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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 84-86

Misalignment of a toric introaocular lens and reoperation after phacoemulsification with implantation of AT TORBI 709M: A case report


Eye Institute, Eye and ENT Hospital, College of Medicine; State Key Laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Shanghai Medical College, Fudan University; Shanghai Key Laboratory of Visual Impairment and Restoration, Science and Technology Commission of Shanghai Municipality; Key Laboratory of Myopia (Fudan University), Chinese Academy of Medical Sciences, National Health Commission, Shanghai, China

Date of Submission11-Aug-2020
Date of Acceptance16-Mar-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Yi Luo
EENT Hospital of Fudan University, 83 Fenyang Road, Shanghai
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2570_20

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  Abstract 


We aimed to report a case of two-time misalignment of a toric intraocular lens (IOL) AT TORBI 709M shortly after cataract surgery and the solution to the problem. A 53-year-old man had progressively decreased vision in his left eye (OS) for more than 5 years. The uncorrected visual acuity was 20/100 in the left eye. Phacoemulsification and toric IOL implantation (AT TORBI 709M, +16.5D with cyl +2.5D) were smoothly performed in the left eye. Only 1 week after surgery, the toric IOL became misaligned. So repositioning surgery was performed 1 month later. However, the toric IOL misalignment reoccurred only 1 day after repositioning surgery. Finally, 2 weeks after repositioning surgery, toric lens replacement (Rayner T-flex Aspheric, +17.0D with cyl +2.5D) was performed in the left eye. The toric IOL became stable in the next 2 months. We concluded that Toric IOLs with larger size are more stable in larger eyes.

Keywords: Case report, intraocular lens replacement, misalignment, repositioning, toric Intraocular lens


How to cite this article:
Gao C, Lin X, Luo Y. Misalignment of a toric introaocular lens and reoperation after phacoemulsification with implantation of AT TORBI 709M: A case report. Indian J Ophthalmol Case Rep 2022;2:84-6

How to cite this URL:
Gao C, Lin X, Luo Y. Misalignment of a toric introaocular lens and reoperation after phacoemulsification with implantation of AT TORBI 709M: A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 23];2:84-6. Available from: https://www.ijoreports.in/text.asp?2022/2/1/84/334939



Implantation of the toric intraocular lens (IOL) is an established safe and effective choice for the correction of regular corneal astigmatism in cataract surgery, especially with cataract in combination with preexisting regular corneal astigmatism.[1],[2],[3],[4] One available model is the bitoric single-piece, plate haptic IOL AT TORBI 709M (Carl Zeiss Meditec AG, Germany). AT TORBI 709M toric IOL could successfully correct ocular astigmatism[5] and provide a predictable correction of corneal astigmatism with low postoperative levels of ocular higher-order aberrations.[6] Both Acrysof SN6AT IOL and AT Torbi 709M IOL have shown clinical effectiveness in terms of astigmatism correction, rotational stability, and optical quality.[7] Even in myopic eyes, implantation of the 4-haptic toric IOLs was effective and safe, and the IOL showed no significant rotation over the 6-month follow-ups.[8] It was reported that mean absolute IOL misalignment was 3.5° with values ranging from 0° to 10°.[6]

However, in the present case, AT TORBI 709M IOL was misaligned only 1 week after cataract surgery, and misaligned again only 1 day after repositioning surgery. The problem was solved by replacing it with another type of toric IOL (Rayner T-flex Aspheric). Here, we reported this rare case and shared our experience with solution to misaligned toric IOL in a certain condition.


  Case Report Top


A 53-year-old man came to our hospital due to progressively decreased vision in his left eye (OS) for more than 5 years. The uncorrected visual acuity was 20/20 in the right eye (OD) and 20/100 in the left eye, and the best visual acuity did not improve in the left eye. The man had no ocular trauma or operation history. In ocular examination, anterior segments were normal in both eyes except severe cataract in the left eye [Figure 1]a and [Figure 1]b. Fundus examination showed a well-attached retina and pinkish optic disc in both eyes. Basically normal retinal structure was shown in both eyes by optical coherence tomography (OCT) scanning (Cirrus OCT 5000, Carl Zeiss Meditec AG, Germany) [Figure 1]c and [Figure 1]d. His keratometry data were collected by Pentacam (Oculus, Wetzlar, Germany) [Figure 1]e and [Figure 1]f. His biometry data were collected by IOL Master (IOL Master 700, Carl Zeiss Meditec AG, Germany) [Figure 1]g, including axial length (AL), anterior chamber depth (ACD) and white to white (WTW). All the data were measured for three times by the same experienced doctor. A regular astigmatism of 2.1 D was found in the left eye by Pentacam [Figure 1]f. Therefore, a toric IOL (AT TORBI 709M) was chosen for this patient.
Figure 1: Anterior segment imaging, examination of OCT, keratometry and biometry data collected by Pentacam and IOL Master. (a) Anterior segment photograph of the right eye. (b) Anterior segment photograph of the left eye. (c) OCT image of the right eye. (d) OCT image of the left eye. (e) The Pentacam result of the right eye. (f) The Pentacam result of the left eye. (g) The IOL Master result of both eyes

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Phacoemulsification and toric IOL implantation were smoothly performed in the left eye by an experienced surgeon. A Toric IOL AT TORBI 709M (Carl Zeiss Meditec AG, Germany) +16.5D with cyl +2.5D was implanted with the astigmatic axis at 112°. Biometry of the toric lens was done through Z CALC online IOL calculator (https://zcalc.meditec.zeiss.com/).

One day post-operation, the uncorrected visual acuity (UCVA) was 20/25. One week post-operation, UCVA was 20/50 in the left eye and the best-corrected visual acuity (BCVA) was 20/20 with a spectacle correction of –0.25/–1.75 × 55. One month post-operation, UCVA was 20/50 in the left eye and BCVA was 20/20 with a spectacle correction of –0.25/–1.50 × 175. During this period, the patient had no strenuous exercises, strikes or eye rubbing. Therefore, 2 months post-operation, repositioning surgery was performed in the left eye by the same surgeon. The astigmatic axis of toric IOL was repositioned from 170° to 112° during the surgery. One day after surgery, UCVA was 20/40 in the left eye and BCVA was 20/20 with a spectacle correction of -0.50/-1.25 × 170. One week after surgery, UCVA was 20/40 in the left eye and BCVA was 20/20 with a spectacle correction of –0.25/–2.25 × 5. Ocular anterior photograph showed the astigmatic axis was about 170° which misaligned approximately 60° [Figure 2].
Figure 2: Ocular anterior photograph of the left eye one week after repositioning surgery

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Then a toric lens replacement was considered and a Rayner IOL (Rayner T-flex Aspheric, United Kingdom) was selected. Biometry of the toric lens was done through Raytrace online IOL calculator (https://www.raytrace.rayner.com/).

Two weeks after the repositioning surgery, the toric lens replacement surgery was smoothly performed in the left eye by the same surgeon. AT TORBI 709M toric lens was taken out and Rayner T-flex Aspheric +17.0D with cyl +2.5D was implanted with the astigmatic axis at 113°. One day after lens replacement surgery, UCVA was 20/25 in the left eye and BCVA was 20/20 with a spectacle correction of –0.25/–0.50 × 90. Two months after lens replacement, UCVA was 20/20 in the left eye. The ocular anterior photograph showed well-aligned astigmatic axis at approximately 113° [Figure 3].
Figure 3: Ocular anterior photograph of the left eye 2 months after lens replacement

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  Discussion Top


A case was described before of a misaligned AT TORBI 709M IOL 15 months after uneventful phacoemulsification and IOL implantation in the capsular bag, in which keratoconus with partly regular astigmatism was preexisting.[9] In our case, the AL was 24.82 mm and ACD was 3.65 mm of the left eye. A regular astigmatism of 2.1 D was found in the left eye. There existed no other ocular diseases except cataract. Theoretically, AT TORBI 709M toric IOL was suitable for this patient. However, AT TORBI 709M IOL was misaligned only 1 week after cataract surgery, and was misaligned again only 1 day after repositioning surgery of toric IOL. The problem was eventually solved through IOL replacement by another type of toric IOL (Rayner T-flex Aspheric).

As mentioned in previous study,[8] implantation of AT TORBI 709M IOL in myopic eyes was effective and safe, and the IOL showed no significant rotation over the 6-month follow-up. In this study, patients had the AL ranging from 25.00 to 27.00 mm, the ACD ranging from 3.00 to 3.80 mm, and WTW ranging from 11.50 to 12.10 mm. In our case, the patient had an AL of 24.82 mm, an ACD of 3.65 mm, and WTW of 12.40 mm. The patient did have a myopic eye, and only WTW was significantly different (12.4 mm versus 11.5 to 12.1 mm).

We doubted that one possible reason for the misalignment of AT TORBI 709M IOL might be WTW of the left eye (12.4 mm). Considering that the total diameter was 11 mm of AT TORBI 709M IOL and 12 mm of Rayner T-flex Aspheric IOL, and the optical diameter was 6 mm of AT TORBI 709M IOL and 6.25 mm of Rayner T-flex Aspheric IOL. Compared with AT TORBI 709M IOL, Rayner T-flex Aspheric IOL was larger in size which might be more suitable for this patient [Figure 4].
Figure 4: Comparison of AT TORBI 709M IOL and Rayner T-flex Aspheric IOL in total and optical diameter

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There were several limitations of the study. Firstly, this is only a case report, and a further large-scale prospective study on these cases is necessary to illuminate the relationship between the stability and the size of different toric IOLs in patients with different sizes of eyeballs. Secondly, WTW might account for the misalignment of AT TORBI 709M IOL, but there might still exist other factors resulting in this problem, which might not be explained clearly and thoroughly in only one case. We still need confirmation by a large-scale study in the future.


  Conclusion Top


Toric IOLs with larger size are more stable in larger eyes. However, a large-scale study is necessary in the future.

Ethics approval and consent to participate

This study was performed in accordance with the tenets of the Declaration of Helsinki for research involving human subjects. Written informed consent was obtained from the patient.

Consent for publication

The patient agreed to publish the findings and figures gathered from himself in this paper.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bethke W. Surgeons embrace toric intraocular lenses. Rev Ophthalmol 2008;15:60-5.  Back to cited text no. 1
    
2.
Bethke W. The upward trend continues for toric IOLs. Rev Ophthalmol 2009;16:43-6.  Back to cited text no. 2
    
3.
Krall EM, Arlt EM, Hohensinn M, Moussa S, Jell G, Alió JL, et al. Vector analysis of astigmatism correction after toric intraocular lens implantation. J Cataract Refract Surg 2015;41:790-9.  Back to cited text no. 3
    
4.
Mustafa OM, Prescott C, Alsaleh F, Dzhaber D, Daoud YJ. Refractive and visual outcomes and rotational stability of toric intraocular lenses in eyes with and without previous ocular surgeries: A longitudinal study. J Refract Surg 2019;35:781-8.  Back to cited text no. 4
    
5.
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.  Back to cited text no. 5
    
6.
Kretz FT, Breyer D, Klabe K, Auffarth GU, Kaymak H. Clinical outcomes and capsular bag stability of a four-point haptic bitoric intraocular lens. J Refract Surg 2015;31:431-6.  Back to cited text no. 6
    
7.
Scialdone A, De Gaetano F, Monaco G. Visual performance of 2 aspheric toric intraocular lenses: Comparative study. J Cataract Refract Surg 2013;39:906-14.  Back to cited text no. 7
    
8.
Mencucci R, Favuzza E, Guerra F, Giacomelli G, Menchini U. Clinical outcomes and rotational stability of a 4-haptic toric intraocular lens in myopic eyes. J Cataract Refract Surg 2014;40:1479-87.  Back to cited text no. 8
    
9.
Brandlhuber U, Haritoglou C, Kreutzer TC, Kook D. Reposition of a misaligned Zeiss AT TORBI 709M® intraocular lens 15 months after implantation. Eur J Ophthalmol 2014;24:800-2.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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