Refractive Outcomes of Toric and Non-Toric IOLs in Post-Radial Keratotomy Eyes: A Comparative Study

Refractive Outcomes of Toric and Non-Toric IOLs in Post-Radial Keratotomy Eyes: A Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Refractive Outcomes of Toric and Non-Toric IOLs in Post-Radial Keratotomy Eyes: A Comparative Study Aditya Kelkar, Jai Kelkar, Rabia Naaz, Harsh Jain, Sabyasachi Sengupta This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7605979/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To compare refractive outcomes in post-radial keratotomy (RK) eyes undergoing cataract surgery with toric versus non-toric intraocular lenses (IOLs), using clinical and vector-based astigmatism analysis. Methods Consecutive post-RK eyes undergoing uneventful phacoemulsification were included. Toric IOLs were offered to eyes with clear corneas and repeatable keratometry; acceptance was based on patient preference and affordability. The Barrett True-K Toric calculator was used. All surgeries were performed with digital marking and low-pressure phaco settings. Intraoperative wound leaks were noted and sutured if required . Results Of 24 eyes included, 10 received toric IOLs and 14 non-toric. The non-toric group had significantly longer axial lengths (30.01±3.5mm vs. 26.31±2.4 mm, p=0.02) and worse baseline BCVA (0.83 ± 0.5 vs. 0.41 ± 0.5 logMAR, p=0.01). At 1 month, cylindrical neutrality was achieved in 70% of toric eyes versus 20% of non-toric eyes (p < 0.001). Among eyes with residual cylinder, the mean was –0.35 ± 0.6D in the toric group versus –1.43 ± 1.3 D in the non-toric group (p=0.03). Vector analysis corroborated superior astigmatic correction in the toric group. Wound leaks occurred in 11 eyes (46%) overall, predominantly in 16-cut RK eyes and those with longer axial lengths. Conclusion Toric IOLs significantly improve refractive outcomes in post-RK eyes. While wound leaks remain a major surgical concern, particularly in 16-cut RK eyes, careful planning, appropriate IOL selection, and intraoperative vigilance can lead to safe surgery and excellent visual outcomes. Cataract surgery Toric IOL Post Radial Keratotomy High Astigmatism Outcomes Figures Figure 1 Figure 2 Figure 3 Introduction Radial keratotomy (RK), a popular refractive procedure in the 1980s and 1990s, aimed to correct myopia by creating radial corneal incisions to flatten central curvature. 1 While initially effective, RK often resulted in long-term complications such as progressive hyperopic shift, irregular astigmatism, and fluctuating vision, which now pose challenges during cataract surgery planning. 2 , 3 Biometry in post-RK eyes is difficult due to altered corneal curvature and irregularity, affecting keratometry and axial length estimation. 4 Standard IOL formulas often fall short and are further confounded by irregular astigmatism and altered effective lens position prediction, yielding suboptimal results that necessitate the use of specialised approaches, such as the Barrett True-K formula. 5 Toric intraocular lenses (IOLs) offer a logical and potential solution by addressing astigmatism at the time of cataract surgery and improving uncorrected distance vision. Their efficacy is established in post-keratoplasty and stable keratoconus. 6 , 7 Arcuate keratotomy, commonly used in normal eyes with low astigmatism, is contraindicated in RK due to the risk of wound dehiscence, making toric IOLs the only viable corneal-plane-independent option. 8 , 9 Despite improvements in toric IOL design, rotational stability, and the availability of advanced planning tools like digital marking systems and post-refractive surgery calculators, there remains limited literature supporting the use of toric IOLs in eyes with prior RK. Many surgeons remain apprehensive due to concerns about rotational instability in elongated eyes, unreliable preoperative keratometry, and unexpected postoperative refractive surprises. 3 , 5 , 10 Yet, this is a growing concern, patients who underwent RK decades ago are now candidates for cataract surgery and still seek spectacle independence. With modern biometry techniques (e.g., IOLMaster 700), better IOL power formulas, 4,5 and stable toric IOLs, 11,12 successful outcomes are more feasible. This study compares refractive outcomes in post-RK eyes implanted with toric versus non-toric IOLs, using vector analysis to quantify astigmatic correction. By bridging this knowledge gap, we aim to guide clinical decision-making in a complex yet increasingly common surgical scenario. Unlike prior studies that selectively included eyes with regular astigmatism, 13 we included all consecutive cases with repeatable keratometry, thereby reflecting real-world clinical variability and challenges. Methods Study Design This was a retrospective comparative study conducted at a tertiary eye care centre in western India and was approved by the institutional ethics committee. Written informed consent for cataract surgery was obtained from all patients preoperatively. The study adhered to the tenets of the Declaration of Helsinki. Participants Medical records of consecutive patients with a prior history of RK who underwent uneventful phacoemulsification with IOL implantation between June 2021 and July 2024 were reviewed. Eyes were included if they had a minimum of 1 month of postoperative follow-up, consistent with the institution’s protocol for refractive evaluation and spectacle prescription. Exclusion criteria included any intraoperative complications such as posterior capsular rupture, zonular dialysis, or the need for anterior vitrectomy, as well as ocular comorbidities associated with high myopia that could independently limit visual outcomes such as retinal detachment or retinal surgery, myopic macular neovascularization or chorioretinal atrophy, anisometropic amblyopia, strabismus with central suppression, significant epiretinal membrane or macular hole, and advanced glaucomatous optic neuropathy. Preoperative Assessment Preoperative evaluation included measurement of uncorrected (UCVA) and best-corrected visual acuity (BCVA), manifest refraction, slit-lamp biomicroscopy, axial length (AXL), anterior chamber depth (ACD), and keratometry (K1, K2). Biometry was performed using the IOL Master 700 (Carl Zeiss Meditec, Germany). On slit-lamp examination, the number of RK incisions was recorded, categorising eyes into 8-cut or 16-cut RK patterns based on the visible extent and distribution of radial scars. Additional parameters, such as lens thickness, corneal toricity, white-to-white diameter, and preoperative astigmatism, were also recorded. IOL Selection Toric IOL power was calculated using the ASCRS post-refractive IOL calculator (Barret True K Calculator available at https://www.ascrs.org/tools/barrett-true-k-calculator ) with the “post-RK” mode. Toric IOLs were offered to all eyes with clear corneas (apart from RK scars) and consistent keratometry readings, defined as a difference of ≤ 0.5 D between two consecutive measurements obtained during the same session. The final IOL choice (toric vs. non-toric) was made by the patient after comprehensive counselling regarding the potential benefits (reduced postoperative spectacle dependence for distance vision) and risks (possible calculation errors, the need for repositioning in case of misalignment, especially in eyes with long axial length). Toric axis markings were performed using the Callisto Eye system (Carl Zeiss Meditec). Surgical Protocol Phacoemulsification was performed via a temporal clear corneal incision under topical anesthesia using the Alcon Centurion phacoemulsification system (Alcon, USA), with intraoperative intraocular pressure settings deliberately lowered to reduce the risk of RK wound dehiscence. In cases where wound gaping was noted intraoperatively, a single partial-thickness 10 − 0 nylon suture at the site of the leaking RK incision was typically sufficient to achieve watertight closure; rarely, a second suture was required. All sutures were placed starting at the limbus, exactly perpendicular to the RK cut, ensuring adequate length on either side of the gape, and tied with just enough tension to secure apposition without inducing corneal distortion. A foldable toric IOL (Alcon AcrySof® IQ Toric or Johnson & Johnson Eyhance Toric) was implanted in the capsular bag. After thorough viscoelastic removal, the toric IOL was rotated under irrigation to the intended axis as guided by the Callisto overlay. Stability was confirmed before concluding surgery. Outcome Measures and Statistical Analysis The primary outcome measure was residual refractive astigmatism at 1 month postoperatively, comparing eyes that received toric versus non-toric IOLs. Secondary measures included postoperative visual acuity, spherical equivalent, and astigmatism vector parameters. Statistical Analysis All continuous variables were summarized as mean (standard deviation) or median (interquartile range) as appropriate, and categorical variables as counts and percentages (n, %). For head-to-head group comparisons (e.g., toric vs. non-toric IOLs, wound leak vs. no wound leak), independent samples t-tests or Mann-Whitney U tests were used for continuous variables, and chi-square or Fisher’s exact tests for categorical variables, depending on data distribution and sample size. Comparisons between pre and post surgery parameters were done using paired t-tests with Bonferroni’s corrections. Analyses of astigmatism were performed using both categorical and vectorial methods as per standard analysis techniques. 14 , 15 The distribution of astigmatism magnitudes was summarised using bar graphs stratified by treatment group (Fig. 1 ). To assess the orientation and magnitude of astigmatism, double-angle plots were constructed for both preoperative and postoperative data, separately for Toric and Non-Toric groups (Fig. 2 ). Additionally, double-angle error plots were generated to visualize the distribution of surgically induced astigmatic changes and residual errors (Fig. 3 ). These graphical methods provided a comprehensive visualization of both the magnitude and axis of astigmatism, facilitating groupwise comparisons and assessment of surgical outcomes. To identify risk factors for wound leak, univariate logistic regression was first performed for each candidate variable. Variables with p < 0.10 in univariate analysis were included in a multivariable logistic regression model to adjust for potential confounders. Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test and area under the receiver operating characteristic (ROC) curve. Statistical significance was set at p < 0.05. All analyses were conducted using R (version 4.3.3) and relevant statistical packages using the Julius AI interface. Results The study cohort consisted of 24 eyes, with a mean age of 55.7 years (SD ≈ 8.9). There was a male preponderance (n = 19 males, 79%), and the majority of eyes had moderate to high myopia, as reflected by a mean axial length of 28.16 mm (SD ≈ 3.2). The mean preoperative corneal toricity was 3.04 diopters (SD ≈ 1.6). Intraoperatively, nearly half of the eyes (n = 10, 42%) received toric intraocular lenses, while another 10 opted out and four were not offered toric IOL due to corneal opacity, making toric calculations unreliable. Intraoperative wound leak was observed in 11 eyes (46%). Postoperatively, an IOP spike was observed on day 1 (mean IOP = 30.75 mmHg (SD ≈ 12.7), which decreased to a mean of 16.9 mmHg (SD ≈ 1.9) by day 15. The uncorrected visual acuity (UCVA) improved from a preoperative mean of 0.55 (SD 0.22) to 0.38 (SD 0.18) at 1 month postoperatively (p = 0.19, paired t-test). The mean residual refractive cylinder was − 0.89 diopters (SD ≈ 1.1), and the mean axis of astigmatism was 66.8 degrees (SD ≈ 21.7). The BCVA also showed improvement, with the mean preoperative BCVA of 0.53 (SD 0.22) improving to 0.35 (SD 0.18) at 1 month postoperatively (p = 0.09, paired t-test). In the comparison of preoperative characteristics between eyes receiving toric (n = 10) and non-toric intraocular lenses (n = 10) (Table 1), eyes in the non-toric IOL group had a significantly longer mean axial length (p = 0.014) and, therefore, required a lower mean lens power compared to the toric IOL group (p = 0.002). Additionally, lens thickness was slightly lower in the non-toric group (p = 0.03), and anterior chamber depth was greater in the non-toric group (p = 0.032). Other preoperative variables, such as age and corneal toricity, showed no significant differences between groups, although there was a trend toward higher toricity in the toric IOL group (Fig. 1 ). When comparing intraoperative and postoperative outcomes, most variables did not differ significantly between the toric and non-toric groups (Table 2 ). Although both groups experienced IOP spikes on day 1, a trend toward higher IOP in the toric IOL group was seen; however, this difference did not reach statistical significance. The UCVA was better in the toric IOL group, and this group also had lower spherical equivalent at one month. Additionally, the toric IOL group also demonstrated significantly fewer eyes (3/10) with residual astigmatism (30% vs 80%, p < 0.001), and the three eyes that did, had lesser residual postoperative cylinder compared to the non-toric group (p = 0.028), even after adjusting for axial length and number of RK cuts (adjusted p = 0.06). Astigmatism profile changes were further analyzed using vector decomposition. The double-angle plot (Fig. 2 ) illustrated the distribution of postoperative astigmatism vectors, with the toric IOL group (n = 3 eyes) showing a tighter cluster and lower mean residual astigmatism compared to the non-toric group (n = 8 eyes). Quantitative analysis confirmed that the toric group had a lower mean residual astigmatism (0.58 D) in the three eyes compared to the non-toric group (0.89 D), although this difference did not reach statistical significance (p = 0.25). Vector analysis (Fig. 3 ) further supported these findings, with the toric group demonstrating a trend toward more accurate and predictable astigmatism correction, as indicated by lower difference vectors and correction indices closer to unity. Intraoperative wound leak was seen in nearly half the eyes (n = 11 eyes, 46%). Group-wise comparisons were performed between eyes with and without postoperative wound leak (Supplementary Table 1). Eyes that developed wound leak tended to have longer axial lengths, flatter preoperative corneal curvature (K1 and K2), and a higher proportion of 16-cut radial keratotomy (RK) procedures, while hypertension was less common in the wound leak group. In particular, the risk of wound leak was dramatically higher, several-fold greater, in eyes that had undergone 16-cut RK compared to those with 8-cuts. Univariate logistic regression confirmed that 16-cut RK was associated with an extremely elevated risk of wound leak, with the odds ratio being infinite (95% CI: 5.84 to not estimable, p < 0.01) due to the absence of no-wound leaks in the 16-cut group (vs. 13% in 8-cut group). Other factors also showed significant associations: for each 1 mm increase in axial length, the odds of wound leak increased more than twofold (OR = 2.1, 95% CI: 1.2–3.68, p = 0.01); and each diopter increase in lens power (shorter eyes) was associated with a lower risk (OR = 0.82, 95% CI: 0.69–0.98, p = 0.03). Hypertension was also associated with a lower risk of wound leak in univariate analysis (OR = 0.09, 95% CI: 0.01–0.88, p = 0.04). In the multivariable model (excluding 16-cut RK), only axial length remained a borderline significant predictor (OR = 2.0, 95% CI: 1.0–4.01, p = 0.05), while the associations for hypertension (OR = 0.33, 95% CI: 0.01–8.37, p = 0.5) was no longer statistically significant. Discussion This retrospective comparative study evaluated outcomes of toric versus non-toric IOL implantation in eyes with prior RK undergoing cataract surgery, an inherently complex clinical scenario that often deters surgeons from choosing toric IOLs due to concerns about corneal instability and postoperative unpredictability. Our findings challenge this hesitation: toric IOLs provided superior refractive outcomes, with significantly lower residual astigmatism and higher rates of postoperative cylindrical neutrality compared to non-toric lenses. These differences held true not only in direct clinical comparisons but also under vector-based astigmatism analysis, reinforcing the precision and predictability of toric correction even in surgically altered corneas. However, the study also highlighted a critical intraoperative complication: nearly half the eyes experienced wound leak during surgery, with the risk being especially pronounced in eyes with 16-cut RK and longer axial lengths. These observations emphasise the need for careful preoperative planning and intraoperative vigilance when operating on such eyes, regardless of IOL choice. The refractive outcomes observed in this study highlight the potential of toric IOLs to deliver significantly better astigmatic correction than non-toric lenses, even in eyes with complex corneal profiles following RK. Our results showed markedly lower residual refractive astigmatism and a higher proportion of eyes achieving cylindrical neutrality in the toric group, both clinically and under rigorous vector analysis. These findings align with the limited available literature. In a retrospective series by Canedo et al., 13 40 eyes with prior RK implanted with toric IOLs showed a significant reduction in refractive cylinder from 2.10 ± 0.98 D to 0.46 ± 0.44 D, with 73% achieving ≤ 0.5 D and 88% achieving ≤ 1.0 D postoperatively. Their findings highlighted the effectiveness of toric IOLs in treating regular astigmatism in post-RK eyes, provided there is stable refraction and topographic regularity. However, their highly selective cohort, limited to eyes with regular bowtie astigmatism and minimal inter-device keratometry variance, differs from our real-world sample. Our study included a broader spectrum of corneal irregularity, including 43% with 16-cut RK, which is more prone to wound instability and irregular astigmatism. Still, toric IOLs consistently outperformed non-toric IOLs in both vector and clinical measures. While non-toric eyes showed modest refractive improvement, likely from incision-induced flattening, the results were less predictable and less pronounced than those seen with toric lenses, similar to results reported by Soare et al. 2 In addition to this, only a few case reports exist supporting toric IOL use in post-RK eyes. Basilious et al. reported that toric IOL implantation in a post-RK eye, with flat corneal powers (below 30 diopters) led to reduced astigmatism from 3.24 D to 1.00 D in the right eye and from 4.13 D to 1.00 D in the left eye, 16 underscoring the value of pre-cataract refractions, findings comparable to the 30% of our cases with residual astigmatism. Case reports by Nuzzi et al. and Chen et al. support the use of toric IOLs in post-RK eyes, 17,18 emphasising the need for personalised planning and stable, symmetric corneal astigmatism to achieve predictable outcomes, even in complex cases such as a customised toric multifocal IOL in a post-RK eye with prior cross-linking and hyperopia/astigmatism, 18 or a toric IOL in a 71-year-old with over 30 RK incisions and confirmed diurnal stability. 17 However, these are inherently limited in scope and generalizability. To supplement this sparse literature, studies evaluating toric IOLs in eyes with irregular astigmatism from other causes, such as post-keratoplasty and stable keratoconus, provide valuable insight. In these contexts, toric IOLs have demonstrated reductions in refractive astigmatism of 3–4 D or more and significant improvements in uncorrected distance visual acuity (UDVA), with over 85% of eyes achieving ≤ 1.00 D of residual astigmatism. 6 , 19 These outcomes reinforce the viability of toric correction in structurally altered corneas and highlight its potential benefit in post-RK eyes when executed with appropriate planning and technique. Despite these encouraging results, many surgeons remain hesitant to use toric IOLs in post-RK eyes due to concerns about inaccurate keratometry, axis misalignment, or IOL rotation, particularly in eyes with long axial lengths, with some studies clearly warning against the use of toric IOLs in post RK eyes. 3 , 10 , 20 Our study demonstrates that, when guided by reliable topography and biometry (e.g., IOLMaster 700, Barrett True-K), toric IOLs can outperform non-toric lenses in this challenging subset. This real-world evidence supports expanding toric IOL usage in appropriately selected post-RK eyes. Wound leak was a notable intraoperative complication in our study, particularly in eyes with 16-cut RK. The structural fragility of RK-altered corneas, especially with a higher number of incisions, predisposes them to spontaneous dehiscence during cataract surgery. 8 , 21 Prior studies have shown that incomplete healing of RK incisions and their poor tensile strength increase the risk of rupture under surgical stress, 22 further aggravated by phaco-induced thermal injury or rapid chamber fluctuations. Our findings echo these concerns, underscoring the importance of preoperative counseling, low-pressure fluidics, and readiness to place partial-thickness radial sutures when needed. Meticulous wound management, especially in eyes with extensive RK patterns, helps maintain chamber stability, reduces intraoperative complications, and ensures safer cataract surgery. This study is limited by its retrospective design and relatively small sample size, which may restrict generalizability. However, its strengths include a direct comparison between toric and non-toric IOLs in the same surgical setting, a quasi-randomized design based on patient affordability and preference, and the inclusion of robust vector analysis to validate refractive outcomes. In conclusion, toric IOL implantation in post-RK eyes undergoing cataract surgery offers superior astigmatic correction and greater refractive predictability compared to non-toric IOLs, even in the presence of significant corneal irregularity. While intraoperative wound leaks remain a concern, particularly in eyes with extensive RK patterns, appropriate surgical precautions can mitigate risk. These findings support the considered use of toric IOLs in post-RK patients and may help overcome long-standing hesitations among cataract surgeons when managing this challenging group. Declarations Conflict of Interest: Nil. Sources of Support: Nil Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [JK, RN], [JK, HJ] and [SS]. The first draft of the manuscript was written by [AK] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data Availability The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request, subject to approval by the Institutional Ethics Committee. References Radial keratotomy for myopia. American Academy of Ophthalmology. Ophthalmology. 1993 July;100(7):1103–15. Soare C, Patel DS, Ionides A. Cataract surgery outcomes in eyes with previous radial keratotomy. Eye (Lond). 2022;36(9):1804–1809. Gauthier A, Awidi AA, Noble PM, Daoud YJ. Factors Predictive of Refractive Error After Toric Lens Implantation. Clin Ophthalmol. 2023;17:1813–1821. Wang L, Koch DD. Intraocular Lens Power Calculations in Eyes with Previous Corneal Refractive Surgery: Review and Expert Opinion. Ophthalmology. 2021;128(11):e121–31. Qiu X, Shi Y, Han X, Hua Z, Lu Y, Yang J. Toric Intraocular Lens Implantation in the Correction of Moderate-To-High Corneal Astigmatism in Cataract Patients: Clinical Efficacy and Safety. J Ophthalmol. 2021;2021:5960328. Moreno-Martínez A, Martín-Melero O, Andrés-Pretel F, Gómez-Cortés A, Granados-Centeno JM. Outcomes of Phacoemulsification With Toric Intraocular Lenses in Addressing Postkeratoplasty Astigmatism. Cornea. 2024;43(1):76–82 Lockington D, Wang EF, Patel DV, Moore SP, McGhee CN. Effectiveness of cataract phacoemulsification with toric intraocular lenses in addressing astigmatism after keratoplasty. J Cataract Refract Surg. 2014;40(12):2044–9. Meduri A, Urso M, Signorino GA, Rechichi M, Mazzotta C, Kaufman S. Cataract surgery on post radial keratotomy patients. Int J Ophthalmol. 2017;10(7):1168–1170. Hirnschall N, Hoffmann PC, Draschl P, Maedel S, Findl O. Evaluation of factors influencing the remaining astigmatism after toric intraocular lens implantation. J Refract Surg. 2014;30(6):394–400. Trinh T, Solomon B, Mimouni M, Cohen E, Gouvea L, Santaella G, et al. Outcomes of femtosecond laser-assisted cataract and refractive lens surgery in patients with prior radial keratotomy. J Cataract Refract Surg. 2022;48(4):449–455. Jeeva IK, Masud S, Ali TS, Siddiqui MAR, Waheed AA, Awan A. Evaluation of visual outcomes with toric intraocular lens implantation using digital marker during cataract surgery. J Pak Med Assoc. 2024;74(3):450–455. Singh A, Kapoor G, Baranwal VK, Kalra N. Rotational stability of Toric intraocular lenses. Med J Armed Forces India. 2022;78(1):68–73 Canedo ALC, Wang L, Koch DD, Al-Mohtaseb Z. Accuracy of astigmatism correction with toric intraocular lens implantation in eyes with previous radial keratotomy. J Cataract Refract Surg. 2022;48(4):417–420. Kohnen T, Næser K, Holladay JT, Stulting RD, Wang L, Abulafia A, et al. Standards for analyzing astigmatic outcomes: Part I: astigmatism basics. J Cataract Refract Surg. 2025;51(6):440. Koch DD, Holladay JT, Naeser K, Abulafia A, Wang L, Stulting RD, et al. Standards for analyzing astigmatic outcomes: Part II: Recommended statistical methods. J Cataract Refract Surg. 2025;51(6):447. Basilious A, Basilious A. Outcomes of Toric Intraocular Lens Implantation After Radial Keratotomy. Journal of refractive surgery case reports. 2022;2(4):e68–e71. Chen SSW, Torii H, Yotsukura E, Nishi Y, Negishi K. Implantation of a toric intraocular lens after repeated radial keratotomy procedures: A case report. Heliyon. 2023 17;9(12):e22500 Nuzzi R, Monteu F, Tridico F. Implantation of a Multifocal Toric Intraocular Lens after Radial Keratotomy and Cross-Linking with Hyperopia and Astigmatism Residues: A Case Report. Case Rep Ophthalmol. 2017;8(2):440–445. Bascaran L, Mendicute J, Macias-Murelaga B, Arbelaitz N, Martinez-Soroa I. Efficacy and stability of AT TORBI 709 M toric IOL. J Refract Surg. 2013;29(3):194–9. Julio C. Hernandez-Camarena, Raul E. Ruiz-Lozano, Brandon Rodriguez-Pinzon, Jorge E. Valdez-García. Hyperopic shift after refractive lens surgery in a patient with prior history of radial keratotomy. The Pan-American journal of ophthalmology. 2022;4(1):39–39. Behl S, Kothari K. Rupture of a radial keratotomy incision after 11 years during clear corneal phacoemulsification. J Cataract Refract Surg. 2001;27(7):1132–4. Leroux les Jardins S, Bertrand I, Massin M. Intraoperative and early postoperative complications in 466 radial keratotomies. Refract Corneal Surg. 1992;8(3):215–6. Tables Tables: Table 1: Preop comparisons between eyes with and without Toric IOL implantation. Variable Toric IOL (n=10) Non-Toric IOL (n=10) p-value Age 57.6 (6.67), 58 (53-61) 53.8 (10.89), 53 (47.75-64.75) 0.362 Axial length 26.31 (2.37), 25.32 (24.49-27.82) 30.01 (3.5), 29.84 (27.26-31.97) 0.014 Lens Power 24.4 (3.56), 23.5 (22.5-27) 17 (5.26), 15.25 (12.62-21.12) 0.002 Lens Thickness 4.27 (0.36), 4.4 (4.33-4.44) 4.1 (0.23), 4.13 (3.89-4.28) 0.031 Toricity 3.33 (1.59), 3.75 (1.88-4.31) 2.75 (1.6), 2.62 (1.5-3.75) 0.431 Anterior chamber depth 3.06 (0.37), 3.06 (2.71-3.34) 3.46 (0.39), 3.3 (3.26-3.64) 0.032 Preop_K1 33.92 (3.86), 32 (31.63-35.87) 33.76 (3.92), 34.58 (30.14-37.09) 0.853 Preop_K2 36.48 (3.81), 34.97 (34.31-37.45) 36.03 (3.61), 36.12 (32.91-38.58) 0.787 Preop UCVA (logMAR) 0.48 (0.28), 0.45 (0.27-0.65) 1.38 (0.73), 1.45 (0.83-2) 0.086 Preop BCVA (logMAR) 0.41 (0.21), 0.4 (0.2-0.58) 0.83 (0.47), 0.6 (0.6-0.9) 0.010 Male 6 (60%) 9 (90%) 0.303 Diabetes 7 (70%) 3 (30%) 0.070 Hypertension 5 (50%) 2 (20%) 0.350 RK - 8 Cut 8 (80) 5 (50) 0.35 RK- 16 Cut 2 (20) 5 (50) Duration Of Radial Keratotomy Surgery (Yrs) 31.8 (3.88), 33 (30.25-35) 26.3 (6.15), 27 (25.25-30) 0.038 Glaucoma On antiglaucoma medications 1 (10%) 2 (20%) 1.000 Amblyopia 0 (0%) 2 (20%) 0.474 Preoperative Phacodonesis 0 (0%) 1 (10%) 1.000 Grade Of Cataract: 1 0 (0%) 1 (10%) 0.12 Grade Of Cataract: 2 9 (90%) 4 (40%) Grade Of Cataract: 3 1 (10%) 3 (30%) Grade Of Cataract: 4 0 (0%) 2 (20%) Preop Cylinder -1.67 (2.04), -2.25 (-2.75 to -0.5) -1.93 (1.79), -2 (-3.5 to -0.25) 0.79 Continuous variables are presented as mean (SD), Median (Interquartile range limits), Bold face = statistically significant differences, UCVA=Uncorrected visual acuity, BCVA=Best Corrected visual acuity. logMAR = logarithm of the minimum angle of resolution. Table 2: Intra and Postop comparisons between eyes with and without Toric IOL implantation. Variable Toric IOL (n=10) Non-Toric IOL (n=10) p-value Intraoperative parameters Wound Leak 3 (30%) 5 (50%) 0.650 Dehiscence Of RK Wound: No 10 (100%) 10 (100%) 1.000 Postoperative parameters Postop Intraocular pressure Day 1 34.5 (11.74), 34.5 (25.5-45.5) 27 (13.52), 22 (16-38.25) 0.112 Postop Intraocular pressure Day 15 17.5 (2.01), 18 (16.25-18.75) 16.4 (1.78), 16 (15-17.75) 0.212 Postop UCVA (logMAR) 0.36 (0.18), 0.35 (0.23-0.4) 0.69 (0.45), 0.6 (0.28-0.95) 0.114 Postop Sphere 0.15 (0.47), 0 (0-0) 0.1 (0.32), 0 (0-0) 1.000 Postop Cylinder -0.35 (0.59) 0 (-0.56-0) -1.43 (1.34) -1.25 (-1.5--0.75) 0.028 Post Op ZERO Cylinder 7/10 (70%) 2/10 (20%) <0.001 Postop Axis 56.67 (5.77) 60 (55-60) 76.88 (28.9) 75 (57.5-92.5) 0.401 Postop BCVA (logMAR) 0.26 (0.07) 0.25 (0.2-0.3) 0.4 (0.21) 0.35 (0.2-0.6) 0.200 Predicted Spherical Equivalent -0.17 (0.1) -0.16 (-0.25--0.13) -0.23 (0.19) -0.17 (-0.24--0.13) 0.712 Actual Spherical Equivalent -0.03 (0.35) 0 (0-0) -0.61 (0.76) -0.5 (-0.75--0.09) 0.039 Predicted Residual Cylinder 0.12 (0.1) 0.15 (0.07-0.17) 0.31 (0.48) 0.19 (0.06-0.24) 0.368 Retinal Detachment 0 (0%) 1 (10%) 1.000 Postop AGM 7 (70%) 3 (30%) 0.179 Continuous variables are presented as mean (SD), Median (Interquartile range limits), Bold face = statistically significant differences, UCVA=Uncorrected visual acuity, BCVA=Best Corrected visual acuity. logMAR = logarithm of the minimum angle of resolution. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7605979","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":530265559,"identity":"9cb51944-8837-4d32-8213-9b6f8feacee0","order_by":0,"name":"Aditya Kelkar","email":"","orcid":"","institution":"National Institute of Ophthalmology","correspondingAuthor":false,"prefix":"","firstName":"Aditya","middleName":"","lastName":"Kelkar","suffix":""},{"id":530265560,"identity":"37e7fc7d-02be-46d9-a415-f20392b74d85","order_by":1,"name":"Jai Kelkar","email":"","orcid":"","institution":"National Institute of Ophthalmology","correspondingAuthor":false,"prefix":"","firstName":"Jai","middleName":"","lastName":"Kelkar","suffix":""},{"id":530265561,"identity":"001cbad3-cbf3-48e5-8a6f-8f9f4f3370b4","order_by":2,"name":"Rabia Naaz","email":"","orcid":"","institution":"National Institute of Ophthalmology","correspondingAuthor":false,"prefix":"","firstName":"Rabia","middleName":"","lastName":"Naaz","suffix":""},{"id":530265562,"identity":"3f09db7f-e548-4077-af49-b989d9754abc","order_by":3,"name":"Harsh Jain","email":"","orcid":"","institution":"National Institute of Ophthalmology","correspondingAuthor":false,"prefix":"","firstName":"Harsh","middleName":"","lastName":"Jain","suffix":""},{"id":530265563,"identity":"d67ff63a-72ea-4345-8607-36eb36efe0ff","order_by":4,"name":"Sabyasachi Sengupta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDCCAxCKh5+9sfEBiMFHrBYZyZ7Dhw1AWtiI1WJjcCMtTQLEIqiF7/bxZ9KFOw7zGJw5Y1b5NcdOho2B+eGjG3i0SJ7LMZOeeeYwj+TxHrPbstuSgQ5jMzbOwaPF4AwPmzRv22EePqAttyW3MQO1AEXwa2F/BtbCcCPHrFhyWz0xWhjMwFoEgN5n/LjtMGEtkmd4jK1529J5QIEszbjtOA8bMwG/8J1hf3ibt83aHhSVH39uqwYymh8+xqcFCprBJDMPmCSsHATqwCTjD+JUj4JRMApGwQgDAHC0RpUiDrO0AAAAAElFTkSuQmCC","orcid":"","institution":"National Institute of Ophthalmology","correspondingAuthor":true,"prefix":"","firstName":"Sabyasachi","middleName":"","lastName":"Sengupta","suffix":""}],"badges":[],"createdAt":"2025-09-13 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02:24:19","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94506,"visible":true,"origin":"","legend":"","description":"","filename":"7404ae2fdaf0415b9d4f135d23f0f8101structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7605979/v1/bbb095dde7904a1daafae187.xml"},{"id":93731904,"identity":"cda4f54f-dd8b-4e2c-9d6d-c0ac080f96e1","added_by":"auto","created_at":"2025-10-17 02:24:23","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":104349,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7605979/v1/f19a38c79e151496ad1edccc.html"},{"id":93731898,"identity":"881eecbb-729e-455f-b828-baf835896403","added_by":"auto","created_at":"2025-10-17 02:24:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57100,"visible":true,"origin":"","legend":"\u003cp\u003eBar graph showing the distribution of astigmatism magnitude categories in the Toric and Non-Toric groups. The percentage of eyes in each astigmatism category is displayed for both preoperative and postoperative time points.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7605979/v1/87e2220e48ebf20b12033119.png"},{"id":93731843,"identity":"00e3154e-56bc-4b38-8b21-cc9f9c3063e4","added_by":"auto","created_at":"2025-10-17 02:24:12","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":312489,"visible":true,"origin":"","legend":"\u003cp\u003eDouble-angle plots illustrating the distribution of astigmatism vectors preoperatively and postoperatively in the Toric and Non-Toric groups. Each point represents the magnitude and axis of astigmatism for an individual eye.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7605979/v1/a4e62279bd2886ce7b44b2fd.jpeg"},{"id":93731872,"identity":"f1231aa2-2e0d-4487-9698-6cddb89d27e2","added_by":"auto","created_at":"2025-10-17 02:24:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":162461,"visible":true,"origin":"","legend":"\u003cp\u003eDouble-angle error plots depicting the distribution of surgically induced astigmatic changes and residual errors in the Toric and Non-Toric groups. The plots visualize both the magnitude and direction of astigmatic error vectors following surgery.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7605979/v1/3c2ca3099b5b2637ac522f09.png"},{"id":97139210,"identity":"5169fb6d-816d-4a50-863f-181ae363f78b","added_by":"auto","created_at":"2025-12-01 09:59:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1462651,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7605979/v1/ea46d1fa-763f-4b00-bdbf-25554b4b47ef.pdf"},{"id":93731854,"identity":"cc9b0112-8607-4cfe-abe0-04479139a91b","added_by":"auto","created_at":"2025-10-17 02:24:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16970,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7605979/v1/0c27dbcb133f581668d5ab57.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Refractive Outcomes of Toric and Non-Toric IOLs in Post-Radial Keratotomy Eyes: A Comparative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRadial keratotomy (RK), a popular refractive procedure in the 1980s and 1990s, aimed to correct myopia by creating radial corneal incisions to flatten central curvature.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e While initially effective, RK often resulted in long-term complications such as progressive hyperopic shift, irregular astigmatism, and fluctuating vision, which now pose challenges during cataract surgery planning.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Biometry in post-RK eyes is difficult due to altered corneal curvature and irregularity, affecting keratometry and axial length estimation.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Standard IOL formulas often fall short and are further confounded by irregular astigmatism and altered effective lens position prediction, yielding suboptimal results that necessitate the use of specialised approaches, such as the Barrett True-K formula.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eToric intraocular lenses (IOLs) offer a logical and potential solution by addressing astigmatism at the time of cataract surgery and improving uncorrected distance vision. Their efficacy is established in post-keratoplasty and stable keratoconus.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Arcuate keratotomy, commonly used in normal eyes with low astigmatism, is contraindicated in RK due to the risk of wound dehiscence, making toric IOLs the only viable corneal-plane-independent option.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDespite improvements in toric IOL design, rotational stability, and the availability of advanced planning tools like digital marking systems and post-refractive surgery calculators, there remains limited literature supporting the use of toric IOLs in eyes with prior RK. Many surgeons remain apprehensive due to concerns about rotational instability in elongated eyes, unreliable preoperative keratometry, and unexpected postoperative refractive surprises.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Yet, this is a growing concern, patients who underwent RK decades ago are now candidates for cataract surgery and still seek spectacle independence. With modern biometry techniques (e.g., IOLMaster 700), better IOL power formulas,\u003csup\u003e4,5\u003c/sup\u003e and stable toric IOLs,\u003csup\u003e11,12\u003c/sup\u003e successful outcomes are more feasible.\u003c/p\u003e\u003cp\u003eThis study compares refractive outcomes in post-RK eyes implanted with toric versus non-toric IOLs, using vector analysis to quantify astigmatic correction. By bridging this knowledge gap, we aim to guide clinical decision-making in a complex yet increasingly common surgical scenario. Unlike prior studies that selectively included eyes with regular astigmatism,\u003csup\u003e13\u003c/sup\u003e we included all consecutive cases with repeatable keratometry, thereby reflecting real-world clinical variability and challenges.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis was a retrospective comparative study conducted at a tertiary eye care centre in western India and was approved by the institutional ethics committee. Written informed consent for cataract surgery was obtained from all patients preoperatively. The study adhered to the tenets of the Declaration of Helsinki.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eMedical records of consecutive patients with a prior history of RK who underwent uneventful phacoemulsification with IOL implantation between June 2021 and July 2024 were reviewed. Eyes were included if they had a minimum of 1 month of postoperative follow-up, consistent with the institution\u0026rsquo;s protocol for refractive evaluation and spectacle prescription. Exclusion criteria included any intraoperative complications such as posterior capsular rupture, zonular dialysis, or the need for anterior vitrectomy, as well as ocular comorbidities associated with high myopia that could independently limit visual outcomes such as retinal detachment or retinal surgery, myopic macular neovascularization or chorioretinal atrophy, anisometropic amblyopia, strabismus with central suppression, significant epiretinal membrane or macular hole, and advanced glaucomatous optic neuropathy.\u003c/p\u003e\n\u003ch3\u003ePreoperative Assessment\u003c/h3\u003e\n\u003cp\u003ePreoperative evaluation included measurement of uncorrected (UCVA) and best-corrected visual acuity (BCVA), manifest refraction, slit-lamp biomicroscopy, axial length (AXL), anterior chamber depth (ACD), and keratometry (K1, K2). Biometry was performed using the IOL Master 700 (Carl Zeiss Meditec, Germany). On slit-lamp examination, the number of RK incisions was recorded, categorising eyes into 8-cut or 16-cut RK patterns based on the visible extent and distribution of radial scars. Additional parameters, such as lens thickness, corneal toricity, white-to-white diameter, and preoperative astigmatism, were also recorded.\u003c/p\u003e\n\u003ch3\u003eIOL Selection\u003c/h3\u003e\n\u003cp\u003eToric IOL power was calculated using the ASCRS post-refractive IOL calculator (Barret True K Calculator available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ascrs.org/tools/barrett-true-k-calculator\u003c/span\u003e\u003cspan address=\"https://www.ascrs.org/tools/barrett-true-k-calculator\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) with the \u0026ldquo;post-RK\u0026rdquo; mode. Toric IOLs were offered to all eyes with clear corneas (apart from RK scars) and consistent keratometry readings, defined as a difference of \u0026le;\u0026thinsp;0.5 D between two consecutive measurements obtained during the same session. The final IOL choice (toric vs. non-toric) was made by the patient after comprehensive counselling regarding the potential benefits (reduced postoperative spectacle dependence for distance vision) and risks (possible calculation errors, the need for repositioning in case of misalignment, especially in eyes with long axial length). Toric axis markings were performed using the Callisto Eye system (Carl Zeiss Meditec).\u003c/p\u003e\n\u003ch3\u003eSurgical Protocol\u003c/h3\u003e\n\u003cp\u003ePhacoemulsification was performed via a temporal clear corneal incision under topical anesthesia using the Alcon Centurion phacoemulsification system (Alcon, USA), with intraoperative intraocular pressure settings deliberately lowered to reduce the risk of RK wound dehiscence. In cases where wound gaping was noted intraoperatively, a single partial-thickness 10\u0026thinsp;\u0026minus;\u0026thinsp;0 nylon suture at the site of the leaking RK incision was typically sufficient to achieve watertight closure; rarely, a second suture was required. All sutures were placed starting at the limbus, exactly perpendicular to the RK cut, ensuring adequate length on either side of the gape, and tied with just enough tension to secure apposition without inducing corneal distortion. A foldable toric IOL (Alcon AcrySof\u0026reg; IQ Toric or Johnson \u0026amp; Johnson Eyhance Toric) was implanted in the capsular bag. After thorough viscoelastic removal, the toric IOL was rotated under irrigation to the intended axis as guided by the Callisto overlay. Stability was confirmed before concluding surgery.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eOutcome Measures and Statistical Analysis\u003c/h2\u003e\u003cp\u003eThe primary outcome measure was residual refractive astigmatism at 1 month postoperatively, comparing eyes that received toric versus non-toric IOLs. Secondary measures included postoperative visual acuity, spherical equivalent, and astigmatism vector parameters.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll continuous variables were summarized as mean (standard deviation) or median (interquartile range) as appropriate, and categorical variables as counts and percentages (n, %). For head-to-head group comparisons (e.g., toric vs. non-toric IOLs, wound leak vs. no wound leak), independent samples t-tests or Mann-Whitney U tests were used for continuous variables, and chi-square or Fisher\u0026rsquo;s exact tests for categorical variables, depending on data distribution and sample size. Comparisons between pre and post surgery parameters were done using paired t-tests with Bonferroni\u0026rsquo;s corrections.\u003c/p\u003e\u003cp\u003eAnalyses of astigmatism were performed using both categorical and vectorial methods as per standard analysis techniques.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e The distribution of astigmatism magnitudes was summarised using bar graphs stratified by treatment group (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). To assess the orientation and magnitude of astigmatism, double-angle plots were constructed for both preoperative and postoperative data, separately for Toric and Non-Toric groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Additionally, double-angle error plots were generated to visualize the distribution of surgically induced astigmatic changes and residual errors (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These graphical methods provided a comprehensive visualization of both the magnitude and axis of astigmatism, facilitating groupwise comparisons and assessment of surgical outcomes.\u003c/p\u003e\u003cp\u003eTo identify risk factors for wound leak, univariate logistic regression was first performed for each candidate variable. Variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.10 in univariate analysis were included in a multivariable logistic regression model to adjust for potential confounders. Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test and area under the receiver operating characteristic (ROC) curve. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All analyses were conducted using R (version 4.3.3) and relevant statistical packages using the Julius AI interface.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study cohort consisted of 24 eyes, with a mean age of 55.7 years (SD\u0026thinsp;\u0026asymp;\u0026thinsp;8.9). There was a male preponderance (n\u0026thinsp;=\u0026thinsp;19 males, 79%), and the majority of eyes had moderate to high myopia, as reflected by a mean axial length of 28.16 mm (SD\u0026thinsp;\u0026asymp;\u0026thinsp;3.2). The mean preoperative corneal toricity was 3.04 diopters (SD\u0026thinsp;\u0026asymp;\u0026thinsp;1.6). Intraoperatively, nearly half of the eyes (n\u0026thinsp;=\u0026thinsp;10, 42%) received toric intraocular lenses, while another 10 opted out and four were not offered toric IOL due to corneal opacity, making toric calculations unreliable. Intraoperative wound leak was observed in 11 eyes (46%).\u003c/p\u003e\n\u003cp\u003ePostoperatively, an IOP spike was observed on day 1 (mean IOP\u0026thinsp;=\u0026thinsp;30.75 mmHg (SD\u0026thinsp;\u0026asymp;\u0026thinsp;12.7), which decreased to a mean of 16.9 mmHg (SD\u0026thinsp;\u0026asymp;\u0026thinsp;1.9) by day 15. The uncorrected visual acuity (UCVA) improved from a preoperative mean of 0.55 (SD 0.22) to 0.38 (SD 0.18) at 1 month postoperatively (p\u0026thinsp;=\u0026thinsp;0.19, paired t-test). The mean residual refractive cylinder was \u0026minus;\u0026thinsp;0.89 diopters (SD\u0026thinsp;\u0026asymp;\u0026thinsp;1.1), and the mean axis of astigmatism was 66.8 degrees (SD\u0026thinsp;\u0026asymp;\u0026thinsp;21.7). The BCVA also showed improvement, with the mean preoperative BCVA of 0.53 (SD 0.22) improving to 0.35 (SD 0.18) at 1 month postoperatively (p\u0026thinsp;=\u0026thinsp;0.09, paired t-test).\u003c/p\u003e\n\u003cp\u003eIn the comparison of preoperative characteristics between eyes receiving toric (n\u0026thinsp;=\u0026thinsp;10) and non-toric intraocular lenses (n\u0026thinsp;=\u0026thinsp;10) (Table 1), eyes in the non-toric IOL group had a significantly longer mean axial length (p\u0026thinsp;=\u0026thinsp;0.014) and, therefore, required a lower mean lens power compared to the toric IOL group (p\u0026thinsp;=\u0026thinsp;0.002). Additionally, lens thickness was slightly lower in the non-toric group (p\u0026thinsp;=\u0026thinsp;0.03), and anterior chamber depth was greater in the non-toric group (p\u0026thinsp;=\u0026thinsp;0.032). Other preoperative variables, such as age and corneal toricity, showed no significant differences between groups, although there was a trend toward higher toricity in the toric IOL group (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eWhen comparing intraoperative and postoperative outcomes, most variables did not differ significantly between the toric and non-toric groups (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Although both groups experienced IOP spikes on day 1, a trend toward higher IOP in the toric IOL group was seen; however, this difference did not reach statistical significance. The UCVA was better in the toric IOL group, and this group also had lower spherical equivalent at one month. Additionally, the toric IOL group also demonstrated significantly fewer eyes (3/10) with residual astigmatism (30% vs 80%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the three eyes that did, had lesser residual postoperative cylinder compared to the non-toric group (p\u0026thinsp;=\u0026thinsp;0.028), even after adjusting for axial length and number of RK cuts (adjusted p\u0026thinsp;=\u0026thinsp;0.06).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u003c/div\u003e\n\u003cp\u003eAstigmatism profile changes were further analyzed using vector decomposition. The double-angle plot (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) illustrated the distribution of postoperative astigmatism vectors, with the toric IOL group (n\u0026thinsp;=\u0026thinsp;3 eyes) showing a tighter cluster and lower mean residual astigmatism compared to the non-toric group (n\u0026thinsp;=\u0026thinsp;8 eyes). Quantitative analysis confirmed that the toric group had a lower mean residual astigmatism (0.58 D) in the three eyes compared to the non-toric group (0.89 D), although this difference did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.25). Vector analysis (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) further supported these findings, with the toric group demonstrating a trend toward more accurate and predictable astigmatism correction, as indicated by lower difference vectors and correction indices closer to unity.\u003c/p\u003e\n\u003cp\u003eIntraoperative wound leak was seen in nearly half the eyes (n\u0026thinsp;=\u0026thinsp;11 eyes, 46%). Group-wise comparisons were performed between eyes with and without postoperative wound leak (Supplementary Table\u0026nbsp;1). Eyes that developed wound leak tended to have longer axial lengths, flatter preoperative corneal curvature (K1 and K2), and a higher proportion of 16-cut radial keratotomy (RK) procedures, while hypertension was less common in the wound leak group. In particular, the risk of wound leak was dramatically higher, several-fold greater, in eyes that had undergone 16-cut RK compared to those with 8-cuts.\u003c/p\u003e\n\u003cp\u003eUnivariate logistic regression confirmed that 16-cut RK was associated with an extremely elevated risk of wound leak, with the odds ratio being infinite (95% CI: 5.84 to not estimable, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) due to the absence of no-wound leaks in the 16-cut group (vs. 13% in 8-cut group). Other factors also showed significant associations: for each 1 mm increase in axial length, the odds of wound leak increased more than twofold (OR\u0026thinsp;=\u0026thinsp;2.1, 95% CI: 1.2\u0026ndash;3.68, p\u0026thinsp;=\u0026thinsp;0.01); and each diopter increase in lens power (shorter eyes) was associated with a lower risk (OR\u0026thinsp;=\u0026thinsp;0.82, 95% CI: 0.69\u0026ndash;0.98, p\u0026thinsp;=\u0026thinsp;0.03). Hypertension was also associated with a lower risk of wound leak in univariate analysis (OR\u0026thinsp;=\u0026thinsp;0.09, 95% CI: 0.01\u0026ndash;0.88, p\u0026thinsp;=\u0026thinsp;0.04). In the multivariable model (excluding 16-cut RK), only axial length remained a borderline significant predictor (OR\u0026thinsp;=\u0026thinsp;2.0, 95% CI: 1.0\u0026ndash;4.01, p\u0026thinsp;=\u0026thinsp;0.05), while the associations for hypertension (OR\u0026thinsp;=\u0026thinsp;0.33, 95% CI: 0.01\u0026ndash;8.37, p\u0026thinsp;=\u0026thinsp;0.5) was no longer statistically significant.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis retrospective comparative study evaluated outcomes of toric versus non-toric IOL implantation in eyes with prior RK undergoing cataract surgery, an inherently complex clinical scenario that often deters surgeons from choosing toric IOLs due to concerns about corneal instability and postoperative unpredictability. Our findings challenge this hesitation: toric IOLs provided superior refractive outcomes, with significantly lower residual astigmatism and higher rates of postoperative cylindrical neutrality compared to non-toric lenses. These differences held true not only in direct clinical comparisons but also under vector-based astigmatism analysis, reinforcing the precision and predictability of toric correction even in surgically altered corneas. However, the study also highlighted a critical intraoperative complication: nearly half the eyes experienced wound leak during surgery, with the risk being especially pronounced in eyes with 16-cut RK and longer axial lengths. These observations emphasise the need for careful preoperative planning and intraoperative vigilance when operating on such eyes, regardless of IOL choice.\u003c/p\u003e\u003cp\u003eThe refractive outcomes observed in this study highlight the potential of toric IOLs to deliver significantly better astigmatic correction than non-toric lenses, even in eyes with complex corneal profiles following RK. Our results showed markedly lower residual refractive astigmatism and a higher proportion of eyes achieving cylindrical neutrality in the toric group, both clinically and under rigorous vector analysis. These findings align with the limited available literature. In a retrospective series by Canedo et al.,\u003csup\u003e13\u003c/sup\u003e 40 eyes with prior RK implanted with toric IOLs showed a significant reduction in refractive cylinder from 2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98 D to 0.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44 D, with 73% achieving\u0026thinsp;\u0026le;\u0026thinsp;0.5 D and 88% achieving\u0026thinsp;\u0026le;\u0026thinsp;1.0 D postoperatively. Their findings highlighted the effectiveness of toric IOLs in treating regular astigmatism in post-RK eyes, provided there is stable refraction and topographic regularity. However, their highly selective cohort, limited to eyes with regular bowtie astigmatism and minimal inter-device keratometry variance, differs from our real-world sample. Our study included a broader spectrum of corneal irregularity, including 43% with 16-cut RK, which is more prone to wound instability and irregular astigmatism. Still, toric IOLs consistently outperformed non-toric IOLs in both vector and clinical measures. While non-toric eyes showed modest refractive improvement, likely from incision-induced flattening, the results were less predictable and less pronounced than those seen with toric lenses, similar to results reported by Soare et al.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn addition to this, only a few case reports exist supporting toric IOL use in post-RK eyes. Basilious et al. reported that toric IOL implantation in a post-RK eye, with flat corneal powers (below 30 diopters) led to reduced astigmatism from 3.24 D to 1.00 D in the right eye and from 4.13 D to 1.00 D in the left eye,\u003csup\u003e16\u003c/sup\u003e underscoring the value of pre-cataract refractions, findings comparable to the 30% of our cases with residual astigmatism. Case reports by Nuzzi et al. and Chen et al. support the use of toric IOLs in post-RK eyes,\u003csup\u003e17,18\u003c/sup\u003e emphasising the need for personalised planning and stable, symmetric corneal astigmatism to achieve predictable outcomes, even in complex cases such as a customised toric multifocal IOL in a post-RK eye with prior cross-linking and hyperopia/astigmatism,\u003csup\u003e18\u003c/sup\u003e or a toric IOL in a 71-year-old with over 30 RK incisions and confirmed diurnal stability.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e However, these are inherently limited in scope and generalizability.\u003c/p\u003e\u003cp\u003eTo supplement this sparse literature, studies evaluating toric IOLs in eyes with irregular astigmatism from other causes, such as post-keratoplasty and stable keratoconus, provide valuable insight. In these contexts, toric IOLs have demonstrated reductions in refractive astigmatism of 3\u0026ndash;4 D or more and significant improvements in uncorrected distance visual acuity (UDVA), with over 85% of eyes achieving\u0026thinsp;\u0026le;\u0026thinsp;1.00 D of residual astigmatism.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e These outcomes reinforce the viability of toric correction in structurally altered corneas and highlight its potential benefit in post-RK eyes when executed with appropriate planning and technique.\u003c/p\u003e\u003cp\u003eDespite these encouraging results, many surgeons remain hesitant to use toric IOLs in post-RK eyes due to concerns about inaccurate keratometry, axis misalignment, or IOL rotation, particularly in eyes with long axial lengths, with some studies clearly warning against the use of toric IOLs in post RK eyes.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Our study demonstrates that, when guided by reliable topography and biometry (e.g., IOLMaster 700, Barrett True-K), toric IOLs can outperform non-toric lenses in this challenging subset. This real-world evidence supports expanding toric IOL usage in appropriately selected post-RK eyes.\u003c/p\u003e\u003cp\u003eWound leak was a notable intraoperative complication in our study, particularly in eyes with 16-cut RK. The structural fragility of RK-altered corneas, especially with a higher number of incisions, predisposes them to spontaneous dehiscence during cataract surgery.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Prior studies have shown that incomplete healing of RK incisions and their poor tensile strength increase the risk of rupture under surgical stress,\u003csup\u003e22\u003c/sup\u003e further aggravated by phaco-induced thermal injury or rapid chamber fluctuations. Our findings echo these concerns, underscoring the importance of preoperative counseling, low-pressure fluidics, and readiness to place partial-thickness radial sutures when needed. Meticulous wound management, especially in eyes with extensive RK patterns, helps maintain chamber stability, reduces intraoperative complications, and ensures safer cataract surgery.\u003c/p\u003e\u003cp\u003eThis study is limited by its retrospective design and relatively small sample size, which may restrict generalizability. However, its strengths include a direct comparison between toric and non-toric IOLs in the same surgical setting, a quasi-randomized design based on patient affordability and preference, and the inclusion of robust vector analysis to validate refractive outcomes.\u003c/p\u003e\u003cp\u003eIn conclusion, toric IOL implantation in post-RK eyes undergoing cataract surgery offers superior astigmatic correction and greater refractive predictability compared to non-toric IOLs, even in the presence of significant corneal irregularity. While intraoperative wound leaks remain a concern, particularly in eyes with extensive RK patterns, appropriate surgical precautions can mitigate risk. These findings support the considered use of toric IOLs in post-RK patients and may help overcome long-standing hesitations among cataract surgeons when managing this challenging group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e Nil.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of Support:\u003c/strong\u003e Nil\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [JK, RN], [JK, HJ] and [SS]. The first draft of the manuscript was written by [AK] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request, subject to approval by the Institutional Ethics Committee.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRadial keratotomy for myopia. American Academy of Ophthalmology. Ophthalmology. 1993 July;100(7):1103\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSoare C, Patel DS, Ionides A. Cataract surgery outcomes in eyes with previous radial keratotomy. Eye (Lond). 2022;36(9):1804\u0026ndash;1809.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGauthier A, Awidi AA, Noble PM, Daoud YJ. Factors Predictive of Refractive Error After Toric Lens Implantation. Clin Ophthalmol. 2023;17:1813\u0026ndash;1821.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang L, Koch DD. Intraocular Lens Power Calculations in Eyes with Previous Corneal Refractive Surgery: Review and Expert Opinion. Ophthalmology. 2021;128(11):e121\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQiu X, Shi Y, Han X, Hua Z, Lu Y, Yang J. Toric Intraocular Lens Implantation in the Correction of Moderate-To-High Corneal Astigmatism in Cataract Patients: Clinical Efficacy and Safety. J Ophthalmol. 2021;2021:5960328.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoreno-Mart\u0026iacute;nez A, Mart\u0026iacute;n-Melero O, Andr\u0026eacute;s-Pretel F, G\u0026oacute;mez-Cort\u0026eacute;s A, Granados-Centeno JM. Outcomes of Phacoemulsification With Toric Intraocular Lenses in Addressing Postkeratoplasty Astigmatism. Cornea. 2024;43(1):76\u0026ndash;82\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLockington D, Wang EF, Patel DV, Moore SP, McGhee CN. Effectiveness of cataract phacoemulsification with toric intraocular lenses in addressing astigmatism after keratoplasty. J Cataract Refract Surg. 2014;40(12):2044\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeduri A, Urso M, Signorino GA, Rechichi M, Mazzotta C, Kaufman S. Cataract surgery on post radial keratotomy patients. Int J Ophthalmol. 2017;10(7):1168\u0026ndash;1170.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHirnschall N, Hoffmann PC, Draschl P, Maedel S, Findl O. Evaluation of factors influencing the remaining astigmatism after toric intraocular lens implantation. J Refract Surg. 2014;30(6):394\u0026ndash;400.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTrinh T, Solomon B, Mimouni M, Cohen E, Gouvea L, Santaella G, et al. Outcomes of femtosecond laser-assisted cataract and refractive lens surgery in patients with prior radial keratotomy. J Cataract Refract Surg. 2022;48(4):449\u0026ndash;455.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJeeva IK, Masud S, Ali TS, Siddiqui MAR, Waheed AA, Awan A. Evaluation of visual outcomes with toric intraocular lens implantation using digital marker during cataract surgery. J Pak Med Assoc. 2024;74(3):450\u0026ndash;455.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSingh A, Kapoor G, Baranwal VK, Kalra N. Rotational stability of Toric intraocular lenses. Med J Armed Forces India. 2022;78(1):68\u0026ndash;73\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCanedo ALC, Wang L, Koch DD, Al-Mohtaseb Z. Accuracy of astigmatism correction with toric intraocular lens implantation in eyes with previous radial keratotomy. J Cataract Refract Surg. 2022;48(4):417\u0026ndash;420.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKohnen T, N\u0026aelig;ser K, Holladay JT, Stulting RD, Wang L, Abulafia A, et al. Standards for analyzing astigmatic outcomes: Part I: astigmatism basics. J Cataract Refract Surg. 2025;51(6):440.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoch DD, Holladay JT, Naeser K, Abulafia A, Wang L, Stulting RD, et al. Standards for analyzing astigmatic outcomes: Part II: Recommended statistical methods. J Cataract Refract Surg. 2025;51(6):447.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBasilious A, Basilious A. Outcomes of Toric Intraocular Lens Implantation After Radial Keratotomy. Journal of refractive surgery case reports. 2022;2(4):e68\u0026ndash;e71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen SSW, Torii H, Yotsukura E, Nishi Y, Negishi K. Implantation of a toric intraocular lens after repeated radial keratotomy procedures: A case report. Heliyon. 2023 17;9(12):e22500\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNuzzi R, Monteu F, Tridico F. Implantation of a Multifocal Toric Intraocular Lens after Radial Keratotomy and Cross-Linking with Hyperopia and Astigmatism Residues: A Case Report. Case Rep Ophthalmol. 2017;8(2):440\u0026ndash;445.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBascaran L, Mendicute J, Macias-Murelaga B, Arbelaitz N, Martinez-Soroa I. Efficacy and stability of AT TORBI 709 M toric IOL. J Refract Surg. 2013;29(3):194\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJulio C. Hernandez-Camarena, Raul E. Ruiz-Lozano, Brandon Rodriguez-Pinzon, Jorge E. Valdez-Garc\u0026iacute;a. Hyperopic shift after refractive lens surgery in a patient with prior history of radial keratotomy. The Pan-American journal of ophthalmology. 2022;4(1):39\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBehl S, Kothari K. Rupture of a radial keratotomy incision after 11 years during clear corneal phacoemulsification. J Cataract Refract Surg. 2001;27(7):1132\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeroux les Jardins S, Bertrand I, Massin M. Intraoperative and early postoperative complications in 466 radial keratotomies. Refract Corneal Surg. 1992;8(3):215\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTables: Table 1: Preop comparisons between eyes with and without Toric IOL implantation.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eToric IOL (n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-Toric IOL (n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57.6 (6.67),\u0026nbsp;\u003cbr\u003e\u0026nbsp;58 (53-61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.8 (10.89),\u0026nbsp;\u003cbr\u003e\u0026nbsp;53 (47.75-64.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.362\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAxial length\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e26.31 (2.37),\u0026nbsp;\u003cbr\u003e\u0026nbsp;25.32 (24.49-27.82)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e30.01 (3.5),\u0026nbsp;\u003cbr\u003e\u0026nbsp;29.84 (27.26-31.97)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLens Power\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e24.4 (3.56),\u0026nbsp;\u003cbr\u003e\u0026nbsp;23.5 (22.5-27)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e17 (5.26),\u003cbr\u003e\u0026nbsp;15.25 (12.62-21.12)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLens Thickness\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.27 (0.36),\u003cbr\u003e\u0026nbsp;4.4 (4.33-4.44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.1 (0.23),\u003cbr\u003e\u0026nbsp;4.13 (3.89-4.28)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eToricity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.33 (1.59),\u0026nbsp;\u003cbr\u003e\u0026nbsp;3.75 (1.88-4.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.75 (1.6),\u0026nbsp;\u003cbr\u003e\u0026nbsp;2.62 (1.5-3.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.431\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnterior chamber depth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.06 (0.37),\u0026nbsp;\u003cbr\u003e\u0026nbsp;3.06 (2.71-3.34)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.46 (0.39),\u0026nbsp;\u003cbr\u003e\u0026nbsp;3.3 (3.26-3.64)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.032\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreop_K1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.92 (3.86),\u0026nbsp;\u003cbr\u003e\u0026nbsp;32 (31.63-35.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.76 (3.92),\u0026nbsp;\u003cbr\u003e\u0026nbsp;34.58 (30.14-37.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.853\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreop_K2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.48 (3.81),\u0026nbsp;\u003cbr\u003e\u0026nbsp;34.97 (34.31-37.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.03 (3.61),\u0026nbsp;\u003cbr\u003e\u0026nbsp;36.12 (32.91-38.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.787\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreop UCVA (logMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.48 (0.28),\u003cbr\u003e\u0026nbsp;0.45 (0.27-0.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.38 (0.73),\u0026nbsp;\u003cbr\u003e\u0026nbsp;1.45 (0.83-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreop BCVA\u0026nbsp;\u003c/strong\u003e(logMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.41 (0.21),\u003cbr\u003e\u0026nbsp;0.4 (0.2-0.58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.83 (0.47),\u0026nbsp;\u003cbr\u003e\u0026nbsp;0.6 (0.6-0.9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.303\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.350\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRK - 8 Cut\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRK- 16 Cut\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration Of Radial Keratotomy Surgery (Yrs)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e31.8 (3.88),\u003cbr\u003e\u0026nbsp;33 (30.25-35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e26.3 (6.15),\u0026nbsp;\u003cbr\u003e\u0026nbsp;27 (25.25-30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.038\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGlaucoma On antiglaucoma medications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAmblyopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.474\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreoperative Phacodonesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrade Of Cataract: 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrade Of Cataract: 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrade Of Cataract: 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrade Of Cataract: 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreop Cylinder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.67 (2.04),\u003c/p\u003e\n \u003cp\u003e-2.25 (-2.75 to -0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.93 (1.79),\u003c/p\u003e\n \u003cp\u003e-2 (-3.5 to -0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eContinuous variables are presented as mean (SD), Median (Interquartile range limits), Bold face = statistically significant differences, UCVA=Uncorrected visual acuity, BCVA=Best Corrected visual acuity. logMAR = logarithm of the minimum angle of resolution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Intra and Postop comparisons between eyes with and without Toric IOL implantation.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eToric IOL (n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-Toric IOL (n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative parameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWound Leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.650\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDehiscence Of RK Wound: No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative parameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostop Intraocular pressure Day 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34.5 (11.74),\u003cbr\u003e\u0026nbsp;34.5 (25.5-45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27 (13.52),\u0026nbsp;\u003cbr\u003e\u0026nbsp;22 (16-38.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostop Intraocular pressure Day 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.5 (2.01),\u003cbr\u003e\u0026nbsp;18 (16.25-18.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.4 (1.78),\u003cbr\u003e\u0026nbsp;16 (15-17.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostop UCVA (logMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.36 (0.18),\u0026nbsp;\u003cbr\u003e\u0026nbsp;0.35 (0.23-0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.69 (0.45),\u0026nbsp;\u003cbr\u003e\u0026nbsp;0.6 (0.28-0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostop Sphere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.15 (0.47),\u0026nbsp;\u003cbr\u003e\u0026nbsp;0 (0-0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1 (0.32),\u0026nbsp;\u003cbr\u003e\u0026nbsp;0 (0-0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostop Cylinder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.35 (0.59)\u003cbr\u003e\u0026nbsp;0 (-0.56-0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-1.43 (1.34)\u003cbr\u003e\u0026nbsp;-1.25 (-1.5--0.75)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.028\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Post Op ZERO Cylinder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e7/10 (70%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2/10 (20%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostop Axis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56.67 (5.77)\u003cbr\u003e\u0026nbsp;60 (55-60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.88 (28.9)\u003cbr\u003e\u0026nbsp;75 (57.5-92.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.401\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostop BCVA (logMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.26 (0.07)\u003cbr\u003e\u0026nbsp;0.25 (0.2-0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4 (0.21)\u003cbr\u003e\u0026nbsp;0.35 (0.2-0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePredicted Spherical Equivalent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.17 (0.1)\u003cbr\u003e\u0026nbsp;-0.16 (-0.25--0.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.23 (0.19)\u003cbr\u003e\u0026nbsp;-0.17 (-0.24--0.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActual Spherical Equivalent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.03 (0.35)\u003cbr\u003e\u0026nbsp;0 (0-0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.61 (0.76)\u003cbr\u003e\u0026nbsp;-0.5 (-0.75--0.09)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.039\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePredicted Residual Cylinder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.12 (0.1)\u003cbr\u003e\u0026nbsp;0.15 (0.07-0.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.31 (0.48)\u003cbr\u003e\u0026nbsp;0.19 (0.06-0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.368\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRetinal Detachment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostop AGM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eContinuous variables are presented as mean (SD), Median (Interquartile range limits), Bold face = statistically significant differences, UCVA=Uncorrected visual acuity, BCVA=Best Corrected visual acuity. logMAR = logarithm of the minimum angle of resolution.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cataract surgery, Toric IOL, Post Radial Keratotomy, High Astigmatism, Outcomes","lastPublishedDoi":"10.21203/rs.3.rs-7605979/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7605979/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003cbr\u003e\n\u003c/strong\u003eTo compare refractive outcomes in post-radial keratotomy (RK) eyes undergoing cataract surgery with toric versus non-toric intraocular lenses (IOLs), using clinical and vector-based astigmatism analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003cbr\u003e\n\u003c/strong\u003eConsecutive post-RK eyes undergoing uneventful phacoemulsification were included. Toric IOLs were offered to eyes with clear corneas and repeatable keratometry; acceptance was based on patient preference and affordability. The Barrett True-K Toric calculator was used. All surgeries were performed with digital marking and low-pressure phaco settings. Intraoperative wound leaks were noted and sutured if required\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003cbr\u003e\n\u003c/strong\u003eOf 24 eyes included, 10 received toric IOLs and 14 non-toric. The non-toric group had significantly longer axial lengths (30.01±3.5mm vs. 26.31±2.4 mm, p=0.02) and worse baseline BCVA (0.83 ± 0.5 vs. 0.41 ± 0.5 logMAR, p=0.01). At 1 month, cylindrical neutrality was achieved in 70% of toric eyes versus 20% of non-toric eyes (p \u0026lt; 0.001). Among eyes with residual cylinder, the mean was –0.35 ± 0.6D in the toric group versus –1.43 ± 1.3 D in the non-toric group (p=0.03). Vector analysis corroborated superior astigmatic correction in the toric group. Wound leaks occurred in 11 eyes (46%) overall, predominantly in 16-cut RK eyes and those with longer axial lengths.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003cbr\u003e\n\u003c/strong\u003eToric IOLs significantly improve refractive outcomes in post-RK eyes. While wound leaks remain a major surgical concern, particularly in 16-cut RK eyes, careful planning, appropriate IOL selection, and intraoperative vigilance can lead to safe surgery and excellent visual outcomes.\u003c/p\u003e","manuscriptTitle":"Refractive Outcomes of Toric and Non-Toric IOLs in Post-Radial Keratotomy Eyes: A Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 02:23:29","doi":"10.21203/rs.3.rs-7605979/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ebb9c15a-a68a-4909-923e-87c3b31e9b31","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-29T03:53:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 02:23:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7605979","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7605979","identity":"rs-7605979","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}