Influence of tilt and decentration of scleral-sutured intraocular
lens on ocular higher-order wavefront aberration
T Oshika, G Sugita, K Miyata, T Tokunaga, T Samejima, C Okamoto, Y Ishii
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See end of article for
T Oshika, Department of
Ophthalmology, Institute of
Clinical Medicine, University
of Tsukuba, 1-1-1
Tennoudai, Tsukuba, Ibaraki
Accepted 31 July 2006
Published Online First
16 August 2006
Br J Ophthalmol 2007;91:185–188. doi: 10.1136/bjo.2006.099945
Aim: To investigate the influence of tilt and decentration of scleral-sutured intraocular lenses (IOLs) on ocular
higher-order wavefront aberrations.
Methods: In 45 eyes of 36 patients who had undergone scleral suture fixation of posterior chamber IOL, tilt
and decentration of IOLs were determined by Scheimpflug videophotography, and higher-order aberration
for a 4-mm pupil was measured using the Hartmann–Shack aberrometer. In another 100 eyes of 100 patients
after standard cataract surgery with posterior chamber IOL implantation, ocular higher-order aberration was
Results: In eyes with scleral-sutured IOL, the mean (SD) tilt angle and decentration were 4.43˚ (3.02˚) and
0.279 (0.162) mm, respectively. Ocular coma-like aberration in the sutured IOL group was 0.324
(0.170) mm, which was significantly greater than that of the standard cataract surgery group (0.169
(0.061) mm, p,0.001, Student’s t test). No significant difference was found in ocular spherical-like
aberration between the sutured IOL group (0.142 (0.065) mm) and standard surgery group (0.126
(0.033) mm; p=0.254). In the sutured IOL group, IOL tilt significantly correlated with ocular coma-like
aberration (Pearson’s correlation coefficient r=0.628, p,0.001), but no significant correlation was found
between IOL tilt and ocular spherical-like aberration (r=0.222, p=0.175). The IOL tilt did not correlate with
corneal coma-like (r=0.289, p=0.171) and spherical-like (r=0.150, p=0.356) aberrations. The IOL
decentration did not correlate with any higher-order aberrations.
Conclusion: In eyes with scleral-sutured posterior chamber IOL, tilting of the lens induces considerable amount
of ocular coma-like aberrations.
decentred IOLs may be unhappy with the results of otherwise
successful cataract surgery. In fact, malposition of an IOL is one
of the leading indications for removal, exchange or reposition-
ing of a posterior chamber IOL.1–5
Malposition of the IOL comprises decentration and tilt.
Although it has been known that decentration of the IOL can
cause unwanted optical image or dysphotopsia,6–10the influence
of major IOL tilting on the optical quality of the eye has never
been reported. With expanding indications of cataract surgery,
more complicated cases will undergo cataract removal and IOL
implantation procedures, which would increase the risk of IOL
misalignment after surgery. Patients tend to have longer
longevity after surgery, which might further increase the risk
of postoperative events. The optical performance of IOLs in the
presence of displacement has been an important issue even in
modern cataract surgery.11–15We conducted the current retro-
spective study to assess the influence of tilting and decentration
of scleral-sutured posterior chamber IOLs on ocular higher-
roper positioning and on-axis alignment of an intraocular
lens (IOL) are critical in obtaining satisfactory quality of
vision after cataract surgery. Patients with tilted or
PATIENTS AND METHODS
Forty five eyes of 36 patients (16 men and 20 women) who had
undergone scleral suture fixation of a posterior chamber IOL
were included. Their age ranged from 46 to 87 years (mean
(standard deviation, SD)) 66.3 (14.2) years). The scleral-
sutured IOLswere hydrophobic
(MA60AC, AcrySof, Alcon Laboratories, Fort Worth, Texas,
USA) in 18 eyes and polymethylmethacrylate IOL in 19 eyes,
but details were not available in the remaining 8 eyes. Another
100 eyes of 100 patients (41 men and 59 women) after standard
cataract surgery with in-the-bag implantation of hydrophobic
acrylic foldable IOL (MA60AC) served as age-matched controls,
ranging in age from 48 to 88 years (64.5 (13.5) years). The
research protocol had institutional review board approval, and
written informed consent was obtained from each patient. The
study adhered to the tenets of the Declaration of Helsinki.
In the scleral-sutured IOL group, tilt and decentration of IOLs
as well as higher-order wavefront aberration were measured. In
the standard cataract surgery group, higher-order wavefront
aberration of the eye was measured.
Tilt and decentration of IOLs were determined by an anterior
eye segment analysis system (EAS-1000; NIDEK, Gamagori,
Scheimpflug CCD video camera unit and an image analysis
computer. The online computer included a special software
package to quantitate the length of the decentration and the
degree of the tilt.16–18Two Scheimpflug images of the IOL after
full mydriasis were taken at slit angles of 45˚and 135˚by the
CCD camera. After geometric correction, the weakly exposed
original images were then enhanced further using binarisation
and curve-fitting techniques. Next, by plotting the anterior
surface of the IOL as well as the corneal surface on these
images, the tilt angle of the IOL optic axis relative to the cornea
vertex was quantified by the image analysis computer. The
length of decentration was indicated by the distance of the IOL
optic axis from the corneal vertex. The data of the two different
Scheimpflug images were analysed in a three-dimensional
Abbreviation: IOL, intraocular lens
Corneal and ocular wavefront aberrations for a 4-mm pupil
were measured using the Hartmann–Shack wavefront aber-
rometer (Topcon, Tokyo, Japan).19–21The light source of the
wavefront sensor is an infrared super luminescent diode laser
(l=840 nm;the spectral
mum=14 nm; power at the cornea=20 mW). Reflected light
from the point image was led to a Hartmann–Shack wavefront
sensor by a lens system. The Hartmann–Shack wavefront
edge=0.6 mm) aligned in a grid on a Hartmann plate and a
cooled charge-coupled device (pixel size=9 mm). All of the
Hartmann images were revised to the pupil-centre images. The
obtained data were expanded into the set of orthogonal Zernike
polynomials. The root-mean squares of third-order Zernike
components (Z323to Z33) were used to represent coma-like
aberration and root-mean squares of fourth-order Zernike
components (Z424to Z44) were used to represent spherical-like
The average mean (SD) tilt angle and decentration of scleral-
sutured IOLs were 4.43˚ (3.02˚) and 0.279 (0.162) mm,
respectively. The amounts of ocular coma-like and spherical-
like aberrations in the eyes with sutured IOL were 0.324 (0.170)
and 0.142 (0.065) mm, respectively. The ocular coma-like
aberration in the sutured IOL group was significantly greater
than that of the standard cataract surgery group (0.169
(0.061) mm, p,0.001, Student’s t test). No significant differ-
ence was observed in the ocular spherical-like aberration
between the sutured IOL group and the standard cataract
surgery group (0.126 (0.033) mm; p=0.254).
The amounts of corneal coma-like and spherical-like aberra-
tions in the eyes with sutured IOL were 0.192 (0.116) and 0.097
(0.096) mm, respectively. The amounts of corneal coma-like and
spherical-like aberrations in the standard cataract surgery
group were 0.153 (0.095) mm and 0.072 (0.054) mm, respec-
tively. Corneal aberrations did not differ considerably between
the sutured IOL and standard cataract surgery groups.
Among the sutured IOL group, there was no significant
difference in the amount of tilt, decentration, and ocular and
corneal aberrations between the hydrophobic acrylic foldable
and polymethylmethacrylate IOL groups.
In the sutured IOL group, there was a significant positive
correlation between the IOL tilt and ocular coma-like aberra-
tion (Pearson’s correlation coefficient r=0.628, p,0.001; fig 1),
but no significant correlation was found between the IOL tilt
and ocular spherical-like aberration (r=0.222, p=0.175; fig 2).
The IOL tilt did not correlate with corneal coma-like (r=0.289,
p=0.171; fig 3) and spherical-like (r=0.150, p=0.356; fig 4)
The IOL decentration did not correlate with ocular coma-like
p=0.685), corneal coma-like (r=0.121, p=0.456) and corneal
spherical-like (r=20.187, p=0.249) aberrations.
There have been several studies on the tilt and decentration of
IOLs.9 25–31In general, modern cataract surgery yields smaller
amount of tilt and decentration than the previous surgical
procedures. On the other hand, a significant amount of tilt and
decentration can sometimes be induced after trans-scleral
suture fixation of IOLs in the absence of capsular support.32 33
Hayashi et al34reported mean (SD) tilt angle of 6.35˚(3.09˚) and
decentration length of 0.62 (0.31) mm in eyes with scleral
suture-fixed IOLs, which were significantly greater than the
values obtained in eyes with in-the-bag IOLs, tilt angle of 3.18˚
(1.66˚) and decentration length of 0.29 (0.21) mm. Durak et al35
reported that mean (SD) tilt and decentration of trans-sclerally
sutured posterior chamber IOLs were 6.09˚(3.80˚) and 0.67
(0.43) mm, respectively. In the current study, we obtained a
mean (SD) tilt angle of 4.43˚(3.02˚) and decentration length of
0.28 (0.16) mm in eyes with sutured IOL, which are favourably
compared with the previous data.
In the present study, we found that major tilting of an IOL
caused a substantial amount of ocular coma-like aberration.
There was a significant positive correlation between IOL tilt and
ocular coma-like aberration. Ocular spherical-like aberration,
and corneal coma-like and spherical aberrations did not
correlate with the amount of IOL tilt. Similarly, IOL decentra-
tion showed no correlation with any ocular or corneal higher-
order aberrations. Recently, there has been a case report of a
significant amount of ocular coma-like aberration caused by
major tilting of an IOL, 28.87˚, which was successfully treated
by IOL repositioning surgery.36Taketani et al30reported that IOL
tilt of even a small amount, 3.43˚ (4.55˚), significantly
correlated with ocular coma-like aberration.30
As shown in the results, the ocular coma-like aberration in
the sutured IOL group (0.324 (0.170) mm) was significantly
greater than that of the standard cataract surgery group (0.169
(0.061) mm). On the other hand, there was no significant
difference in the ocular spherical-like aberration between the
intraocular lens tilt and ocular coma-like aberration (Pearson’s correlation
coefficient r=0.628, p,0.001).
A significant positive correlation was found between the
lens tilt and ocular spherical-like aberration (Pearson’s correlation
coefficient r=0.222, p=0.175).
No significant correlation was found between the intraocular
186Oshika, Sugita, Miyata, et al
sutured IOL group (0.142 (0.065) mm) and the standard
cataract surgery group (0.126 (0.033) mm). In eyes after
standard cataract surgery with foldable acrylic IOL implanta-
tion, the mean (SD) ocular coma-like and spherical-like
aberrations for 4.0-mm aperture diameter were reported to be
0.194 (0.081) and 0.144 (0.07) mm, respectively.30In pseudo-
phakic eyes with acrylic IOLs, ocular coma-like aberration for a
4-mm pupil was 0.125–0.15 mm and ocular spherical-like
aberration for a 4-mm pupil was 0.075–0.082 mm.37Similar
values have been reported for 4-mm to 5-mm aperture diameter
in eyes after standard cataract surgery with implantation of
spherical IOLs,38 39indicating that coma-like aberration was
remarkably increased in eyes after scleral suture fixation of the
It would be interesting to know the influence of IOL tilt and
coma-like aberration on visual quality of patients after scleral
suture fixation of IOLs. These patients, however, had under-
gone complicated surgical procedures, which included primary
or secondary scleral suture fixation of the IOL, and many of
them have other ocular pathologies that affect visual functions.
Thus, such evaluation is difficult in this study population. There
have been several simulation studies on the visual impairment
caused by IOL misalignment.11–13These studies, however, did
not consider higher-order aberrations of human corneas, and
therefore exact simulation of situations in living human eyes
was rather difficult. In a case report, retinal image simulation of
a Landolt ring was conducted using the wavefront aberration
profile.36It was found that major tilt of the IOL resulted in
remarkably skewed and blurred Landolt images, which were
Compared with that report, the amount of IOL tilt in the
current study was small, but still induced coma-like aberration
may have induced skewed distortion of the object image. The
present study alone cannot determine the extent of these
changes in human eyes. Future studies are needed to elucidate
Another weakness of this retrospective study is that various
types of IOLs were used in the sutured IOL group. This was
because of the retrospective nature of the current study.
Moreover, surgical details including the type of IOL were not
available in several patients, because they had been operated on
at different surgical sites. There is a possibility that the
differences in IOL design and material resulted in different
amount and pattern of ocular wavefront aberrations. Bellucci et
al39have reported, however, that ocular coma-like aberrations
did not differ significantly among various types of IOLs,
whereas ocular spherical-like aberrations were largely affected
by the style of IOLs. Thus, we believe that there was little, if
any, influence of the type of IOLs on the results of the current
Scleral suture fixation of a posterior chamber IOL is one of
the surgical procedures used to implant an IOL in eyes with
inadequate capsular support.40 41Other options to correct
aphakic eyes in the absence of capsular support include
anterior chamber IOL, iris-sutured posterior chamber IOL and
contact lens correction of aphakia. Until now, these alternatives
have been compared in terms of safety, efficiency and
feasibility. The data obtained in the current study suggest that
the influence of these procedures on optical quality of the eye
should also be evaluated, making these comparisons more
comprehensive and elaborate.
Although the current study was conducted in eyes with
scleral suture fixation of IOLs, the findings obtained may have
clinical implications in regular cataract surgery. The advent and
widespread use of continuous curvilinear capsulorhexis greatly
contributed to long-term centration of IOLs. However, perfect
centration of IOLs is rare for many reasons including in–out-of-
the-bag placement, incongruence between bag diameter and
overall IOL diameter, a large capsulorhexis, asymmetrical
capsule coverage, IOL placement in the sulcus, capsule fibrosis,
capsule phimosis and radial bag tears.13 42Even if the IOL is
perfectly centred, the other optical components of a human eye
are rarely, if ever, centred on the visual axis or on any common
axis. A new class of IOLs designed to offset corneal spherical
aberration has been recently introduced,43–46making the relative
alignments of IOLs and other optical components of the eye
more important. Further studies in these fields are warranted.
T Oshika, C Okamoto, Y Ishii, Department of Ophthalmology, Institute of
Clinical Medicine, University of Tsukuba, Ibaraki, Japan
G Sugita, Sugita Eye Hospital, Aichi, Japan
K Miyata, T Tokunaga, T Samejima, Miyata Eye Hospital, Miyazaki, Japan
Funding: This study was supported in part by grants-in-aid for Scientific
Research from the Ministry of Education, Culture, Sports, Science and
Competing interests: None.
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No significant correlation was found between the intraocular
IOL tilt and higher-order aberration 187
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