Role of Galilei in IOL power calculations in post-lasik/prk and post-rk eyes

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1 Role of Galilei in IOL power calculations in post-lasik/prk and post-rk eyes Li Wang, M.D., Ph.D, Mariko Shirayama, M.D. Christopher M. Pruet, Mitchell M Weikert, M.D. Douglas D. Koch, M.D. Cullen Eye Institute Baylor College of Medicine Houston, TX

2 Financial Disclosure Travel support (ASCRS 2009) Li Wang, Mariko Shirayama

3 Background Difficulties in determining true corneal refractive power in post-lasik/prk/rk eyes Keratometric inaccuracy Invalid use of effective refractive index of cornea (1.3375) Problems in 3 rd and 4 th generation IOL formulas Inaccurate estimation of ELP Exception: Haigis formula

4 Galilei Dual Scheimpflug Analyzer Placido disk + dual Scheimpflug camera Calculate total corneal power with ray tracing method

5 Purpose To evaluate the accuracy of the Galilei for measuring corneal power in patients following myopic LASIK/PRK To assess the accuracy of IOL power calculation in eyes that underwent myopic LASIK/PRK or RK and subsequent cataract surgery

6 Accuracy for measuring corneal power in patients following myopic LASIK/PRK

7 Patients Inclusion criteria Wavefront-guided LASIK/PRK in our center Stable refraction after the surgery (post-lasik 3 months, post-prk 6 months) Galilei images with good quality 63 eyes Age: 37 ± 9 years (range 21 to 54 years) Refractive correction: 3.66 ±1.65 D (range 1.00 to 7.58 D)

8 Methods Gold standard Corneal power obtained from clinical history method (HisRP) Accurate historical data available in our center Corneal powers from the Galilei Divided into 3 categories according to involvement of posterior corneal power

9 Most accurate corneal power: Total corneal power (0-4mm) y = 1.057x R 2 = HisRP P< Ray Tracing (Total central average)

10 ASCRS IOL Calculator IOL report

11 Accuracy of IOL power calculation in eyes with prior myopic LASIK/PRK

12 Patients Consecutive cases of IOL implantation between April 08 to Feb. 10 Inclusion criteria Prior myopic-lasik/prk Good quality maps with EyeSys, Atlas and Galilei Post-cataract surgery BSCVA 20/30 at 3 weeks or later

13 Patients 28 eyes of 22 patients Mean age: 58 ± 9 years (range 34 to 73 years) IOLs: SN60WF (n=18), Toric (n=4), Crystalens (n=4), ZCB00 (n=1), MA60AC (n=1) 17 eyes of 14 patients had all historical data Myopic LASIK correction: 4.28 ± 2.61 D (range 0.88 to 8.50 D)

14 ASCRS IOL calculator

15 Galilei TCP 0-4 mm Additional zones analyzed for Galilei TCP: 0-2 mm, 0-3 mm, 0-5 mm 3 categories of formulas Target at actual refraction after cataract surgery Double-K Holladay 1 and Haigis-L formulas

16 Methods IOL prediction error = IOL implanted IOL calculated Variance consistency of performance Refractive prediction error Assume 1 D of IOL prediction error producing 0.7 D of refractive error Mean absolute prediction error (MAE) Mean numerical error (MNE) adjusted to zero Eyes within 0.5 D and 1.0 D of refractive error

17 Variance of IOL prediction error with methods using no prior data (n=28) Variance (D 2 ) Wang-Koch- Maloney Shammas Haigis-L Haigis-L tended to have better consistency of performance (all P>0.05). TCP-2mm TCP-3mm TCP-4mm TCP-5mm

18 Refractive mean absolute error (MAE) with methods using no prior data (n=28) MAE (D) Wang-Koch- Maloney Shammas Haigis-L Haigis-L tended to have smaller MAE (all P>0.05). TCP-2mm TCP-3mm TCP-4mm TCP-5mm

19 % of eyes Refractive prediction error with methods using no prior data (n=28) /- 0.5 D 89 +/- 1.0 D % Wang-Koch- Maloney Shammas Haigis-L 39 Proposed benchmark for normal eyes: Gale RP, et al. Benchmark standards for refractive outcomes after NHS cataract surgery. Eye. 2009;23: TCP-2mm 46 TCP-3mm 43 TCP-4mm 46 TCP-5mm UK NHS benchmark ±1.0 D 55% ±0.5 D

20 Refractive MAE with all methods (n=17) Clinical History Feiz-Mannis Corneal Bypass Adjusted EffRP Adjusted Atlas0-3 Masket Modified-Masket Wang-Koch-Maloney Shammas Haigis-L TCP-2mm TCP-3mm TCP-4mm TCP-5mm MAE (D) Significant greater MAE with methods using pre-lasik Ks and MR than those with (all P<0.05)

21 Refractive prediction error with all methods (n=17) /- 0.5 D +/- 1.0D UK NHS benchmark 85% ±1.0 D % ±0.5 D % of eyes Clinical History Feiz-Mannis Corneal Bypass Adjusted EffRP Adjusted Atlas0-3 Masket Modified-Masket Wang-Koch-Maloney Shammas Haigis-L TCP-2mm TCP-3mm TCP-4mm TCP-5mm

22 Summary Refractive MAE with Galilei TCP Tended to be smaller than those with historical data Similar with other methods using no prior data % of eyes within 0.5 D of refractive prediction errors with Galilei Tended to be smaller than those with other methods using no prior data

23 Accuracy of IOL power calculation in eyes with prior RK

24 Purpose Because RK eyes have variable front and back curvatures, IOL calcs are especially challenging To evaluate the accuracy of 4 devices for calculating corneal power for IOL calculations in RK eyes undergoing cataract surgery IOLMaster, EyeSys, Atlas, Galilei

25 Patients Consecutive cases of IOL implantation between April 08 to February 10 Inclusion criteria Prior RK Good quality maps with IOLMaster, EyeSys, Atlas, and Galilei Post-cataract surgery BSCVA 20/30 at 3 weeks or later

26 Patients 21 eyes of 14 patients Mean age: 63 ± 10 years (range 47 to 79 years) 5 male and 9 female IOLs: SN60WF (n=12), Toric (n=8), SA60AT (n=1)

27 Corneal powers evaluated IOLMaster (anterior) K readings: Average of K1 and K2 IOLMaster K EyeSys (anterior) Zone: EffRP - all points within the central 3 mm and takes into account the Stiles-Crawford effect EyeSys EffRP

28 Corneal powers evaluated Atlas (anterior) Zones: Averages over central 2-, 3-, 4-, and 5-mm zones Atlas zone0-2, Atlas zone0-3, Atlas zone0-4, and Atlas zone0-5 Annuli: Average of 1-, 2- and 3-mm and average of 1-, 2-, 3- and 4-mm annuli Atlas annuli1-3 and Atlas annuli1-4

29 Corneal powers evaluated Galilei Dual Scheimpflug Analyzer (anterior and posterior) Zones: Total corneal power (TCP) with ray tracing Average over central 2-, 3-, 4-, and 5-mm zones TCP zone0-2, TCP zone0-3, TCP zone0-4, and TCP zone0-5 Annuli: Average: 1-, 2-, 3-mm and 1-, 2-, 3-, 4-mm annuli TCP annuli1-3 and TCP annuli1-4

30 Target at actual refraction after cataract surgery Double-K Holladay 1 formulas

31 Methods Refractive prediction error Assume 1 D of IOL prediction error producing 0.7 D of refractive error Mean absolute prediction error (MAE) Mean numerical error (MNE) adjusted to zero % of eyes within 0.5 D and 1.0 D

32 Methods Select the best method for Atlas and Galilei Smallest variance (SD 2 ) of IOL prediction error Compare accuracy among devices

33 Variance of IOL prediction error with Atlas 3.0 Variance (D 2 ) Atlas zone0-2 Atlas zone0-3 Atlas zone0-4 Atlas zone0-5 Atlas annuli1-3 Atlas annuli1-4

34 Variance of IOL prediction error with Galilei TCPzone0-2 TCPzone0-3 TCPzone0-4 TCPzone0-5 TCPannuli1-3 TCPannuli1-4 Variance (D 2 )

35 Refractive mean absolute error (MAE) with different devices MAE (D) EyeSys EffRP IOLMasterK Atlas zone0-3 TCP annuli1-4 Galilei TCP annuli1-4 tended to produce smallest MAE (all P>0.05).

36 Refractive prediction error / D +/- 1.0 D UK NHS benchmark 85% ±1.0 D % of eyes % ±0.5 D EyeSys EffRP IOLMaster K Atlas zone0-3 TCP annuli1-4 Proposed benchmark for normal eyes: Gale RP, et al. Benchmark standards for refractive outcomes after NHS cataract surgery. Eye. 2009;23:

37 Sample case: 59 yo female, AL=23.91 mm IOLMaster K = D EyeSys EffRP = D

38 Atlas zone0-3 = D Galilei TCP zone0-4 = D Galilei TCP annuli1-4 = D

39 Targeting refraction of D Devices Corneal powers (D) Predicted IOL power (D) IOLMaster K EyeSys EffRP Atlas zone Galilei TCP zone Galilei TCP annuli IOL prediction error (D) SN60WF 29 D implanted x90 = 1.13 D Ideal IOL power for ref = 31.3 D

40 Summary Galilei TCP annular average 1-4 mm tended to have the most consistent performance in IOL power prediction Met the UK NHS benchmark standards for normal eyes Surprises still occur Need: more eyes and more sites!

41 Conclusion Galilei is a useful adjunct in IOL power calculations in post-lasik/prk eyes Getting better Recent new software Refining ongoing Galilei is a outstanding tool for RK eyes

42 Current practice Use Total Corneal Power from the Ray Tracing calculation One of our key parameters in estimating corneal refractive power in eyes that have undergone corneal refractive surgery

43 Thank you for your attention!

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