Journal of Refractive Surgery

Original Article 

Effect of Capsular Tension Ring Implantation on Postoperative Rotational Stability of a Toric Intraocular Lens

Magdaléna Vokrojová, MD, PhD; Lenka Havlíčková, PhD; Markéta Brožková, MD, FEBO; Zuzana Hlinomazová, MD, PhD

Abstract

PURPOSE:

To analyze clinical outcomes of cataract surgery with implantation of a toric intraocular lens (IOL) and to evaluate the effect of capsular tension ring (CTR) presence or absence on the rotational stability of implanted IOLs and postoperative refraction.

METHODS:

This cohort study included 64 eyes of 41 patients who underwent uneventful cataract surgery with implantation of a toric IOL (enVista toric MX60T; Bausch & Lomb, Rochester, NY) to correct preoperative corneal astigmatism. In 30 eyes, a CTR (11 SR model; Videris s.r.o., Prague, Czech Republic) was co-implanted. Analyzed parameters were refraction, visual acuity, and misalignment of toric lenses.

RESULTS:

The mean patient age was 67 years (range: 42 to 89 years) and the mean follow-up period was 5 months. Mean manifest astigmatism improved from −1.53 ± 1.15 diopters (D) preoperatively to −0.40 ± 0.61 D postoperatively (P < .001). Postoperative uncorrected distance visual acuity was 0.10 ± 0.13 logMAR (20/25 Snellen). Mean absolute IOL misalignment was 3.70° with CTR and 3.85° without CTR (P = .683). In eyes with an axial length of 24 mm or greater, IOL axis matched the planned axis in 90.5% of eyes with CTR and 81.8% of eyes without CTR (P = .964). Four eyes (6.25%) needed additional surgical IOL rotation.

CONCLUSIONS:

In eyes after cataract surgery with implantation of a toric IOL, there were no significant differences in the rotational stability of the lens with respect to the presence or absence of CTR. In eyes with an axial length of 24 mm or greater, better IOL alignment was observed in the group with CTR.

[J Refract Surg. 2020;36(3):186–192.]

Abstract

PURPOSE:

To analyze clinical outcomes of cataract surgery with implantation of a toric intraocular lens (IOL) and to evaluate the effect of capsular tension ring (CTR) presence or absence on the rotational stability of implanted IOLs and postoperative refraction.

METHODS:

This cohort study included 64 eyes of 41 patients who underwent uneventful cataract surgery with implantation of a toric IOL (enVista toric MX60T; Bausch & Lomb, Rochester, NY) to correct preoperative corneal astigmatism. In 30 eyes, a CTR (11 SR model; Videris s.r.o., Prague, Czech Republic) was co-implanted. Analyzed parameters were refraction, visual acuity, and misalignment of toric lenses.

RESULTS:

The mean patient age was 67 years (range: 42 to 89 years) and the mean follow-up period was 5 months. Mean manifest astigmatism improved from −1.53 ± 1.15 diopters (D) preoperatively to −0.40 ± 0.61 D postoperatively (P < .001). Postoperative uncorrected distance visual acuity was 0.10 ± 0.13 logMAR (20/25 Snellen). Mean absolute IOL misalignment was 3.70° with CTR and 3.85° without CTR (P = .683). In eyes with an axial length of 24 mm or greater, IOL axis matched the planned axis in 90.5% of eyes with CTR and 81.8% of eyes without CTR (P = .964). Four eyes (6.25%) needed additional surgical IOL rotation.

CONCLUSIONS:

In eyes after cataract surgery with implantation of a toric IOL, there were no significant differences in the rotational stability of the lens with respect to the presence or absence of CTR. In eyes with an axial length of 24 mm or greater, better IOL alignment was observed in the group with CTR.

[J Refract Surg. 2020;36(3):186–192.]

Postoperative intraocular lens (IOL) misalignment may appear in 2% to 20% of cases (depending on the type of implanted IOL).1–12 Potential risk factors affecting rotational stability of toric IOLs may comprise IOL design and material, higher axial length, and eyes with potential capsular bag instability (eg, pseudoexfoliation syndrome or zonulolysis).2,4,13–16 The rotational stability of the implanted lens in the capsular bag can be further affected by surgical factors such as an asymmetric capsulorhexis, its size, shape, and centration, and incomplete removal of cortical and viscoelastic material. To overcome these issues, reaching a stable position of the implanted lens might be facilitated by a capsular tension ring (CTR),17–19 especially in eyes with greater axial length.18–20 The CTR is a polymethylmethacrylate intraocular implantation device. It was first used in 1993 by Witschel and Legler to reinforce the zonule in eyes with zonular dehiscence during cataract surgery.21

Khng and Osher22 observed differences in horizontal and vertical parameters of the capsule and sulcus ciliaris in their study on cadaverous eyes. Blum et al.23 reported an oval shape of sulcus ciliaris with larger proportions vertically compared to horizontally. The reason to use CTR is therefore an increased symmetry of the capsular bag and flattening of the bag in the anterior-posterior axis. This extends the contact area between the anterior and posterior part of the capsule to obtain better friction and thus prevent the rotation of the lens.18

The aim of our study was to evaluate clinical outcomes and the effect of CTR co-implantation on the rotational stability of implanted toric IOLs in patients after cataract surgery. Apart from eyes with higher axial length where the benefit of CTR use was already documented, our study also comprised eyes with hyperopia and emmetropia to test whether CTR implantation may be beneficial in patients with various types of refractive errors.

Patients and Methods

This non-randomized cohort study comprised 64 eyes of 41 consecutive patients who underwent uneventful cataract surgery with implantation of a toric IOL to correct preoperative corneal astigmatism. Surgeries were performed at the European Eye Clinic Lexum, Prague, Czech Republic, between 2014 and 2017. All patients provided signed informed consent in accordance with the tenets of the Declaration of Helsinki.

Patients enrolled in the study were myopic, emme-tropic, and hyperopic. Inclusion criteria comprised visually significant cataract and regular astigmatism. Exclusion criteria were irregular astigmatism (corneal scarring, ectatic disease, and previous corneal refractive surgery), ocular disease (uveitis, advanced glaucoma, and extensive macular disease), and potential intraoperative complications (posterior capsule rupture and radial tears in capsulorhexis).

The mean follow-up period was 5 ± 6 months (range: 1 to 36 months).

Surgical Technique

Preoperatively, before the patient was taken to the operating room, limbal reference marks at the 3-, 6-, and 9-o'clock positions were marked on the patient's eye under a slit lamp while the patient was in an upright position. The head of the patient was carefully aligned to avoid misalignment due to cyclorotation. The patient was asked to focus on an object at distance. The final axis of IOL placement was determined using a coaxial thin slit and the position was marked by a surgical marking pen (Viscot Medical LLC, East Hanover, NJ).

A single-piece aspheric toric IOL (enVista toric MX60T; Bausch & Lomb, Rochester, NY) was implanted in all cases. It is a hydrophobic acrylic IOL with a total diameter of 12.5 mm and an optic diameter of 6 mm. In our dataset, we implanted lenses from 1.25 to 5.75 diopters (D) cylinder. IOL power was calculated based on keratometry from a topographer (Oculus Optikgeräte GmbH, Wetzlar, Germany) and IOLMaster (Carl Zeiss Meditec AG, Jena, Germany) using the enVista toric IOL Calculator (Bausch & Lomb).

Surgeries were performed under topical anesthesia, with a temporal corneal clear incision of 2.2 mm in all cases, by two experienced surgeons. The technique consisted of a well-centered continuous curvilinear capsulorhexis with a diameter of 5 mm, uneventful cataract phacoemulsification, irrigation and aspiration, thorough cortical clean up, and an injection of ophthalmic viscosurgical device (OVD) (sodium hyaluronate 1% Provisc; Alcon Laboratories, Inc., Fort Worth, TX) into the capsular bag. After verification of reference marks, the exact IOL position was marked using the Cionni toric axis marker (Duckworth and Kent Ltd., Baldock, United Kingdom). The toric IOL was implanted through the main incision 10° to 20° before the desired position. The implantation in the bag was performed using the Monarch III injector (Alcon Laboratories, Inc.) with a D-cartridge. After a careful OVD removal, the IOL was rotated to its final position.

Our dataset consisted of two groups based on the presence (30 eyes) or absence (34 eyes) of a CTR (11 SR model; Videris s.r.o., Prague, Czech Republic). If a CTR was used, it was implanted through the main incision before IOL implantation. The CTR was implanted in eyes regardless of their axial length.

Patient Examination

Preoperatively, patients underwent a complete ophthalmic examination, including measurement of subjective and objective refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, corneal topography, tonometry, slit-lamp examination, and funduscopy in all patients.

Postoperative examinations (at 1 week, 2 months, and 6 months) consisted of the measurement of refraction, residual astigmatism, visual acuity, and IOL position. Exact lens position after the surgery was verified on slit lamp (Topcon IS-600; Topcon Europe Medical BV, Capelle aan den Ijssel, The Netherlands) using a rotating slit in eyes in the mydriatic state with the patient's head in an upright position. The slit-lamp beam was aligned with toric marks of the implanted IOL to determine its axis. Toric IOL misalignment angle was defined as the difference between planned implantation axis and final toric IOL axis. Exact IOL misalignment was further verified on slit-lamp retroillumination photographs using a superimposed protractor and the outcome was saved for future comparison of rotation between visits. Rotation of implanted lenses was considered positive when clockwise and negative when counterclockwise.

Data Analyses

Clinical data were analyzed using Datagraph-med software (version 5.30; Ingenieurbüro Pieger GmbH, Wendelstein, Germany). Statistical analyses were performed using STATISTICA software (version 12.7; Dell Software Inc., Aliso Viejo, CA). Normality of data was tested by the Shapiro–Wilk test. Changes in refraction and visual acuity before and after the surgery were tested using a non-parametric Wilcoxon signed-rank test. Differences in refraction, visual acuity, and rotational stability in eyes with or without CTR were tested by the Mann–Whitney U test. A P value of less than .05 was considered statistically significant.

Results

In our dataset, the mean patient age was 67 ± 10 years (range: 42 to 89 years). The mean axial length of eyes was 24.01 ± 1.53 mm (range: 21.50 to 29.00 mm). Detailed preoperative and postoperative values of refraction and visual acuity are summarized in Table 1. The difference between mean preoperative and postoperative sphere was not significant (P = .319). Postoperative manifest spherical equivalent differed significantly from preoperative values (P = .033) (Figure 1A), and it was within ±1.00 D in 92% of eyes (Figures 1B–1C). The mean manifest astigmatism improved from −1.53 ± 1.15 D preoperatively to −0.40 ± 0.61 D postoperatively (P < .001) (Figure 1D). A statistically significant change was observed in UDVA, which changed from 20/150 preoperatively to 20/25 after the surgery (P = < .001). UDVA was 20/40 or better in 90% of eyes (Figure 1E). Improvement was also recorded in CDVA, which changed from 20/40 to 20/22 (P < .001). Mean rotation of implanted toric IOLs was 0.73° ± 9.91° (range: −20.00° to 60.00°). Absolute mean rotation within the dataset was 4.14° ± 9.03° (range: 0.00° to 60.00°). At the last follow-up visit, 83% of eyes gained one Snellen line or more of CDVA, 14% remained unchanged, and 3% lost one line or more of CDVA (Figure 1F).

Preoperative vs Postoperative Refraction and Visual Acuity

Table 1:

Preoperative vs Postoperative Refraction and Visual Acuity

(A) Stability of spherical equivalent refraction (after correction to target refraction) during follow-up in eyes after cataract surgery with implantation of a toric intraocular lens. (B) Spherical equivalent refractive accuracy (after correction to target refraction) in studied eyes at last follow-up visit. (C) Attempted vs achieved spherical equivalent in 64 eyes at last follow-up visit. (D) Preoperative vs postoperative refractive astigmatism within the dataset. (E) Cumulative postoperative uncorrected distance visual acuity (UDVA) vs preoperative corrected distance visual acuity (CDVA). (F) Change in CDVA. D = diopters

Figure 1.

(A) Stability of spherical equivalent refraction (after correction to target refraction) during follow-up in eyes after cataract surgery with implantation of a toric intraocular lens. (B) Spherical equivalent refractive accuracy (after correction to target refraction) in studied eyes at last follow-up visit. (C) Attempted vs achieved spherical equivalent in 64 eyes at last follow-up visit. (D) Preoperative vs postoperative refractive astigmatism within the dataset. (E) Cumulative postoperative uncorrected distance visual acuity (UDVA) vs preoperative corrected distance visual acuity (CDVA). (F) Change in CDVA. D = diopters

Outcomes of eyes with and without CTR are summarized in Table 2. The mean implanted IOL spherical power was 19.13 ± 3.76 D (range: 7.00 to 26.00 D) in 30 eyes with CTR and 21.82 ± 3.97 D (range: 12.50 to 30.00 D) in 34 eyes without CTR. Average axial length was 24.70 ± 1.54 mm (range: 22.00 to 29.00 mm) in eyes with CTR and 23.40 ± 1.25 mm (range: 21.50 to 26.50 mm) in eyes without CTR. Axis alignment (≤ 5° difference) was achieved in 77% of eyes with CTR and 79% of eyes without CTR. Mean absolute IOL mis-alignment was 3.70° in eyes with CTR and 3.85° in eyes without CTR (P = .683) (Figure 2). In eyes with axial length of 24 mm or greater, postoperative toric IOL axis matched the planned axis in 90.5% of eyes with CTR and 81.8% of eyes without CTR (P = .964).

Differences Between the Groups With and Without CTR

Table 2:

Differences Between the Groups With and Without CTR

Final absolute rotational stability in the group with or without capsular tension ring (CTR).

Figure 2.

Final absolute rotational stability in the group with or without capsular tension ring (CTR).

In our dataset, 4 eyes (6.25%) needed additional surgical IOL rotation, which was performed within at least 1 week after the surgery. Three eyes were from the group with CTR and 1 eye from the group without CTR. In the group with CTR, there was a misalignment of 24° in the first eye (with an axial length of 23 mm), 18° in the second eye (axial length = 23 mm), and 30° in the third eye (axial length = 26.2 mm). In the group without CTR, the 1 eye (axial length = 21.5 mm) was misaligned by 63°. We did not observe any intraoperative complication, and no complications related to the insertion of the CTR were reported in the group with CTR.

Discussion

In our study, we achieved good refractive outcomes and a statistically significant improvement in both UDVA and CDVA. These results confirm good experiences of other authors with this type of IOL.7,8,24,25 Similar outcomes showing a substantial increase of UDVA after the surgery were also reported for other types of toric IOLs.1,2,6–8,26

Mean astigmatism in our dataset improved from −1.53 ± 1.15 D preoperatively to −0.40 ± 0.61 D postoperatively. Using the same type of implanted lens, Garzón et al.8 reported similar results of astigmatism reduction. In their study, the preoperative astigmatism of 1.89 ± 0.57 D improved to 0.41 ± 0.51 D postoperatively. Torio et al.7 described a change in astigmatism from −1.45 ± 1.29 D preoperatively to −0.93 ± 0.52 D postoperatively. The reduction of astigmatism in our study is also in accordance with other published studies where implantation of toric IOLs resulted in postoperative manifest astigmatism between 0.90 and 4.50 D, depending on the type of toric IOL.1,2,4 When the groups with and without CTR were compared, the difference in postoperative astigmatism was not statistically significant.

The major requirement for a toric IOL is its rotational stability, because misalignment of the lens may lead to the presence of postoperative residual astigmatism where 1° of rotation can cause a reduction of IOL cylinder power up to 3.3%. More than a 10° rotation causes a substantial decrease in visual acuity, which usually requires surgical rotation of the lens into the correct position. Complete loss of cylinder power occurs when the IOL is misaligned by more than 30°.19,26 In our dataset, we observed a mean difference from the planned axis of 0.73° ± 9.91°. In most eyes, implanted IOLs matched the planned axis or showed a slight but clinically insignificant misalignment. However, in 4 eyes from our dataset, additional surgical IOL rotation was required (in 3 eyes with implanted CTR and 1 eye without CTR) due to substantial misalignment. Surgical repositioning was performed 1 week after the surgery in all cases because such a delay is considered ideal timing.27

In these 4 eyes, we assessed potential surgical factors that could have contributed to the IOL decentration. One of these factors could be a slower unfolding of the IOL in the bag. Compared to other hydrophobic IOLs, the enVista IOL has a relatively higher glass transition temperature (ie, the temperature above which an IOL becomes flexible and below which it remains rigid).28 A higher transition temperature makes implantation with an injector more rigid and the unfolding of the lens in the bag becomes slower. Thus, providing enough time for complete unfolding can help prevent IOL rotation.28,29 Another key factor for postoperative outcomes is a correct surgical technique, especially the size and technique of capsulorhexis creation. The size of the capsulorhexis should be approximately 4.5 to 5.5 mm.1,30 Moreover, a well-centered capsulorhexis with a 360° overlap of the IOL should be achieved to provide optimal centration of the IOL, reduce tilting of the IOL, and minimize the incidence of posterior capsule opacification.1

Apart from insufficient extension of the IOL and larger or irregular capsulorhexis, rotation of the lens may also be caused by an incomplete removal of OVD.2 Based on the study of IOL axis position 1 hour, 1 day, 1 week, and 1 month after the surgery, Garzón et al.8 reported that the highest rotation appeared during the first hour after the surgery. The authors suggested that this is caused by an incomplete removal of OVD, which prevents contact of the IOL with the capsular bag and also prevents ideal friction and subsequent stabilization of the IOL in the bag. Rotation of the lens later after the surgery was not reported.

None of the mentioned issues, including differences in size and symmetry of capsulorhexis and remains of viscomaterial or cortex of the natural lens, were recorded in our study in eyes requiring additional IOL rotation.

Despite the efforts of surgeons to avoid these factors, undesired rotation of a toric IOL may occur. In our study, we used a CTR as a supportive device to help us reach a stable position of the toric lens in the capsular bag. We were interested in whether a CTR could be used to achieve better stability of toric IOLs in eyes with various axial lengths. Thus, patients with myopia, hyperopia, and emmetropia were included in our study.

Improving the stability of the IOL in the bag using a CTR was first described by Wiley17 as the IOL lock technique. Prior to the plate-haptic IOL implantation, he inserted a CTR into the capsular bag. He observed a substantial reduction in surgically needed postoperative IOL rotation compared to eyes without CTR. However, he has not performed any comparative study. Safran19 reported two cases of eyes with high axial myopia where a CTR was used to reduce rotation of the IOL in the bag. Sagiv and Sachs18 even showed an example of the use of two CTRs to reach the rotational stability of the lens in a patient with high axial myopia. In 2016, Zhao et al.20 reported outcomes of CTR use in highly myopic eyes that had been implanted with Acrysof toric IOL. They found that the mean residual astigmatism in the group with CTR was significantly lower than in the group without CTR postoperatively. When compared to our study, Zhao et al.20 observed fewer cases of substantial rotation in their group of eyes with an implanted CTR.

Rastogi et al.31 showed statistically better results of postoperative mean rotation in the group with CTR compared to the group without CTR. In their study of 50 eyes implanted with a hydrophilic acrylic Auro-flex toric IOL, the authors found the mean rotation was 1.85° ± 1.72° in the group with CTR compared to 4.02° ± 2.04° in the group without CTR. However, axial length and preoperative astigmatism were not specified in this study. Unlike Rastogi et al.,31 we did not observe a significant difference in the postoperative rotational stability of the lens with respect to the presence or absence of an implanted CTR. Nevertheless, in eyes with an axial length of 24 mm or greater, we observed a closer match with the planned IOL axis in the group of eyes with CTR compared to without CTR.

Several authors studied the impact of CTR coimplantation with an IOL on postoperative refraction.32–35 Similarly, as shown in the publication of Park et al.32 on enVista MX60 co-implantation with CTR, our dataset also showed a slight hyperopic shift in the group with CTR compared to the group without CTR. However, the difference was not statistically significant. Similar findings were published by Alió et al.33 and Nistad et al.34 in their studies on CTR coimplantation with multifocal lenses. Schild et al.35 focused on the effect of CTR on postoperative refraction in eyes with higher axial length, but did not find any difference compared to eyes without CTR.

Our study shows that implantation of a toric enVista IOL is a suitable solution when treating both corneal astigmatism and cataract. Although differences in the stability of the IOL between the group with and without CTR were not significant, implantation of a CTR may facilitate better IOL stability in myopic eyes.

References

  1. Visser N, Bauer NJ, Nuijts RM. Toric intraocular lenses: historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications. J Cataract Refract Surg. 2013;39(4):624–637. doi:10.1016/j.jcrs.2013.02.020 [CrossRef]
  2. Miyake T, Kamiya K, Amano R, Iida Y, Tsunehiro S, Shimizu K. Long-term clinical outcomes of toric intraocular lens implantation in cataract cases with preexisting astigmatism. J Cataract Refract Surg. 2014;40(10):1654–1660. doi:10.1016/j.jcrs.2014.01.044 [CrossRef]
  3. Chua W, YuenChua J, The G, Hill W. Matched comparison of rotational stability of 1-piece acrylic and plate-haptic silicon toric intraocular lenses in Asian eyes. J Cataract Refract Surg. 2012;38:620–624. doi:10.1016/j.jcrs.2011.10.037 [CrossRef]
  4. Shah GD, Praveen MR, Vasavada AR, Vasavada VA, Rampal G, Shastry LR. Rotational stability of a toric intraocular lens: influence of axial length and alignment in the capsular bag. J Cataract Refract Surg. 2012;38(1):54–59. doi:10.1016/j.jcrs.2011.08.028 [CrossRef]
  5. Bachernegg A, Rückl T, Riha W, Grabner G, Dexl AK. Rotational stability and visual outcome after implantation of a new toric intraocular lens for the correction of corneal astigmatism during cataract surgery. J Cataract Refract Surg. 2013;39(9):1390–1398. doi:10.1016/j.jcrs.2013.03.033 [CrossRef]
  6. Agresta B, Knorz MC, Donatti C, Jackson D. Visual acuity improvements after implantation of toric intraocular lenses in cataract patients with astigmatism: a systematic review. BMC Ophthalmol. 2012;12(1):41. doi:10.1186/1471-2415-12-41 [CrossRef]
  7. Torio KC, Ang RET, Martinez GHA. Comparison of the rotational stability of different toric intraocular lens implants. Phillipine J Ophthal. 2014;39:67–72.
  8. Garzón N, Poyales F, de Zárate BO, Ruiz-García JL, Quiroga JA. Evaluation of rotation and visual outcomes after implantation of monofocal and multifocal toric intraocular lenses. J Refract Surg. 2015;31(2):90–97. doi:10.3928/1081597X-20150122-03 [CrossRef]
  9. Chang DF. Comparative rotational stability of single-piece open-loop acrylic and plate-haptic silicone toric intraocular lenses. J Cataract Refract Surg. 2008;34(11):1842–1847. doi:10.1016/j.jcrs.2008.07.012 [CrossRef]
  10. Waltz KL, Featherstone K, Tsai L, Trentacost D. Clinical outcomes of TECNIS toric intraocular lens implantation after cataract removal in patients with corneal astigmatism. Ophthalmology. 2015;122(1):39–47. doi:10.1016/j.ophtha.2014.06.027 [CrossRef]
  11. Lubinski W, Kazmierczak B, Gronkowska-Serafin J, Podboraczynska-Jodko K. Clinical outcomes after uncomplicated cataract surgery with implantation of Tecnis Toric intraocular lens. J Ophthalmol. 2016;2016:3257217. doi:10.1155/2016/3257217 [CrossRef]
  12. Miháltz K, Lasta M, Burgmüller M, Vécsei-Marlovits PV, Weingessel B. Comparison of two toric IOLs with different haptic design: optical quality after 1 year. J Ophthalmol. 2018;2018:4064369. doi:10.1155/2018/4064369 [CrossRef]
  13. Linnola RJ, Sund M, Ylönen R, Pihlajaniemi T. Adhesion of soluble fibronectin, laminin, and collagen type IV to intraocular lens materials. J Cataract Refract Surg. 1999;25(11):1486–1491. doi:10.1016/S0886-3350(99)00238-2 [CrossRef]
  14. Ruhswurm I, Scholz U, Zehetmayer M, Hanselmayer G, Vass C, Skorpik C. Astigmatism correction with a foldable toric intraocular lens in cataract patients. J Cataract Refract Surg. 2000;26(7):1022–1027. doi:10.1016/S0886-3350(00)00317-5 [CrossRef]
  15. Weinand F, Jung A, Stein A, Pfützner A, Becker R, Pavlovic S. Rotational stability of a single-piece hydrophobic acrylic intraocular lens: new method for high-precision rotation control. J Cataract Refract Surg. 2007;33(5):800–803. doi:10.1016/j.jcrs.2007.01.030 [CrossRef]
  16. Patel CK, Ormonde S, Rosen PH, Bron AJ. Postoperative intraocular lens rotation: a randomized comparison of plate and loop haptic implants. Ophthalmology. 1999;106(11):2190–2195. doi:10.1016/S0161-6420(99)90504-3 [CrossRef]
  17. Wiley WF. Combining a CTR with a plate haptic toric IOL. Cataract Refract Surg Today. 2012:32–33.
  18. Sagiv O, Sachs D. Rotation stability of a toric intraocular lens with a second capsular tension ring. J Cataract Refract Surg. 2015;41(5):1098–1099. doi:10.1016/j.jcrs.2015.04.004 [CrossRef]
  19. Safran SG. Use of capsular tension ring to prevent early post-operative rotation of a toric intraocular lens in high axial myopia. JCRS Online Case Rep. 2015;2(3):41–43. https://www.jcrscasereports.com/article/S2214-1677(15)00008-3/pdf. Accessed July 9, 2019. doi:10.1016/j.jcro.2015.02.001 [CrossRef]
  20. Zhao Y, Li J, Yang K, Li X, Zhu S. Combined special capsular tension ring and toric IOL implantation for management of astigmatism and high axial myopia with cataracts. Semin Ophthalmol. 2016;2016:1–6.
  21. Lanzetta P, Chiodini RG, Polito A, Bandello F. Use of capsular tension ring in phacoemulsification: indications and technique. Indian J Ophthalmol. 2002;50(4):333–337.
  22. Khng C, Osher RH. Evaluation of the relationship between corneal diameter and lens diameter. J Cataract Refract Surg. 2008;34(3):475–479. doi:10.1016/j.jcrs.2007.10.043 [CrossRef]
  23. Blum M, Tetz MR, Faller U, Völcker HE. Age-related changes of the ciliary sulcus: implications for implanting sulcus-fixated lenses. J Cataract Refract Surg. 1997;23(1):91–96. doi:10.1016/S0886-3350(97)80157-5 [CrossRef]
  24. Poyales F, Garzón N, Pérez-Izquierdo R. Lens stability and vision quality following envista EnVista toric intraocular placement. Presented at: XXXI Congress of the ESCRS. ; October 5–9, 2013. ; Amsterdam, Netherlands. .
  25. Packer M, Rajan M, Ligabue E, Heiner P. Clinical properties of a novel, glistening-free, single-piece, hydrophobic acrylic IOL. Clin Ophthalmol. 2014;8:421–427. doi:10.2147/OPTH.S57114 [CrossRef]
  26. Bauer NJ, de Vries NE, Webers CA, Hendrikse F, Nuijts RM. Astigmatism management in cataract surgery with the AcrySof toric intraocular lens. J Cataract Refract Surg. 2008;34(9):1483–1488. doi:10.1016/j.jcrs.2008.05.031 [CrossRef]
  27. Oshika T, Inamura M, Inoue Y, et al. Incidence and outcomes of repositioning surgery to correct misalignment of toric intraocular lenses. Ophthalmology. 2018;125(1):31–35. doi:10.1016/j.ophtha.2017.07.004 [CrossRef]
  28. Eom Y, Lee JS, Rhim JW, Kang SY, Song JS, Kim HM. A simple method to shorten the unfolding time of prehydrated hydro-phobic intraocular lens. Can J Ophthalmol. 2014;49(4):382–387. doi:10.1016/j.jcjo.2014.06.002 [CrossRef]
  29. Packer M, Fry L, Lavery KT, et al. Safety and effectiveness of a glistening-free single-piece hydrophobic acrylic intraocular lens (enVista). Clin Ophthalmol. 2013;7:1905–1912. doi:10.2147/OPTH.S50499 [CrossRef]
  30. Torquetti L. Toric intraocular lens rotation related to the capsulorhexis. J Cataract Refract Surg. 2015;41(2):483. doi:10.1016/j.jcrs.2014.12.046 [CrossRef]
  31. Rastogi A, Khanam S, Goel Y, Thacker P, Kumar P, Kamlesh. Comparative evaluation of rotational stability and visual outcome of toric intraocular lenses with and without a capsular tension ring. Indian J Ophthalmol. 2018;66(3):411–415.
  32. Park HJ, Lee H, Kim W, Kim EK, Seo KY, Kim TI. Effect of co-implantation of a capsular tension ring on clinical outcomes after cataract surgery with monofocal intraocular lens implantation. Yonsei Med J. 2016;57(5):1236–1242. doi:10.3349/ymj.2016.57.5.1236 [CrossRef]
  33. Alió JL, Elkady B, Ortiz D, Bernabeu G. Microincision multifocal intraocular lens with and without a capsular tension ring: optical quality and clinical outcomes. J Cataract Refract Surg. 2008;34(9):1468–1475. doi:10.1016/j.jcrs.2008.05.042 [CrossRef]
  34. Nistad K, Göransson F, Støle E, Shams H, Gjerdrum B. The use of capsular tension rings to reduce refractive shift in patients with implantation of trifocal intraocular lenses. J Refract Surg. 2017;33(12):802–806. doi:10.3928/1081597X-20170829-02 [CrossRef]
  35. Schild AM, Rosentreter A, Hellmich M, Lappas A, Dinslage S, Dietlein TS. Effect of a capsular tension ring on refractive outcomes in eyes with high myopia. J Cataract Refract Surg. 2010;36(12):2087–2093. doi:10.1016/j.jcrs.2010.06.065 [CrossRef]

Preoperative vs Postoperative Refraction and Visual Acuity

Parameter Preoperative, Mean ± SD (Range) Postoperative, Mean ± SD (Range) P
Sphere (D) −0.56 ± 3.92 (−17.50 to 6.25) 0.30 ± 0.69 (−1.00 to 3.00)a .319
Cylinder (D) −1.53 ± 1.15 (−4.75 to 0.00) −0.40 ± 0.61 (−4.00 to 0.00) < .001
SE (D) −1.30 ± 3.95 (−17.50 to 5.25) 0.10 ± 0.55 (−1.25 to 2.38)a .033
UDVA (logMAR) 0.88 ± 0.42 (0.18 to 1.60) 0.10 ± 0.13 (0.00 to 0.40)b < .001
CDVA (logMAR) 0.31 ± 0.25 (0.05 to 1.60) 0.04 ± 0.07 (0.00 to 0.30)b < .001

Differences Between the Groups With and Without CTR

Parameter With CTR, Mean ± SD (Range) Without CTR, Mean ± SD (Range) P
Sphere (D)
  Preoperatively −2.06 ± 3.85 (−17.50 to 2.50) 0.76 ± 3.49 (−8.50 to 6.25) .001
  Postoperativelya 0.38 ± 0.80 (−0.50 to 3.00) 0.23 ± 0.57 (−1.00 to 1.75) .994
Cylinder (D)
  Preoperatively −1.31 ± 1.24 (−4.75 to 0.00) −1.72 ± 1.03 (−4.00 to 0.00) .083
  Postoperatively −0.45 ± 0.77 (−4.00 to 0.00) −0.36 ± 0.40 (−1.25 to 0.00) .890
SE (D)
  Preoperatively −2.71 ± 3.77 (−17.50 to 1.50) −0.06 ± 3.68 (−10.50 to 5.25) .001
  Postoperativelya 0.15 ± 0.57 (−0.75 to 2.38) 0.05 ± 0.52 (−1.25 to 1.25) .841
UDVA (logMAR)
  Preoperatively 0.87 ± 0.48 (0.20 to 1.60) 0.89 ± 0.37 (0.18 to 1.60) .827
  Postoperativelyb 0.09 ± 0.14 (0.00 to 0.40) 0.11 ± 0.13 (0.00 to 0.40) .482
CDVA (logMAR)
  Preoperatively 0.29 ± 0.28 (0.05 to 1.60) 0.33 ± 0.21 (0.05 to 0.80) .234
  Postoperativelyb 0.04 ± 0.07 (0.00 to 0.30) 0.04 ± 0.07 (0.00 to 0.30) .767
Lens rotation (°)
  Postoperatively 0.03 ± 7.96 (−20.00 to 30.00) 1.35 ± 11.31 (−11.00 to 60.00) .578
Absolute lens rotation (°)
  Postoperatively 3.70 ± 7.31 (0.00 to 30.00) 3.85 ± 10.98 (0.00 to 63.00) .683
Authors

From European Eye Clinic Lexum, Prague, Czech Republic (MV, LH, MB, ZH); Eye Clinic of the Faculty Hospital Královské Vinohrady and Third Faculty of Medicine of the Charles University, Prague, Czech Republic (MV); and the Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic (MB).

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

AUTHOR CONTRIBUTIONS

Study concept and design (MV, LH); data collection (MV, LH, MB); analysis and interpretation of data (MV, LH, ZH); writing the manuscript (MV, LH, MB); critical revision of the manuscript (ZH); statistical expertise (LH)

Correspondence: Lenka Havlíčková, PhD, European Eye Clinic Lexum–Optegra, Antala Staška 1670/80, CZ-140 00 Prague, Czech Republic. E-mail: nely@seznam.cz

Received: July 24, 2019
Accepted: January 20, 2020

10.3928/1081597X-20200120-01

Sign up to receive

Journal E-contents