 56.5% and 60.5% of the cases during the same follow-up intervals, respectively. Study cases showed statistically significantly inferior uncorrected distance visual acuity (UDVA) compared to controls at 1 month postoperatively (0.27 ± 0.24 and 0.17 ± 0.21 logMAR, respectively, P = .027) but not during the later follow-up (0.19 ± 0.19 and 0.16 ± 0.19 logMAR, respectively, P = .431). Corrected distance visual acuity (CDVA) was slightly lower in the study cases than in controls at 1 month postoperatively (0.13 ± 0.16 and 0.07 ± 0.14, respectively, P = .005) and subsequent follow-up months (0.10 ± 0.13 and 0.03 ± 0.10, respectively, P < .001). Of the examined study cases, 93.9% and 88.4% had IOL axes within 5° of intended axis at postoperative 1 month and 3 to 12 months, respectively.

CONCLUSIONS:

Toric IOLs provided significant and sustained improvement in visual acuity and refraction in eyes with a history of prior ophthalmic surgery. Refractive outcomes achieved postoperatively were comparable to those in eyes without a prior history of ophthalmic surgery, although the rate of visual recovery may be different.

[J Refract Surg. 2019;35(12):781–788.]

Cataract surgery is one of the most commonly performed surgeries in modern medicine. Although vision is largely restored after surgery, a considerable proportion of patients with cataract may not achieve their best unaided visual potential due to the presence of concomitant corneal astigmatism.1,2 Fortunately, there are alternative techniques that could be used to correct astigmatism during cataract surgery, such as limbal relaxing incisions and toric intraocular lenses (IOLs). Of note, a recent systematic review and meta-analysis of the existing literature found that toric IOL implantation offered better postoperative uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and spectacle independence.3

Despite predictability and reliability in the typical patient with cataract,3 toric IOL implantation can be challenging in patients with ocular comorbidities and/or previous ocular surgery. Challenges may arise from the natural course of the comorbidity or its management. Indeed, previous ocular surgery can induce changes in ocular surface, corneal parameters, retinal health, and anterior chamber dimensions and dynamics, leading to difficulty in interpreting observations and findings in these eyes.4,5 The current trend in published clinical investigations is to exclude such complex cases.3,6–9 To our knowledge, no report comparing outcomes of toric implantation in eyes with and without a history of prior surgery exists in the literature. Nonetheless, complex eyes can often present with cataract and concurrent astigmatism, and investigating toric IOL outcomes in such cases could provide an informative, practical perspective. Given the paucity of existing data, this study was conducted to assess refractive and visual outcomes and rotational stability of toric IOL implantation in patients with and without previous ocular surgeries.

Patients and Methods

This retrospective longitudinal cohort study was conducted on cataract cases with previous corneal, vitreoretinal, and/or glaucoma surgeries that underwent cataract extraction with toric IOL implantation (referred to as study cases hereafter). Controls without a history of previous ophthalmic surgery who underwent cataract extraction and toric IOL implantation during the same time period were randomly selected for outcome comparison. The study was approved by the institutional review board at The Johns Hopkins University and conducted in accordance with the tenets of the Declaration of Helsinki.

The inclusion criteria were eyes with cataract, a preoperative corneal astigmatism greater than 0.75 diopters (D), and treatment with cataract extraction and toric IOL implantation. Additionally, a history of previous ocular surgery was required for inclusion in the study group (vs controls without previous surgery). Study cases with a history of prior minor retinal procedures only (eg, pneumatic retinopexy or laser photocoagulation) and eyes lacking follow-up data were excluded.

Data from medical records were collected on patient demographics, previous ocular surgery history, UDVA, CDVA, manifest refraction, keratometry, IOL power, target toric IOL axis, and postoperative axis alignment. Corneal biometry was recorded using laser interference biometry (IOLMaster; Carl Zeiss Meditec, Jena, Germany) in addition to Scheimpflug imaging (Pentacam; Oculus Optikgeräte GmbH, Wetzlar, Germany), scanning-slit topography (Orbscan; Bausch & Lomb, Rochester, NY), and/or manual keratometry. Holladay II and SRK/T formulas were used for IOL power determination in most cases, and the Haigis-L formula was used for highly myopic cases. The American Society of Cataract and Refractive Surgery calculator ( http://iolcalc.ascrs.org) was used to optimize IOL calculations for study cases with prior refractive surgery. No additional surgeon adjustments were made on these cases. The Alcon AcrySof toric calculator was used to determine the toric IOL power and axis of placement. In all surgeries, preoperative corneal marking of reference axes (at 0°, 90°, and 180°) was performed with patients fixating on a distant target while in the upright position to nullify any cyclorotation error. Subsequently, intra-operative marking of the target axis of astigmatism was done with the patient in the supine position to facilitate correct axis alignment of the implanted toric IOL.

Surgeries were performed by two surgeons (CP and YJD) between April 2013 and April 2017 at The Johns Hopkins University Wilmer Eye Institute, Baltimore, Maryland. A hydrophobic acrylic toric lens was used (Acrysof IQ toric IOLs; Alcon Laboratories, Inc., Fort Worth, TX). Outcomes were recorded postoperatively at 1 month (POM1) and 3 to 12 months (POM3-12) for each study case. The primary study outcomes covered refractive (eg, refractive prediction error) and visual (ie, UDVA and CDVA) domains. The secondary outcome was the IOL's postoperative rotational axis stability. The refractive prediction error was calculated in diopters as the difference between predicted and actual postoperative spherical equivalents (SEQ). Visual acuity was recorded in Snellen format and transformed to the logMAR equivalents for the statistical analysis. Postoperative axis alignment was determined using a biomicroscope (Haag-Streit AG, Koeniz, Switzerland).

Statistical Analysis

Baseline findings were summarized descriptively using frequencies, means, medians, and standard deviations. Friedman's analysis of variance by ranks and Cochran's Q tests were used to assess the statistical significance of prediction error and visual acuity differences across different examination intervals, with the appropriate tests applied for pairwise comparisons. Comparisons between study cases and controls were conducted using t, Mann–Whitney U, and chi-square or Fisher's exact tests, where appropriate. Visual outcome analyses examining uncorrected vision excluded cases with a myopic target (target SEQ ≤ −1.00 D) due to the deliberate/planned refractive error. The statistical analysis was performed using SPSS software (version 22; IBM Corporation, Armonk, NY). A P value less than .05 was considered to be significant.

Results

Study Population and Baseline Characteristics

A total of 133 eyes (59 study cases [48 patients] and 74 controls [63 patients]) were included in the study. The baseline characteristics of the study population are summarized in Table 1. The mean preoperative corneal astigmatism was 1.97 ± 1.47 D and 1.83 ± 0.75 D for the study cases and controls, respectively. All study cases had one or more previous ocular surgeries, with the most common being laser in situ keratomileusis (LASIK) (40.8%), scleral buckle (21.1%), and pars plana vitrectomy (18.3%).

Baseline Characteristics of Study Cases (59 Eyes) and Controls (74 Eyes)

Table 1:

Baseline Characteristics of Study Cases (59 Eyes) and Controls (74 Eyes)

Refractive Outcomes

Figure 1 shows the refractive and visual outcomes in Standard Graph format.

Refractive and visual outcomes showing the cumulative proportion (%) of postoperative UDVA and CDVA (Snellen; 20/X or better) at postoperative month (POM) 1 for (A) cases and (E) controls; the proportion of eyes in relation to the difference in visual acuity (Snellen) lines between UDVA and CDVA at postoperative month 1 for (B) cases and (F) controls; the distribution of postoperative spherical equivalent relative to the intended target spherical equivalent at postoperative month 1 in (C) cases and (G) controls; and the proportion of eyes with postoperative manifest cylinder (D) at postoperative month 1 for (D) cases and (H) controls. UDVA = uncorrected distance visual acuity; CDVA = corrected distance visual acuity; D = diopters

Figure 1.

Refractive and visual outcomes showing the cumulative proportion (%) of postoperative UDVA and CDVA (Snellen; 20/X or better) at postoperative month (POM) 1 for (A) cases and (E) controls; the proportion of eyes in relation to the difference in visual acuity (Snellen) lines between UDVA and CDVA at postoperative month 1 for (B) cases and (F) controls; the distribution of postoperative spherical equivalent relative to the intended target spherical equivalent at postoperative month 1 in (C) cases and (G) controls; and the proportion of eyes with postoperative manifest cylinder (D) at postoperative month 1 for (D) cases and (H) controls. UDVA = uncorrected distance visual acuity; CDVA = corrected distance visual acuity; D = diopters

The mean absolute refractive prediction error in study cases was 0.50 ± 0.37 D (median = 0.38) at POM1 and 0.51 ± 0.44 D (median = 0.38) at POM3-12. Compared to the cases with a history of previous ocular surgery, controls without prior ocular surgery had better prediction errors, although the difference was not statistically significant (Table 2). Figure A (available in the online version of this article) shows the percentage of eyes whose prediction errors were within ±0.50 D and ±1.00 D at different follow-up intervals. The proportions of study cases with a refractive prediction error within ±0.50 D and ±1.00 D (P = .23 and > .99, respectively) were not significantly different between POM1 and POM3-12 or in comparison to controls (Figure A).

Comparison of Refractive and Visual Outcomes Between Study Cases (59 Eyes) and Controls (74 Eyes), Mean ± SD (Median)

Table 2:

Comparison of Refractive and Visual Outcomes Between Study Cases (59 Eyes) and Controls (74 Eyes), Mean ± SD (Median)

The proportion of eyes whose refractive prediction error (PE) was within ±0.50 and ±1.00 diopters (D) at postoperative 1 month (POM1; cases = 46, controls = 44) and postoperative 3 to 12 months (POM3-12; cases = 43, controls = 56). The difference between proportions of cases and controls was not statistically significant at either follow-up interval (P > .05).

Figure A.

The proportion of eyes whose refractive prediction error (PE) was within ±0.50 and ±1.00 diopters (D) at postoperative 1 month (POM1; cases = 46, controls = 44) and postoperative 3 to 12 months (POM3-12; cases = 43, controls = 56). The difference between proportions of cases and controls was not statistically significant at either follow-up interval (P > .05).

The mean manifest cylinder in the study cases decreased from 1.47 ± 1.44 D (median = 1.25) preoperatively to 0.70 ± 0.68 D (median = 0.50) at POM1 and 0.69 ± 0.50 D (median = 0.50) at POM3-12. On average, residual astigmatism was slightly higher in cases with prior ocular surgery than in controls, but the difference was not statistically significant (Table 2). Figure B (available in the online version of this article) shows the percentage of eyes whose residual cylinders were within ±0.50 D and ±1.00 D at different follow-up intervals. The frequency of study cases with residual cylinder within ±0.50 D and ±1.00 D (P > .99 for both) was not significantly different between POM1 and POM3-12 or between cases and controls (Figure B).

The proportion of eyes whose residual cylinder was within ±0.50 and ±1.00 diopters (D) at postoperative 1 month (POM1; cases = 46, controls = 44) and postoperative 3 to 12 months (POM3-12; cases = 45, controls = 56). The difference between proportions of cases and controls was not significant at either follow-up interval (P > .05).

Figure B.

The proportion of eyes whose residual cylinder was within ±0.50 and ±1.00 diopters (D) at postoperative 1 month (POM1; cases = 46, controls = 44) and postoperative 3 to 12 months (POM3-12; cases = 45, controls = 56). The difference between proportions of cases and controls was not significant at either follow-up interval (P > .05).

Visual Outcomes

There was an overall significant improvement in the preoperative to postoperative UDVA (P < .001) and CDVA (P < .001) scores in the study cases with prior ocular surgery. Compared to the preoperative scores, this improvement was significant at POM1 and POM3-12 (Tables AB, available in the online version of this article). UDVA was 20/40 or better in 72.7% and 78.6% of the study cases at POM1 and POM3-12, respectively. CDVA was 20/40 or better in 88.9% and 92.7% of the study cases at POM1 and POM3-12, respectively. The difference in the proportion of cases achieving UDVA or CDVA of 20/40 or better across the follow-up intervals was not statistically significant (P = .63 and .50, respectively).

UDVA Preoperatively and Postoperatively in Study Eyes (Mean ± SD)

Table A:

UDVA Preoperatively and Postoperatively in Study Eyes (Mean ± SD)

CDVA (logMAR) Preoperatively and Postoperatively in Study Eyes (Mean ± SD)

Table B:

CDVA (logMAR) Preoperatively and Postoperatively in Study Eyes (Mean ± SD)

For the control group, there was also an overall significant improvement in the preoperative to postoperative CDVA (P < .001) scores (preoperative UDVA scores were not available for most controls). Comparison between study cases and controls revealed a significantly better UDVA in controls at POM1 (difference of means P = .027) but not at POM3-12 (P = .431, Table 2). CDVA was found to be significantly better in controls without prior ocular surgery at POM1 and POM3-12 (Table 2). Although the proportion of eyes achieving UDVA of 20/40 or better was higher in controls than study cases, the difference was not statistically significant at either POM1 (72.7% and 79.1% for cases and controls, respectively; P = .489) or POM3-12 (78.6% and 91.8% for cases and controls, respectively; P = .054). Similarly, the proportion of eyes achieving CDVA of 20/40 or better was lower in study cases than controls, but not statistically significantly different at either POM1 (88.9% and 93.8% for cases and controls, respectively; P = .495) or POM3-12 (92.7% and 98.5% for cases and controls, respectively; P = .176).

Rotational Stability With Previous Ocular Surgery

Records of axis alignment were available for 49 and 43 eyes with previous surgery at POM1 and POM3-12, respectively (Figure 2). In total, 18 (36.7%) IOLs rotated during the immediate postoperative period. The majority (83.3% of rotated IOLs) had 5° or less off-axis rotation, with only one IOL rotating 10° or more off the intended axis during the immediate postoperative period. During POM3-12, axis rotation was present in a total of 18 (41.8%) implanted IOLs. The majority (77.8% of rotated IOLs) remained within 5° of the intended axis, and no new IOL rotated more than 10° off the intended axis.

Toric intraocular lens (IOL) axis orientation in relation to the intended axis in the study cases at postoperative 1 month (POM1) and postoperative 3 to 12 months (POM3-12) follow-up intervals.

Figure 2.

Toric intraocular lens (IOL) axis orientation in relation to the intended axis in the study cases at postoperative 1 month (POM1) and postoperative 3 to 12 months (POM3-12) follow-up intervals.

Discussion

Ocular surgery may directly or indirectly cause changes to the refractive apparatus of the eye. It may induce higher-order refractive aberrations, change the anterior-to-posterior corneal surface relationship, and/or modify the axial length and lens position relative to the retina.4,5,10,11 The literature on toric IOL outcomes in eyes with prior surgery is limited, because eyes with comorbid conditions or prior surgery are commonly excluded from clinical investigations.3,6–8,12,13 Of the few published cases, two patients with keratoconus and scleral buckle14 and a few others with pterygium surgery15 were reported. Few additional reports exist, but long-term follow-up data have been lacking.16–20 To our knowledge, this is the largest report of eyes with prior surgery thus far. In addition, no attempt has been made to directly compare toric IOL outcomes in eyes with previous ocular surgery against comparable controls without previous surgery. Because studying complex eyes offers practical advantages for the specialized practice, we conducted this study to examine refractive and visual outcomes of toric IOLs in eyes with previous ocular surgeries and compare them with those of matched controls.

Stability of visual outcomes of toric IOLs during follow-up is well established in eyes with age-related cataract and regular astigmatism that have no significant corneal, anterior chamber, or retinal pathology and/or prior surgery. In this study, both the study cases and controls showed a significant improvement from preoperative to postoperative visual acuity scores. Interestingly, mean UDVA logMAR scores were significantly better in the controls than the study cases at POM1, although further improvement in UDVA among the study cases during subsequent follow-up rendered the difference non-significant. This may indicate, despite the comparable long-term visual outcomes, that eyes without prior ocular surgery may have faster recovery than eyes that had been previously operated on for non-cataract pathology.

In terms of the frequency of eyes achieving UDVA of 20/40 or better, Visser et al.21 reviewed the published literature and found the pooled estimate to be 90% in standard cataract cases (reported frequencies ranged from 81% to 100%). In our study, the proportion of eyes with prior surgery that had 20/40 or better UDVA at postoperative month 3 (78.6%) was lower than the pooled estimate reported by Visser et al. In contrast, the proportion of eyes without prior surgery was well within that estimate (91.8%). Nonetheless, the difference between the two groups was not statistically significant (P = .054). With the comorbidities and prior surgeries in mind, the observed difference in eyes achieving UDVA of 20/40 or better is not unexpected. Compared to previously published cases with significant comorbidities, our UDVA findings in cases with prior surgery were close to those reported in patients with keratoconus,22,23 but may be somewhat higher than after keratoplasty18 and combined vitrectomy and cataract cases.24 As such, findings in our study support the few previous observations of the viability of toric IOL implantation as an astigmatism-correcting modality in eyes previously operated on. We did observe a statistically significant difference in CDVA among study cases and controls, with controls achieving better CDVA than study cases with previous ocular surgery (Table 2). However, this difference, on average, is arguably not clinically substantial. The presence of comorbidities such as posterior segment diseases (with or without prior surgery) could limit the visual potential and reflect on CDVA postoperatively.

Consistent with the visual outcomes, the refractive outcomes were significantly better postoperatively compared to preoperatively in study cases with prior ocular surgery. The absolute mean prediction error was approximately 0.50 D. Compared to controls, cases with previous ocular surgery had similar absolute mean prediction errors (Table 2). Of note, the relationship of expected prediction errors in complex eyes compared to those in healthy eyes may be procedure-specific. For example, prediction errors were not different between standard eyes and eyes after penetrating keratoplasty.20 In contrast, combined cataract/vitrectomy cases had higher prediction errors than standard cases.25 In our cohort, the percentage of eyes within ±0.50 and ±1.00 D was slightly worse than that reported in stable keratoconus cases at 3 months,22 although investigations with a longer follow-up period yielded results similar to ours.26 Certainly, the challenge of predicting outcomes in eyes with previous refractive surgeries has been widely discussed.27 In this study, the difference between corneal and vitreoretinal surgery groups was neither statistically nor clinically significant at any of the follow-up intervals (unpublished data). It should be noted that necessary adjustments for cases after refractive surgery were made in accordance with calculations made using the American Society of Cataract and Refractive Surgeons online IOL calculator. We suspect that the corneal group would have had significantly higher prediction errors compared to the vitreoretinal group if no such adjustments were made. In such a patient population, using intraoperative aberrometry may further improve the refractive outcomes.

Although the residual refractive astigmatism findings were acceptable in this cohort, it seems to be less than that achievable in eyes with no previous surgeries. An examination of the residual astigmatism outcomes from studies that used the same lens suggested that, on average, 71% and 92% of standard cataract cases achieve residual astigmatism of 0.50 D or less and 1.00 D or less, respectively.21 We found 53.3% and 84.4% of eyes with previous ocular surgery to have 0.50 D or less and 1.00 D or less of residual astigmatism, respectively, within the first follow-up year. These findings were also somewhat lower than those we observed in controls (64.3% and 87.5% were within 0.50 D or less and 1.00 D or less, respectively). Therefore, we suggest that patient expectations be guided by the understanding that, although elimination of clinically significant astigmatism (≥ 0.75 D) may be possible in some cases, astigmatism reduction rather than elimination would be a more realistic goal of toric IOL implantation in eyes with prior surgeries.

Owing to the importance of rotational stability of toric IOLs in guaranteeing the best visual and refractive outcomes postoperatively, rotational stability has been the focus of many prior investigations.3,6,7,19,28–32 It is commonly accepted that rotations greater than 10° are of concern clinically,21,29 with rotations of approximately 30° negating the astigmatism-correcting effect of toric IOLs.29 High degrees of rotation can also lead to new astigmatic errors appearing along the misplaced axis.29 We expected that, because of potential anatomical changes, prior ocular surgery could be a risk factor for IOL rotation.32 In this cohort, IOL rotation was not an uncommon event. However, the overwhelming majority of cases were within 5°, which should have minimal effect on astigmatic correction of toric IOLs.29 The absolute IOL rotation at the immediate postoperative (1.08° ± 2.21°) and POM3-12 (1.74° ± 3.02°) follow-up intervals were well within the 1° to 5° range reported previously in eyes without prior ocular surgery.3 Similar rotational stability was also reported with combined vitrectomy and toric IOL implantation,24 but the proportion of IOLs whose axes were within 5° was less in combined procedures than what we observed here in eyes with previous surgeries.33,34

Similar to the typical cataract case, we found proper wound construction (to prevent leakage and hypotony) and removal of viscoelastic device posterior to the IOL to be helpful in reducing the chances of substantial IOL rotation. With only one eye rotating more than 10°, the observed rate of large, clinically relevant rotations was similar to that previously reported in eyes with high myopia (≤ 2%).6,28 This large IOL rotation was noted during the first postoperative week, which is consistent with previous observations in standard cataract cases.6,30 Of note, the eye with more than 10° of rotation had glaucoma with prior trabeculectomy. There was no history of trauma, and the reason for the rotation could not be clinically discerned. In addition, the fellow eye of the same patient also had prior glaucoma surgery but only rotated by 1°. Due to the rarity of such an event, and the lack of apparent clinical cause, we could not determine whether it was related to the prior surgery. In certain situations, clinically significant rotations may necessitate IOL repositioning. In a recent review of 6,431 eyes implanted with toric IOLs, the incidence of repositioning surgery was found to be 0.65% in eyes without prior ocular surgery.35 In our study, the patient elected not to undergo repositioning given the underlying glaucoma. Therefore, none of the rotated IOLs needed repositioning.

Finally, as is the case with all historical longitudinal studies, potential limitations from non-standardized examination time points and variable follow-up duration may be applicable. In addition, although the attempt was made to avoid collecting data during acute clinical situations, the complexity of cases and presence of comorbid conditions might have influenced the refractive and visual results. Future studies investigating differences in outcomes between prior glaucoma, corneal, and vitreoretinal surgeries are recommended.

Cataract extraction and toric IOL implantation provided significant and sustained improvement in visual acuity and refraction in eyes with prior ocular surgeries. Eyes with and without a history of prior ocular surgery generally showed clinically comparable visual and refractive outcomes, although the visual recovery may be faster in eyes without a history of previous surgery.

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Baseline Characteristics of Study Cases (59 Eyes) and Controls (74 Eyes)

CharacteristicCases (%)Controls (%)P
Age (y)
  Mean ± SD63.5 ± 8.4468.6 ± 9.1.003
  Range39 to 8049 to 87
Sex
  Male23 (47.9%)26 (41.3%).485
  Female25 (52.1%)37 (58.7%)
Total previous surgeriesb71 (100.0%)N/A
  Corneal/refractive surgery40 (56.3%)N/A
    LASIK29 (40.8%)
    Radial keratotomy5 (7.0%)
    Othera6 (8.5%)
  Vitreoretinal surgery28 (39.4%)N/A
    Scleral buckle15 (21.1%)
    Pars plana vitrectomy13 (18.3%)
  Glaucoma surgery3 (4.2%)N/A
    Trabeculoplasty2 (2.8%)
    Trabeculectomy1 (1.4%)
Preoperative UDVA (logMAR)
  Mean ± SD0.725 ± 0.569 (Snellen 20/105)Not available
  Median0.699N/A
  Range0.1 to 2.82
Preoperative CDVA (logMAR)
  Mean ± SD0.29 ± 0.17 (Snellen 20/40)0.24 ± 0.19 (Snellen 20/35)
  Median0.300.18.136
  Range0.0 to 0.7−0.12 to 1.18
Preoperative SEQ (D)
  Mean ± SD−2.68 ± 4.01−2.67 ± 4.48
  Median−1.50−1.90.938
  Range−14.00 to 3.75−14.88 to 5.50
Preoperative corneal astigmatism (D)
  Mean ± SD1.97 ± 1.471.83 ± 0.75
  Median1.571.64.553
  Range0.77 to 10.050.77 to 4.13

Comparison of Refractive and Visual Outcomes Between Study Cases (59 Eyes) and Controls (74 Eyes), Mean ± SD (Median)

ParameterCasesControlsP
MRPE (D)
  POM10.50 ± 0.37 (0.38)0.45 ± 0.42 (0.32).343
  POM3-120.51 ± 0.44 (0.38)0.38 ± 0.31 (0.29).241
Manifest cylinder (D)
  POM10.70 ± 0.68 (0.50)0.61 ± 0.58 (0.50).569
  POM3-120.69 ± 0.50 (0.50)0.56 ± 0.45 (0.50).207
UDVA (logMAR)
  POM10.27 ± 0.24 (0.18) [Snellen 20/40]0.17 ± 0.21 (0.10) [Snellen 20.30].027
  POM3-120.19 ± 0.19 (0.10) [Snellen 20/31]0.16 ± 0.19 (0.10) [Snellen 20/29].431
CDVA (logMAR)
  POM10.13 ± 0.16 (0.10) [Snellen 20/27]0.07 ± 0.14 (0.0) [Snellen 20/23].005
  POM3-120.10 ± 0.13 (0.10) [Snellen 20/25]0.03 ± 0.1 (0.0) [Snellen 20/21]< .001

UDVA Preoperatively and Postoperatively in Study Eyes (Mean ± SD)

ParameterPreoperative (n = 43)POM1 (n = 44)POM3-12 (n = 42)
UDVA (logMAR)0.73 ± 0.57 [Snellen 20/107]0.27 ± 0.24 [Snellen 20/37]0.19 ± 0.19 [Snellen 20/31]
Median0.70 [Snellen 20/100]0.18 [Snellen 20/30]0.10 [Snellen 20/25]
Range0.1 to 2.820 to 1−0.12 to 0.7
PReference< .001< .001

CDVA (logMAR) Preoperatively and Postoperatively in Study Eyes (Mean ± SD)

ParameterPreoperative (n = 59)POM1 (n = 54)POM3-12 (n = 55)
CDVA (logMAR)0.29 ± 0.17 (Snellen 20/39)0.13 ± 0.16 (Snellen 20/27)0.10 ± 0.13 (Snellen 20/25)
Median0.30 (Snellen 20/40)0.10 (Snellen 20/25)0.10 (Snellen 20/25)
Range0 to 0.7−0.12 to 0.54−0.12 to 0.48
PReference< .001< .001
Authors

From the Cornea, Cataract, and Refractive Surgery Division, The Johns Hopkins University Wilmer Eye Institute, Baltimore, Maryland (OMM, CP, DD, YJD); and the Department of Ophthalmology, McGill University, Montréal, Quebec, Canada (FA).

The authors have no financial or proprietary interest in the materials presented herein.

Supported by an unrestricted grant from the Michael O'Bannon Foundation and the Turner Family.

AUTHOR CONTRIBUTIONS

Study concept and design (OMM, CP, YJD); data collection (OMM, CP, FA); analysis and interpretation of data (OMM, DD, YJD); writing the manuscript (OMM); critical revision of the manuscript (OMM, CP, FA, DD, YJD); statistical expertise (OMM); administrative, technical, or material support (YJD); supervision (YJD)

Correspondence: Yassine J. Daoud, MD, FACS, Cornea, Cataract, and Refractive Surgery Division, Maumenee 327, The Johns Hopkins University Wilmer Eye Institute, 600 North Wolfe Street, Baltimore, MD 21287. E-mail: ydaoud1@jhmi.edu

Received: July 04, 2019
Accepted: October 21, 2019

10.3928/1081597X-20191021-03

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