Case Study: Navigating Complex Astigmatism and Achieving Spectacular Outcomes
A 67-year-old male presented to us in April 2024 for cataract evaluation. His case was complex, involving irregular astigmatism from pellucid marginal degeneration and a history of INTACS in both eyes. After careful consideration, we recommended cataract surgery with Light Adjustable Lenses (LAL) in both eyes.
Post-operatively in May 2024, his left eye exhibited nearly 7 diopters of astigmatism despite pre-op measurements showing only 4D of corneal cylinder. This is a classic example of the refractive surprises that can occur with irregular corneas.
Initial Post-Op Refractions:
- OD: +0.50-4.75×095
- OS: +0.25-7.00×100
The patient opted to focus on treating his left eye first. After three LAL adjustments, we reduced the astigmatism but couldn’t fully correct it, leaving him at +0.75-3.50×100 OS. Recognizing the limits of further adjustments, we recommended an IOL exchange.
We removed his LAL, implanted a toric IOL (max available correction: 4D at the corneal plane), and added a piggyback LAL for fine-tuning.
Results:
- Day 1 Post-Exchange: Unaided vision in OS was an impressive 20/20-.
- 1 Month Post-Exchange: After LAL adjustments, unaided vision was 20/15 in OS with plano refraction.
The patient decided to preserve his right eye for near vision, achieving unaided J1 OD and -0.75-1.00×104 refraction by September 2024.
Left eye topography showing large amount of against-the-rule astigmatism w/ Pellucid Marginal Degeneration presentation.
Right eye topography showing irregular against-the-rule astigmatism of Pellucid Marginal Degeneration
OS corneal view w/ inferior INTACS segment
OD corneal view with 2 INTACS segments
View through the Light Delivery Device (LDD) with anterior haptic of the LAL IOL in focus
This case is a reminder of the artistry and science involved in tackling irregular corneas and achieving exceptional outcomes. Together, we continue to redefine what’s possible in vision correction for our patients.
