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Cataract Surgery Using Biaspheric IOLs in Patients With Corneal Irregularities James P. Gills, MD St. Lukes Cataract & Laser Institute Tarpon Springs FL Financial Disclosure: Dr. Gills is a stockholder In Lenstec, Allergan, Alcon and Abbott Medical.

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Purpose To present case reports of patients with pre-existing corneal irregularities who underwent routine cataract surgery with an aberration free, biaspheric IOL between May and October 2010.

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What is Paraxial Focus? Why is it important to the biaspheric lens design? The strategy of the lens design is to reduce spherical aberrations by controlling the paraxial ray of light so that it intersects at the paraxial focal point instead of in front or behind it.

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Case 1: Keratoconus Surgical Status Uncomplicated surgery on 7/19/2010 9.0 D Softec HD IOL 2mm CRI @ 7:30 in 8 mm optical zone (1/2 the usual correction) Presentation 1-2+ cortical spoke cataract Keratoconus OS Diabetic with no evidence of BDR Manifest Refraction: -4.50 -5.25 x 140 20/40 Pachymetry: 492 m Cell Count: 1761 cells/m 2 Axial Length: 28.39 mm 2 Month Postoperative Outcome (9/22/10) UCVA: 20/20 J10 Ref: Plano 20/20 Imp: Less astigmatism correction required; patients awareness of glare was minimized

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Case 2: Hexagonal Keratotomy Surgical History 1993 Hexagonal Keratotomy OD Surgical Status Uncomplicated surgery on 5/25/2010 14.0 D Softec HD IOL Presentation 2+ nuclear cataract Pachymetry: 607m Axial Length: 23.56 mm Manifest refraction: - 2.25 - 2.00 x 130 20/30 3 Month Postoperative Outcome (8/25/10) UCVA: 20/25 J1 Ref: - 0.25 - 0.75 x 150 20/25 Imp: Less astigmatism correction required; patients awareness of glare was minimized

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Case 3: LASIK Surgical History Bilateral LASIK Surgical Status Uncomplicated surgery 11.5 D Softec HD IOL Presentation Cataract OD Axial Length: OD: 27.88 mm Manifest Refraction: OD: -10.25 0.25 x 10 5 Month Postoperative Outcome UCVA: 20/40 J8 Ref: 0.50 0.50 x 35 20/30 Imp: Patients awareness of glare was minimized despite extremely irregular cornea

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Case 4: ABMD Presentation Bilateral cataract ABMD with Corneal Scarring Amblyopia OS Normal macula Pachymetry: OS: 546 m Biometry: OS: 21.98 mm Manifest Refraction: OS: +3.25 0.75 x 105 Slide 1 of 2

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Case 4: ABMD Continued Surgical Status Planned monovision: -2.0 D Target with 30.0 D Softec HD IOL OS Uncomplicated surgery LRIs: OS: 7 mm @ 4:45 OS: 5 mm @ 10:30 and 4:30 enhancement Postoperative Outcome 3 Month Postoperative OS UCVA: 20/200 J1+ Ref: -2.50 0.75 x 10 20/25 Imp: Patients awareness of glare was minimal; improved quality of vision post-operatively despite corneal irregularities

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Case 5: Radial Keratotomy Surgical History Radial Keratotomy in 1990s 24 cut OD / 20 cut OS Cataract Removal OD ReSTOR +4 with piggyback lens Presentation (6/15/10) Pseudophakic OD / Cataract OS Anterior surface pigment piggyback (OD) Cobblestone OS Cell Count: 1618 cells/m 2 OD / 2625 cells/m 2 OS Pachymetry: 478 m OD / 673 m OS Biometry: 25.57 mm OD / 24.90 mm OS Manifest Refraction: OD: +1.75 0.75 x 135 OS: +0.50 1.25 x 150 Slide 1 of 2 (Performed elsewhere)

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Case 5: Radial Keratotomy Surgical Status OD (7/16/10) Exchanged both IOLs -1.25 D Target with 21.0 D Softec HD IOL Scleral incision 6 mm @ 9:00 9-0 nylon suture at 2:30 OS (6/25/10) -2.00 D Target with 28.0 D Softec HD IOL Scleral incision 2.75 mm @ 2:30 Postoperative Outcomes 5 Month Postoperative OD UCVA: 20/40 J10 Ref: +1.50 1.50 x 30 20/25 5 Month Postoperative OS UCVA: 20/100 J1+ Ref: -3.00 1.00 x 165 20/25 OD OS Imp: Biaspheric IOLs improved paraxial focus by reducing spherical aberrations resulting in marked improvement in VA

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Conclusion As demonstrated, the aberration free, biaspheric IOL is preferred for patients with corneal irregularities. Compared with conventional spherical IOL cases, those presented here require approximately half as much astigmatic correction and reported little or no glare. This phenomena may be attributed to the aberration free, biaspheric optic of the reported IOL. The paraxial focus that is associated with this IOL appears to primarily use the central cornea. This paraxial focus appears to reduce spherical and optical aberrations, thus improving pseudophakic vision.