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 Table of Contents  
Year : 2023  |  Volume : 3  |  Issue : 2  |  Page : 339-342

Six-year follow-up of toric intra-ocular lens implantation for post keratoplasty astigmatism and cataract – Case reports

1 Cataract, Glaucoma and Refractive Services, ASG Eye Hospital, Kolkata, West Bengal, India
2 Glaucoma Services, Aravind Eye Hospital, Pondicherry, India
3 Department of Ophthalmology, Manaktala Eye and Maternity Home, Meerut, Uttar Pradesh, India
4 Vitreo Retina Consultant, Shree Ram Netralaya, Bhavnagar, Gujarat, India
5 General Ophthalmology, Aravind Eye Hospital, Pondicherry, India
6 Cornea Services, Aravind Eye Hospital, Pondicherry, India

Date of Submission31-Oct-2022
Date of Acceptance08-Feb-2023
Date of Web Publication28-Apr-2023

Correspondence Address:
Annamalai Odayappan
C/O Aravind Eye Hospital, Cuddalore Main Road, Thavalakuppam, Pondicherry - 605 007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2891_22

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We describe the long-term outcomes of two patients who underwent toric intra-ocular lens (IOL) implantation for cataract with post-keratoplasty astigmatism. At 6 years, the IOL was found to be stable with a rotation of less than 2°. Neither of our patients had graft rejection after IOL implantation. There was no significant increase in the corneal thickness, and graft clarity was maintained. The endothelial cell loss in our patients was 10.8% at 1 year, 13.2% at 2 years, and 7.8% at 6 years in case 1 and 9.3% at 1 year, 12.4% at 2 years, and 37.3% at 6 years in case 2.

Keywords: Astigmatism, graft clarity, post-keratoplasty, toric intra-ocular lens

How to cite this article:
Nath M, Odayappan A, Bhatia K, Khodifad AM, Nachiappan S, Shivananda N. Six-year follow-up of toric intra-ocular lens implantation for post keratoplasty astigmatism and cataract – Case reports. Indian J Ophthalmol Case Rep 2023;3:339-42

How to cite this URL:
Nath M, Odayappan A, Bhatia K, Khodifad AM, Nachiappan S, Shivananda N. Six-year follow-up of toric intra-ocular lens implantation for post keratoplasty astigmatism and cataract – Case reports. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 6];3:339-42. Available from: https://www.ijoreports.in/text.asp?2023/3/2/339/374996

Corneal astigmatism following keratoplasty is one of the most common causes of low vision in the presence of a clear graft. After suture removal, the various treatment options available to deal with post-keratoplasty corneal astigmatism include spectacles, contact lenses, relaxing incision with compression sutures, astigmatic keratotomy, photo-refractive keratectomy, laser-assisted in situ keratomileusis, intra-corneal ring segments, and toric intra-ocular lens (IOL). Spectacles are useful for lower degrees of astigmatism but not so effective in anisometropia and high and irregular astigmatism. Contact lenses are less well tolerated because of surface irregularities and dry eyes. In addition, it may predispose to peripheral corneal vascularization, increasing the chances of graft rejection. Corneal refractive surgical procedures may lead to graft dehiscence when suction is applied. The presence of a cataract would anyhow need surgical removal. Phaco-emulsification with toric IOL implantation has been described as an effective option in such patients with coexistent cataract, and it does so without compromising the structural integrity of the eye with more predictable outcomes.[1],[2] However, existing reports have shorter follow-ups.

We report two cases of post-keratoplasty astigmatism with cataract treated with phaco-emulsification, toric IOL implantation, and their 6 years follow-up outcomes with respect to their rotational stability, endothelial cell count, pachymetry, and graft clarity.

  Case Reports Top

Case 1

A 32-year-old female had bilateral recurrent viral keratitis of 9-year duration. The best corrected visual acuity (BCVA) was 6/36 in right eye (OD) and 1/60 in left eye (OS). Anterior segment examination revealed bilateral corneal stromal scarring with vascularization. After a 5-month period of quiescence, she underwent OS penetrating keratoplasty (PKP). Over the next 3 years, the cataract increased to grade 3 nuclear sclerosis. The corneal astigmatism was +8.85 D [Figure 1]. In view of high corneal astigmatism, she underwent OS phaco-emulsification with toric IOL implantation (AcrysofIQ Toric IOL SN60T9, Alcon, Fort Worth, TX, USA). Six years later, the graft was still clear with a stable toric IOL and a BCVA of 6/9.
Figure 1: Corneal topography image of case 1 before cataract surgery taken with Orbscan (a) and at last follow-up using Pentacam (b)

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Case 2

A 35-year-old male was diagnosed to have bilateral macular corneal dystrophy. His BCVA was 6/60 in OD and 6/36 in OS. He underwent bilateral PKP 2 years apart. Two years after OS PKP, he developed a mature cataract with a corneal astigmatism of 2.08 D. Phaco-emulsification with toric IOL implantation (Auroflex Toric IOL FH560T3.0, Aurolab, Madurai, Tamil Nadu, India) was therefore performed. At 6 years, the graft was still clear with a stable toric IOL and a BCVA of 6/9 [Figure 2]. The workup details of both patients are summarized in [Table 1].
Figure 2: Diffuse illumination picture of a patient (a) at 6 weeks and (b) at 6 years

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Table 1: Summary of the patient workup details

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Surgical Technique

Reference markings were made at 0 and 180° using the anterior stromal puncture technique under the slit lamp in the preparatory room.[3] Clear corneal phaco-emulsification was performed under topical anesthesia using the INFINITI® Vision System (Alcon, Fort Worth, TX, USA). Care was taken during incision to not reach the graft–host junction. A dispersive ophthalmic visco-surgical device (OVD) (Viscoat, Alcon, Fort Worth, TX, USA) was used. Direct chop technique of fragmentation was performed to reduce the amount of energy utilized. The main incision was finally sutured with 10-0 nylon for better stability. The workup details of the patient at day 1, 6 months, 1 year, 2 years, and 6 years follow-up visits are summarized in [Table 2].
Table 2: Post-cataract surgery assessment at various timepoints

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  Discussion Top

Here, we note that the IOL was stable with no significant change in corneal thickness or graft clarity 6 years after phaco-emulsification. There was a slight decrease in endothelial cell density (ECD) over the period of 6 years, which was comparable to other post-PKP eyes mentioned in the literature.

Wade et al.[1] described a series of 21 eyes where toric IOL was implanted for post-PKP astigmatism with cataract. The average follow-up was 15 months, and they reported that more than 80% had BCVA ≥20/30. Lockington et al.[2] retrospectively evaluated 26 eyes that underwent toric IOL implantation after keratoplasty and reported BCVA ≥6/12 in 92.3% eyes with a mean follow-up of 14 months. Our patients had a BCVA better than or equal to 6/9 at 6 years after phaco-emulsification.

Stewart et al.[4] compared the IOL rotational stability between PKP and non-PKP groups of patients who underwent Rayner toric IOL implant and found no difference in the rotational stability. We too note that neither of our patients needed IOL re-alignment. The average rotation of toric IOL has been reported to be <7 degrees varying with the IOL material and design.[5] Both our implanted IOLs, one being a hydrophobic lens with C-loop haptics and the other being a hydrophilic lens with plate haptics, seem to maintain good rotational stability.

It has been reported that after keratoplasty, the ECD decreases at the rate of 7.8% per year.[6] Furthermore, following cataract surgery after PKP, accelerated endothelial cell loss was noted, which was around 44.8% at 1 year and 58.1% at 2 years after cataract surgery.[7]

We note that the endothelial cell loss after phaco-emulsification was 10.8% at 1 year, 13.2% at 2 years, and 7.8% at 6 years in case 1 and 9.3% at 1 year, 12.4% at 2 years, and 37.3% at 6 years in case 2. The apparent improvement in ECD in case 1 at 6 years probably reflects the longitudinal variability in estimation of ECD using specular microscopy because endothelial cells do not replicate.[8] Probably, recent advances in phaco-emulsification such as torsional movement, intelligent phaco-emulsification with less energy utilization, and use of a dispersive OVD are successful in protecting the endothelium to a significant extent.

The highlights from this report are that the decrease in ECD after cataract surgery in a post-PKP eye is comparable to other post-PKP eyes. A toric IOL seems to have good rotational stability in these cases and gives good uncorrected vision.

Still longer follow-up of these patients may be necessary to know if corneal decompensation develops and to assess the timing of its onset. The strength of this report lies in its longer follow-up, which is needed to assess the tolerance of the graft unlike many reports in the literature; however, this is only a two-patient series. Prospective long-term evaluation for at least 10 years with ECD assessment from all quadrants with a greater sample may throw new information about the success of toric IOL implantation after keratoplasty.

  Conclusion Top

Toric IOL provides excellent correction of post-keratoplasty astigmatism with cataract with apparently good long-term results but with a slightly higher rate of endothelial cell loss, however not to the magnitude as described in earlier reports.

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 initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wade M, Steinert RF, Garg S, Farid M, Gaster R. Results of toric intraocular lenses for post-penetrating keratoplasty astigmatism. Ophthalmology 2014;121:771-7.  Back to cited text no. 1
Lockington D, Wang EF, Patel DV, Moore SP, McGhee CN. Effectiveness of cataract phacoemulsification with toric intraocular lenses in addressing astigmatism after keratoplasty. J Cataract Refract Surg 2014;40:2044-9.  Back to cited text no. 2
Bhandari S, Nath M. Anterior stromal puncture with staining: A modified technique for preoperative reference corneal marking for toric lenses and its retrospective analyses. Indian J Ophthalmol 2016;64:559-62.  Back to cited text no. 3
[PUBMED]  [Full text]  
Stewart CM, McAlister JC. Comparison of grafted and non-grafted patients with corneal astigmatism undergoing cataract extraction with a toric intraocular lens implant. Clin Exp Ophthalmol 2010;38:747-57.  Back to cited text no. 4
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;40:1654-60.  Back to cited text no. 5
Bourne WM, Hodge DO, Nelson LR. Corneal endothelium five years after transplantation. Am J Ophthalmol 1994;118:185-96.  Back to cited text no. 6
Kim EC, Kim MS. A comparison of endothelial cell loss after phacoemulsification in penetrating keratoplasty patients and normal patients. Cornea 2010;29:510-5.  Back to cited text no. 7
Lužnik Z, Sun Z, Yin J, Benetz BA, Lass JH, Dana R. A standardized methodology for longitudinal assessment of corneal endothelial morphometry in eye banked corneas. J Biol Methods 2019;6:e120.  Back to cited text no. 8


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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