Elaine Tran and Kevin Tang are Medical Students; David Rivera and Jorge Rivera are Clinical Assistant Professors of Surgery (Ophthalmology); and Paul Greenberg is a Professor of Surgery (Ophthalmology); all at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. Allison Chen is an Ophthalmology Resident at the Shiley Eye Institute, University of California San Diego Health in La Jolla. Michael Chen is a Student at Harvard University in Cambridge, Massachusetts. David Rivera and Jorge Rivera are Staff Ophthalmologists, and Paul Greenberg is Chief of Ophthalmology; all at the Providence Veterans Affairs Medical Center in Rhode Island. Correspondence: Paul Greenberg (paul_greenberg@brown.edu)
Author disclosures The authors report no actual or potential conflicts of interest for this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Of 325 charts reviewed during the study period, 34 patients were excluded due to lack of postoperative refraction within the designated follow-up period, 5 for worse than 20/40 postoperative BCVA (4 had preexisting ocular disease), 2 for complications, and 1 for missing data. We included 283 eyes from 283 patients in the final study. Resident ophthalmologists were the primary surgeons in 87.6% (248/283) of the cases.
The median postoperative BCVA was 20/20, and 92% of patients had a postoperative BCVA of 20/25 or better. The prediction outcomes of the toric SN6AT IOLs are shown in Table 2. The Barrett toric formula had a lower MAE than the Holladay 2 formula, but this difference was not statistically significant. The Barrett toric formula also predicted a higher percentage of eyes with postoperative refraction within ≥ 0.25 D (53.2%), ≥ 0.5 D (77.3%), and ≥ 1.0 D (96.1%). For both formulae, > 95% of eyes had prediction errors that fell within 1.0 D.
While the Barrett formula demonstrated a lower MAE in all 3 AL groups, no statistically significant differences were found between the Barrett and Holladay formulae (P = .94, P = .49, and P = .08 for short, medium, and long eyes, respectively). Both formulae produced the lowest MAE in the long AL group: Barrett had a MAE of 0.221 D and Holladay 2 had one of 0.329 D. The Barrett formula produced its highest percentage of eyes with prediction errors falling within 0.25 D and 0.5 D in the long AL group. In comparison, both formulae had the highest MAEs in the short AL group (Barrett toric, 0.598 D; Holladay 2, 0.613 D) and produced the lowest percentage of eyes with prediction errors falling within ≥ 0.25 D and ≥ 0.5 D in the short AL group.
A cumulative histogram of the preoperative corneal and postoperative refractive astigmatism magnitude is shown in Figure 1. The same data are presented as double-angle plots in the Appendix, which shows that the centroid values for preoperative corneal astigmatism were greatlyreduced when compared with the postoperative refractive astigmatism (mean absolute value of 1.77 D ≥ 0.73 D to 0.5 D ≥ 0.50 D).
Preoperative corneal astigmatism and postoperative refractive astigmatism were compared since preoperative refractive astigmatism has noncorneal contributions, including lenticular astigmatism, and there is minimal expected change between preoperative and postoperative corneal astigmatism.14 For comparison, double-angle plots of postoperative refractive astigmatism prediction errors for the Holladay and Barrett formulae are shown in Figure 2.
Discussion
To our knowledge, this is the largest study of resident-performed cataract surgery using toric IOLs, the largest study that compared the performance of the Barrett toric and Holladay 2 formulae, and the first that compared these formulae in a teaching hospital setting. This study found no significant difference in the predictive accuracy of the Barrett and Holladay 2 biometric formulae for cataract surgery using toric IOLs. In addition, our refractive outcomes were consistent with the results of previous toric IOL outcome studies conducted in teaching and nonteaching hospital settings.6,10-13
