Analysis of factors associated with rotational stability of toric intraocular lens after high axial myopia cataract surgery

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Methods: This study was approved by a certified local review board (Registered: 2023-387-01, Date: 2023.01.04) and enrolled 60 cataract patients after TIOL implantation in GuangZhou Red Cross Hospital of Jinan University from January 2023 to June 2023, of which 30 patients in group A were diagnosed high axial myopia (Axial Length, AL ≥ 26 mm) and 30 patients in group B were normal AL (22 mm <AL < 26 mm), and the data of were collected and analysed at least half a year after surgery. To analyse the RS of TIOL and the correlation between RS and AL, TIOL material, White-To-White (WTW) and IOL power. Results: The difference in rotation angle (RA) between group A and B was statistically significant (RA A group = 16.03 ± 21.47, RA B group = 5.60 ± 8.27, p = 0.013 < 0.05); the difference in clinically significant rotation (CSR) between group A and group B was statistically significant (CSR A group = 17, CSR B group = 7, P = 0. 008 < 0.05), postoperative RA and CSR were positively correlated with the AL (p RA = 0.010, r RA = 0.332; p CSR = 0.008, r CSR = 0.342); and there was significantly more CSR of hydrophilic lens in group A than hydrophilic lens in group B (CSR Hydrophilic-A group = 10 ＞ CSR Hydrophilic-B group = 3, p = 0.01 < 0.05). There was a strong correlation between CSR and AL (p = 0.002, r = 0.720); more patients rotated counterclockwise than clockwise after TIOL and the difference was statistically significant (P = 0.004 < 0.05), and significantly more patients with hydrophobic lens rotated counterclockwise ( P= 0.035 < 0.05). Conclusions: The longer the AL of the eye, the more likely the toric lens will rotate post-operatively and the greater the RA; the toric lens tends to rotate counterclockwise, which is more pronounced in hydrophobic IOLs; hydrophilic toric lenses tend to rotate in patients with high axial myopia and the longer the AL, the greater the likelihood of rotation. Toric intraocular lens Rotational stability Rotation angle Direction of rotation Clinically significant rotation TIOL material Figures Figure 1 Figure 2 Figure 3 Introduction Astigmatism can cause symptoms such as blurred vision, double vision, halos and visual fatigue, some studies [ 1 ] had shown that astigmatism > 0.75D can causes many visual disturbances. Even low levels of astigmatism reduce visual acuity and postoperative satisfaction in cataract surgery patients [ 2 ] . Corneal astigmatism (CA) is prevalent in cataract patients and is an important determinant of whole-eye astigmatism after cataract surgery [ 3 ] . There are three modalities to correct CA: astigmatic keratotomy (AK), limbal relaxing incisions (LRI) and TIOL implantation. Among these, TIOL has become the procedure of choice for the correction of regular CA due to its wide range of astigmatism correction, surgical predictability, safety and ability to significantly reduce postoperative residual astigmatism (RAS) and improve postoperative visual acuity [ 4 – 7 ] . The rotational stability of the IOL is an important index for the evaluation of TIOL, and a study [ 8 ] showed that within 15° of the implantation axis, the amount of corrected astigmatism decreases by 3.5% for every 1° of rotation, and that the corrective effect of astigmatism disappears completely when the rotation reaches 30°. Patients with high axial myopia may be prone to rotation due to factors such as long AL, large lens capsule and zonular laxity [ 9 – 10 ] , but some researchers [ 11 – 12 ] have argued that there is no relationship between AL and TIOL rotation. The rotational stability of TIOL in axial myopia has not been conclusively determined, and its correlation with TIOL materials has been also less researched. The purpose of this paper is to observe the rotational stability of TIOL in high axial myopia cataract patients after surgery and to analyse its correlation with factors such as AL, lens material, WTW and IOL power. Materials and Methods Patient characteristics This is a prospective, nonrandomized controlled clinical study, which complied with the Declaration of Helsinki, in accordance with Good Clinical Practices and local regulatory requirements. The protocols were approved by the institutional Ethics Committee of GuangZhou Red Cross Hospital of Jinan University (Registered: 2023-387-01, Date: 2023.01.04). Patients were given detailed explanations of the study protocol and operative complications. They signed an informed consent form to participate in the study and provided permission for the results to be published anonymously. Cataract eyes were enrolled during January 2023 to June 2023, at the Guangzhou Red Cross Hospital. All patients were enrolled monocularly and randomly selected with a 1:1 ratio. The experimental group were patients with high axial myopia (Group A, AL ≥ 26 mm, 30 patients, hydrophilic hydrophilic toric lens / hydrophobic toric lens = 15: 15) and the normal cataract patients in the control group (Group B, 20 mm < AL < 26 mm, 30 patients, hydrophilic toric lens / hydrophobic toric lens = 15 : 15). There were 18 (9 : 9) males and 42 (21 : 21) females, and the mean age was 65.63 ± 8.73 in group A and 75.50 ± 6.78 in group B, and there was no statistically significant difference between the two groups in terms of gender, WTW, CA, IOL power and lens material in this study (Table 1 ). Although there were some differences between the two groups in terms of age and preoperative uncorrected distance visual acuity (UDVA), this was mainly due to the fact that high myopia is a high risk factor for early cataract development, and preoperative UDVA was also generally lower in this patients [ 13 ] . Table 1 Patient characteristics Group A (n = 30) Mean ± SD Group A (n = 30) Mean ± SD p-Value Materials (Hydrophilic/Hydrophobic) 15/15 15/15 1.000 Sex (men/women) 9/21 9/21 - Age(y) 65.63 ± 8.73 75.50 ± 6.78 < 0.001*** AL(mm) 28.24 ± 1.44 23.34 ± 0.86 < 0.001*** WTW(mm) 12.29 ± 2.42 11.62 ± 0.45 0.054 Pre-op UDVA (logMAR) 1.25 ± 0.59 0.83 ± 0.38 0.004** IOL Power (D) 17.00 ± 8.42 21.13 ± 2.53 0.059 AL = Axial Length, WTW = White-To-White, pre-op = pre-operatively; UDVA = uncorrected distance visual acuity Sample size estimation The sample size is calculated based on the sample size calculation formula (powerandsamplesize.com/). The following assumptions were made for the sample size cal culation: type 1 error (alpha) was set at 5%, and power (1-beta) on 0.90. The proportion of cases between the experimental and control groups was set to 1:1. Follow to our previous retrospective study, mean rotation angle of group A was set to greater than 15 and mean rotation angle of group B was set to less than 6. Then the sample calculator showed a minimum sample size of 26 patients. Considering a 15% dropout rate in each group, the sample size was calculated to be 30 patients for each group. Inclusion and Exclusion Criteria Inclusion criteria Cataract patients who implanted TIOL in Guangzhou Red Cross Hospital between January 2023 and June 2023; voluntarily signed an informed consent form. Exclusion Criteria Ocular trauma, severe dry eye, keratitis, pterygium, irregular astigmatism, glaucoma, severe vitreoretinopathy, optic neuropathy, history of internal angle or refractive surgery, intraoperative complications such as posterior capsular rupture, intraocular bleeding, post-operative secondary glaucoma, after-cataract, unwillingness to sign informed consent, mental abnormality. Examination Equipment IOL-Marster 500 (Zeiss, Germany), ophthalmic auto refractometer (ARK-510A, Nideke, Japan), slit lamp microscope (HS-5000, Huvitz, Korea), all examinations were performed by one person, and measurements were taken at least three times to reduce operator error. Marking the astigmatism axis After surface anaesthesia with proparacaine hydrochloride, the patient was seated in front of the slit lamp and the jaw rest was adjusted so that the outer canthus of both eyes was aligned with the line planes on either side of the slit lamp and the slit lamp light band was adjusted to a horizontal narrow slit, so that the horizontal light band passed through the centre of the pupil of both eyes, and the angle of the light band was adjusted to the angle of the surgical incision and the TIOL implantation axis, and the marking point was stained with colour using a 1ml syringe needle; the marking point was then stained with colour using a marker pen. Surgical procedure After surface anaesthesia with proparacaine hydrochloride, the main incision angle was 135°, 15° knife was used as secondary incision, the anterior chamber was injected with Viscoelastic agent, An approximately 5.5 mm − 6 mm continuous curvilinear capsulorhexis was then completed, followed by hydrodissection, phacoemulsification, and cortex removal, reinjecte the viscoelastic agent, implantation of IOL (AT Torbi 709M IOL / AcrySof Toric IOL), clockwise adjustment of the axial position to 20° undercorrection, remove the viscoelastic agent behind the TIOL, lightly press the IOL attach the posterior capsule membrane, readjustment of the IOL to align the alignment line with the preoperative markings. Finally, the incision was sealed by hydration. After returning to the ward, patients were restrained for at least 2 hours. As postoperative treatments for all patients, topical tobramycin-dexamethasone drops at least 2 weeks. All surgeries were performed by a single, experienced surgeon (Y.YG) using a standard procedure. Postoperative measurement After dilating the pupil with compound-tropicamide, the patient is seated in front of the slit lamp, the jaw rest is adjusted so that the outer canthus of both eyes is in the plane of the alignment line on both sides of the slit lamp, adjusts the slit lamp band to a horizontal narrow slit so that the light band passes through the centre of the pupil of both eyes, adjusts the angle of the light band so that it passes through the alignment line for the axis of TIOL astigmatism, and records the angle of the light band turntable at this time. All surgeries were performed by one person. Postoperative follow-up and examination All patients completed the Log MAR visual acuity, IOL-Marster 500, ophthalmic auto refractometer and recorded the toric axial alignment (0°-180°) under a slit lamp with dilated pupils at least six months after surgery. Observational measures Uncorrected distance visual acuity (UDVA) Visual acuity was converted to LogMAR visual acuity for statistical purposes; Ocular parameters Patients' white-to-white (WTW) and axial length (AL) were recorded by measuring the IOL marster; IOL parameters IOL power, material properties (AT Torbi 709M IOL = hydrophilic acrylate / AcrySof Toric IOL = hydrophobic acrylate). Rotational Stability This study analyses the rotational stability of TIOL in terms of rotation angle, clinically significant rotation and direction of rotation. 4. Rotation Angle (RA) The minimum angle at which the astigmatic axis of the TIOL deviates from the preoperative implantation axis after surgery is the RA. 5. Clinically significant rotation (CSR) Clinically significant rotation is considered to have occurred when the astigmatic axis of the postoperative TIOL deviates more than 5° from the implant axis. 6. Direction of rotation If clinically significant rotation of the TIOL occurs and the direction of the minimum angle of the postoperative TIOL axis deviating from the preoperative implantation axis is clockwise, it is recorded as clockwise rotation (CW), and if the direction of the minimum angle is counterclockwise, it is recorded as counterclockwise rotation (CCW); RA ≤ 5° is recorded as no rotation (N). Statistical Analysis SPSS 25.0 statistical software was used. In the measurement data of this study, the AL conformed to normal distribution with independent t-test and the others did not conform with u-test, and gender, TIOL material were tested with chi-squared test. For correlation analysis, dichotomous and continuous variables were correlated by Spearman correlation, and dichotomous and continuous variables were tested by χ2 test, with α = 0.05, and the difference was considered statistically significant with P < 0.05. Results Visual Outcomes Preoperative UDVA was 1.25 ± 0.59 and postoperative UDVA was 0.32 ± 0.30 in group A, with a statistically significant difference (p < 0.05), in group B preoperative UDVA was 0.83 ± 0.38 and postoperative visual acuity was 0.25 ± 0.18, with a statistically significant difference (Table 2 ). The correlation analysis found a positive correlation between RA and postoperative log MAR UDVA (p = 0.025, r = 0.409) in group A (Fig. 1 A), and a positive correlation between postoperative RA and postoperative log MAR UDVA in hydrophilic materials (p = 0.029, r = 0.563) (Fig. 1 B). Table 2 Comparison of preoperative and postoperative UDVA between group A and group B Pre-op UDVA (logMAR) Post-op UDVA (logMAR) p Value Group A 1.25 ± 0.59 0.32 ± 0.30 < 0.001*** Group B 0.83 ± 0.38 0.25 ± 0.18 < 0.001*** pre-op = pre-operatively; post-op = post-operatively; UDVA = uncorrected distance visual acuity Comparison of rotational stability between group A and group B The difference in RA between group A and group B was statistically significant (RA Group A = 16.03 ± 21.47, RA Group B = 5.60 ± 8.27, P = 0.013 CSR Group B = 7, P = 0.008 < 0.05) (Table 3 ); correlation analysis revealed a positive correlation between RA and AL (p = 0.010, r = 0.332) (Fig. 2 A) and a positive correlation between CSR and AL (p = 0.008, r = 0.342) (Fig. 2 B). Table 3 Comparison of postoperative rotational stability between Group A and Group B -1 Group A Group A p Value RA 16.03 ± 21.47 5.60 ± 8.27 0.013* CSR(Y/N) 17/13 7/23 0.008** RA = Rotation Angle; CSR = Clinically Significant Rotation Comparison of RS between hydrophilic toric lens and hydrophobic toric lens The mean RA of hydrophilic TIOL in group A was greater than that of hydrophilic TIOL in group B (RA Group A/Hydrophilic = 21.73 ± 27.31 > RA Group B/Hydrophilic = 6.6 ± 10. 93), the average RA of hydrophobic lens in group A was larger than that of hydrophobic lens in group B (RA Group A/hydrophobic = 10.33 ± 11.81>RA Group B/hydrophobic = 4.60 ± 4.47), and the differences between them were not statistically significant (P Group A−Hydrophilicity/Group B−Hydrophilicity =0.061, P Group A−Hydrophilicity/Group A−Hydrophilic =0.367, P Group A−Hydrophilic/Group B−Hydrophilic =0.187, P Group B−Hydrophilicity/Group B−Hydrophilic =0.775) (Table 4 ); Table 4 Comparison of post-operative rotational stability of different materials between Group A and Group B Group A Group A p Value AR(Y/N) Hydrophilic Toric Lens 10/5 3/12 0.010* Hydrophobic Toric Lens 7/8 4/11 0.256 p Value 0.269 0.666 - CSR Hydrophilic Toric Lens 21.73 ± 27.31 6.6 ± 10.93 0.061 Hydrophobic Toric Lens 10.33 ± 11.81 4.60 ± 4.47 0.187 p Value 0.367 0.775 - RA = Rotation Angle; CSR = Clinically Significant Rotation The CSR of hydrophilic lens in group A was significantly higher than that of hydrophilic lens in group B (CSR Hydrophilic−A group = 10 > CSR Hydrophilic−B group = 3, P = 0.01 CSR hydrophobic−B group = 4, P = 0.256). the difference in CSR between the different materials was not statistically significant (P Hydrophilic−group A / Hydrophobic−group A = 0.269, P Hydrophilic−group B/Hydrophobic−group B = 0.666) (Table 4 ). Correlation analysis further revealed a strong correlation between CSR and AL in axial high myopia patients implanted with hydrophilic lenses (p = 0.002, r = 0.720) (Fig. 3 ). Comparison of rotation directions between hydrophilic and hydrophobic toric lens More patients rotated counterclockwise than clockwise and the difference was statistically significant (N = 36, CW = 5, CCW = 19, P N/CW/CCW = 0.019 < 0.05, P CW/CCW = 0.004 < 0. 05) (Table 5 ); patients implanted with hydrophilic lens had more cases of counterclockwise rotation and the difference was not statistically significant (N = 17, CW = 3, CCW = 10, P CW/CCW = 0.052 > 0.05); patients implanted with hydrophilic lens had more cases of counterclockwise rotation and the difference was statistically significant (N = 19, CW = 2, CCW = 9, P CW/CCW = 0.035 < 0.05). Table 5 Comparison of direction of rotation N (A) Clockwise (B) Counterclockwise (C) p Value ALL 36(60.0%) 5(8.3%) 19(31.7%) < 0.001*** AvsB: <0.001*** BvsC: 0.004** AvsC: 0.022* Hydrophilic Toric Lens 17(56.7%) 3(10.0%) 10(33.3%) 0.007** AvsB: 0.002** BvsC: 0.052 AvsC: 0.178 Hydrophobic Toric Lens 19(63.3%) 2(3.3%) 9(30.0%) 0.001** AvsB: <0.001*** BvsC: 0.035* AvsC: 0.059 Discussion Corneal astigmatism (CA) is common in cataract patients, and with the transition of cataract surgery from refractive to refractive, CA has been increasingly recognised as the major source of whole-eye astigmatism after cataract surgery. TIOL is currently the preferred surgical procedure for the correction of CA, which can safely, efficiently and accurately correct regular CA, reduce RAS and improve the patient's postoperative UDVA, and studies [ 14 – 15 ] have shown that monocular TIOL has a postoperative decortication rate of 60–85%, and binocular TIOL has a decortication rate of 69–97%. With the widespread use of TIOL, the rotational stability of TIOL has also attracted much attention, as rotation tends to occur early after TIOL, especially within the first hour postoperatively [ 16 ] . The main factors thought to be potentially associated with rotational stability include the AL, anterior capsule opacification, TIOL properties (material, shape and size of the loops), intraocular ring and the time after implantation [ 17 ] , with the AL receiving the most attention. Studies on the relationship between AL and rotational stability are inconclusive, and previous researchers have suggested that patients with high axial myopia may be susceptible to rotation after TIOL due to the combination of a long AL, large lens capsule and zonular laxity. However, there were also many scientists [ 11 – 12 ] argued that AL does not have much to do with TIOL rotation recently. Furthermore, there are fewer studies on the relationship between TIOL materials and rotational stability. Zhu [ 18 ] concluded that hydrophilic TIOL with a lower degree of postoperative rotation than hydrophobic lens are better able to reduce postoperative RAS, but more relevant studies are still lacking. In this study, we introduced the concept of clinically significant rotation, and evaluated the rotational stability of TIOL in terms of rotation angle, CSR and direction of rotation, comparing the rotational stability of TIOL at least six months after cataract surgery in patients with high axial myopia and normal AL, and to analyse its correlation with AL, lens material, IOL power and WTW. Visual Outcomes All patients showed significant improvement in postoperative UDVA compared to preoperative. Correlation analysis of each experimental group also showed that postoperative RA was positively correlated with postoperative log MAR UDVA in group A (p = 0.025, r = 0.409), and postoperative RA was positively correlated with postoperative log MAR UDVA in the case of hydrophilic material (p = 0.029, r = 0.563), suggesting that the greater the RA in patients with high axial myopia and hydrophilic TIOL implantation, the worse the postoperative UDVA. This is consistent with previous results [ 19 ] , and the presumed reason for this is that the larger the RA, the smaller the amount of astigmatism correction, resulting in a larger postoperative RAS and worse visual acuity. However, we did not observe this correlation in patients with normal AL or implanted hydrophobic materials, which may be due to insufficient sample size and requires further investigation. Comparison of rotational stability between group A and group B At present, the measurement of postoperative TIOL rotation is mostly examined under the slit lamp, and the accuracy of the slit lamp with a turntable is only 5°, so there is an inevitable measurement error; secondly, although the unification of the operator can minimise the error, but it still exists, and even if intraoperative navigation technology is used, the error will still exist in every aspect from preoperative horizontal marking to intraoperative adjustment of astigmatism axes; finally, the lens 1° off-axis is associated with a 3.5% decrease in astigmatism correction, and only when the RA exceeds 10° needs further surgical adjustment recommended [ 8 ] , so an RA ≤ 5° is not of great clinical significance. Taking into account the above considerations, this study introduced for the first time clinically significant rotation as an index to evaluate the rotational stability of TIOL after surgery, and the TIOL was considered to be undergoing CSR only when the astigmatic axis deviated more than 5° from the preoperative implantation axis after cataract surgery. In this study we found that postoperative RA was significantly greater in patients with high axial myopia (group A) than in patients with normal AL (group B), with the mean RA in group A being 10.43° greater than that in group B. Correlation analysis showed that there was a positive correlation between RA and AL (p = 0.010, r = 0.332). The number of CSR occurring in Group A was significantly higher than that in Group B (P CSR−Group A / CSR−Group B = 0.008 < 0.05), and correlation analysis revealed a positive correlation between postoperative CSR and AL (p = 0.008, r = 0.342), suggesting that the longer the AL, the more prone the toric lens is to occur CSR, and that the longer the AL, the greater the RA. We hypothesise that this is due to the fact that the longer the AL, the lower the elastic stress between the TIOL loops and the equatorial part of the lens capsule, which results in a corresponding decrease in both static and sliding friction between them, The lower the static friction, the easier the lens to rotate, while the lower the sliding friction, the less able it is to quickly curb the tendency to rotate, and the end result of the manifestation is that the longer the AL, the more likely the toric lens to rotate, with the greater RA. At present, the research on the AL and TIOL rotation is inconclusive, there is the same opinion that the AL is a relevant risk factor for postoperative RA, and some [ 19 ] believe that there is no correlation between the AL and postoperative RA. Zhu [ 10 ] found that the hydrophobic material TIOL had a positive correlation between RA and AL in patients with high myopia (Pearson correlation analysis, r = 0.380, P = 0. 380, P = 0.035), which were similar to the results of this study. It is important to note that RA is a continuous counting data, which can only measure the degree of rotation, and the determination of whether the lens are prone to rotate needs to be analysed in terms of whether CSR occurs after TIOL, however, few scholars have analysed the rotational stability of toric lens from CSR. Comparison of RS between hydrophilic toric lens and hydrophobic toric lens The number of high axial myopia patients who occurred CSR significantly exceeded the number of patients with normal AL among patients implanted with hydrophilic lens (p = 0.011 < 0.05), and that there is a strong positive correlation between CSR and AL(p = 0.002, r = 0.720); although the CSR of hydrophobic lenses in group A was higher than that of hydrophobic lenses in group B, it did not show a significant difference. This results suggesting that the longer the AL of high axial myopia implanted with hydrophilic lenses, the more likely they are to rotate. Some studies [ 20 ] have also shown that the postoperative rotational stability of TIOL with hydrophilic lens material is weaker than that of TIOL with hydrophobic material. The reason for this may be that the adhesion between the hydrophobic material and the lens capsule is stronger than that of the hydrophilic material, which increases the friction between the two and therefore reduces the possibility of TIOL rotation, which helps to explain the results of this study; in addition, patients with high axial myopia have a large lens capsular, which makes poor contact with the TIOL loops and reduces the friction, finally, the longer the AL of the eye, the thinner the thickness of the lens, and therefore the lighter the weight of the lens, which also reduces the stability of the lens rotation [ 21 ] , and the combined effect of the above causes the axial high myopic patients implanted with hydrophilic TIOL to be more prone to CSR as AL increases. Another study [ 22 ] compared hydrophobic toric loop lens with hydrophilic flat plate loop lens and found that the rotational stability of the two lenses was similar, but the study did not include patients with high axial myopia. Overall, there is a lack of research on the rotational stability of lens materials and TIOL, more attention and research is needed. Comparison of rotation directions between hydrophilic and hydrophobic toric lens Based on SCR, the direction of rotation was classified as no rotation (RA ≤ 5°), clockwise rotation and counterclockwise rotation, and the data showed that counterclockwise rotation was significantly more common than clockwise rotation after implanting TIOL, and hydrophobic crystals are more likely to rotate counterclockwise after TIOL. It has been widely assumed that TIOL rotate predominantly clockwise in the eye. Interestingly, a number of studies [ 4 , 6 , 20 ] have shown that there is a tendency for TIOL to rotate counterclockwise after surgery, and the tendency is even greater in hydrophobic materials,, which is similar to our study, while these authors also observed that the lens rotate more counterclockwise when placed horizontally, speculating that gravity may play a key role in this. However, the mechanism that causes counterclockwise rotation of the TIOL is still unclear and further studies are needed. In Conclusion, our study shows that the longer the AL, the more likely the toric lens is to rotate and the greater the RA; the direction of rotation of the toric lens tends to be counterclockwise and this tendency is more pronounced in hydrophobic materials; in high axial myopia cataract patients implanted with hydrophilic TIOL, the longer the AL, the more likely it is to rotate. Therefore, patients with high axial myopia may avoid hydrophilic acrylic materials when choosing a toric lens preoperatively, they are also recommended completing pupil dilation to check toric lens axial position early after cataract surgery. Declarations Acknowledgements None. Author contributions TL and XTT designed research and wrote the main manuscript text; WW conducted research and provided funding; MSH performed statistical analysis; YMM provided essential technical and material support; YGY was the surgical operator and had primary responsibility for final content; All authors read and approved the final manuscript Funding This work was supported by the Western medicine project of Guangzhou Health Committee in 2021 under Grant [20211A011022]; and Basic and applied basic research project of Guangzhou science and technology plan funded by the City and University (college) jointly under Grant [202201020008]. Data availability statement The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Committee of GuangZhou Red Cross Hospital of Jinan University, China. (Registered: 2023-387-01, Date: 2023.01.04). All patients have signed an informed consent form to participate in the study and provided permission for the results to be published anonymously. Consent for publication Not applicable. Competing interests The authors declare that they have no conflict of interest. ORCID Tao Lin: https://orcid.org/0009-0002-7127-8838 References Gupta PC, Caty JT. Astigmatism evaluation prior to cataract surgery. CURR OPIN OPHTHALMOL. 2018-01-01;29(1):9-13. DOI: 10.1097/ICU.0000000000000446. Wolffsohn, James S; Bhogal, Gurpreet; Shah, Sunil. Effect of uncorrected astigmatism on vision. J CATARACT REFR SURG. 2011-03-01;37(3):454-60. DOI: 10.1016/j.jcrs.2010.09.022. Gao, Y C; Jiang, Y F; Lin, S; Tian, F. Comparison of corneal refractive power and astigmatism measured by the new anterior segment optical coherence tomographic device and Scheimpflug imaging device in age-related cataract patients. Zhonghua Yan Ke Za Zhi. 2021-01-11;57(1):48-55. DOI: 10.3760/cma.j.cn112142-20200904-00574. Kramer, Brent A; Hardten, David R; Berdahl, John P. Rotation Characteristics of Three Toric Monofocal Intraocular Lenses. Clin Ophthalmol. 2020-12-16;14:4379-4384. DOI: 10.2147/OPTH.S285818. Yang, Juan-Juan; Qin, Ya-Zhou; Qin, Li; Li, Jing-Ming. Comparison of the clinical efficacy of AcrySof®IQ and TECNIS®toric intraocular lenses: a real-world study. EXP THER MED. 2020-11-01;20(5):25. DOI: 10.3892/etm.2020.9153. Oshika, Tetsuro; Fujita, Yoshifumi; Hirota, Atsushi; Inamura, Mikio; Inoue, Yasushi; Miyata, Kazunori; Miyoshi, Teruyuki; Nakano, Shinichiro; Nishimura, Tomohisa; Sugita, Toru. Comparison of incidence of repositioning surgery to correct misalignment with three toric intraocular lenses. EUR J OPHTHALMOL. 2020-07-01;30(4):680-684. DOI: 10.1177/1120672119834469. Núñez, Maria X; Henriquez, Maria A; Escaf, Luis J; Ventura, Bruna V; Srur, Miguel; Newball, Lyle; Espaillat, Arnaldo; Centurion, Virgilio A. Consensus on the management of astigmatism in cataract surgery. Clin Ophthalmol. 2019-02-11;13:311-324. DOI: 10.2147/OPTH.S178277. McAlinden, Colm; Janicek, David. Toric Intraocular Lenses for the Management of Corneal Astigmatism at the Time of Cataract Surgery. J OPHTHALMOL. 2021-12-18;2021:3286043. DOI: 10.1155/2021/3286043. Miyake, Toshiyuki; Kamiya, Kazutaka; Amano, Rie; Iida, Yoshihiko; Tsunehiro, Shuntaro; Shimizu, Kimiya. Long-term clinical outcomes of toric intraocular lens implantation in cataract cases with preexisting astigmatism. J CATARACT REFR SURG. 2014-10-01;40(10):1654-60. DOI: 10.1016/j.jcrs.2014.01.044. Zhu, Xiangjia; He, Wenwen; Zhang, Keke; Lu, Yi. Factors influencing 1-year rotational stability of AcrySof Toric intraocular lenses. BRIT J OPHTHALMOL. 2016-02-01;100(2):263-8. DOI: 10.1136/bjophthalmol-2015-306656. Sasaki, Koh; Eguchi, Shuichiro; Miyata, Akira; Nishimura, Tomohisa; Miyata, Kazunori; Hasegawa, Yumi; Oshika, Tetsuro. Anterior capsule coverage and rotational stability of an acrylic toric intraocular lens. J CATARACT REFR SURG. 2021-05-01;47(5):618-621. DOI: 10.1097/j.jcrs.0000000000000489. He, Suhong; Chen, Xiang; Wu, Xingdi; Ma, Yajuan; Yu, Xuewen; Xu, Wen. Early-stage clinical outcomes and rotational stability of TECNIS toric intraocular lens implantation incataract cases with long axial length. BMC Ophthalmol. 2020-05-25;20(1):204. DOI: 10.1186/s12886-020-01465-2. Hashemi, Hassan; Khabazkhoob, Mehdi; Jafarzadehpur, Ebrahim; Yekta, Abbas Ali; Emamian, Mohammad Hassan; Shariati, Mohammad; Fotouhi, Akbar. High prevalence of myopia in an adult population, Shahroud, Iran. OPTOMETRY VISION SCI. 2012-07-01;89(7):993-9. DOI: 10.1097/OPX.0b013e31825e6554. Srivannaboon, Sabong; Soeharnila; Chirapapaisan, Chareenun; Chonpimai, Pratuangsri. Comparison of corneal astigmatism and axis location in cataract patients measured by total corneal power，automated keratometry and simulated keratometry. J CATARACT REFR SURG. 2012-12-01;38(12):2088-93. DOI: 10.1016/j.jcrs.2012.07.024. Ahmed, Iqbal Ike K; Rocha, Guillermo; Slomovic, Allan R; Climenhaga, Harold; Gohill, Jit; Grégoire, Alain; Ma, Joseph. Visual function and patient experience after bilateral implantation of toric intraocular lenses. J CATARACT REFR SURG. 2010-04-01;36(4):609-16. DOI: 10.1016/j.jcrs.2009.10.044. VVarsits, Ralph M; Hirnschall, Nino; Döller, Birgit; Findl, Oliver. Evaluation of an intraoperative toric intraocular lens alignment system using an image-guided system. J CATARACT REFR SURG. 2019-09-01;45(9):1234-1238. DOI: 10.1016/j.jcrs.2019.04.009. Ke SR, Li C. Rotational stability of intraocular lens and its influencing factors. [J] Int Eye Sci 2021;21(9):1548-1551. DOI: 10.3980/j.issn.1672-5123.2021.9.11. Zhu, Xiangjia; Meng, Jiaqi; He, Wenwen; Rong, Xianfang; Lu, Yi. Comparison of the rotational stability between plate-haptic toric and C-loop haptic toric IOLs in myopic eyes. J CATARACT REFR SURG. 2020-10-01;46(10):1353-1359. DOI: 10.1097/j.jcrs.0000000000000259. Yao, Yunqian; Meng, Jiaqi; He, Wenwen; Zhang, Keke; Wei, Ling; Cheng, Kaiwen; Lu, Yi; Zhu, Xiangjia. Associations between anterior segment parameters and rotational stability of a plate-haptic toric intraocular lens. J CATARACT REFR SURG. 2021-11-01;47(11):1436-1440. DOI: 10.1097/j.jcrs.0000000000000653. Haripriya, Aravind; Gk, Sweekruthi; Mani, Iswarya; Chang, David F. Comparison of surgical repositioning rates and outcomes for hydrophilic vs hydrophobic single－piece acrylic toric IOLs. J CATARACT REFR SURG. 2021-02-01;47(2):178-183. DOI: 10.1097/j.jcrs.0000000000000415. Li, Shuyi; Li, Xi; He, Suhong; Zheng, Qianyin; Chen, Xiang; Wu, Xingdi; Xu, Wen. Early postoperative rotational stability and its related factors of a single-piece acrylic toric intraocular lens. EYE. 2020-03-01;34(3):474-479. DOI: 10.1038/s41433-019-0521-0. Scialdone, Antonio; De Gaetano, Francesco; Monaco, Gaspare. Visual performance of 2 aspheric toric intraocular lenses: comparative study. J CATARACT REFR SURG. 2013-06-01;39(6):906-14. DOI: 10.1016/j.jcrs.2013.01.037. Additional Declarations No competing interests reported. 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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-3856535","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":268041922,"identity":"49f79ae9-8f17-408d-a79e-3cd61a4d8b00","order_by":0,"name":"Tao Lin","email":"","orcid":"","institution":"GuangZhou Red Cross Hospital of Jinan University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Lin","suffix":""},{"id":268041923,"identity":"42448a1f-c3b5-4d1c-8f58-bdf9284cf1f1","order_by":1,"name":"XiaoTing Tang","email":"","orcid":"","institution":"Zhongshan Ophthalmic Center, Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"XiaoTing","middleName":"","lastName":"Tang","suffix":""},{"id":268041924,"identity":"a2b5e48c-3e37-4b39-a6e2-5025351392a6","order_by":2,"name":"Wei Wu","email":"","orcid":"","institution":"GuangZhou Red Cross Hospital of Jinan University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Wu","suffix":""},{"id":268041925,"identity":"b7619241-cdf0-48fc-a547-444574a96541","order_by":3,"name":"ManSha Huang","email":"","orcid":"","institution":"GuangZhou Red Cross Hospital of Jinan University","correspondingAuthor":false,"prefix":"","firstName":"ManSha","middleName":"","lastName":"Huang","suffix":""},{"id":268041926,"identity":"d5e92f48-2b0e-4c09-902f-7b5159386bc0","order_by":4,"name":"Yiming Ma","email":"","orcid":"","institution":"GuangZhou Red Cross Hospital of Jinan University","correspondingAuthor":false,"prefix":"","firstName":"Yiming","middleName":"","lastName":"Ma","suffix":""},{"id":268041927,"identity":"b7c15575-14d6-4a5e-9546-31903aa66483","order_by":5,"name":"YongGang Yuan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsUlEQVRIiWNgGAWjYJCCAx8MbBjYSNHBeHBGRRppWpgP85w5TIJ6gxvpFw7wtp2355NufsDwcwdRWnIKDki23U5skzlmwNh7hjgtCQcM224nsEkkGDAzthGrJbHtnD2bRPoHYrWkHzhw4MwBxjaJHCJtkTzzhuFgQ0VyIlBLwcFeYrTwHU9//PmPgZ29/Iz0jQ9+EqNF4UKOAZxzgAgNDAzy/ccfEKVwFIyCUTAKRjAAAHE7PnutJEmFAAAAAElFTkSuQmCC","orcid":"","institution":"GuangZhou Red Cross Hospital of Jinan University","correspondingAuthor":true,"prefix":"","firstName":"YongGang","middleName":"","lastName":"Yuan","suffix":""}],"badges":[],"createdAt":"2024-01-12 10:14:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3856535/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3856535/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49992565,"identity":"2ddfdcff-7bea-4f2f-94b5-a88c8b00ca91","added_by":"auto","created_at":"2024-01-22 18:57:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35985,"visible":true,"origin":"","legend":"","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3856535/v1/e7ba8541d9580cf1cd2b573a.jpg"},{"id":49992568,"identity":"71e40d04-6312-4e41-b89a-1ab439ac7694","added_by":"auto","created_at":"2024-01-22 18:57:08","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34561,"visible":true,"origin":"","legend":"","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3856535/v1/a911cd088c2099561684e943.jpg"},{"id":49992567,"identity":"cc84042c-4c2e-409f-8ddf-1a4015870882","added_by":"auto","created_at":"2024-01-22 18:57:08","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":15355,"visible":true,"origin":"","legend":"","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3856535/v1/dbfbc5f582a62019821f0ccb.jpg"},{"id":51940289,"identity":"61e84445-75ab-40e9-ab93-76fb3f6f380f","added_by":"auto","created_at":"2024-03-04 09:03:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":593039,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3856535/v1/ae03758e-c5d5-4f0f-bcf5-e5b632a4de27.pdf"},{"id":49992570,"identity":"2cad1e06-f8e3-4f2d-a3eb-7f53d77c97d4","added_by":"auto","created_at":"2024-01-22 18:57:08","extension":"xlsx","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":16525,"visible":true,"origin":"","legend":"","description":"","filename":"DATA.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3856535/v1/4edc3f35c64b886374c3c023.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of factors associated with rotational stability of toric intraocular lens after high axial myopia cataract surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAstigmatism can cause symptoms such as blurred vision, double vision, halos and visual fatigue, some studies\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e had shown that astigmatism\u0026thinsp;\u0026gt;\u0026thinsp;0.75D can causes many visual disturbances. Even low levels of astigmatism reduce visual acuity and postoperative satisfaction in cataract surgery patients\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Corneal astigmatism (CA) is prevalent in cataract patients and is an important determinant of whole-eye astigmatism after cataract surgery\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. There are three modalities to correct CA: astigmatic keratotomy (AK), limbal relaxing incisions (LRI) and TIOL implantation. Among these, TIOL has become the procedure of choice for the correction of regular CA due to its wide range of astigmatism correction, surgical predictability, safety and ability to significantly reduce postoperative residual astigmatism (RAS) and improve postoperative visual acuity\u003csup\u003e[\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. The rotational stability of the IOL is an important index for the evaluation of TIOL, and a study\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e showed that within 15\u0026deg; of the implantation axis, the amount of corrected astigmatism decreases by 3.5% for every 1\u0026deg; of rotation, and that the corrective effect of astigmatism disappears completely when the rotation reaches 30\u0026deg;. Patients with high axial myopia may be prone to rotation due to factors such as long AL, large lens capsule and zonular laxity\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, but some researchers\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e have argued that there is no relationship between AL and TIOL rotation. The rotational stability of TIOL in axial myopia has not been conclusively determined, and its correlation with TIOL materials has been also less researched. The purpose of this paper is to observe the rotational stability of TIOL in high axial myopia cataract patients after surgery and to analyse its correlation with factors such as AL, lens material, WTW and IOL power.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003e This is a prospective, nonrandomized controlled clinical study, which complied with the Declaration of Helsinki, in accordance with Good Clinical Practices and local regulatory requirements. The protocols were approved by the institutional Ethics Committee of GuangZhou Red Cross Hospital of Jinan University (Registered: 2023-387-01, Date: 2023.01.04). Patients were given detailed explanations of the study protocol and operative complications. They signed an informed consent form to participate in the study and provided permission for the results to be published anonymously.\u003c/p\u003e \u003cp\u003eCataract eyes were enrolled during January 2023 to June 2023, at the Guangzhou Red Cross Hospital. All patients were enrolled monocularly and randomly selected with a 1:1 ratio. The experimental group were patients with high axial myopia (Group A, AL\u0026thinsp;\u0026ge;\u0026thinsp;26 mm, 30 patients, hydrophilic hydrophilic toric lens / hydrophobic toric lens\u0026thinsp;=\u0026thinsp;15: 15) and the normal cataract patients in the control group (Group B, 20 mm\u0026thinsp;\u0026lt;\u0026thinsp;AL\u0026thinsp;\u0026lt;\u0026thinsp;26 mm, 30 patients, hydrophilic toric lens / hydrophobic toric lens\u0026thinsp;=\u0026thinsp;15 : 15). There were 18 (9 : 9) males and 42 (21 : 21) females, and the mean age was 65.63\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73 in group A and 75.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78 in group B, and there was no statistically significant difference between the two groups in terms of gender, WTW, CA, IOL power and lens material in this study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Although there were some differences between the two groups in terms of age and preoperative uncorrected distance visual acuity (UDVA), this was mainly due to the fact that high myopia is a high risk factor for early cataract development, and preoperative UDVA was also generally lower in this patients\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup A (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaterials (Hydrophilic/Hydrophobic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (men/women)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9/21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.63\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAL(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWTW(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.29\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-op UDVA (logMAR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIOL Power (D)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.00\u0026thinsp;\u0026plusmn;\u0026thinsp;8.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAL\u0026thinsp;=\u0026thinsp;Axial Length, WTW\u0026thinsp;=\u0026thinsp;White-To-White, pre-op\u0026thinsp;=\u0026thinsp;pre-operatively; UDVA\u0026thinsp;=\u0026thinsp;uncorrected distance visual acuity\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample size estimation\u003c/h3\u003e\n\u003cp\u003eThe sample size is calculated based on the sample size calculation formula (powerandsamplesize.com/). The following assumptions were made for the sample size cal\u003c/p\u003e \u003cp\u003eculation: type 1 error (alpha) was set at 5%, and power (1-beta) on 0.90. The proportion of cases between the experimental and control groups was set to 1:1. Follow to our previous retrospective study, mean rotation angle of group A was set to greater than 15 and mean rotation angle of group B was set to less than 6. Then the sample calculator showed a minimum sample size of 26 patients. Considering a 15% dropout rate in each group, the sample size was calculated to be 30 patients for each group.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInclusion and Exclusion Criteria\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInclusion criteria\u003c/b\u003e Cataract patients who implanted TIOL in Guangzhou Red Cross Hospital between January 2023 and June 2023; voluntarily signed an informed consent form.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eExclusion Criteria\u003c/b\u003e Ocular trauma, severe dry eye, keratitis, pterygium, irregular astigmatism, glaucoma, severe vitreoretinopathy, optic neuropathy, history of internal angle or refractive surgery, intraoperative complications such as posterior capsular rupture, intraocular bleeding, post-operative secondary glaucoma, after-cataract, unwillingness to sign informed consent, mental abnormality.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eExamination Equipment\u003c/h2\u003e \u003cp\u003eIOL-Marster 500 (Zeiss, Germany), ophthalmic auto refractometer (ARK-510A, Nideke, Japan), slit lamp microscope (HS-5000, Huvitz, Korea), all examinations were performed by one person, and measurements were taken at least three times to reduce operator error.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMarking the astigmatism axis\u003c/h2\u003e \u003cp\u003eAfter surface anaesthesia with proparacaine hydrochloride, the patient was seated in front of the slit lamp and the jaw rest was adjusted so that the outer canthus of both eyes was aligned with the line planes on either side of the slit lamp and the slit lamp light band was adjusted to a horizontal narrow slit, so that the horizontal light band passed through the centre of the pupil of both eyes, and the angle of the light band was adjusted to the angle of the surgical incision and the TIOL implantation axis, and the marking point was stained with colour using a 1ml syringe needle; the marking point was then stained with colour using a marker pen.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eAfter surface anaesthesia with proparacaine hydrochloride, the main incision angle was 135\u0026deg;, 15\u0026deg; knife was used as secondary incision, the anterior chamber was injected with Viscoelastic agent, An approximately 5.5 mm \u0026minus;\u0026thinsp;6 mm continuous curvilinear capsulorhexis was then completed, followed by hydrodissection, phacoemulsification, and cortex removal, reinjecte the viscoelastic agent, implantation of IOL (AT Torbi 709M IOL / AcrySof Toric IOL), clockwise adjustment of the axial position to 20\u0026deg; undercorrection, remove the viscoelastic agent behind the TIOL, lightly press the IOL attach the posterior capsule membrane, readjustment of the IOL to align the alignment line with the preoperative markings. Finally, the incision was sealed by hydration. After returning to the ward, patients were restrained for at least 2 hours. As postoperative treatments for all patients, topical tobramycin-dexamethasone drops at least 2 weeks. All surgeries were performed by a single, experienced surgeon (Y.YG) using a standard procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative measurement\u003c/h2\u003e \u003cp\u003eAfter dilating the pupil with compound-tropicamide, the patient is seated in front of the slit lamp, the jaw rest is adjusted so that the outer canthus of both eyes is in the plane of the alignment line on both sides of the slit lamp, adjusts the slit lamp band to a horizontal narrow slit so that the light band passes through the centre of the pupil of both eyes, adjusts the angle of the light band so that it passes through the alignment line for the axis of TIOL astigmatism, and records the angle of the light band turntable at this time. All surgeries were performed by one person.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative follow-up and examination\u003c/h2\u003e \u003cp\u003eAll patients completed the Log MAR visual acuity, IOL-Marster 500, ophthalmic auto refractometer and recorded the toric axial alignment (0\u0026deg;-180\u0026deg;) under a slit lamp with dilated pupils at least six months after surgery.\u003c/p\u003e \u003cp\u003e \u003cb\u003eObservational measures\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eUncorrected distance visual acuity (UDVA)\u003c/b\u003e Visual acuity was converted to LogMAR visual acuity for statistical purposes;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eOcular parameters\u003c/b\u003e Patients' white-to-white (WTW) and axial length (AL) were recorded by measuring the IOL marster;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eIOL parameters\u003c/b\u003e IOL power, material properties (AT Torbi 709M IOL\u0026thinsp;=\u0026thinsp;hydrophilic acrylate / AcrySof Toric IOL\u0026thinsp;=\u0026thinsp;hydrophobic acrylate).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eRotational Stability\u003c/b\u003e This study analyses the rotational stability of TIOL in terms of rotation angle, clinically significant rotation and direction of rotation.\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eRotation Angle (RA)\u003c/b\u003e The minimum angle at which the astigmatic axis of the TIOL deviates from the preoperative implantation axis after surgery is the RA.\u003c/p\u003e \u003cp\u003e5. \u003cb\u003eClinically significant rotation (CSR)\u003c/b\u003e Clinically significant rotation is considered to have occurred when the astigmatic axis of the postoperative TIOL deviates more than 5\u0026deg; from the implant axis.\u003c/p\u003e \u003cp\u003e6. \u003cb\u003eDirection of rotation\u003c/b\u003e If clinically significant rotation of the TIOL occurs and the direction of the minimum angle of the postoperative TIOL axis deviating from the preoperative implantation axis is clockwise, it is recorded as clockwise rotation (CW), and if the direction of the minimum angle is counterclockwise, it is recorded as counterclockwise rotation (CCW); RA\u0026thinsp;\u0026le;\u0026thinsp;5\u0026deg; is recorded as no rotation (N).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eSPSS 25.0 statistical software was used. In the measurement data of this study, the AL conformed to normal distribution with independent t-test and the others did not conform with u-test, and gender, TIOL material were tested with chi-squared test. For correlation analysis, dichotomous and continuous variables were correlated by Spearman correlation, and dichotomous and continuous variables were tested by \u003cb\u003eχ2\u003c/b\u003e test, with α\u0026thinsp;=\u0026thinsp;0.05, and the difference was considered statistically significant with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eVisual Outcomes\u003c/h2\u003e \u003cp\u003ePreoperative UDVA was 1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59 and postoperative UDVA was 0.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30 in group A, with a statistically significant difference (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), in group B preoperative UDVA was 0.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38 and postoperative visual acuity was 0.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18, with a statistically significant difference (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The correlation analysis found a positive correlation between RA and postoperative log MAR UDVA (p\u0026thinsp;=\u0026thinsp;0.025, r\u0026thinsp;=\u0026thinsp;0.409) in group A (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA), and a positive correlation between postoperative RA and postoperative log MAR UDVA in hydrophilic materials (p\u0026thinsp;=\u0026thinsp;0.029, r\u0026thinsp;=\u0026thinsp;0.563) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Comparison of preoperative and postoperative UDVA between group A and group B\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-op UDVA (logMAR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-op UDVA (logMAR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003epre-op\u0026thinsp;=\u0026thinsp;pre-operatively; post-op\u0026thinsp;=\u0026thinsp;post-operatively; UDVA\u0026thinsp;=\u0026thinsp;uncorrected distance visual acuity\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eComparison of rotational stability between group A and group B\u003c/h2\u003e \u003cp\u003eThe difference in RA between group A and group B was statistically significant (RA\u003csub\u003eGroup A\u003c/sub\u003e = 16.03\u0026thinsp;\u0026plusmn;\u0026thinsp;21.47, RA\u003csub\u003eGroup B\u003c/sub\u003e = 5.60\u0026thinsp;\u0026plusmn;\u0026thinsp;8.27, P\u0026thinsp;=\u0026thinsp;0.013\u0026thinsp;\u0026lt;\u0026thinsp;0.05), there were more cases of CSR in group A than in group B,the difference was statistically significant (CSR\u003csub\u003eGroup A\u003c/sub\u003e = 17\u0026thinsp;\u0026gt;\u0026thinsp;CSR\u003csub\u003eGroup B\u003c/sub\u003e = 7, P\u0026thinsp;=\u0026thinsp;0.008 \u0026lt; 0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e); correlation analysis revealed a positive correlation between RA and AL (p\u0026thinsp;=\u0026thinsp;0.010, r\u0026thinsp;=\u0026thinsp;0.332) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA) and a positive correlation between CSR and AL (p\u0026thinsp;=\u0026thinsp;0.008, r\u0026thinsp;=\u0026thinsp;0.342) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of postoperative rotational stability between Group A and Group B -1\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.03\u0026thinsp;\u0026plusmn;\u0026thinsp;21.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.60\u0026thinsp;\u0026plusmn;\u0026thinsp;8.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.013*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSR(Y/N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17/13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.008**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eRA\u0026thinsp;=\u0026thinsp;Rotation Angle; CSR\u0026thinsp;=\u0026thinsp;Clinically Significant Rotation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eComparison of RS between hydrophilic toric lens and hydrophobic toric lens\u003c/h2\u003e \u003cp\u003eThe mean RA of hydrophilic TIOL in group A was greater than that of hydrophilic TIOL in group B (RA\u003csub\u003eGroup A/Hydrophilic\u003c/sub\u003e = 21.73\u0026thinsp;\u0026plusmn;\u0026thinsp;27.31\u0026thinsp;\u0026gt;\u0026thinsp;RA\u003csub\u003eGroup B/Hydrophilic\u003c/sub\u003e = 6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10. 93), the average RA of hydrophobic lens in group A was larger than that of hydrophobic lens in group B (RA\u003csub\u003eGroup A/hydrophobic\u003c/sub\u003e = 10.33\u0026thinsp;\u0026plusmn;\u0026thinsp;11.81\u0026gt;RA\u003csub\u003eGroup B/hydrophobic\u003c/sub\u003e = 4.60\u0026thinsp;\u0026plusmn;\u0026thinsp;4.47), and the differences between them were not statistically significant (P\u003csub\u003eGroup A\u0026minus;Hydrophilicity/Group B\u0026minus;Hydrophilicity\u003c/sub\u003e=0.061, P\u003csub\u003eGroup A\u0026minus;Hydrophilicity/Group A\u0026minus;Hydrophilic\u003c/sub\u003e =0.367, P\u003csub\u003eGroup A\u0026minus;Hydrophilic/Group B\u0026minus;Hydrophilic\u003c/sub\u003e=0.187, P\u003csub\u003eGroup B\u0026minus;Hydrophilicity/Group B\u0026minus;Hydrophilic\u003c/sub\u003e=0.775) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e);\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of post-operative rotational stability of different materials between Group A and Group B\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAR(Y/N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHydrophilic Toric Lens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3/12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.010*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHydrophobic Toric Lens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.666\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHydrophilic Toric Lens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.73\u0026thinsp;\u0026plusmn;\u0026thinsp;27.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHydrophobic Toric Lens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.33\u0026thinsp;\u0026plusmn;\u0026thinsp;11.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.60\u0026thinsp;\u0026plusmn;\u0026thinsp;4.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.367\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eRA\u0026thinsp;=\u0026thinsp;Rotation Angle; CSR\u0026thinsp;=\u0026thinsp;Clinically Significant Rotation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe CSR of hydrophilic lens in group A was significantly higher than that of hydrophilic lens in group B (CSR\u003csub\u003eHydrophilic\u0026minus;A group\u003c/sub\u003e = 10 \u0026gt; CSR\u003csub\u003eHydrophilic\u0026minus;B group\u003c/sub\u003e = 3, P\u0026thinsp;=\u0026thinsp;0.01\u0026thinsp;\u0026lt;\u0026thinsp;0.05), the CSR of hydrophobic lens in group A was higher than that of hydrophobic lens in group B, the difference was not statistically significant (CSR\u003csub\u003ehydrophobic\u0026minus;A group\u003c/sub\u003e = 7 \u0026gt; CSR\u003csub\u003ehydrophobic\u0026minus;B group\u003c/sub\u003e = 4, P\u0026thinsp;=\u0026thinsp;0.256). the difference in CSR between the different materials was not statistically significant (P\u003csub\u003eHydrophilic\u0026minus;group A / Hydrophobic\u0026minus;group A\u003c/sub\u003e = 0.269, P\u003csub\u003eHydrophilic\u0026minus;group B/Hydrophobic\u0026minus;group B\u003c/sub\u003e = 0.666) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCorrelation analysis further revealed a strong correlation between CSR and AL in axial high myopia patients implanted with hydrophilic lenses (p\u0026thinsp;=\u0026thinsp;0.002, r\u0026thinsp;=\u0026thinsp;0.720) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eComparison of rotation directions between hydrophilic and hydrophobic toric lens\u003c/h2\u003e \u003cp\u003eMore patients rotated counterclockwise than clockwise and the difference was statistically significant (N\u0026thinsp;=\u0026thinsp;36, CW\u0026thinsp;=\u0026thinsp;5, CCW\u0026thinsp;=\u0026thinsp;19, P\u003csub\u003eN/CW/CCW\u003c/sub\u003e = 0.019\u0026thinsp;\u0026lt;\u0026thinsp;0.05, P\u003csub\u003eCW/CCW\u003c/sub\u003e = 0.004\u0026thinsp;\u0026lt;\u0026thinsp;0. 05) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e); patients implanted with hydrophilic lens had more cases of counterclockwise rotation and the difference was not statistically significant (N\u0026thinsp;=\u0026thinsp;17, CW\u0026thinsp;=\u0026thinsp;3, CCW\u0026thinsp;=\u0026thinsp;10, P\u003csub\u003eCW/CCW\u003c/sub\u003e = 0.052\u0026thinsp;\u0026gt;\u0026thinsp;0.05); patients implanted with hydrophilic lens had more cases of counterclockwise rotation and the difference was statistically significant (N\u0026thinsp;=\u0026thinsp;19, CW\u0026thinsp;=\u0026thinsp;2, CCW\u0026thinsp;=\u0026thinsp;9, P\u003csub\u003eCW/CCW\u003c/sub\u003e = 0.035\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Comparison of direction of rotation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (A)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClockwise (B)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCounterclockwise (C)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36(60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5(8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19(31.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001***\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAvsB: \u003cb\u003e\u0026lt;0.001***\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBvsC: \u003cb\u003e0.004**\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAvsC: \u003cb\u003e0.022*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHydrophilic Toric Lens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17(56.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3(10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10(33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.007**\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAvsB: \u003cb\u003e0.002**\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBvsC: 0.052\u003c/p\u003e \u003cp\u003eAvsC: 0.178\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHydrophobic Toric Lens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19(63.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9(30.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001**\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAvsB: \u003cb\u003e\u0026lt;0.001***\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBvsC: \u003cb\u003e0.035*\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAvsC: 0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eCorneal astigmatism (CA) is common in cataract patients, and with the transition of cataract surgery from refractive to refractive, CA has been increasingly recognised as the major source of whole-eye astigmatism after cataract surgery. TIOL is currently the preferred surgical procedure for the correction of CA, which can safely, efficiently and accurately correct regular CA, reduce RAS and improve the patient's postoperative UDVA, and studies\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e have shown that monocular TIOL has a postoperative decortication rate of 60\u0026ndash;85%, and binocular TIOL has a decortication rate of 69\u0026ndash;97%. With the widespread use of TIOL, the rotational stability of TIOL has also attracted much attention, as rotation tends to occur early after TIOL, especially within the first hour postoperatively\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. The main factors thought to be potentially associated with rotational stability include the AL, anterior capsule opacification, TIOL properties (material, shape and size of the loops), intraocular ring and the time after implantation\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, with the AL receiving the most attention. Studies on the relationship between AL and rotational stability are inconclusive, and previous researchers have suggested that patients with high axial myopia may be susceptible to rotation after TIOL due to the combination of a long AL, large lens capsule and zonular laxity. However, there were also many scientists\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e argued that AL does not have much to do with TIOL rotation recently. Furthermore, there are fewer studies on the relationship between TIOL materials and rotational stability. Zhu\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e concluded that hydrophilic TIOL with a lower degree of postoperative rotation than hydrophobic lens are better able to reduce postoperative RAS, but more relevant studies are still lacking. In this study, we introduced the concept of clinically significant rotation, and evaluated the rotational stability of TIOL in terms of rotation angle, CSR and direction of rotation, comparing the rotational stability of TIOL at least six months after cataract surgery in patients with high axial myopia and normal AL, and to analyse its correlation with AL, lens material, IOL power and WTW.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eVisual Outcomes\u003c/h2\u003e \u003cp\u003eAll patients showed significant improvement in postoperative UDVA compared to preoperative. Correlation analysis of each experimental group also showed that postoperative RA was positively correlated with postoperative log MAR UDVA in group A (p\u0026thinsp;=\u0026thinsp;0.025, r\u0026thinsp;=\u0026thinsp;0.409), and postoperative RA was positively correlated with postoperative log MAR UDVA in the case of hydrophilic material (p\u0026thinsp;=\u0026thinsp;0.029, r\u0026thinsp;=\u0026thinsp;0.563), suggesting that the greater the RA in patients with high axial myopia and hydrophilic TIOL implantation, the worse the postoperative UDVA. This is consistent with previous results\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e, and the presumed reason for this is that the larger the RA, the smaller the amount of astigmatism correction, resulting in a larger postoperative RAS and worse visual acuity. However, we did not observe this correlation in patients with normal AL or implanted hydrophobic materials, which may be due to insufficient sample size and requires further investigation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eComparison of rotational stability between group A and group B\u003c/h2\u003e \u003cp\u003eAt present, the measurement of postoperative TIOL rotation is mostly examined under the slit lamp, and the accuracy of the slit lamp with a turntable is only 5\u0026deg;, so there is an inevitable measurement error; secondly, although the unification of the operator can minimise the error, but it still exists, and even if intraoperative navigation technology is used, the error will still exist in every aspect from preoperative horizontal marking to intraoperative adjustment of astigmatism axes; finally, the lens 1\u0026deg; off-axis is associated with a 3.5% decrease in astigmatism correction, and only when the RA exceeds 10\u0026deg; needs further surgical adjustment recommended\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e, so an RA\u0026thinsp;\u0026le;\u0026thinsp;5\u0026deg; is not of great clinical significance. Taking into account the above considerations, this study introduced for the first time clinically significant rotation as an index to evaluate the rotational stability of TIOL after surgery, and the TIOL was considered to be undergoing CSR only when the astigmatic axis deviated more than 5\u0026deg; from the preoperative implantation axis after cataract surgery.\u003c/p\u003e \u003cp\u003eIn this study we found that postoperative RA was significantly greater in patients with high axial myopia (group A) than in patients with normal AL (group B), with the mean RA in group A being 10.43\u0026deg; greater than that in group B. Correlation analysis showed that there was a positive correlation between RA and AL (p\u0026thinsp;=\u0026thinsp;0.010, r\u0026thinsp;=\u0026thinsp;0.332). The number of CSR occurring in Group A was significantly higher than that in Group B (P\u003csub\u003eCSR\u0026minus;Group A / CSR\u0026minus;Group B\u003c/sub\u003e = 0.008\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and correlation analysis revealed a positive correlation between postoperative CSR and AL (p\u0026thinsp;=\u0026thinsp;0.008, r\u0026thinsp;=\u0026thinsp;0.342), suggesting that the longer the AL, the more prone the toric lens is to occur CSR, and that the longer the AL, the greater the RA. We hypothesise that this is due to the fact that the longer the AL, the lower the elastic stress between the TIOL loops and the equatorial part of the lens capsule, which results in a corresponding decrease in both static and sliding friction between them, The lower the static friction, the easier the lens to rotate, while the lower the sliding friction, the less able it is to quickly curb the tendency to rotate, and the end result of the manifestation is that the longer the AL, the more likely the toric lens to rotate, with the greater RA. At present, the research on the AL and TIOL rotation is inconclusive, there is the same opinion that the AL is a relevant risk factor for postoperative RA, and some\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e believe that there is no correlation between the AL and postoperative RA. Zhu\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e found that the hydrophobic material TIOL had a positive correlation between RA and AL in patients with high myopia (Pearson correlation analysis, r\u0026thinsp;=\u0026thinsp;0.380, P\u0026thinsp;=\u0026thinsp;0. 380, P\u0026thinsp;=\u0026thinsp;0.035), which were similar to the results of this study. It is important to note that RA is a continuous counting data, which can only measure the degree of rotation, and the determination of whether the lens are prone to rotate needs to be analysed in terms of whether CSR occurs after TIOL, however, few scholars have analysed the rotational stability of toric lens from CSR.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eComparison of RS between hydrophilic toric lens and hydrophobic toric lens\u003c/h2\u003e \u003cp\u003eThe number of high axial myopia patients who occurred CSR significantly exceeded the number of patients with normal AL among patients implanted with hydrophilic lens (p\u0026thinsp;=\u0026thinsp;0.011\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and that there is a strong positive correlation between CSR and AL(p\u0026thinsp;=\u0026thinsp;0.002, r\u0026thinsp;=\u0026thinsp;0.720); although the CSR of hydrophobic lenses in group A was higher than that of hydrophobic lenses in group B, it did not show a significant difference. This results suggesting that the longer the AL of high axial myopia implanted with hydrophilic lenses, the more likely they are to rotate. Some studies\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e have also shown that the postoperative rotational stability of TIOL with hydrophilic lens material is weaker than that of TIOL with hydrophobic material. The reason for this may be that the adhesion between the hydrophobic material and the lens capsule is stronger than that of the hydrophilic material, which increases the friction between the two and therefore reduces the possibility of TIOL rotation, which helps to explain the results of this study; in addition, patients with high axial myopia have a large lens capsular, which makes poor contact with the TIOL loops and reduces the friction, finally, the longer the AL of the eye, the thinner the thickness of the lens, and therefore the lighter the weight of the lens, which also reduces the stability of the lens rotation\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e, and the combined effect of the above causes the axial high myopic patients implanted with hydrophilic TIOL to be more prone to CSR as AL increases. Another study\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e compared hydrophobic toric loop lens with hydrophilic flat plate loop lens and found that the rotational stability of the two lenses was similar, but the study did not include patients with high axial myopia. Overall, there is a lack of research on the rotational stability of lens materials and TIOL, more attention and research is needed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eComparison of rotation directions between hydrophilic and hydrophobic toric lens\u003c/h2\u003e \u003cp\u003eBased on SCR, the direction of rotation was classified as no rotation (RA\u0026thinsp;\u0026le;\u0026thinsp;5\u0026deg;), clockwise rotation and counterclockwise rotation, and the data showed that counterclockwise rotation was significantly more common than clockwise rotation after implanting TIOL, and hydrophobic crystals are more likely to rotate counterclockwise after TIOL. It has been widely assumed that TIOL rotate predominantly clockwise in the eye. Interestingly, a number of studies\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e have shown that there is a tendency for TIOL to rotate counterclockwise after surgery, and the tendency is even greater in hydrophobic materials,, which is similar to our study, while these authors also observed that the lens rotate more counterclockwise when placed horizontally, speculating that gravity may play a key role in this. However, the mechanism that causes counterclockwise rotation of the TIOL is still unclear and further studies are needed.\u003c/p\u003e \u003cp\u003eIn Conclusion, our study shows that the longer the AL, the more likely the toric lens is to rotate and the greater the RA; the direction of rotation of the toric lens tends to be counterclockwise and this tendency is more pronounced in hydrophobic materials; in high axial myopia cataract patients implanted with hydrophilic TIOL, the longer the AL, the more likely it is to rotate. Therefore, patients with high axial myopia may avoid hydrophilic acrylic materials when choosing a toric lens preoperatively, they are also recommended completing pupil dilation to check toric lens axial position early after cataract surgery.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTL and XTT designed research and wrote the main manuscript text; WW conducted research and provided funding; MSH performed statistical analysis; YMM provided essential technical and material support; YGY was the surgical operator and had primary responsibility for final content; All authors read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Western medicine project of Guangzhou Health Committee in 2021 under Grant [20211A011022]; and Basic and applied basic research project of Guangzhou science and technology plan funded by the City and University (college) jointly under Grant \u0026nbsp;[202201020008].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Committee of GuangZhou Red Cross Hospital of Jinan University, China. (Registered: 2023-387-01, Date: 2023.01.04). All patients have signed an informed consent form to participate in the study and provided permission for the results to be published anonymously.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eORCID\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTao Lin: https://orcid.org/0009-0002-7127-8838\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGupta PC, Caty JT. Astigmatism evaluation prior to cataract surgery. CURR OPIN OPHTHALMOL. 2018-01-01;29(1):9-13. DOI: 10.1097/ICU.0000000000000446.\u003c/li\u003e\n\u003cli\u003eWolffsohn, James S; Bhogal, Gurpreet; Shah, Sunil. Effect of uncorrected astigmatism on vision. J CATARACT REFR SURG. 2011-03-01;37(3):454-60. DOI: 10.1016/j.jcrs.2010.09.022.\u003c/li\u003e\n\u003cli\u003eGao, Y C; Jiang, Y F; Lin, S; Tian, F. Comparison of corneal refractive power and astigmatism measured by the new anterior segment optical coherence tomographic device and Scheimpflug imaging device in age-related cataract patients. Zhonghua Yan Ke Za Zhi. 2021-01-11;57(1):48-55. DOI: 10.3760/cma.j.cn112142-20200904-00574.\u003c/li\u003e\n\u003cli\u003eKramer, Brent A; Hardten, David R; Berdahl, John P. Rotation Characteristics of Three Toric Monofocal Intraocular Lenses. Clin Ophthalmol. 2020-12-16;14:4379-4384. DOI: 10.2147/OPTH.S285818.\u003c/li\u003e\n\u003cli\u003eYang, Juan-Juan; Qin, Ya-Zhou; Qin, Li; Li, Jing-Ming. Comparison of the clinical efficacy of AcrySof\u0026reg;IQ and TECNIS\u0026reg;toric intraocular lenses: a real-world study. EXP THER MED. 2020-11-01;20(5):25. DOI: 10.3892/etm.2020.9153.\u003c/li\u003e\n\u003cli\u003eOshika, Tetsuro; Fujita, Yoshifumi; Hirota, Atsushi; Inamura, Mikio; Inoue, Yasushi; Miyata, Kazunori; Miyoshi, Teruyuki; Nakano, Shinichiro; Nishimura, Tomohisa; Sugita, Toru. Comparison of incidence of repositioning surgery to correct misalignment with three toric intraocular lenses. EUR J OPHTHALMOL. 2020-07-01;30(4):680-684. DOI: 10.1177/1120672119834469.\u003c/li\u003e\n\u003cli\u003eN\u0026uacute;\u0026ntilde;ez, Maria X; Henriquez, Maria A; Escaf, Luis J; Ventura, Bruna V; Srur, Miguel; Newball, Lyle; Espaillat, Arnaldo; Centurion, Virgilio A. Consensus on the management of astigmatism in cataract surgery. Clin Ophthalmol. 2019-02-11;13:311-324. DOI: 10.2147/OPTH.S178277.\u003c/li\u003e\n\u003cli\u003eMcAlinden, Colm; Janicek, David. Toric Intraocular Lenses for the Management of Corneal Astigmatism at the Time of Cataract Surgery. J OPHTHALMOL. 2021-12-18;2021:3286043. DOI: 10.1155/2021/3286043.\u003c/li\u003e\n\u003cli\u003eMiyake, Toshiyuki; Kamiya, Kazutaka; Amano, Rie; Iida, Yoshihiko; Tsunehiro, Shuntaro; Shimizu, Kimiya. Long-term clinical outcomes of toric intraocular lens implantation in cataract cases with preexisting astigmatism. J CATARACT REFR SURG. 2014-10-01;40(10):1654-60. DOI: 10.1016/j.jcrs.2014.01.044.\u003c/li\u003e\n\u003cli\u003eZhu, Xiangjia; He, Wenwen; Zhang, Keke; Lu, Yi. Factors influencing 1-year rotational stability of AcrySof Toric intraocular lenses. BRIT J OPHTHALMOL. 2016-02-01;100(2):263-8. DOI: 10.1136/bjophthalmol-2015-306656.\u003c/li\u003e\n\u003cli\u003eSasaki, Koh; Eguchi, Shuichiro; Miyata, Akira; Nishimura, Tomohisa; Miyata, Kazunori; Hasegawa, Yumi; Oshika, Tetsuro. Anterior capsule coverage and rotational stability of an acrylic toric intraocular lens. J CATARACT REFR SURG. 2021-05-01;47(5):618-621. DOI: 10.1097/j.jcrs.0000000000000489.\u003c/li\u003e\n\u003cli\u003eHe, Suhong; Chen, Xiang; Wu, Xingdi; Ma, Yajuan; Yu, Xuewen; Xu, Wen. Early-stage clinical outcomes and rotational stability of TECNIS toric intraocular lens implantation incataract cases with long axial length. BMC Ophthalmol. 2020-05-25;20(1):204. DOI: 10.1186/s12886-020-01465-2.\u003c/li\u003e\n\u003cli\u003eHashemi, Hassan; Khabazkhoob, Mehdi; Jafarzadehpur, Ebrahim; Yekta, Abbas Ali; Emamian, Mohammad Hassan; Shariati, Mohammad; Fotouhi, Akbar. High prevalence of myopia in an adult population, Shahroud, Iran. OPTOMETRY VISION SCI. 2012-07-01;89(7):993-9. DOI: 10.1097/OPX.0b013e31825e6554.\u003c/li\u003e\n\u003cli\u003eSrivannaboon, Sabong; Soeharnila; Chirapapaisan, Chareenun; Chonpimai, Pratuangsri. Comparison of corneal astigmatism and axis location in cataract patients measured by total corneal power，automated keratometry and simulated keratometry. J CATARACT REFR SURG. 2012-12-01;38(12):2088-93. DOI: 10.1016/j.jcrs.2012.07.024.\u003c/li\u003e\n\u003cli\u003eAhmed, Iqbal Ike K; Rocha, Guillermo; Slomovic, Allan R; Climenhaga, Harold; Gohill, Jit; Gr\u0026eacute;goire, Alain; Ma, Joseph. Visual function and patient experience after bilateral implantation of toric intraocular lenses. J CATARACT REFR SURG. 2010-04-01;36(4):609-16. DOI: 10.1016/j.jcrs.2009.10.044.\u003c/li\u003e\n\u003cli\u003eVVarsits, Ralph M; Hirnschall, Nino; D\u0026ouml;ller, Birgit; Findl, Oliver. Evaluation of an intraoperative toric intraocular lens alignment system using an image-guided system. J CATARACT REFR SURG. 2019-09-01;45(9):1234-1238. DOI: 10.1016/j.jcrs.2019.04.009.\u003c/li\u003e\n\u003cli\u003eKe SR, Li C. Rotational stability of intraocular lens and its influencing factors. [J] Int Eye Sci 2021;21(9):1548-1551. DOI: 10.3980/j.issn.1672-5123.2021.9.11.\u003c/li\u003e\n\u003cli\u003eZhu, Xiangjia; Meng, Jiaqi; He, Wenwen; Rong, Xianfang; Lu, Yi. Comparison of the rotational stability between plate-haptic toric and C-loop haptic toric IOLs in myopic eyes. J CATARACT REFR SURG. 2020-10-01;46(10):1353-1359. DOI: 10.1097/j.jcrs.0000000000000259. \u003c/li\u003e\n\u003cli\u003eYao, Yunqian; Meng, Jiaqi; He, Wenwen; Zhang, Keke; Wei, Ling; Cheng, Kaiwen; Lu, Yi; Zhu, Xiangjia. Associations between anterior segment parameters and rotational stability of a plate-haptic toric intraocular lens. J CATARACT REFR SURG. 2021-11-01;47(11):1436-1440. DOI: 10.1097/j.jcrs.0000000000000653.\u003c/li\u003e\n\u003cli\u003eHaripriya, Aravind; Gk, Sweekruthi; Mani, Iswarya; Chang, David F. Comparison of surgical repositioning rates and outcomes for hydrophilic vs hydrophobic single－piece acrylic toric IOLs. J CATARACT REFR SURG. 2021-02-01;47(2):178-183. DOI: 10.1097/j.jcrs.0000000000000415.\u003c/li\u003e\n\u003cli\u003eLi, Shuyi; Li, Xi; He, Suhong; Zheng, Qianyin; Chen, Xiang; Wu, Xingdi; Xu, Wen. Early postoperative rotational stability and its related factors of a single-piece acrylic toric intraocular lens. EYE. 2020-03-01;34(3):474-479. DOI: 10.1038/s41433-019-0521-0.\u003c/li\u003e\n\u003cli\u003eScialdone, Antonio; De Gaetano, Francesco; Monaco, Gaspare. Visual performance of 2 aspheric toric intraocular lenses: comparative study. J CATARACT REFR SURG. 2013-06-01;39(6):906-14. DOI: 10.1016/j.jcrs.2013.01.037.\u003c/li\u003e\n\u003c/ol\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":"Toric intraocular lens, Rotational stability, Rotation angle, Direction of rotation, Clinically significant rotation, TIOL material","lastPublishedDoi":"10.21203/rs.3.rs-3856535/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3856535/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTo observe the rotational stability (RS) of toric intraocular lens (TIOL) in patients with high axial myopia cataract and to analyse the factors associated with it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This study was approved by a certified local review board (Registered: 2023-387-01, Date: 2023.01.04) and enrolled 60 cataract patients after TIOL implantation in GuangZhou Red Cross Hospital of Jinan University from January 2023 to June 2023, of which 30 patients in group A were diagnosed high axial myopia (Axial Length, AL ≥ 26 mm) and 30 patients in group B were normal AL (22 mm \u0026lt;AL \u0026lt; 26 mm), and the data of were collected and analysed at least half a year after surgery. To analyse the RS of TIOL and the correlation between RS and AL, TIOL material, White-To-White (WTW) and IOL power.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The difference in rotation angle (RA) between group A and B was statistically significant (RA\u003csub\u003eA group \u003c/sub\u003e= 16.03 ± 21.47, RA\u003csub\u003eB group \u003c/sub\u003e= 5.60 ± 8.27, p = 0.013 \u0026lt; 0.05); the difference in clinically significant rotation (CSR) between group A and group B was statistically significant (CSR\u003csub\u003eA group \u003c/sub\u003e= 17, CSR\u003csub\u003eB group \u003c/sub\u003e= 7, P = 0. 008 \u0026lt; 0.05), postoperative RA and CSR were positively correlated with the AL (p\u003csub\u003eRA\u003c/sub\u003e = 0.010, r\u003csub\u003eRA\u003c/sub\u003e = 0.332; p\u003csub\u003eCSR\u003c/sub\u003e = 0.008, r\u003csub\u003eCSR\u003c/sub\u003e = 0.342); and there was significantly more CSR of hydrophilic lens in group A than hydrophilic lens in group B (CSR\u003csub\u003eHydrophilic-A group\u003c/sub\u003e = 10 ＞ CSR\u003csub\u003eHydrophilic-B group\u003c/sub\u003e = 3, p = 0.01 \u0026lt; 0.05). There was a strong correlation between CSR and AL (p = 0.002, r = 0.720); more patients rotated counterclockwise than clockwise after TIOL and the difference was statistically significant (P\u003csub\u003e \u003c/sub\u003e= 0.004 \u0026lt; 0.05), and significantly more patients with hydrophobic lens rotated counterclockwise ( P= 0.035 \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe longer the AL of the eye, the more likely the toric lens will rotate post-operatively and the greater the RA; the toric lens tends to rotate counterclockwise, which is more pronounced in hydrophobic IOLs; hydrophilic toric lenses tend to rotate in patients with high axial myopia and the longer the AL, the greater the likelihood of rotation.\u003c/p\u003e","manuscriptTitle":"Analysis of factors associated with rotational stability of toric intraocular lens after high axial myopia cataract surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-22 18:57:03","doi":"10.21203/rs.3.rs-3856535/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":"f09ede4a-0a65-4a31-90a8-7c9dff4217a0","owner":[],"postedDate":"January 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-04T09:03:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-22 18:57:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3856535","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3856535","identity":"rs-3856535","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}