The Use of Intraoperative Aberrometry in Normal Eyes: An Analysis of Intraocular Lens Selection in Scenarios of Disagreement

Abstract

PURPOSE: To compare prediction error outcomes between the Optiwave Refractive Analysis System (ORA) (Alcon Laboratories, Inc) and two modern intraocular lens (IOL) formulas (Hill-RBF2.0 [HRBF] and Barrett Universal II [BUII]), and further analyze IOL selection in scenarios of disagreement between methods. METHODS: Patients with no previous history of corneal refractive surgery who underwent cataract extraction and had intraoperative aberrometry measurements between October 2016 and December 2019 were analyzed. The prediction error for the ORA, HRBF, and BUII were calculated based on the postoperative manifest refraction. Further analysis was performed evaluating prediction error for scenarios of disagreement between the three methods. RESULTS: After exclusions, 281 eyes were included. The mean absolute prediction errors were 0.28 diopters (D) (ORA), 0.31 D (HRBF), and 0.33 D (BUII) ( P < .05). In instances when the IOL recommended by the ORA was in disagreement with what was selected preoperatively, there was no benefit when the lens recommended by the ORA was selected based on anecdotal experience. When further analyzing these instances of disagreement, selecting the ORA-recommended lens when it is higher in power results in improved refractive outcomes: the ORA resulted in more eyes within ±0.25 diopters (D) of predicted spherical error (65% ORA, 37% HRBF, 32% BUII; P = .004) and fewer hyperopic surprises (5% ORA, 15% HRBF, 24% BUII; P = .009). CONCLUSIONS: In normal eyes without previous corneal refractive surgery, intraoperative aberrometry is not different from to two modern preoperative IOL formulas. Placing the ORA-recommended lens when it is higher in power than that selected preoperatively results in better refractive outcomes. [ J Refract Surg . 2022;38(5):304–309.]

Intraoperative aberrometry: an update on applications and outcomes

“…The results of studies of intraoperative aberrometry in non-post-refractive patients appear to be mixed. Some studies have shown a statistically significant but perhaps not clinically significant benefit of intraoperative aberrometry over preoperative calculations in non-post-refractive eyes: in these studies, mean absolute prediction error is approximately 0.03-0.06D less for intraoperative aberrometry than for preoperative calculations [6,32,50]. Other studies show similar mean absolute prediction error between intraoperative aberrometry and preoperative calculations for non-postrefractive eyes [28 & ,33 & ,34 -36].…”

“…In 60 cases with disagreement (53.1%), intraoperative aberrometry recommended a higher IOL power; selecting this higher power would result in a higher percentage of mean absolute prediction error within AE0.25 diopters: 65% for intraoperative aberrometry, 37% for Hill-RBF 2.0, and 32% for BUII (P ¼ 0.004). However, when intraoperative aberrometry recommended a lower IOL power, there was no difference in percentage of mean absolute prediction error within AE0.25D: 47% for intraoperative aberrometry, 38% for Hill-RBF 2.0, 40% for BUII (P ¼ 0.584) [32]. Thus, on a case-bycase basis the surgeon might consider changing their IOL selection intraoperatively based on intraoperative aberrometry.…”

“…The database study by Cionni et al [6] also examined the subset of 12 779/32 189 cases (39.7%) in which intraoperative aberrometry and preoperative calculations did not agree on the IOL power, and in this subset of patients the percentage within ±0.50D absolute prediction error was higher for intraoperative aberrometry than for preoperative calculations (81.3 vs. 68.8%, P < 0.0001) [6]. In a single-surgeon study by Greenwood et al [32], 113 of 281 cases (40.2%) had disagreement between intraoperative aberrometry and preoperative calculations using BUII or Hill-RBF 2.0. In 60 cases with disagreement (53.1%), intraoperative aberrometry recommended a higher IOL power; selecting this higher power would result in a higher percentage of mean absolute prediction error within ±0.25 diopters: 65% for intraoperative aberrometry, 37% for Hill-RBF 2.0, and 32% for BUII ( P = 0.004).…”

“…Although intraoperative aberrometry on average may not have a large clinical benefit for non-postrefractive cases, an important scenario in which intraoperative aberrometry may have particular utility is when intraoperative aberrometry and the preoperative calculations disagree about IOL power. Intraoperative aberrometry and preoperative calculations may disagree in approximately 40-50% of non-postrefractive cases [6,32,34]. The database study by Cionni et al [6] also examined the subset of 12 779/ 32 189 cases (39.7%) in which intraoperative aberrometry and preoperative calculations did not agree on the IOL power, and in this subset of patients the percentage within AE0.50D absolute prediction error was higher for intraoperative aberrometry than for preoperative calculations (81.3 vs. 68.8%, P < 0.0001) [6].…”

“…Moreover, in studies with broad cohorts, overall outcomes are generally not reported, and instead the focus is on subsets of patients [20 ▪▪ ,28 ▪ ]. In contrast, there are numerous studies that instead focus on either routine/typical non-post-refractive surgery cases alone [6,9,10 ▪ ,11,14,30–32,33 ▪ ,34–38] or on subsets of atypical patients [29,39–52]. This trend in publications may be at least in part a reflection that in the real world, many cataract surgeons utilize intraoperative aberrometry selectively rather than broadly.…”