COMPARISON OF PRE-OPERATIVE AND POST-OPERATIVE

ASTIGMATISM IN PHACO EMULSIFICATION WITH MONO-FOCAL

IOL

RESEARCH PROJECT DONE BY

NIRMIT BHARAT PAREKH

RAI2018B-OPT6F047

UNDER GUIDANCE OF

DR. RAKESH SHAH

VITREO RETINAL, CATARACT & LASER REFRACTIVE SURGEON,

MEDICAL DIRECTOR

SWARAASHI NETRALAYA

SUBMITTED TO

ITM UNIVERSITY

BATCH: 2018-2022
 COMPARISON OF PRE-OPERATIVE ASTIGMATISM AND POST-

OPERATIVE IN PHACO EMULSIFICATION WITH MONO-FOCAL

IOL

RESEARCH PROJECT DONE BY

NIRMIT BHARAT PAREKH

RAI2018B-OPT6F047

UNDER GUIDANCE OF

DR. RAKESH SHAH

VITREO RETINAL, CATARACT & LASER REFRACTIVE SURGEON,

MEDICAL DIRECTOR

SWARAASHI NETRALAYA

SUBMITTED TO

ITM UNIVERSITY

BATCH: 2018- 2022

 RESEARCH PROJECT APPROVAL FORM

OPTOMETRY

This is to certify that the Thesis titled COMPARISON OF PRE-

OPERATIVE AND POST-OPERATIVE ASTIGMATISM IN PHACO

EMULSIFICATION WITH MONO-FOCAL IOL, Submitted by

NIRMIT BHARAT PAREKH having Roll No RAI2018B-OPT6F047

batch 2018-2022 for the partial fulfillment of requirements of B.Optometry

degree.

RESEARCH COMMITTEE

___________________ ___________________ __________________

DIRECTOR PRINCIPAL ASSISTANT

ITM ITM PROFESSOR

ITM

Date: _________ Date: __________ Date: _________

 CERTIFICATE

This is to certify that NIRMIT BHARAT PAREKH having Roll no

RAI2018B-OPT6F047 batch 2018-2022 of B.Optometry student has carried

out this research project titled COMPARISON OF PRE-OPERATIVE

AND POST-OPERATIVE ASTIGMATISM IN PHACO

EMULSIFICATION WITH MONO-FOCAL IOL during the Academic

year 2020-2021.

PRINCIPAL:

DATE: 20/05/2022
 CERTIFICATE

This is to certify that the research project titled COMPARISON OF PRE-

OPERATIVE AND POST-OPERATIVE ASTIGMATISM IN PHACO

EMULSIFICATION WITH MONO-FOCAL IOL submitted by NIRMIT

BHARAT PAREKH having Roll no RAI2018B-OPT6F047 batch 2018-

2022 for the partial fulfillment of the requirements of B.Optometry degree

embodies the work done by him under my guidance.

EXTERNAL GUIDE:

DR. RAKESH SHAH

VITREO RETINAL, CATARACT &

LASER REFRACTIVE SURGEON,

MEDICAL DIRECTOR,

SWARASHI NETRALAYA

DATE: 20/05/2022
 DECLARATION

I, NIRMIT BHARAT PAREKH having Roll no RAI2018B-OPT6F047 batch

2018-2022 hereby declare that this research project titled COMPARISON OF

PRE-OPERATIVE AND POST-OPERATIVE ASTIGMATISM IN

PHACO EMULSIFICATION WITH MONO-FOCAL IOL submitted by

me to the ITM. This is a bonafide work undertaken by me and it is not

submitted to any other organization for the award of any degree or

published any time before.

SIGNATURE:

NAME: NIRMIT BHARAT PAREKH

DATE: 20/05/2022
 ACKNOWLEDGEMENT

▪ I would like to thank Mr. Purushottam Naidu Principal of ITM College

of Optometry, for giving me the opportunity to work on this project.

▪ I would like to thank my guide Dr. Rakesh Shah and Dr. Sahana Bangera

who has been a constant source of inspiration for me, without whose

knowledge the project would not have been materialized on time.

▪ My sincere gratitude towards the entire Faculty of ITM College of

Optometry for supporting and guiding me throughout this project.

▪ I would also like to thank Swaraashi Netralaya Hospital for allowing me

to use their instrument for my project.

▪ I would like to thank all my participants without whose participation this

project would not been possible.

▪ Lastly, I would like to thank my family and friends for their constant

support throughout this period.

 TABLE OF CONTENT

SR. NO TOPICS PAGE NO

1 ABSTRACT 1-3

2 AIM AND OBJECTIVE 4

3 INTRODUCTION 5-6

4 REVIEW OF LITERATURES 7-8

5 MATERIALS & METHODOLOGY 9-10

6 PLAN FOR STATISTICAL ANALYSIS 11

7 RESULTS 12-15

8 DISCUSSION 16-17

9 LIMITATION & RECOMMENDATION 18

10 CONCLUSION 19

11 REFERENCES 20-21

11 CHECKLIST 22
 ABSTRACT

TITLE: Comparison of pre-operative and post-operative astigmatism in phaco

emulsification with mono-focal iol.

AIM: To evaluate corneal astigmatism after phaco emulsification using 2.2 mm

clear corneal micro-incisions and its effects on visual function and to assess the

prevalence and severity of preoperative and postoperative astigmatism in

subjects with cataract.

METHODOLOGY: In this retrospective study we include 100 subjects with 45

females and 55 males with Age related Cataract of all grades. 100 subjects had

undergone a standardized protocol of Cataract Assessment in our hospital

including, History Taking, Un Corrected visual activity(UCVA) for both distance

and near and Best Corrected Visual Acuity (BCVA) for both Distance and near

including pinhole vision. 100 subjects with cataract underwent superior incision

2.2 mm clear corneal micro-incision phaco emulsification combined with folding

monocular intra ocular lens implantation operated by a single surgeon. All the

above protocols were carried out again after the surgery on day 1, 1 week and

3 weeks after surgery, subject’s both Un Corrected Visual Acuity (UCVA) and Best

Corrected visual acuity (BCVA) was obtained to check if there was any difference

in the residual astigmatism. All these data was retrieved from the electronic

medical records.
1
INCLUSION CRITERIA:

1. Subject with age between 20-80 years with the subject who is suffering from

decreased vision due to cataract of all grades along with Astigmatism before

surgery.

2. Subjects who opted for mono-focal Intra Ocular Lens.

3. Cataract of all grades.

EXCLUSION CRITERIA:

1. Toric, Multifocal, Trifocal and Toric Trifocal Intra Ocular Lens are excluded

from the study.

2. Subjects with any pathological conditions (eg:- glaucoma, optic neuropathy,

uveitis and etc.) are excluded from the study.

3. Complicated cataracts.

RESULTS:

Our result indicates, p value is 1 of Astigmatism Before Surgery with Astigmatism

After Surgery so that there is no significance difference (p value is more that 0.05

at 95% confidence interval level) between two variables as mean (-0.8550) of

both variable is same (t=1)

2
Our result indicates, p value is 0.081 of Astigmatism Before Surgery with

Astigmatism After Surgery so that there is no significance difference (p value is

more that 0.05 at 95% confidence interval level) between two variables as mean

difference of both variable is not more. (t=-1.761). No statistically significant

difference was found in corneal astigmatism with superior 2.2 mm superior

micro incision cataract surgery.

CONCLUSION:

1. There is a significant burden of preoperative astigmatism with the

subjects. The available refraction data indicate that this burden is not

reduced after surgery with implantation of standard mono focal IOLs.

2. 2.2 mm superior micro incision cataract surgery resulted in relatively small

surgically induced astigmatism with no difference in visual function and

corneal astigmatism.

3. As the study concludes that astigmatism doesn’t get corrected after

implantation of mono-focal IOL. It was due to financial conditions where

subjects opted for mono-focal IOL rather than opting for toric and trifocal

toric IOL.

KEYWORDS: Astigmatism, Cataract, IOLs, Phaco emulsification

3
 AIM AND OBJECTIVE

Cataract surgery with intra ocular lens (IOL) implantation is one of the most

common ophthalmic procedures in clinical practice; however, post-operative

refractive outcomes remain a key area of concern for surgeons. To assess

surgically induced astigmatism with 2.2 mm superior micro incision operated by

a single surgeon.

4
 INTRODUCTION

Cataract extraction is the most commonly performed surgery overall by the

National Health Service (NHS). Approximately, persons aged 50 years and over

have visually impairing cataracts in one or both eyes. There is an increasing

patient demand to minimize postoperative refractive error during cataract

surgery. Residual astigmatism after cataract surgery may result in reduced

unaided distance visual acuity (VA), which in turn may hinder satisfactory post-

operative refractive results. Spectacle independence for distance activities is

unlikely unless patients achieve ≤0.50 dioptres (D) of astigmatism after surgery

and the reason of needing spectacles has been found to increase significantly

with each dioptre of astigmatism.

Currently, epidemiological evidence on the prevalence and severity of

astigmatism prior to cataract surgery is mostly sourced from single-site,

prospective or cross-sectional studies. In addition, there is very little

epidemiological evidence on the prevalence and severity of residual astigmatism

following cataract surgery.

Large, longitudinal real world studies describing astigmatic patients undergoing

cataract surgery are needed to inform the potential requirement of

simultaneous correction of astigmatism during surgery. The principle aim of the

present study was to address this knowledge gap by determining the prevalence
5
and severity of preoperative and post- operative astigmatism in a large, real

world population of eyes with cataract. An exploratory objective was to describe

the effect of postoperative residual astigmatism on subject’s VA.

Surgically induced astigmatism remains one of the most common complications.

The introduction of suture less clear corneal incision has gained increasing

popularity worldwide because it offers several advantages over the traditional

suture limbal incision and scleral tunnel. Post-operative surgically induced

astigmatism depends on location, size and architecture of the wound and also

surgeon’s position and comfort during the procedure. This small size incision

gives a rapid and a stable optical recovery and thus a lesser surgically induced

astigmatism.

6
 REVIEW OF LITERATURES

A study was performed by Alexander C Day,1,2 Mukesh Dhariwal,3 Michael S

Keith,3 Frank Ender,4 Caridad Perez Vives,4 Cristiana Miglio,5 Lu Zou,5 and

David F Anderson,6,7 the distribution of preoperative astigmatism in the large

population reported in this study confirms evidence from previous smaller

studies, both in the UK and worldwide. Similar to this study, corneal astigmatism

of ≥0.5 D was 75% in Wales6 (N=1231 eyes). Astigmatism ≥1.0 D was found in

36% of eyes with cataract in Germany7 (N=15 448 eyes), 47% in China22 (N=12

449) and 35% in South Korea9 (N=2847 eyes). Recently, Curragh et al reported

that 41% of eyes undergoing cataract surgery (N=2080) in Northern Ireland had

>1.0 D of corneal astigmatism.10

A study was performed by Patil, Mayuri Sh.; Nikose, Archana S; Bharti, Shadwala

about Pre existing corneal astigmatism has a significant impact on the refractive

outcome of cataract surgery. One of the several surgical options to correct

corneal astigmatism during cataract surgery is the use of toric IOLs. An important

advancement in modern cataract surgery is stable and effective toric IOL

implantation in the capsular bag during routine phacoemulsification cataract

surgery without any corneal procedures. In our study, mean and SD of

preoperative refractive astigmatism was 3.55 ± 0.97. Mean and SD of refractive

astigmatism on postoperative day 1 and 7 was 1.13 ± 1.20. Mean and SD of

7
postoperative refractive astigmatism was 0.81 ± 0.28 on 1 month, while it was

0.79 ± 0.27 at 3 months.

A study was performed by Ahmed Abdul Sadik,1 David Ben Kumah,1 Eugene

Appenteng Osae,1 Felix Agyemang Mireku,1 Frank Yeboah

Asiedu,2 and Reynolds Kwame Ablordeppey1 about postoperative corneal and

surgically induced astigmatism (SIA) in patients with preoperative against-the-

rule (ATR) astigmatism who underwent superior approach manual small incision

cataract surgery (MSICS). The Shapiro-Wilk test of normality was used to test

the normal distribution of our preoperative and postoperative corneal astigmatism

data. The Shapiro-Wilk test came out significant for both the preoperative and the

postoperative corneal astigmatism data. Hence, the nonparametric Wilcoxon

signed rank test was used to compare the means of the preoperative and

postoperative corneal astigmatism values. For the purpose of comparing the mean

preoperative and postoperative corneal astigmatism, only the magnitude of the

corneal astigmatism was considered [15]. Cohen’s d was used as the effect size

measure to determine clinical significance and was calculated using GPower

calculator 3.1 [25]. A Cohen’s d value of 0.8 or greater was taken as high or

clinically significant [26]. The double-angle plots (DAP) were drawn with Sigma

Plot 13.0 (Systat Software, San Jose, CA, USA). A p value < 0.05 was considered

statistically significant. All values are presented as mean ± SD.

8
 MATERIALS & METHODOLOGY\

It is retrospective study conducted at SWARAASHI NETRALAYA between January

2021 to June 2021.

The study involved 100 subjects with 45 females and 55 males who have been

undergone cataract surgery by Dr. Rakesh Shah from January 2021 to June 2021

at Swaraashi Netralaya.

In this retrospective study we include 100 subjects with Age related Cataract of

all grades.

All subjects had undergone a standardized protocol of Cataract Assessment in

our hospital including, History Taking, Un Corrected visual activity(UCVA) for

both distance and near and Best Corrected Visual Acuity (BCVA) for both

Distance and near including pinhole vision. All these data was retrieved from the

electronic medical records.

HISTORY TAKING:

A detailed history was taken. Which included visual complaints, past ocular

history, any systemic illness and medication, and history of any allergy.

9
VISION: The subject was made to sit at a distance of 6 meters comfortably.

Distance Vision was taken (aided/unaided). The vision was taken by log MAR

chart.

NEAR VISION: Reduced Snellen near vision chart was used to test near visual

acuity.

REFRACTION: Subjective refraction was done for near and distance, monocularly

and binocularly to give the best corrected visual acuity (BCVA).

To calculate the lens power and lens measurement Lens star (ASCAN) was used.

For the Next Procedure, Comparatively the eye which had more amount of

decreased vision was selected first for the surgery.

100 subjects with cataract underwent superior incision 2.2 mm clear corneal

micro-incision phaco emulsification combined with foldable monocular intra

ocular lens implantation operated by a single surgeon. All the above protocols

were carried out again after the surgery on day 1, 1 week and 3 weeks after

surgery, subject’s both Un Corrected Visual Acuity (UCVA) and Best Corrected

visual acuity (BCVA) was obtained to check if there was any difference in residual

astigmatism.

10
 PLAN FOR STATISTICAL ANALYSIS

Data from the Electronic Medical software were reviewed for the period of last 6

months from January 2021 to June 2021 and then relevant data was transferred to

excel sheet. Statistical analysis was performed using IBM SPSS (Statistical

Package for the social sciences) version 20. The continuous variables were

summarized using mean and standard deviation and categorical data were

summarized using frequency count and percentage. Probability (P) value of more

than 0.05 was considered to be significant (p>0.05).

11
 RESULTS

In this retrospective study we included 100 subjects with 45 females and 55 males

who fulfilled our inclusion criteria of the study.

GENDER DISTRIBUTION

MALE
45%
55% FEMALE

In the given pair t-test table, p value is 1 of Astigmatism_Before_Surgery1 with

Astigmatism_After_Surgery-1 so that there is no significance difference (p value

is more that 0.05 at 95% confidence interval level) between two variables as

mean (-0.8550) of both variable is same (t=1)

MEANWISE COMPARISION
0.0000
-0.1000 Astigmatism_Before_Surgery1 Astigmatism_After_Surgery1

-0.2000
-0.3000
-0.4000
-0.8550 -0.8550
-0.5000
-0.6000
-0.7000
-0.8000
-0.9000

Mean wise Comparison of Astigmatism Before and After Surgery

12
 Astig_before_cyl
-2.5

Astig_After_cyl
-2

-1.5

-1

-0.5
-2.5 -2 -1.5 -1 -0.5 0
0

0.5

Fig. Graph Number 1

200
180
160
Astig_before_axis

140
120
100
80
60
40
20
0
0 50 100 150 200
Astig_after_axis

Fig. Graph Number 2

Following graph represents the comparison between astigmatism before surgery

and astigmatism after surgery (Fig.1) and comparison between axis of the

astigmatism before surgery and axis of the astigmatism after surgery (Fig.2).

From these graphs we can correlate that there is no such significant difference

13
between the astigmatism before surgery and after surgery formulated using pair

t-test. Where p value is more that 0.05 at 95% confidence interval

Type Mean N Std. Std. Error

Deviation Mean

Pair 1 Astigmatism_Before_Surgery1 -0.8550 100 0.35742 0.3574

Astigmatism_After_Surgery1 -0.8550 100 0.44122 0.04412

Pair 2 Astigmatism_Before_Surgery1 89.15 100 27.853 2.785

Astigmatism_After_Surgery2 93.85 100 32.285 3.229

Type N Correlation Sig.

Astigmatism_Before_Surgery1
Pair 1 100 0.690 2.01949E-15
Astigmatism_Before_Surgery1 &

Astigmatism_After_Surgery1

Astigmatism_After_Surgery1

Astigmatism_Before_Surgery2
Pair 2 100 0.615 1.02015E-11
Astigmatism_Before_Surgery2 &

Astigmatism_After_Surgery2

Astigmatism_After_Surgery2

14
 Type Mean Std. Std. 95% 95% t df Sig. (2-

Deviation Error confidence confidence tailed)

Mean interval of interval of

the the

difference difference

lower upper

Astigmatism_Before_Surgery1
Pair 0.00000 0.32373 0.03237 -0.06423 0.06423 0.000 99 1.000
Astigmatism_Before_Surgery1

1 &

Astigmatism_After_Surgery1

Astigmatism_After_Surgery1

Astigmatism_Before_Surgery2
Pair -4.700 26.693 2.669 -9.997 0.597 -1.761 99 0.081
Astigmatism_Before_Surgery2

2 &

Astigmatism_After_Surgery2

Astigmatism_After_Surgery2

Descriptive statistics, In the above pair t-test table, p value is 1 of

Astigmatism_Before_Surgery1 with Astigmatism_After_Surgery-1 so that there

is no significance difference (p value is more that 0.05 at 95% confidence

interval level) between two variables as mean (-0.8550) of both variable is same

(t=1)

In the above pair t-test table, p value is 0.081 of Astigmatism_Before_Surgery2

with Astigmatism_After_Surgery-2 so that there is no significance difference (p

value is more that 0.05 at 95% confidence interval level) between two variables

as mean difference of both variable is not more. (t=-1.761). No statistically

significant difference was found in corneal astigmatism with superior 2.2 mm

micro incision cataract surgery.

15
 DISCUSSION

The consensus of my study is that we described the prevalence and severity of

astigmatism both prior to and following age-related cataract surgery in selected

amount of eyes derived from the hospital. A variety of treatment options exist

for reducing corneal astigmatism at the time of cataract surgery, including toric

and toric trifocal IOLs. 2.2 mm superior micro incision cataract surgery resulted

in relatively small surgically induced astigmatism with no difference in visual

function and corneal astigmatism. A superior approach may come with its own

advantages and hence the reason it is more preferred by the surgeon. It does

not require the surgeon to adapt to a different surgical position while other

incision approach does. It provides a forehead support for the surgeon’s hands

for a stable incision to make. However, since the postoperative corneal

astigmatism is statistically and clinically significantly same so we can conclude

that superior micro corneal incision is safe and helps in better recovery of the

eye. We divide the subjects into three groups according to their age and gender

with 45 females and 55 males with 50 right eye and 50 left eye and no subject

had any significant changes post-operatively in their astigmatism. Our study

shows that incisions with same characteristics of width and location, calculated

by the surgeon, results in similar surgically induced astigmatism. It is our belief,

16
that our study can safely include eyes operated by the surgeon as long as they

present same incision characteristics and surgically induced astigmatism,

without fear of inconsistency. Thus, larger studies may be performed and safer

conclusions could be drawn.

17
 LIMITATIONS AND RECOMMENDATIONS

LIMITATIONS:

1. The study did not include subjects with any pathological conditions (eg:-

glaucoma, optic neuropathy, uveitis and etc.).

2. Toric, Multifocal, Trifocal and Toric Trifocal Intra Ocular Lenses were also

not include for study purpose.

3. Complicated cataracts.

RECOMMENDATION:

• 2.2 mm superior micro incision gives a rapid and a stable optical recovery

and thus a lesser surgically induced astigmatism.

• For better correction of astigmatism subjects should opt for toric and toric

trifocal IOLs.

18
 CONCLUSION

1. There is a significant burden of preoperative astigmatism with the subjects.

The available refraction data indicate that this burden is not reduced after

surgery with implantation of standard mono focal IOLs.

2. 2.2 mm superior micro incision cataract surgery resulted in relatively small

surgically induced astigmatism with no difference in visual function and

corneal astigmatism.

3. As the study concludes that astigmatism doesn’t get corrected after

implantation of mono-focal IOL. It was due to financial conditions where

subjects opted for mono-focal IOL rather than opting for toric and trifocal

toric IOL.

19
 References

1. Donachie J, Sparrow JM, Johnston RL. 2016.Year 1 annual report – piloting

of thenational ophthalmology database audit methodology national

ophthalmology database audit

https://www.nodaudit.org.uk/u/docs/20/thsumcnchv/NOD%20Audit%

20Annual%20Report%202016.pdf (accessed 24 Apr 2017)

2. The Royal College of Ophthalmologists. 2010.Cataract surgery guidelines.

London https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2010-

SCI-069-Cataract- Surgery-Guidelines-2010-SEPTEMBER-2010.pdf (accessed

13 Dec 2016)

3. Lyall DA, Srinivasan S, Ng J, et al. Changes in corneal astigmatism among

patients with visually significant cataract. Can J Ophthalmol 2014;49:297–

303.

4. Rubenstein JB, Raciti M. Approaches to corneal astigmatism in cataract

surgery. Curr Opin Ophthalmol 2013;24:30–4.

5. Wilkins MR, Allan B, Rubin G. Moorfields IOL Study Group MIS. Spectacle

use after routine cataract surgery. Br J Ophthalmol 2009;93:1307–12.

20
 6. Khan MI, Muhtaseb M. Prevalence of corneal astigmatism in patients

having routine cataract surgery at a teaching hospital in the United

Kingdom. J Cataract Refract Surg 2011;37:1751–5.

7. Hoffmann PC, Hütz WW. Analysis of biometry and prevalence data for

corneal astigmatism in 23,239 eyes. J Cataract Refract Surg 2010;36:1479–

85.

8. Kessel L, Andresen J, Tendal B, et al. Toric Intraocular lenses in the

correction of astigmatism during cataract surgery: a systematic review and

meta-analysis. Ophthalmology 2016;123:275–86.

9. 26 Wolffsohn JS, Bhogal G, Shah S. Effect of uncorrected astigmatism on

vision. J Cataract Refract Surg 2011;37:454–60.

10. 27 Hayashi K, Manabe S, Yoshida M, et al. Effect of astigmatism on visual

acuity in eyes with a diffractive multifocal intraocular lens. J Cataract

Refract Surg 2010;36:1323–9.

21
 CHECKLIST

1. Is the Cover page in proper format? Yes / No

2. Is the Title page in proper format? Yes / No

Is the Certificate from the Guide in proper format? Has it been

3. Yes / No
signed?

4. Is Abstract included in the report? Is it properly written? Yes / No

5 Does the Report contain a summary of the literature survey? Yes / No

Does the Table of Contents page include chapter page numbers? Yes / No
(i). Are the Pages numbered properly? Yes / No
(ii). Are the Figures numbered properly? Yes / No
6
(iii). Are the Tables numbered properly? Yes / No
(iv). Are the Captions for the Figures and Tables proper? Yes / No
(v). Are the Appendices numbered? Yes / No

7. Does the Report have Conclusion/ Recommendations of the work? Yes / No

8. Are References/Bibliography given in the Report? Yes / No

9. Have the References been cited in the Report? Yes / No

10 Is the citation of References in proper format? Yes / No

I have verified all the items in the checklist and ensured that the report is in proper

format.

22
SIGNATURE: SIGNATURE:

NAME OF THE STUDENT: EXTERNAL GUIDE:

NIRMIT BHARAT PAREKH DR. RAKESH SHAH

DATE: 20/05/2022 DATE: 20/05/2022

23