Multifocal intraocular lenses: An overview

Tear Film Stability Affects Visual Acuity After Implantations of Monofocal and Multifocal Intraocular Lenses: An Evaluation by Objective Scatter Index

Purpose

To assess the impact of tear film on postoperative visual acuity after cataract surgery to implant an intraocular lens (IOL).

Methods

Tear break-up time (TBUT), Schirmer I test, objective scatter index (OSI), and uncorrected distance visual acuity (UCDVA), intermediate visual acuity (UCIVA), and near visual acuity (UCNVA) were collected 6 months after cataract surgery.

Results

Fifteen eyes with monofocal (Mo-) IOLs and 15 eyes with multifocal (Mu-) IOLs from 30 subjects were included. The Mu-IOL group exhibited higher baseline OSI (1.92 ± 0.69, P < 0.001). Negative correlations-both groups: tear film-related OSI (TF-OSI) and TBUT/Schirmer I test; Mo-IOL: TBUT and logMAR UCDVA-and positive correlations-both groups: TF-OSI and baseline OSI, baseline OSI/TF-OSI and logMAR UCDVA; Mu-IOL: baseline OSI/TF-OSI and logMAR UCIVA/UCNVA-were found. Linear regression showed associations between TF-OSI and TBUT (Mo-IOL: R2 = 0.455, P = 0.006; Mu-IOL: R2 = 0.454, P = 0.006)/Schirmer I test (Mo-IOL: R2 = 0.527, P = 0.002; Mu-IOL: R2 = 0.266, P = 0.049). Multiple regression showed associations between baseline OSI (Mo-IOL: R2 = 0.309, P = 0.032; Mu-IOL: R2 = 0.305, P = 0.033)/TF-OSI (Mo-IOL: R2 = 0.332, P = 0.025; Mu-IOL: R2 = 0.523, P = 0.002)/TBUT (Mo-IOL only: R2 = 0.315, P = 0.029) and logMAR UCDVA.

Conclusions

TF-OSI reflects the UCDVA performance in eyes with IOLs and facilitates a better understanding of the effects of the tear film.

Translational Relevance

TF-OSI offers a developmental and objective approach to assessing the changing visual performance caused by tear film after cataract surgery and IOL implantation in clinical practices.

Optical Quality and Higher Order Aberrations of Refractive Extended Depth of Focus Intraocular Lenses

PURPOSE

To compare the optical quality and higher order aberrations of four different refractive extended depth of focus intraocular lens (EDOF IOL) models (Lentis Comfort [Teleon Surgical BV], MiniWell (SIFI), LuxSmart [Bausch & Lomb], and AcrySof IQ Vivity [Alcon Laboratories, Inc]) and a monofocal IOL (Tecnis ZCB00; Johnson & Johnson Surgical Vision, Inc).

METHODS

An optical metrology instrument (OptiSpheric IOL PRO2; Trioptics GmbH) was used to study image quality metrics of the different IOLs. The modulation transfer function (MTF) was measured at pupil sizes 1 to 5 mm in 1-mm steps. Area under the MTF and simulated visual acuity were calculated for different pupil diameters. Wavefront aberrations were measured with the SHS Ophthalmic device (Optocraft GmbH), which features a Hartmann-Shack sensor.

RESULTS

All EDOF lenses yielded a simulated far visual acuity of 0.00 logMAR (20/20 Snellen) or better. At the 0.20 logMAR visual acuity level, the EDOF IOLs showed an increased depth of focus of at least 0.75 diopters compared to the monofocal IOL. Pupil dependency was more pronounced with the MiniWell, LuxSmart, and Vivity, whereas the Lentis showed a more consistent behavior at different apertures. The wavefront measurement revealed increased central aberrations for the MiniWell, LuxSmart, and Vivity IOL compared to the monofocal control.

CONCLUSIONS

All EDOF IOLs demonstrated increased depth of focus while maintaining good simulated visual acuity at the far focus. Pupil dependency differed between the IOL models. The wavefront analysis revealed the complex design of the different EDOF IOLs with several zones with varying aberrations. [J Refract Surg. 2023;39(10):668-674.].

Visual function in eyes with diffractive extended depth-of-focus and monofocal intraocular lenses: 2-year comparison

PURPOSE

To compare long-term visual function after implantation of diffractive extended depth-of-focus (EDF) intraocular lenses (IOLs) using echelett optics and monofocal IOLs with the same platform.

METHODS

In this prospective comparative case series, diffractive EDF or monofocal IOLs were implanted binocularly and followed up for 2 years. At the last visit, distance-corrected binocular visual acuities were measured at distances of 0.3, 0.5, 0.7, 1, 2, 3, and 5 m. Photopic and mesopic contrast sensitivity was also examined. Dynamic visual function was evaluated in terms of functional visual acuity (FVA), standard deviation of visual acuity (SDVA), visual maintenance ratio (VMR), mean response time, and number of blinks. The outcomes were compared between the two IOLs, and the influence of posterior capsule opacification (PCO) on contrast sensitivity and FVA was examined.

RESULTS

Binocular visual acuity of eyes with EDF IOLs was better at distances of 0.5 and 0.7 m than that of eyes with monofocal IOL (P < 0.026). There were no differences in binocular visual acuity at other distances, contrast sensitivities, or dynamic visual functions. The influence of PCO on the visual functions was not found in eyes with EDF IOLs.

CONCLUSION

Up to 2 years postoperatively, eyes with diffractive EDF IOLs sustained superior intermediate visual acuity together with visual function comparable to that of eyes with monofocal IOLs.

Recommendation for Presbyopia-Correcting Intraocular Lenses: A Delphi Consensus Statement by the ESASO Study Group

PURPOSE

To establish consensus among experts in lens and refractive surgery to guide general ophthalmologists on issues related to presbyopia-correcting intraocular lenses (IOLs).

DESIGN

A modified Delphi method to reach a consensus among experts.

METHODS

A steering committee formulated 105 relevant items grouped into four sections (preoperative considerations, IOL selection, intraoperative considerations, and postoperative considerations). The consensus was defined as ≥ 70% of experts agreeing with the evaluation of a statement.

RESULTS

Ten experts participated and completed all rounds of questionnaires (100% response rate). Of 68 items considered in the preoperative considerations, consensus was achieved in 48 (70.6%). There was a lack of consensus over IOL selection, the experts only agreed on the importance of the patient's habits for the optical IOL design selection. Of the 14 considerations related to intraoperative issues, the experts reached a consensus on 10 (71.4%). The postoperative considerations section reached the highest consensus in 10 items of 13 (76.9%).

CONCLUSIONS

Key recommendations for a diffractive multifocal IOL were a potential postoperative visual acuity > 0.5, a keratometry between 40-45 diopters, a pupil >2.8 mm under photopic conditions and <6.0 mm under scotopic conditions, a root mean square of higher order corneal aberrations <0.5 µm for 6-mm pupil size, while monofocal or non-diffractive IOLs should be considered for patients with coexisting eye disorders. A lack of agreement was found in the issues related to the IOL selection.

Design of adjustable multifocal diffractive optical elements with an improved smooth phase profile by continuous variable curve with multi-subperiods method

Multifocal diffractive optical elements (MDOEs), which produce arbitrary light distribution, are widely used in lightweight and compact optical systems. MDOEs that are combined with multiple functions tend to have complex step structures, limiting their applications. We propose a facile method named continuous variable curve with multi-subperiods (CVCMS) to design adjustable multifocal single-layer diffractive optical elements. Through the analysis, the model achieved arbitrary diffraction efficiency distribution with an improved smooth continuous phase profile in each diffractive ring while retaining the periodicity. To display the high design freedom of the method, we utilized this method to design and discuss a broadband multifocal intraocular lens (MIOL) focused on the optimization of far focal point. Finally, the method was compared with other multifocal design methods. The results show that the CVCMS method achieved adjustable multifocal design with better performance and smoother profile than other MDOE design techniques. The proposed model can be applied to multifocal ophthalmic lens designs.

Assessment of Visual Habituation Measured With the Halo & Glare Simulator and Its Impact on Patient Satisfaction Following Quadrifocal IOL Implantation

PURPOSE

To evaluate the levels of habituation and its influence on outcome satisfaction in patients who underwent bilateral multifocal intraocular lens (IOL) implantation.

METHODS

A total of 24 patients underwent bilateral multifocal IOL implantation surgery with the AcrySof IQ PanOptix trifocal diffractive IOL (Alcon Laboratories, Inc) following cataract extraction or for refractive purposes. Data were collected 3 and 6 months after surgery, which included subjective refraction, corrected and uncorrected visual acuity (distance, intermediate, near), a contrast sensitivity test, simulation with the Halo & Glare Simulator (Carl Zeiss Meditec AG), two visual quality surveys, and a slit-lamp examination by an ophthalmologist.

RESULTS

All patients were spectacle independent for distance vision and 92% (n = 22) needed no visual aid for near vision. Minor visual acuity improvement was detected between both examinations at monocular uncorrected distance visual acuity (P = .025). Improvements of presence, size, and intensity of visual disturbances were not statistically significant, but overall patient satisfaction (P = .009) and Weber-Contrast sensitivity under mesopic conditions (P = .029) increased significantly.

CONCLUSIONS

Diffractive multifocal IOLs are a stable treatment for presbyopia and/or cataract with a high spectacle independence rate. Visual disturbances caused by their optics do not decrease significantly between 3 and 6 months after surgery. Habituation and neuroadaptation play a significant role in patient satisfaction and contrast sensitivity during and possibly beyond that period. [J Refract Surg. 2023;39(8):510-517.].

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

Assessing Visual Outcomes: A Comparative Study of US-FDA Premarket Approval Data for Multifocal and EDOF Lens Implants in Cataract Surgery

This study compares the efficacy, safety, and patient-reported outcomes of three intraocular implants (IOL): Tecnis Synergy IOL, AcrySof IQ PanOptix Trifocal, and Tecnis Symfony EDOF IOL. Participants achieving 20/20 or better uncorrected binocular visual acuity were as follows: Synergy-67% distance, 64% intermediate, and 47% near; PanOptix-73% distance, 73% intermediate, and 50% near; and Symfony-63% distance, 75% intermediate, and 22% near. Symfony demonstrated superior intermediate visual acuity compared to Synergy (p = 0.0182) for those achieving 20/25 or better. Both Synergy and PanOptix showed superiority over Symfony for near visual acuity (p < 0.0001). Halos were statistically more common in Synergy participants compared to PanOptix (p = 0.0013) and Symfony (p < 0.0001). Each trial lens outperformed its monofocal IOL in terms of independence from glasses or contacts, with Synergy and PanOptix showing statistical significance over Symfony. Comparing contrast sensitivities and defocus curves was challenging due to data variance and as such, standardization of United States Food and Drug Administration (US-FDA) data reporting is key for better comparison of outcomes among different IOL platforms.

Clinical Outcomes with Extended Depth of Focus Intraocular Lenses in Cases in Which Multifocal Lenses Are Not Primarily Recommended

Purpose

The purpose of the study is to evaluate the visual and patient-reported outcomes of patients undergoing cataract surgery with implantation of an extended depth of focus (EDOF) intraocular lens (IOL) who were not primarily good candidates for multifocal IOL implantation.

Methods

Retrospective analysis of data from 30 eyes (23 patients) undergoing cataract surgery with implantation of one of two EDOF IOLs (follow-up: 37.9 ± 16.2 months) and prospective observational study including 106 eyes (78 patients) implanted with one of 6 different EDOF models (follow-up: 8.0 ± 7.7 months). Patients recruited had one of the following conditions: monofocal IOL implanted in the fellow eye, previous corneal refractive surgery, mild and nonprogressive maculopathy or glaucoma, age > 75 years, amblyopia, or previous vitrectomy.

Results

In the retrospective phase, significant improvements were found in uncorrected distance (UDVA), corrected distance (CDVA), and corrected near visual acuity (CNVA) (p ≤ 0.013), with a nonsignificant trend to improvement in uncorrected near visual acuity (UNVA). A total of 90% of patients were completely to moderately satisfied with the outcome achieved. In the prospective phase, significant improvements were found in UDVA, CDVA, UNVA, and CNVA (p ≤ 0.032), with a total of 85.5% of patients being completely to moderately satisfied (dissatisfaction 3.3%). In both phases, extreme difficulties were only reported by a limited percentage of patients for performing some near vision activities.

Conclusions

EDOF IOLs seem to be a viable option for providing an efficient visual rehabilitation with good levels of patient satisfaction and spectacle independence associated in patients that are not primarily good candidates for multifocal IOL implantation.

Two-surgeon, two-center evaluation of a new combined EDOF intraocular lens approach

PURPOSE

To evaluate visual performance and quality of life after bilateral implantation of 2 extended depth-of-focus intraocular lenses (EDOF IOLs).

SETTING

Ophthalmology Clinic, Department of Medicine and Science of Ageing, University "G. d'Annunzio" Chieti-Pescara, Italy, and Ophthalmic Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy.

DESIGN

Prospective clinical study.

METHODS

60 eyes of 30 patients with senile cataract were enrolled in this study. Patients underwent phacoemulsification and bilateral implantation of the Mini WELL IOL in the dominant eye and the Mini WELL PROXA IOL in the nondominant eye within a month. The main outcome measures over a 3-month follow-up period were uncorrected and corrected visual acuity at different distances (33 cm, 60 cm, and 4 m), defocus curve, contrast sensitivity, and patient satisfaction (evaluated by mean of the National Eye Institute Refractive Error Quality-of-Life instrument-42 questionnaire).

RESULTS

Binocular uncorrected visual acuity at 90 days was 0.03 ± 0.11 logMAR for long distance, 0.05 ± 0.10 logMAR for intermediate distance, 0.03 ± 0.08 logMAR at 40 cm, and 0.06 ± 0.08 logMAR at 33 cm. Statistically significant differences between the 2 EDOF IOLs in favor of Mini WELL PROXA IOL were observed for uncorrected near visual acuity at 40 and 33 cm ( P < .001 and P < .001, respectively) and for distance-corrected near visual acuity at 40 cm ( P < .001). Significant differences between the 2 IOLs in the defocus curves were reported.

CONCLUSIONS

In this small pilot study, bilateral implantation of Mini WELL IOL and Mini WELL PROXA IOL achieved good quantity and quality of vision.

Analysis of visual quality after multifocal intraocular lens implantation in post-LASIK cataract patients

With the development of refractive corneal surgery, excimer laser in situ keratomileusis (LASIK) has become a common refractive surgery procedure. However, post-LASIK patients are at increased risk of developing cataracts as they age and often require IOL implantation. The choice of IOLs is particularly important for these patients, who have smaller residual refractive error and have higher requirements for post-cataract vision recovery and visual quality than the general population. Multifocal IOLs are widely used in clinical practice for patients with high visual acuity needs, such as cataract patients after refractive keratomileusis, due to their advantages of providing excellent near and distance visual acuity; however, compared to monofocal IOLs, multifocal IOLs can lead to postoperative problems related to visual quality such as increased higher order aberrations and decreased contrast sensitivity. Therefore, whether multifocal IOLs have advantages for post-LASIK cataract patients, such as improving the visual quality of such patients, has attracted attention. In this paper, we analyze the current status of research on the implantation of multifocal IOLs in post-LASIK cataract patients by domestic and foreign experts, review and summarize the relevant literature, and propose further discussion in the context of the actual situation of postoperative visual quality and vision recovery.

Patient reported outcomes after implementation of an enhanced depth of focus intraocular lens with low postoperative myopia

Background

Enhanced depth-of- focus intraocular lenses (EDOF IOL) have filled the gap between monofocal and multifocal intraocular implants with optical qualities of monofocal lenses and usually minor dysphotopsias typical for multifocal lenses. The purpose of this study was to evaluate visual outcomes after bilateral implantation of a new EDOF IOL in patients with requirements for perfect near and intermediate vision.

Methods

The study included 15 patients (29 eyes as one was amblyopic) with bilateral implantation of LUXSMART EDOF IOL (Bausch & Lomb) with a targeted myopia (between -0.25 and -0.50D) in both eyes. Monocular corrected and uncorrected visual acuity for far, intermediate and near as well as refractive outcomes were evaluated at 1, 3, 6 and 12 months after the surgery. Additionally, binocular visual acuity, contrast sensitivity and defocus curve were measured at the final follow-up visit. At 12 months' visit patients completed a questionnaire evaluating patient satisfaction, spectacle independence and presence of dysphotopsias.

Results

Binocular uncorrected visual acuities at 12 month's visit were 0.13 ​± ​0.16, 0.06 ​± ​0.08, 0.07 ​± ​0.09 and 0.15 ​± ​0.09 logMAR for far distance, 80 ​cm, 66 ​cm and 40 ​cm respectively. Corrected binocular visual acuities at 12 months were 0.00 ​± ​0.00, 0.05 ​± ​0.07, 0.05 ​± ​0.06, 0.13 ​± ​0.16 respectively for distance, 80 ​cm, 66 ​cm and 40 ​cm. Automated refraction spherical equivalent at 12 months' visit stood at -0.70 ​± ​0.48D, which was 0.46D less than calculated biometric target, however spherical equivalent of subjective refraction at 12 months equaled -0.49 ​± ​0.46D, which was closer to preoperative biometric target. Defocus curve had gentle shape without peaks typical for monofocal IOLs. Binocular contrast sensitivity results were superior to average results for that age group and equaled 1.78 ​± ​0.16 logMAR without correction and 1.81 ​± ​0.13 logMAR with correction. Spectacle independence for near and intermediate distances was achieved in all patients and for far distance in 73.3% of patients. Burdensome dysphotopsias were not reported in any case.

Conclusions

EDOF IOLs targeted bilaterally at low myopia can provide excellent near and intermediate visual acuity and independence of any optical correction in majority of cases. This approach can be used in selected patients who are focused on stationary activities.

Visual and patient-reported outcomes of a diffractive trifocal intraocular lens in highly myopic eyes: a prospective multicenter study

BACKGROUND

To investigate the visual and patient-reported outcomes of a diffractive trifocal intraocular lens (IOL) in highly myopic eyes.

METHODS

Patients with planned cataract removal by phacoemulsification and implantation of a trifocal IOL (AT LISA tri 839MP) were enrolled in the prospective, multicenter cohort study. Patients were allocated into three groups according to their axial length (AL): control group, AL < 26 mm; high myopia group, AL 26-28 mm; extreme myopia group, AL ≥ 28 mm. At 3 months post-surgery, data for 456 eyes of 456 patients were collected, including visual acuity, defocus curve, contrast sensitivity (CS), visual quality, spectacle independence, and overall satisfaction.

RESULTS

After surgery, the uncorrected distance visual acuity improved from 0.59 ± 0.41 to 0.06 ± 0.12 logMAR (P < 0.001). In all three groups, about 60% of eyes achieved uncorrected near and intermediate visual acuity of 0.10 logMAR or better, but significantly fewer eyes in the extreme myopia group achieved uncorrected distance visual acuity of 0.10 logMAR or better (P < 0.05). Defocus curves revealed that the visual acuity was significantly worse in the extreme myopia group than others at 0.00, - 0.50, and - 2.00 diopters (P < 0.05). CS did not differ between the control and high myopia groups but was significantly lower in the extreme myopia group at 3 cycles per degree. The extreme myopia group also had greater higher-order aberrations and coma, lower modulation transfer functions and VF-14 scores, more glare and halos, worse spectacle independence at far distance, and consequently lower patient satisfaction than others (all P < 0.05).

CONCLUSIONS

In eyes with a high degree of myopia (AL < 28 mm), trifocal IOLs have been shown to provide similar visual outcomes to those in non-myopic eyes. However, in extremely myopic eyes, acceptable results may be obtained with trifocal IOLs, but a reduced level of uncorrected distance vision is expected.

Spectral Effects and Range of Focus in a Multizonal-Refractive Intraocular Lens Compared with a Standard Trifocal Diffractive Design

INTRODUCTION

This study was performed to compare the optical performance of a multizonal presbyopia-correcting intraocular lens (IOL) and a conventional trifocal model.

METHODS

The optical quality and simulated visual acuity (VA) of 570 Precizon Presbyopic NVA (OPHTEC BV) and AcrySof IQ PanOptix (Alcon) were compared. The Precizon features a refractive design consisting of alternating optical zones that converge the incident light into two principal foci and a transitional zone for intermediate vision. By contrast, the PanOptix applies a diffractive (non-apodized) profile to achieve trifocality. Simulated VA was derived from the modulation transfer function. Chromatic aberration effects were also studied.

RESULTS

The diffractive and multizonal-refractive lenses yielded comparable simulated VAs at far focus (0.00 logMAR). All curves showed a reduction in expected VA with an increase in negative defocus. At - 1.0 D, the multizonal-refractive IOL's VA dropped by 0.05 logMAR, but for the diffractive model, it was one line (0.11 logMAR). The multizonal-refractive lens's VA prediction at the secondary peak was 0.03 logMAR-minimally better than the 0.06 logMAR of the diffractive lens at - 2.5 D. The refractive lens exhibited a 24% decrease in polychromatic optical quality due to material dispersion. The performance of PanOptix was more substantially affected, showing a 44% loss at 50 lp/mm at far, with minimal effects at other distances.

CONCLUSION

The multizonal-refractive lens does not fall short of the established trifocal IOL, and it can be used to extend the visual range of pseudophakic patients. Although the multizonal-refractive lens has lower material dispersion, the diffractive model corrects chromatism beyond far focus.

Solving STODS-Surgical Temporary Ocular Discomfort Syndrome

The term STODS (Surgical Temporary Ocular Discomfort Syndrome) has been coined to describe the ocular surface perturbations induced by surgery. As one of the most important refractive elements of the eye, Guided Ocular Surface and Lid Disease (GOLD) optimization is fundamental to success in achieving refractive outcomes and mitigating STODS. Effective GOLD optimization and the prevention/treatment of STODS requires an understanding of the molecular, cellular, and anatomic factors that influence ocular surface microenvironment and the associated perturbations induced by surgical intervention. By reviewing the current understanding of STODS etiologies, we will attempt to outline a rationale for a tailored GOLD optimization depending on the ocular surgical insult. With a bench-to-bedside approach, we will highlight clinical examples of effective GOLD perioperative optimization that can mitigate STODS' deleterious effect on preoperative imaging and postoperative healing.

Cataracts

94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.

Hyperopic LASIK Enhanced by Pharmacological Treatment of Presbyopia

Purpose: Regression of the refractive outcome is a major concern of LASIK procedures mainly in presbyopic patients. The purpose of this study was to evaluate the long-term efficacy of the pharmacological treatment of presbyopia performed with Benozzi's method, in combination with hyperopic LASIK surgery in presbyopic population. Methods: A nonrandomized case series was developed, including presbyopic patients who underwent bilateral "Hyperopic LASIK surgery" and were pharmacologically treated with Benozzi's Method from January 2011 to August 2018, with at least 2 years of follow-up, at two private ophthalmological clinics of Argentina. Main outcomes were spherical equivalent (SE), uncorrected distance visual acuity (UDVA), and uncorrected near visual acuity (UNVA). Measurements were evaluated at baseline and postoperative at 1 month (without Benozzi's treatment), 2 months (starting with Benozzi's treatment), and 2 years. The SE stability across the time was statistically compared. Results: A total of 84 eyes of 42 patients, with a mean age at the time of the surgery of 51.07 ± 4.5 (42-59), were found following 2 years of follow-up. Patients have improved and maintained UDVA, achieving Jaeger 1 in the second postoperative month, which was maintained up to the last year of follow-up. Refractive stability across the time is observed comparing first month after surgery with the last year of follow-up, without statistical significant difference (p: 0.11). Conclusion: Hyperopic presbyopic patients that underwent LASIK surgery and 1 month after surgery started with the pharmacological treatment of presbyopia (Benozzi's method) results in excellent UNVA and UDVA that is stable over time without refractive regression.

Depth of focus of four novel extended range of vision intraocular lenses

PURPOSE

To assess the depth of focus of four latest non-diffractive extended range of vision IOLs on the optical bench. Such comparison had not been done before.

METHODS

We assessed and compared the through focus modulation transfer function (MTF) of the following novel IOLs with a nominal power of 22 D: Acrysof Vivity, LuxSmart Crystal, RayOne EMV and Tecnis Eyhance. An ISO-2 model eye was applied with apertures of 3 and 4.5 mm with monochromatic light of 546 nm. Measurements were done on OptiSpheric IOL PRO 2 optical bench.

RESULTS

For the aperture of 3 mm, Eyhance and RayOne EMV showed the most pronounced peak in MTF with only little enlarged depth of power. Vivity and LuxSmart showed two peaks of about 1.7 D respectively 1.3 D depth of focus, yet reduced MTF and with maxima differently located. For 4.5 mm, MTF values for Eyhance and particularly for RayOne EMV dropped. For Vivity and LuxSmart, only the peak for the secondary focus decreased.

CONCLUSION

Vivity and LuxSmart showed a larger depth of focus for our measuring conditions than Eyhance and RayOne EMV. Correspondingly, the peak MTF was best for Eyhance and RayOne ERV with small aperture. With the larger aperture, RayOne EMV considerably lost performance.

Latest Development in Extended Depth-of-Focus Intraocular Lenses: An Update

In recent years, there has been an overwhelming influx of different types of intraocular lenses (IOLs) as treatment for presbyopia. The extended depth-of-focus (EDOF) technology creates a single elongated focal point to enhance depth of focus, in contrast to the multiple foci of multifocal (MF) lenses. In this way, the EDOF lenses aim to reduce photic phenomena, glare, and halos, which have been reported in MF IOLs. A potential disadvantage of this is a blur due to decreased retinal image quality when the amount of the aberrations is increased excessively. Multifocality and EDOF characteristics are not exclusive of each other. Frequently, EDOF IOLs are combined with MF optical designs, a bifocal IOL may exhibit EDOF characteristics, likewise an aspheric monofocal IOL or a diffractive or refractive trifocal IOL. Thus, EDOF lenses are commonly subjected to confusion. A wide range of different types of EDOF lenses are available on the market to surgeons. In this practical update, we aim to clarify what is a true EDOF lens, classify the different types of the EDOF lenses based on their optical principle and review their recently reported outcomes. Comprehensive patient examination and selection, combined with knowledge of the most updated options and adequate patient counseling, can avoid dissatisfaction and yield the desired outcomes.

Dilation devices in cataract surgery

PURPOSE OF REVIEW

Cataract surgery in the setting of small pupil represent a major challenge and it is associated with a higher risk of complications. When pharmacologic pupil dilation fails, mechanical pupil expansion devices are needed to obtain and maintain sufficient intraoperative mydriasis. The purpose of this review is to assess the pupil expansion devices currently available.

RECENT FINDINGS

A variety of pupil expansion devices are offered on the market. They differ for design, material, shape, size, cost, and easiness of insertion/removal, nonetheless they all seem to be effective in improving the pupil size and easing the cataract surgery.

SUMMARY

Mechanical pupil expansion can be effectively achieved with a variety of devices, which are well tolerated and can facilitate cataract surgery in the setting of poor mydriasis.

Age-related visual outcomes in eyes with diffractive multifocal intraocular lenses

BACKGROUND/OBJECTIVES

To assess the influence of patient age on visual outcomes in eyes with diffractive multifocal intraocular lenses (IOLs) SUBJECTS/METHODS: Based on age, we classified eyes with diffractive multifocal IOL into four groups: u50 (under 50 years old), 50s (50-59 years), 60s, and 70s. Corrected distance (CD), distance-corrected near (DCN) visual acuity (VA), and defocus curve were measured postoperatively. Using an "area-of-focus" metric, the distant, intermediate, and near area-of-focus (AoF) were also measured. These postoperative results were compared between the age groups.

RESULTS

At 3 months after surgery, the CDVA in the u50, 50s, 60s, and 70s groups were -0.18, -0.16, -0.14, and -0.10 logMAR, respectively. The 70s CDVA was significantly worse than the u50 and 50s groups (P = 0.002, P = 0.049). The DCNVA in the u50, 50s, 60s, and 70s were 0.01, 0.03, 0.03, and 0.08 logMAR. DCNVA in the 70s group was significantly worse than that in the u50 and 60s groups (P = 0.008 and P = 0.019, respectively). The near AoF was smaller in the 70s than in the u50 and 50s groups (P = 0.040, P = 0.047). In both the intermediate and distant AoFs, there was no significant difference between the four age groups. A steep decline in near AoF was observed in patients over 60 years of age.

CONCLUSIONS

The CDVA, DCNVA, and near AoF declined with patient age in eyes with diffractive multifocal IOL. The near AoF showed a drastic decline over 60 years.

Geometric-phase intraocular lenses with multifocality

We demonstrate a new type of multifocal and extended depth of focus (EDOF) intraocular lenses (IOLs) embedding μm-thin geometric phase (GP) lens layers. As an emerging approach for lens phase design, the GP modulated IOLs outperform conventional diffractive IOLs in multifocality while completely avoiding the clinically undesirable demand for additional surface patterns to standard monofocal IOL designs. The number of foci and light splitting ratio of the GP IOLs are adjusted by changing the number of stacked GP layers and the thickness of each layer. Bifocal and trifocal GP IOLs are fabricated by radial alignment of anisotropic orientation in UV-curable liquid crystal polymers. After characterizing the defocus image and modulation transfer function of the GP IOLs, it is expected that GP IOLs will alleviate the most common problems associated with multifocal and EDOF IOLs, blurred vision and photic phenomena caused by light scattering and posterior capsule opacification.

Influence of ocular biometric parameters such as effective lens position, keratometry, and axial length on near add power of multifocal intraocular lens

Visual quality after multifocal intraocular lens (mIOL) implantation has received increased attention. Postoperative residual ametropia, posterior capsule opacification, dry eye, IOL decentration, pupil size, and other factors can affect patient visual acuity. In addition, patient dissatisfaction after mIOL implantation has a relationship with the near add power of mIOLs, which is correlated with vision habits of different patients. Indeed, the actual spectacle plane add power of mIOLs is incompletely consistent with the near add power given by the manufacturers. Ocular biometric parameters such as effective lens position, keratometry, and axial length have effect on the near add power of mIOLs in the lens plane. In this article, the influence of ocular biometric eye parameters on the actual near add power of mIOLs in the lens plane was reviewed.

Influence of ocular biometric factors on the defocus curve in an enlarged depth-of-focus intraocular lens

BACKGROUND

To assess the influence of biometric measurements on the defocus curve after the implantation of enlarged depth-of-focus (EDoF) intraocular lens (IOL).

METHODS

Patients who underwent cataract surgery with bilateral implantation of Tecnis Symfony IOL were enrolled. Preoperatively, axial length (AL), corneal keratometry (K), pupil size and corneal aberrations were measured. 1 month after surgery, distance, intermediate, and near visual acuities (VA) were recorded. At 3 months, monocular and binocular corrected contrast sensitivities under photopic and mesopic lighting conditions were measured with CSV-1000E test. At 6-months, the defocus curve between -5.00 to + 3.00 diopters (D) was assessed in steps of 0.50 D, and NEI-RQL-42 questionnaire was administered.

RESULTS

One hundred thirty one eyes of 66 patients were included. Binocular logMAR VA better than 0.1 for intermediate vision was obtained in 90% of patients, whereas only 17.7% obtained that result in near vision. The rate of satisfaction was high (96%) and most of them (85.5%) had no or little difficulties in near vision. The mean amplitude of the defocus curve was 2.35D ± 0.73D, and smaller AL, smaller pupils, younger age, and male sex were associated with wider range of clear vision.

CONCLUSIONS

Tecnis Symfony IOL enables functional vision at all distances, but demographic variables and preoperative biometric measurements like AL and pupil size influence the postoperative amplitude of the defocus curve. These parameters could be used to predict the performance of EDoF IOLs.

Comparisons of visual outcomes between bilateral implantation and mix-and-match implantation of three types intraocular lenses

PURPOSE

To compare binocular static visual acuity (SVA), stereopsis, contrast sensitivity (CS) and dynamic visual acuity (DVA) of 5 combinations of bifocal intraocular lenses (IOLs), trifocal IOLs and extended-depth-of-focus (EDOF) IOLs in age-related cataract patients.

METHODS

Two hundred and ninety-two eyes of 146 patients who underwent cataract surgery in the ophthalmology department of the First Affiliated Hospital of Chongqing Medical University were involved. Subgroups included group MM (33patients, bilaterally bifocal IOL, ZMB00), group TT (31patients, bilaterally trifocal IOL, AT LISA tri839MP), group XX (34patients, bilaterally EDOF IOL, ZXR00), group MX (25patients, bifocal IOL, ZMB00 + EDOF IOL, ZXR00) and group TX (23patients, trifocal IOL, AT LISA tri839MP + EDOF IOL, ZXR00). The uncorrected SVAs (UDVA, UIVA and UNVA), uncorrected DVAs (UDDVA, UIDVA and UNDVA), near and distance stereopsis, and CS were assessed 3 months postoperatively.

RESULTS

Subgroups of TT, XX, MX and TX showed better UIVA than MM (bP = 0.039, 0.021, 0.035 and 0.037, respectively). MX showed better UNVA than MM and TX (bP = 0.031 and 0.013, respectively). MX group had the optimal outcomes of both near and distance stereopsis. In the UDDVA, XX group and MX group showed better outcomes than TX group at 24 fps (frames per second) (bP = 0.019 and 0.023, respectively). XX group and MX group showed optimal outcomes at all speeds of UIDVA (P = 0.001, 0.005, 0.003 and 0.005, respectively). As the speed increased, the XX group and the MX group showed better UNDVA than the MM group and the TT group (P = 0.019, 0.002 and 0.003, respectively).

CONCLUSIONS

Mix-and-match implantation of bifocal IOLs and EDOF IOLs provides excellent and stable binocular visual outcomes including SVA, stereopsis and DVA in distant and near distances.

Pharmacological treatment of presbyopia: A systematic review

The aim of this study was to identify the efficacy of drug agents for pharmacological Treatment of Presbyopia. Published research papers were reviewed using the relevant terms in PubMed, Science direct, Google scholar, Medline, Google patent, Ovid, Cochrane Database of Systematic Reviews, Scopus. In the initial search, 2270 records were obtained. By removing duplicate articles and all articles that did not meet the inclusion criteria or were inappropriate due to indirect relevance to the subject, 44 studies were selected. It should be noted that all studies had inclusion criteria. There are a number of topical pharmacological agents available for treating presbyopia such as FOV Tears and PresbiDrop. They consist of parasympathetic agent and non-steroidal anti-inflammatory drugs (NSAIDs), to contract the ciliary and pupil muscle and restore the accommodation. Another example of topical pharmacological agent is EV06. It is a lens-softening eye drop which can affect the rigid lens in presbyopia. Currently there is no pharmacological agent available to treat presbyopia. Although there are limited number of peer-reviewed articles available, the outcome for future agents under investigation are promising.

Evaluation of Visual and Patient-Reported Outcomes, Spectacle Dependence after Bilateral Implantation with a Non-Diffractive Extended Depth of Focus Intraocular Lens Compared to Other Intraocular Lenses

Purpose: To evaluate postoperative outcomes, spectacle dependance and the occurrence of the photic phenomena in patients after cataract surgery following the implantation of a non-diffractive extended depth of focus (EDOF) intraocular lens was compared to monofocal and multifocal lenses. Methods: We enrolled patients with bilateral cataracts who wanted to reduce their dependence on glasses in the study. They were followed for 6 months. The study group in which the EDOF lens was implanted consisted of 70 eyes in 35 patients. The control groups consisted of: 52 eyes in 26 patients in whom a multifocal was implanted and 52 eyes in 26 patients with implanted monofocal lens. After a total of 2 weeks, 2 months and 6 months post-surgery the following were evaluated: uncorrected and corrected visual acuity at 4 m, 80 cm, 40 cm, manifest refraction expressed as mean refractive spherical equivalent (MRSE), contrast sensitivity, intraocular pressure. A questionnaire on independence from ocular correction, the occurrence of photic phenomena, and patient satisfaction was also completed. Results: Monocular and binocular visual acuity and MRSE 6 months after the procedure were compared between three groups. All of the main analyses, except for comparisons of uncorrected distance visual acuity (both monocular and binocular) level, were significant. Contrast sensitivity was lower among patients with multifocal lens than among patients with EDOF lens. Halo and glare after 6 months were seen more often among patients with multifocal lens than among patients with the other lens (65% of eyes with multifocal lens vs. 6% of eyes with EDOF lens and 0% of eyes with monofocal lens). Glasses were needed by 35% of patients with EDOF lens, and by 96% of patients with monofocal lens and in none of the patients with multifocal lens. Conclusions: Most patients qualify for the implantation of a non-diffractive EDOF lens. Post-operative visual acuity improves at any distance. The best monocular visual acuity for intermediate distances is provided by an EDOF lens, and for near distance by a multifocal lens. The EDOF lens definitely increases independence from spectacle correction compared to monofocal lenses; however, the greatest degree of independence from spectacles is provided by multifocal lenses. The incidence of photic phenomena is slightly higher than that of a monofocal lens, and much lower for a multifocal lens.

Analysis of a novel hydrophobic acrylic enhanced monofocal intraocular lens compared to its standard monofocal type on the optical bench

Introduction

The aim of this laboratory study is to objectively analyze the new hydrophobic, acrylic, enhanced monofocal intraocular lens Acunex Quantum (AN6Q) and compare it with the monofocal platform Acunex AN6. 

Methods

Two IOL models were analyzed (Acunex Quantum AN6Q and Acunex AN6, Teleon Surgical, Spankeren, Netherlands), each having the same refractive power of + 22.0 D, on the optical bench with the OptiSpheric IOL PRO 2. The measurements followed the guidelines of the International Standard Organization with following parameters: ISO 2 cornea (+ 0,28 µ), ISO 11979/2, lens placement in situ in NaCl with 35° temperature, 546 nm and selection of different aperture sizes (3.0 mm vs 4.5 mm). The aberrations of each IOL were evaluated by the WaveMaster IOL 2, a high-resolution Shack-Hartmann sensor in reverse projection setup. An in-situ model eye was used according to ISO 11979 in NaCl (n = 1.337) with 546 nm, mask width 4.51. Zernike polynomials up to 10th order were determined by means of the measured wavefront that describe the optical properties of the IOL.

Results

Through frequency modulation transfer function (mean) at 50 lp/mm (AN6Q/AN6 centered) was 0.687/0.731 (3.0 mm aperture) and 0.400/0.509 (4.5 mm aperture). The SR (mean) was 0.592/0.809 (3.0 mm) and 0.332/0.372 (4.5 mm). The MTF (mean) at 50 lp/mm (AN6Q/AN6 decentered by 1 mm) was 0.413/0.478 (3.0 mm) and 0.257/0.229 (4.5 mm). The SR (mean) was 0.393/0.404 (3.0 mm) and 0.183/0.212 (4.5 mm). The MTF (mean) at 50 lp/mm (AN6Q/AN6 tilted by 5°) was 0.508/0.710 (3.0 mm) and 0.337/0.513 (4.5 mm). The SR (mean) was 0.508/0.760 (3.0 mm) and 0.235/0.2372 (4.5 mm). AN6Q showed MTF peak of 0.55 with an enlarged depth of power of about 2.5 D and two cusps in the MTF curve. The spherical aberration Z 4–0 was about -0.21 µm and the secondary spherical aberration Z 6–0 was about 0.16 µm. No other relevant aberration showed up.

Conclusion

The new, enhanced monofocal AN6Q provides an extended range of focus with only slight decrease in contrast quality. Both types of the hydrophobic, acrylic Acunex IOL platform have its particular advantages in clinical settings and therefore its importance, respectively.

Presbyopia-correcting performance and subjective outcomes of a trifocal intraocular lens in eyes with different axial lengths: A prospective cohort study

Purpose

To compare the presbyopia-correcting performance, visual quality, satisfaction and life quality after implantation of a diffractive trifocal intraocular lens (IOL) in eyes with different axial lengths (AL).

Methods

This prospective cohort study enrolled patients with implantation of a trifocal IOL. Manifest refraction, uncorrected and distance-corrected visual acuity at different distances, contrast sensitivity, aberrations and IOL decentration were measured 3 months after surgery. Spectacle independence, adverse photic phenomena, overall satisfaction and life quality were assessed with a questionnaire.

Results

This study included 61 eyes of 61 patients: 16 eyes in the short AL group, 28 eyes in the control group and 17 eyes in the long AL group. Postoperatively, the prediction error (PE) of spherical equivalent showed a difference (P = 0.002). The uncorrected near visual acuity in the long AL group was higher (P = 0.047). Although a higher IOL decentration was obtained in the long AL group (P = 0.034), no significant difference was found in contrast sensitivity and aberrations (all P &gt; 0.05). In the questionnaire, patients in the long AL group showed a relatively lower spectacle independence at near distance (P = 0.060) and had difficulties in near activities, mental health and role in daily life (P = 0.003, 0.021, and 0.033). However, no significant difference was observed in overall satisfaction (P = 0.124).

Conclusion

With detailed preoperative evaluation, the trifocal IOL provided satisfactory visual outcomes for patients with different AL. AL had a certain influence on predictability and IOL decentration. And for patients with long AL, the inadaptability to the near focal point might become an important problem.

Two-dimensional ultrathin Ti3C2 MXene nanosheets coated intraocular lens for synergistic photothermal and NIR-controllable rapamycin releasing therapy against posterior capsule opacification

Posterior capsule opacification (PCO) is one of the most frequent late-onset complications after cataract surgery. Several kinds of drug-eluting intraocular lenses (IOL) were designed for sustainable drug release to suppress ocular inflammation, the proliferation of lens epithelial cells (LECs) and the development of PCO after cataract surgery. Despite previous advances in this field, the drug-loaded IOLs were limited in ocular toxicity, insufficient drug-loading capacity, and short release time. To prevent PCO and to address these drawbacks, a novel drug-loaded IOL (Rapa@Ti3C2-IOL), prepared from two-dimensional ultrathin Ti3C2 MXene nanosheets and rapamycin (Rapa), was fabricated with a two-step spin coating method in this study. Rapa@Ti3C2 was prepared via electrostatic self-assembly of Ti3C2 and Rapa, with a loading capacity of Rapa at 92%. Ti3C2 was used as a drug delivery reservoir of Rapa. Rapa@Ti3C2-IOL was designed to have the synergistic photothermal and near infrared (NIR)-controllable drug release property. As a result, Rapa@Ti3C2-IOL exhibited the advantages of simple preparation, high light transmittance, excellent photothermal conversion capacity, and NIR-controllable drug release behavior. The Rapa@Ti3C2 coating effectively eliminated the LECs around Rapa@Ti3C2-IOL under a mild 808-nm NIR laser irradiation (1.0 W/cm−2). Moreover, NIR-controllable Rapa release inhibited the migration of LECs and suppressed the inflammatory response after photothermal therapy in vitro. Then, Rapa@Ti3C2-IOL was implanted into chinchilla rabbit eyes, and the effectiveness and biocompatibility to prevent PCO were evaluated for 4 weeks. The Rapa@Ti3C2-IOL implant exhibited excellent PCO prevention ability with the assistance of NIR irradiation and no obvious pathological damage was observed in surrounding healthy tissues. In summary, the present study offers a promising strategy for preventing PCO via ultrathin Ti3C2 MXene nanosheet-based IOLs with synergistic photothermal and NIR-controllable Rapa release properties.

Evaluating Optical Quality of a New Hydrophilic Enhanced Monofocal Intraocular Lens and Comparison to the Monofocal Counterpart: An Optical Bench Analysis

INTRODUCTION

The aim of the study was to analyze the optical properties of a new hydrophilic enhanced monofocal intraocular lens (IOL) using optical bench analysis and compare it with its monofocal counterpart.

METHODS

This laboratory study investigates the enhanced monofocal intraocular lens (L-333) and the monofocal counterpart (L-313) IOL by Teleon Surgical, Spankeren, Netherlands on the optical bench, using OptiSpheric IOL PRO2 (Trioptics, Germany) in order to assess the optical quality according to ISO 11979 with ISO-2 Cornea. IOLs (power 22.0 D) were evaluated regarding through frequency modulation transfer function (MTF), Strehl ratio (SR), and through focus MTF at 50 lp/mm using a 3.0-mm and a 4.5-mm aperture. Tilt and decentration were applied. In addition, wavefront measurements were obtained using WaveMaster® IOL 2 device (Trioptics, Germany) and analyzed.

RESULTS

Centered: The MTF (mean) at 50 lp/mm (L-333/L-313) with 3.0 mm aperture was 0.606/0.724 and with 4.5 mm aperture 0.330/0.409. The SR (mean) with 3.0 mm aperture was 0.586/0.809 and with 4.5 mm aperture 0.330/0.348. Decentered by 1 mm: The MTF (mean) at 50 lp/mm (L-333/L-313) with 3.0 mm aperture was 0.485/0.705 and with 4.5 mm aperture 0.255/0.374. The SR (mean) with 3.0 mm aperture was 0.457/0.739 and with 4.5 mm aperture 0.185/0.268. Tilted by 5 degrees: The MTF (mean) at 50 lp/mm (L-333/L-313) with 3.0 mm aperture was 0.577/0.657 and with 4.5 mm aperture 0.345/0.336. The SR (mean) with 3.0 mm aperture was 0.583/0.702 and with 4.5 mm aperture 0.269/0.237. In through focus MTF and aperture of 3.0 mm, the L-333 showed a peak of 0.41 with some enlarged depth of power of about 2 D. For the aperture of 4.5 mm, the MTF values of L-313 and L-333 were slightly reduced; L-333 showed an MTF peak of 0.23 and some reduced depth of power of about 1.5 D. Wavefront measurements showed no major aberrations for the L-313, while a combination of moderate increase in Z 4-0 and Z 6-0 with opposite sign was revealed for the L-333.

CONCLUSION

The enhanced monofocal Lentis Quantum (L-333) produces some enlarged depth of focus by combining spherical aberration of different order and opposite sign. The Lentis Quantum performs very well in comparison to the aspherical monofocal counterpart owing to its optical design. Results with large apertures were sufficient too, suggesting that  the lens is a good option in eyes with a wide pupil and thus in refractive surgeries of young patients.

Evaluation of the Effects of Multifocal Intraocular Lens Oculentis LENTIS Mplus LS-313 MF30 on Visual Performance in Patients Affected by Bilateral Cataract and Treated with Phacoemulsification

Background

The purpose of this study was to evaluate the visual results and patients' satisfaction with surgical treatment of phacoemulsification and implantation of the innovative intraocular multifocal lens (MFIOL) Oculentis LENTIS Mplus MF30 in patients with bilateral cataracts.

Materials and Methods

A single-center prospective observational study was conducted on a total of 20 patients with bilateral cataracts. We evaluated the monocular UCVA and BCVA at 1 day, 7 days, 1 month, 3 months, and 6 months at different distances after phacoemulsification and MFIOL implantation and the binocular UCVA at the same distances. We also assessed the frequency of visual disturbances, overall visual satisfaction, spectacles dependence, and ease of performing different daily activities.

Results

The MFIOL Mplus MF30 was able to significantly improve the monocular UCVA and BCVA at all working distances. Overall visual satisfaction was above 9/10 in all postoperative observation intervals. The degree of independence from spectacles at all distances was 100%. The frequency of adverse visual phenomena was minimal.

Conclusions

In accordance with the literature, the Oculentis LENTIS Mplus MF30 has proved to be a valid therapeutic alternative for visual rehabilitation after phacoemulsification of the cataract in patients also wishing to treat presbyopia, at the cost of very few visual adverse effects. Trials Registration. This trial is registered with ISRCTN20862627.

SMILE for the Treatment of Residual Refractive Error After Cataract Surgery

INTRODUCTION

In the context of managing patients' expectations and satisfaction regarding visual acuity after cataract surgery, we aimed to investigate the improvement in visual acuity and patient satisfaction after small-incision lenticule extraction (SMILE) in pseudophakic (trifocal intraocular lens, IOL) patients with residual myopic refraction after cataract surgery.

METHODS

Seventy-six patients (82 eyes) who underwent cataract surgery with ZEISS AT LISA tri 839MP IOL implantation were included in this retrospective study. The included patients were 56-79 years old, wanted spectacle independence, and had preoperative myopic refraction between - 1.0 and - 2.25 diopters (D) and astigmatism between - 0.75 and - 1.75 D. The treatment status of these patients was defined as trifocal IOL (n = 82). SMILE was performed in patients who were dissatisfied after cataract surgery, and these patients were followed up for 1 year on average. We evaluated visual acuity and satisfaction and further examined laser vision correction and satisfaction levels in patients who were dissatisfied after trifocal IOL implantation.

RESULTS

The possible reasons for patient dissatisfaction were reading books, using a computer, and driving at night. After SMILE, the residual myopic refractive error (spherical) decreased significantly from - 2.08 ± 0.28 [- 2.25 to - 1.0] preoperatively to - 0.25 ± 0.20 - 0.5 to 0] 1 year postoperatively (p < 0.001). Additionally, the uncorrected distance visual acuity increased from 0.65 ± 0.08 [0.52-0.7] logMAR preoperatively to 0.09 ± 0.02 [0.05-0.1] logMAR at 1 month postoperatively (p < 0.001), 0.09 ± 0.02 [0.05-0.1] logMAR at 6 months postoperatively, and 0.06 ± 0.02 [0.05-0.1] logMAR at 12 months postoperatively (p < 0.001). Patient satisfaction measures after SMILE (reading, night driving, and using a computer) were significantly improved.

CONCLUSION

SMILE is a reliable method for treating residual refraction after cataract surgery, as it provides results in the shortest time without complications and increases patient satisfaction.

TRIAL REGISTRATION

The protocol was registered on clinicaltrials.gov (NCT04693663).

Comparison of clinical outcomes of trifocal intraocular lens (AT LISA, Eyecryl SERT trifocal) versus extended depth of focus intraocular lens (Eyhance, Eyecryl SERT EDOF)

Purpose

To compare four different types of intra ocular lenses (IOLs), namely, AT LISA, Eyecryl SERT trifocal, Eyhance, Eyecryl SERT extended depth of focus (EDOF) with respect to their clinical outcomes.

Methods

This is a retrospective comparative study in which patients who underwent surgery and one of the four types of IOL were implanted. Postoperative evaluation was recorded at one month, postoperatively. The monocular uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) (6 m), uncorrected intermediate visual acuity (UIVA) (60 cm), distance-corrected intermediate visual acuity (CIVA), uncorrected near visual acuity (UNVA) (40 cm), and corrected near visual acuity (CNVA) were assessed postoperatively on post operative day 30, for all four IOL groups. Defocus curve and contrast sensitivity were also compared.

Results

With regards to UDVA and CDVA, P value was not statistically significant. (P = 0.534 and 0.421, respectively). EDOF group of IOLs had statistically significant better UIVA and CIVA than trifocal IOL group. (P < 0.001, 0.012, <0.001) and EDOF group had statistically significant worse P value pertaining to UNVA and CNVA (P < 0.001, 0.070, <0.001, 0.190). Pertaining to contrast sensitivity, EDOF group had better contrast sensitivity than Trifocal IOL group (P < 0.001).

Conclusion

All four IOLs compared in this study had good comparable distant visual acuity. Near visual acuity was better with AT LISA and Eyecryl SERT trifocal IOL while intermediate vision was better with Eyhance and Eyecryl SERT EDOF IOL. Contrast sensitivity was better in EDOF IOLs than in both trifocal IOLs.

Self-rated quality of vision and optical phenomena intensity of diffractive presbyopia-correcting IOLs: EDoF, trifocal vs panfocal

PURPOSE

To investigate the self-rated quality of vision (SQV) and optical phenomena intensity of 3 diffractive multifocal intraocular lenses (mIOLs).

SETTING

Department of Ophthalmology, Goethe University Frankfurt, Germany.

DESIGN

Prospective comparative case series.

METHODS

Patients who had bilateral implantation of a diffractive extended depth-of-focus (EDoF), trifocal, or panfocal mIOL were assessed. Outcome parameters were SQV, symptom intensity of optical phenomena under 3 lighting conditions, quality of everyday lifestyle activities, spectacle independence (SI), and contrast sensitivity (CS).

RESULTS

The study comprised 108 eyes. The 3 lenses provided good total SQV under all lighting conditions. EDoF patients reported a slightly better total SQV (EDoF: 9.8 ± 6.67, trifocal: 22.2 ± 7.09, panfocal: 19.6 ± 16.25 visual analog scale, P = .041). A similar percentage of patients reported the presence of optical phenomena with no difference between mIOLs ( P > .05). EDoF, trifocal, and panfocal patients rated symptom intensity of optical phenomena mild to moderate under all lighting conditions; however, EDoF patients reported a lower symptom intensity of halos ( P < .05). Reported quality of everyday lifestyle activities and CS were comparable ( P < .05). All panfocal and trifocal patients (100%) achieved complete SI, whereas almost half (44%) of the EDoF patients used reading spectacles.

CONCLUSIONS

Diffractive EDoF, trifocal, and panfocal mIOLs provided good total SQV with mild to moderate intensity of optical phenomena under all lighting conditions. EDoF patients experienced the same percentage of optical phenomena but reported a weaker symptom intensity of halos and better night-driving ability. EDoF patients would all choose the same IOL, although a significant number of them needed reading spectacles, indicating that SI is not the main factor that determines patient selection of IOLs.

Outcomes of a Refractive Segmented Bifocal Intraocular Lens with a Lower Near Addition

Purpose

To evaluate clinical and subjective outcomes of a segmented bifocal IOL with a 2.0 D near addition.

Patients and Methods

Retrospective analyses of patients who had undergone refractive lens exchange with bilateral implantation of the SBL-2 IOL (Lenstec, Inc., Christ Church, Barbados) were performed. The number of patients included in the study was 389 (778 eyes). Refractive, visual and patient-reported outcomes were presented for the last available visit (mean follow-up 2.05 ± 1.33 months).

Results

The percentage of eyes within ±0.50D and ±1.00D of emmetropia was 82.5% (642/778) and 97.8% (761/778), respectively. The mean uncorrected intermediate visual acuity (66 cm) of the last available visit was 0.08 ± 0.15 logMAR monocularly and 0.04 ± 0.14 logMAR binocularly. The mean monocular and binocular uncorrected near visual acuity (40 cm) were 0.30 ± 0.15 logMAR and 0.24 ± 0.14 logMAR, respectively. Of all patients, 97.2% (378/389) claimed never to use any correction for distance vision, while 93.1% (362/389) of patients did not require any correction for near vision. The mean scores for visual phenomena (on the scale from 1 – no difficulty to 7 – severe difficulty) were 1.8 ± 1.3, 1.7 ± 1.2, 1.7 ± 1.2 and 1.6 ± 1.2 for glare, halo, starburst, and ghosting/double vision, respectively.

Conclusion

Despite the lower near addition of SBL-2 segmented bifocal IOL, patients achieved reasonable rates of spectacle independence and a low incidence of visual phenomena.

An Annotation-Free Restoration Network for Cataractous Fundus Images

Cataracts are the leading cause of vision loss worldwide. Restoration algorithms are developed to improve the readability of cataract fundus images in order to increase the certainty in diagnosis and treatment for cataract patients. Unfortunately, the requirement of annotation limits the application of these algorithms in clinics. This paper proposes a network to annotation-freely restore cataractous fundus images (ArcNet) so as to boost the clinical practicability of restoration. Annotations are unnecessary in ArcNet, where the high-frequency component is extracted from fundus images to replace segmentation in the preservation of retinal structures. The restoration model is learned from the synthesized images and adapted to real cataract images. Extensive experiments are implemented to verify the performance and effectiveness of ArcNet. Favorable performance is achieved using ArcNet against state-of-the-art algorithms, and the diagnosis of ocular fundus diseases in cataract patients is promoted by ArcNet. The capability of properly restoring cataractous images in the absence of annotated data promises the proposed algorithm outstanding clinical practicability.

Visual and satisfaction results with implantation of the trifocal Panoptix® intraocular lens in cataract surgery

PURPOSE

To assess visual results (including the Lapid-Kushlin defocus coefficient), and satisfaction, following the implantation of PanOptix® a trifocal intraocular lens.

METHODS

Observational, retrospective cohort study. 130 eyes of 65 subjects with bilateral implantation were included. Binocular uncorrected visual acuities [distance (Binocular UDVA), intermediate (Binocular UIVA) and near (Binocular UNVA)] were measured. Also, the manifest refraction, binocular defocus curve and binocular contrast sensitivity were determined. The Lapid-Kushlin defocus coefficient, a new single numerical parameter based on the area under the curve of the defocus curve, was calculated. The validated Spanish CATQUEST-9SF satisfaction survey was applied.

RESULTS

Postoperative visual acuity ranges were: binocular UDVA 0.18 to 0.0 LogMAR, binocular UIVA 0.30 to 0.0 LogMAR and Binocular UNVA 0.18 to 0.0 LogMAR. The levels of contrast sensitivity both in bright light conditions (with and without glare) and low light conditions with glare, remained within the limits of normality. Under scotopic conditions without glare values below normality were found at lower spatial frequencies. The binocular defocus curve showed a plateau without a clearly evident peak. The Lapid-Kushlin defocus coefficient was 0.199. Two patients (3.1%) needed glasses after the procedure for near and intermediate vision. No patient manifested great visual difficulties or was dissatisfied with the results.

CONCLUSIONS

The trifocal platform showed very good results in this series of patients. 96.9% of the patients achieved independence of the glasses and expressed a high degree of satisfaction. The Lapid-Kushlin defocus coefficient was better than those calculated from literature, for other multifocal intraocular lenses.

Recent Advances of Intraocular Lens Materials and Surface Modification in Cataract Surgery

Advances in cataract surgery have increased the demand for intraocular lens (IOL) materials. At present, the progress of IOL materials mainly contains further improving biocompatibility, providing better visual quality and adjustable ability, reducing surgical incision, as well as dealing with complications such as posterior capsular opacification (PCO) and ophthalmitis. The purpose of this review is to describe the research progress of relevant IOL materials classified according to different clinical purposes. The innovation of IOL materials is often based on the common IOL materials on the market, such as silicon and acrylate. Special properties and functions are obtained by adding extra polymers or surface modification. Most of these studies have not yet been commercialized, which requires a large number of clinical trials. But they provide valuable thoughts for the optimization of the IOL function.

The relationship between patient satisfaction and visual and optical outcome after bilateral implantation of an extended depth of focus multifocal intraocular lens

Purpose

To evaluate patient satisfaction after implantation of the Tecnis Symfony multifocal intraocular lens (MIOL).

Methods

120 eyes of 60 subjects with senile cataract were bilaterally implanted with the Tecnis Symfony IOL. Follow-up examination was performed 6 months postoperatively. Main outcome measures included uncorrected and corrected distance and near visual acuity, manifest refraction, and visual quality metrics. According to their subjective symptoms patient were divided in two groups: satisfied and unsatisfied.

Results

Uncorrected intermediate (0.15 ​± ​0.11 vs 0.18 ​± ​0.01, P ​= ​0.04) and near (0.26 ​± ​0.12 vs 0.31 ​± ​0.11, P ​= ​0.04) (UIVA, UNVA) log MAR visual acuity was significantly better, cylindrical error less (0.31 ​± ​0.36 vs 0.67 ​± ​0.29, P ​= ​0.05), axial length (AL) smaller (23.68 ​± ​1.3 vs 24.22 ​± ​1.6, P ​= ​0.05), Strehl ratio higher (0.08 ​± ​0.08 vs 0.05 ​± ​0.04, P ​= ​0.03) and mesopic pupil larger (4.3 ​± ​1.1 vs 3.7 ​± ​1.05, P ​= ​0.01) among satisfied patients.Residual cylinder, Strehl ratio, halos, mesopic pupil diameter and UNVA were significant predictors of patient satisfaction. Uncorrected distance visual acuity, higher order Strehl ratio and pupil diameter were significant predictors of halos. Near visual acuity significantly correlated (P ​= ​0.018, R ​= ​0.22) with axial length.

Conclusions

Uncorrected cylindrical error, poor reading quality, larger pupil and halos seem to be the most disturbing factors for patients implanted with the Tecnis Symfony IOL.

The effects of premium intraocular lenses on presbyopia treatments

Background

Presbyopia has become a global disease affecting the world's aging population. Among various treatments, cataract extraction and intraocular lens (IOL) implantation have become the most popular and common methods of presbyopia correction. During the twentieth century, IOLs have underwent significant innovation and advancements to meet the patients' high demands for functional vision at all distances.

Main Text

To meet the increasing needs for excellent near and intermediate vision for daily activities, some premium IOLs with more than one focus have been developed, for example, the refractive MfIOLs, diffractive MfIOLs, extended depth of field (EDOF) IOLs, and accommodating IOLs (AIOLs) were introduced to meet this need. In addition, the add-on MfIOLs have been explored as promising supplementary IOLs for pseudophakic presbyopia. When selecting the MfIOLs, the IOLs' features, patients' characteristics, preoperative eye conditions, and treatment expectations should be considered.

Conclusions

In this review, we focus on the multifocal IOLs (MfIOLs) commonly used for presbyopia correction and systematically summarized their optical designs and clinical outcomes. More evidence-based studies are required to provide guidelines for MfIOL selection, provide maximum visual benefits, and develop personalized visual solutions in the future.

Patient Satisfaction and Visual Performance in Patients with Ocular Pathology after Bilateral Implantation of a New Extended Depth of Focus Intraocular Lens

Aim

To evaluate visual results and patient-perceived outcomes in patients with ocular pathologies implanted with a new extended depth-of-focus intraocular lens (IOL).

Methods

Patients with ocular pathology undergoing cataract surgery and bilaterally implanted with Vivity® IOLs were evaluated three months after surgery. The control group included patients with no ocular pathologies. Binocular defocus curves, corrected and uncorrected mono- and binocular distance visual acuity (DVA), and binocular contrast sensitivity were measured. Patients completed the Catquest-9SF questionnaire and reported on dysphotopsia and their need for spectacle-correction.

Results

Twenty-five patients were included in each group. Monocular uncorrected DVA was better in the control group (-0.01 ± 0.07) compared with the study group (0.03 ± 0.08), p=0.027. There were no other statistically significant differences in DVA, with an uncorrected binocular acuity of -0.06 ± 0.06 for the control group and -0.05 ± 0.06 for the study group. Binocular defocus curves were similar for both groups and there were no differences in contrast sensitivity values. Pooling the refractive results, 96% of eyes were within ±0.50 D of target refraction. Seventy percent of patients in the control group reported no halos, compared with 40% in the study group, p=0.047. In both groups, 40% of patients reported being completely spectacle-independent, with the other 60% requiring glasses for near vision always or often. All patients reported being fairly or very satisfied with their vision.

Conclusion

Initial results of visual function after Vivity implantation in patients with ocular pathologies are encouraging, with high patient satisfaction and few difficulties for daily activities.

Clinical and self-reported outcomes after multifocal intraocular lens implantation of patients with stable keratoconus

BACKGROUND

Multifocal intraocular lens (IOL) implantation is generally not considered in patients with keratoconus; however, it may provide good optical results in selected patients based on two case reports.

AIMS

To evaluate patient satisfaction and clinical outcomes in this patient population.

METHODS

This is a retrospective single-center, non-comparison study. All patients with frank keratoconus who had undergone a trifocal IOL implantation between 2016 and 2019 were invited to participate in this study (18 eyes of 9 patients were included). Postoperatively, refractive outcomes, contrast sensitivity, and ocular aberrations were recorded. A questionnaire was used for determining patient satisfaction and their quality of life. The mean follow-up time was 31.22 ± 6.38 months.

RESULTS

Postoperatively the patients' uncorrected distance visual acuity improved from 1.13 ± 0.93 logMAR to 0.10 ± 0.17 (p ˂ 0.001), corrected distance visual acuity went from 0.10 ± 0.11 to 0.05 ± 0.09 (p = 0.19), mean refractive spherical equivalent changed from -4.34 ± 4.31 to 0.05 ± 0.51 D (p ˂ 0.001), and manifest astigmatism from 2.44 ± 1.92 to 0.88 ± 1.81 D (p = 0.017). A postoperative MRSE of less than ± 0.50 D was achieved in 17 eyes (94%). Three eyes (17%) lost 1 line of best corrected visual acuity and no patient lost two or more lines. The patients were independent of glasses in 78% for all distances. One patient who required an IOL exchange due to photic phenomena was lost to follow-up.

CONCLUSIONS

Use of a trifocal IOL provided relatively predictable refractive outcomes and spectacle independence in most of this small cohort of patients with stable frank keratoconus.

Analysis of Korean Retinal Specialists' Opinions on Implanting Diffractive Multifocal Intraocular Lenses in Eyes with Underlying Retinal Diseases

Multifocal intraocular lenses (MF-IOLs) are increasingly implanted as the need for good near- and intermediate-distance vision increases. Although retinal disease is known to be a relative contraindication for MF-IOL implantation, there are no detailed guidelines for MF-IOL implantation with respect to the type and severity of retinal diseases/statuses. In this study, because retinal diseases can affect the performance of MF-IOLs, we analyzed the opinions of 111 retinal specialists, who were members of the Korean Retina Society, on the implantation of diffractive MF-IOLs in eyes with 15 retinal diseases/statuses using a web-based survey. For each underlying condition, retinal specialists were asked to rate their approval regarding implantation of MF-IOLs on a scale from 1 (completely disapprove) to 7 (completely approve), under the assumption that there were no known contraindications except for a given retinal disease/status. As a result, retinal specialists disapproved MF-IOL implantation (median value of Likert score < 4) in the eyes with wet age-related macular degeneration, dry age-related macular degeneration with geographic atrophy, proliferative diabetic retinopathy, nonproliferative diabetic retinopathy with macular edema, previous macula-off retinal detachment, previous retinal vein occlusion, and epiretinal membrane, but the scores varied by disease/status. The factors that affected the specialists’ opinions were the type of practice and the frequency of MF-IOL implantation (p = 0.013 and p = 0.021, respectively; one-way ANOVA).

[Comparative assessment of the accuracy of toric intraocular lens calculations]

PURPOSE

To compare the accuracy of toric intraocular lens (IOL) calculations on three modern toric calculators.

MATERIAL AND METHODS

The study comprised 35 eyes of 35 patients who underwent phacoemulsification with toric IOL implantation (EnVista Toric). Residual postoperative refractive astigmatism was calculated on three calculators: EnVista Toric Calculator, ASSORT Toric IOL Calculator and the Kane formula. Prediction error for each calculator was determined using vector analysis.

RESULTS

The mean absolute deviation of predicted postoperative refractive astigmatism over actual astigmatism in diopters was distributed in the following way: 0.82±0.58, 0.70±0.67 and 0.72±0.76 using EnVista Toric Calculator, ASSORT Toric IOL Calculator and the Kane formula, respectively. Centroid prediction error was 0.08 (EnVista Toric Calculator), 0.06 (ASSORT) and 0.10 (Kane formula). There was a significantly smaller deviation using ASSORT and the Kane formula compared to the online calculator (p<0.05).

CONCLUSIONS

Toric calculators ASSORT Toric IOL Calculator and the Kane formula showed higher accuracy of toric IOL calculation than EnVista Toric Calculator.

EVO+ Implantable Collamer Lens KS-aquaPORT Location, Stability, and Impact on Quality of Vision and Life

PURPOSE

To determine the longitudinal variation in the KS-aquaPORT central hole location of the phakic EVO+I Implantable Collamer Lens (ICL) (STAAR Surgical) and analyze its influence on visual performance, quality of vision (QoV), and quality of life (QoL).

METHODS

A prospective study was performed including 36 patients who had EVO+ ICL implantation. The KS-aquaPORT central hole location (Cartesian and polar coordinates) was determined with respect to the pupil center and visual axis. The effect of time (6-month follow-up) on central hole location was analyzed using linear mixed models. The effect of the KS-aquaPORT location on visual performance, QoV, and QoL parameters was assessed with multivariate regression models.

RESULTS

With respect to the visual axis, no significant changes in KS-aquaPORT location were found during follow-up. With respect to the pupil center, the X-coordinate and radius of KS-aquaPORT location showed modest, but significant (P ≤ .05) differences between 1-week and 3-month postoperative visits, and between 1-week and 6-month visits. X-coordinate variation was significant (P = .022) between 1-and 6-month visits. With respect to the visual axis, greater KS-aquaPORT decentration was associated with worse visual acuity (X-coordinate: P = .004; radius: P = .006), and inferior decentration with longer xenon-type glare photostress recovery time (P = .021). With respect to the pupil center, a lower radius was associated with better QoV scores (P ≤ .01) and temporal decentration produced higher ring-shaped dysphotopsia (P = .007).

CONCLUSIONS

EVO+ ICL KS-aquaPORT location appears to be clinically stable up to 6 months postoperatively. A central location of the EVO+ ICL KS-aquaPORT hole is preferred because it allows reduced perception of dysphotopic phenomena that can result in better QoV. [J Refract Surg. 2022;38(3):177-183.].

Visual outcomes after vitrectomy for epiretinal membrane in pseudophakic eyes with a diffractive trifocal intraocular lens: a retrospective cohort study

BACKGROUND

Diffractive intraocular lenses (IOLs) could affect visual acuity in patients with macular pathologies such as epiretinal membrane (ERM) and could influence the results of pars plana vitrectomy (PPV) for ERM removal in pseudophakic eyes with these IOLs. The aim of this study is to evaluate the effect on visual outcomes of a diffractive trifocal IOL in PPV for ERM peeling.

METHODS

This is a retrospective cohort study on 20 eyes with a single model of trifocal IOL that underwent PPV for removal of ERM between January 2015 and September 2018 in our clinics. Follow up was at least 1 year. Primary outcome measure was mean change in visual acuity. Secondary outcome measures were mean change in central macular thickness (CMT), recovery of the external retinal layers, and change in spherical equivalent (SE).

RESULTS

Mean corrected distance visual acuity (CDVA) was 0.03 ± 0.03 logMAR after phacoemulsification; this worsened to 0.23 ± 0.10 logMAR with ERM, improving to 0.10 ± 0.04 log MAR 12 months after PPV (p = 0.001). Mean uncorrected near visual acuity (UNVA) was Jaeger 2.62 ± 0.51 after lensectomy. This worsened to Jaeger 5.46 ± 1.67 with ERM and improved to the initial Jaeger 2.69 ± 0.84 after PPV (p = 0.005). CMT decreased significantly, from 380.15 ± 60.50 μm with the ERM to 313.70 ± 36.98 μm after PPV. Mean SE after lensectomy was - 0.18 ± 0.38 D, which minimally changed to - 0.18 ± 0.47 D after PPV (p = 0.99). The only complication recorded after PPV was a case of cystoid macular edema. No difficulties in visualization due to IOL design were reported during PPV.

CONCLUSION

PPV for ERM in eyes with this trifocal IOL seems to be safe and effective, and allows recovery of the loss of UNVA.