Transepithelial or intrastromal

femtosecond laser arcuate

keratotomy to manage corneal
astigmatism at the time of cataract
surgery
D . L o p e s , T. L o u r e i r o , R . C a r r e i r a
S . R o d r i g u e s B a r r o s , J . N o b r e C a r d o s o , P.
Campos, I. Machado, N. Campos
Introduction
Modern cataract surgery allows cataract surgeons to reach excellent visual
acuity results with safety and consistency

Patient expectations regarding postoperative outcomes have also increased

It’s known that residual astigmatism inferior to 1.00 D  result in

deterioration of visual acuity and visual symptoms, like blurred vision,
glare, and halos
Introduction
Cataract surgery  great opportunity to correct preexisting
corneal astigmatism and to prevent residual refractive astigmatism

Clinical application of the image-guided FSL to treat corneal

astigmatism with AI has been reported in multiple situations

PURPOSE OF THIS STUDY

to compare the results of these two types of AI performed at the time

of FLACS to treat low-to-moderate corneal astigmatism
Methods

Design study Study settings

Retrospective study A single center over a period of 5 months

Study participant Inclusion criteria

Patients who underwent elective FLACS with

All included patients had bilateral cataract and
femtosecond laser AIs, transepithelial AI in one
corneal astigmatism between 0.70 to 2.00 D
eye and intrastromal AI in the fellow eye, for
measured by IOL Master®700
astigmatism management
Methods
The eyes of each patient were divided into 2 groups Exclusion Criteria
• The transepithelial
• The intrastromal group • Contact lens wearers
• Patients with history of corneal surgery
The two eyes of each patient were randomly • Irregular astigmatism
assigned using the tool random numbers of the • High ametropia
Quickcalcs software • History of vitreoretinal surgery
• Any ocular pathology limiting visual
acuity
 Methods
Preoperative evaluation and planning
• Slit-lamp biomicroscopy
• Dilated fundoscopy
• Optical biometry
• Corneal topographic analysis with pentacam HR
• Intraocular lens (IOL) power calculations
Each surgeon  used their own surgically induced
astigmatism values, ranging from 0.25 D to 0.5 D.
FSL treatment of the cataract, transepithelial and
intrastromal AIs  performed with Catalys FSL
platform
According to this adaptation
• 100% of the ATR, 180◦± 30◦ astigmatism
• 80% OBL, 45◦± 14◦or135◦± 14◦ astigmatism
• 70% for WTR, 90◦± 30◦ astigmatism
Methods
Anterior penetrating AIs
• Guided by real-time spectral domain
optical coherence tomography
• Placed at a 9.0 mm optical zone,
• limbal centered
• performed orthogonal to the anterior
corneal surface and with a corneal depth
of 80%.
All intrastromal
Nonpenetrating AIs
• programmed to be 8.0 mm diameter paired
symmetrical arcs
• centered on the limbus
• 90-degree side-cut angle
• a depth between 20% and 80% of real-
time corneal pachymetry
Methods

Reference marker  at 3 and 9 o’clock with the patient sitting

upright:
• helping to dock correctly the patient’s eye underneath the laser
apparatus with a proper orientation and correction for
cyclotorsion.

Cataract surgery  completed in another OR by a standard

phacoemulsification procedure

Postoperative final evaluation

• Visual acuity
• Refraction and optical biometry
• Performed between 2 to 3 months after the surgery of the
second eye.
Methods
The outcome measures were the difference between
preoperative and postoperative:

• Keratometric corneal cylinder (kcyl) CI  measure of treatment accuracy and

• Correction index (CI)
• Percentage of eyes with overcorrection,
• Percentage of eyes with ≤ 0.5 D kcyl or ≤ 0.5 D
manifest residual refractive astigmatism (RRA)
• Angle of error
represents the ration between the surgical
induced astigmatism (SIA) and target
induced astigmatism (TIA)
Statistical Analysis

• The analysis and calculation of these 3 parameters were

performed with ASSORT software through a vector analysis,
using the Alpins method.

• Comparative and descriptive statistical analysis was

performed using SPSS

• A p value less than 0.05 was considered statistically

significant.
Results
Results
Results

Figure 1 – Distribution of the surgical induced astigmatism (SIA) in the transepithelial (A)
and intrastromal (B) groups
Results

The percentage of eyes achieving 0.5 D or less of

postoperative Kcyl was 30% in transepithelial group
and 40% in the intrastromal group
Results

Figure 3 – Distribution of astigmatism angles of error

Discussion
There are multiple significant predictors of the efficacy of astigmatic
correction with corneal incisions including:

• Number of incisions • Cylinder meridian

• Incision length • Optical zone
• Age • Corneal biomechanics

Manual LRI  generally considered to have a higher chance of

intraoperative or postoperative complications

• generally performed by experienced surgeons

• both techniques  efficacious and safe at reducing corneal
astigmatism during cataract surgery
Discussion
STUDY FINDING The transepithelial AIs present a higher astigmatism
correction than the intrastromal AIs
(CI of 0.83 vs 0.68)

However this is associated with a higher percentage of eyes with

overcorrection (25% vs 5%)

The nomogram adaptation and the decision about opening the anterior penetrant incisions
can be relevant contributors to the higher CI (0,95 vs 0,83) and the higher percentage of
overcorrection(48 vs 25 %) in comparison to our study.
Treatment

Residual astigmatism  common cause of patient dissatisfaction

Despite the small sample size all
5 cases of overcorrection occurred
in eyes with ATR astigmatism.
However, if the CI was calculated
a parameter that reflected the total
amount of astigmatism  the
percentage of overcorrection
would be inferior in these cases
and spectacles dependence after cataract surgery
Both groups showed a statistically significant reduction in Kcyl
after AIs
Analyzing the manifest RRA
Eyes achieved residual astigmatism ≤ 0.5 D
75% transepithelial group
VS
90% in the intrastromal group
 Treatment
The distribution of the angle error  revealed an
interquartile range of 30o in the transepithelial
group and 24 degrees in the intrastromal group.
Probably results from:
• Imperfect construction
• Location of corneal incisions
Influences the efficacy of corneal incisions as
reported by Chan et al.
An automated identification of the steep corneal
meridian for femtosecond AIs placement would
improve astigmatic axis accuracy  reducing
the angle of error
This study presented an interquartile range
similar to Kaufmann et al. with manual LRI and
Day et al. with FSL
Limitations

1. Small sample size of each group

2. Surgeries performed by different surgeons
3. Short follow-up period.
4. The FSL transepithelial AIs were not deliberately opened and this may
have introduced some variability in the SIA as some incisions may have
opened spontaneously.
5. The inherent measurement variability and thus the results must be
interpreted with caution, in particular, the CI.
Conclusion
Both intrastromal and transepithelial AIs showed potential for
mild to moderateastigmatism correction and appeared to be a safe
procedure. Despite transepithelial AIs presented a higher CI, the
intrastromal AIs results were more predictable.