NEWS & OPINION EWAP DECEMBER 2022 39 which was significantly more frequent in the TECNIS group (3.1%) versus the AcrySof group (0.6%, P <0.0001). Logistic regression identified that the odds ratio for repositioning was 5.57 (3.48–8.92) for the TECNIS lens relative to the AcrySof lens. Further, they found that younger age was a significant risk factor for IOL repositioning with an odds ratio of 0.76 (0.67–0.86) for every 5-year increase in age, suggesting less repositioning among older patients. No other significant risk factors were identified (including sex, race, or region of country where the surgery was performed). Discussion The authors concluded, using IRIS Registry data, that second surgery for IOL realignment was significantly more frequent in eyes implanted with TECNIS monofocal toric IOLs as compared to those implanted with AcrySof monofocal toric IOLs. For both lenses, they found higher rates of surgical repositioning as compared to the registration trials (3.1% versus 2.3% for the TECNIS and 0.6% versus 0.4% for the AcrySof ). For context, this difference between AcrySof and TECNIS in terms of frequency of second surgeries for realignment has been demonstrated before; prior studies have shown greater degrees of misalignment from the intended astigmatic axis associated with TECNIS versus AcrySof lenses and have shown greater frequency of realignment operations in TECNIS-implanted eyes versus AcrySof-implanted eyes.5,6 Beyond TECNIS as a risk factor for realignment, this study also identified younger age as a significant risk factor. The authors posit several hypotheses to explain why this might be: (1) younger patients may be more visually demanding and therefore less tolerant of misalignment, (2) greater activity in the immediate postoperative period may be a cause for postoperative rotation in younger patients, (3) an unspecified difference in the composition of the capsule, or (4) younger patients have more with-the-rule astigmatism and therefore have the toric placed vertically. The main differentiating factor of this article compared to prior studies with similar conclusions is its use of real-world data from the IRIS Registry, purportedly better reflecting the actual experience of surgeons of a variety of experience levels and practice settings as compared to controlled trial conditions. Several limitations are also discussed. First, eyes were identified using a CPT code associated with surgical IOL Real-world incidence of monofocal toric intraocular lens repositioning: analysis of the American Academy of Ophthalmology IRIS Registry Kramer BA, et al. J Cataract Refract Surg. 2022;48:298–303 Purpose: To determine the 12-month incidence of reoperation to realign 2 commercially available types of implanted monofocal toric acrylic intraocular lenses (IOLs) Setting: American Academy of Ophthalmology IRIS (Intelligent Research in Sight) Registry Design: Registry retrospective study Methods: Eyes that underwent cataract extraction and were implanted with a TECNIS (Johnson & Johnson Vision) or AcrySof (Alcon) monofocal toric IOL in 2016 and 2017 were identified. The rate of reoperation for IOL realignment (Current Procedural Terminology code 66825) within 365 days of implantation was determined for each IOL group. Risk factors for repositioning were evaluated using logistic regression modeling. Results: A total of 6,482 eyes were implanted with a monofocal toric IOL, including 2,013 (31.06%) with a TECNIS and 4,469 (68.94%) with an AcrySof IOL. During the first postoperative year, 87 (1.3%) eyes underwent surgical IOL repositioning. The incidence of repositioning was significantly higher (P <.0001) for TECNIS-implanted (3.1%, 62/2013) than for AcrySof-implanted (0.6%, 25/4469) eyes (odds ratio [OR] 5.6; 95% CI, 3.5–8.9). Younger age (OR 0.76; 95% CI, 0.67–0.86 per 5-year increase) was associated with a higher risk for IOL repositioning. Conclusion: Real-world analysis of U.S. patients in the IRIS Registry revealed that the rate of surgical IOL repositioning was 5 times higher in eyes implanted with TECNIS than with AcrySof monofocal toric IOLs for astigmatic correction at the time of cataract surgery. These findings should be considered when selecting a toric IOL for correction of astigmatism in cataract patients, particularly in younger patients with a higher risk for misalignment requiring repositioning. realignment, though they acknowledged that a lens may need realignment for reasons other than astigmatic axis rotation (though the authors pointed out that the latter is responsible for most surgical realignment cases in toric IOLs). Other limitations are inherent to the nature of this being a retrospective database study, namely that factors like method of intraoperative axis alignment and pre- and postoperative measurements were not available to the authors. Further, there was no standard for what requires surgical realignment, which was instead pursued based on mutual agreement by surgeon and patient that it would enhance visual outcomes. continued on page 42
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