Multifocal intraocular lenses: An overview

[Comparative analysis of the functional results after implantation of various diffractive trifocal intraocular lenses]

PURPOSE

To compare visual outcomes after implantation of two models of diffractive trifocal IOLs using various vision assessment systems.

MATERIAL AND METHODS

The study included 25 patients (25 eyes) who were implanted with AcrySof IQ PanOptix (TFN) and 25 patients (25 eyes) implanted with AT LISA tri 839 MP (TRI). Postoperative examination at 1 year included assessment of monocular visual acuity for far, intermediate and near distance using decimal scale, as well as LogMAR and an interactive computer program (ICP). Contrast sensitivity was assessed with the Optec 6500 device. A questionnaire was used to evaluate subjective quality of vision and the intensity of optical phenomena.

RESULTS

Uncorrected visual acuity (UCVA) at distance, intermediate and near was better in the TFN group in comparison with the TRI group as measured with decimal scale, ICP and LogMAR. Under photopic and mesopic conditions with and without glare, at all spatial frequencies the contrast sensitivity function (CSF) was higher after implantation of TFN in comparison with TRI. The average VF-14 score was 97.2 after implantation of TFN and 96.7 after implantation of TRI. The amount of patients who required spectacle correction after the surgery was 5.5% less in the TFN group compared to the TRI group.

CONCLUSION

High visual outcomes at all distances were observed in patients after implantation of both trifocal IOLs with TFN showing a slight advantage. Evaluation of the visual outcomes using various systems showed the benefits of the ICP assessment. The CSF had typical configuration with maximum value in the mid-range region and a decrease in the high-frequency range after implantation of both IOLs, however the indicators were better in the TFN group. The postoperative period was characterized by high levels of patient satisfaction and spectacle independence in both groups.

Multifocal intraocular lenses and retinal diseases

Purpose

Multifocal intraocular lenses (MIOLs) are often discouraged in patients with or at risk of retinal disorders (including diabetic retinopathy, age-related macular degeneration, and epiretinal membranes), as MIOLs are believed to reduce contrast sensitivity (CS). Concerns with MIOLs have also been raised in individuals with visual field defects, fixation instability or eccentric preferred retinal locations. The aim of this study is to review the influence of MIOL on quality of vision in patients with retinal diseases.

Methods

We reviewed the PubMed and Web of Science databases to identify relevant studies using the following keywords: multifocal intraocular lens, cataract surgery, cataract extraction, lens exchange, diabetic retinopathy, age-related macular degeneration, and contrast sensitivity.

Results

Studies evaluating CS in MIOLs present conflicting results: MIOLs either did not influence CS or resulted in worse performance under low-illuminance conditions and higher spatial frequencies when compared to monofocal IOLs. Nevertheless, MIOLs preserved CS levels within the age-matched normal range. Two studies reported that patients with concurrent retinal diseases receiving a MIOL, both unilaterally and bilaterally, reported a significant improvement in visual-related outcomes. Individuals with a monofocal IOL in one eye and a MIOL in the fellow eye reported greater subjective satisfaction with the MIOL.

Conclusion

We were unable to find evidence suggesting that patients with retinal diseases should be advised against MIOLs. Nevertheless, more research is needed to address the aforementioned concerns and to optimize the use of MIOLs in eyes with retinal disease.

Electronic supplementary material

The online version of this article (10.1007/s00417-020-04603-0) contains supplementary material, which is available to authorized users.

Patient selection to optimize near vision performance with a low-addition trifocal lens

PURPOSE

To assess the impact of ocular biometric variables on the visual performance achieved with a low addition trifocal intraocular lens (MIOL).

METHODS

Retrospective observational study including 34 eyes. Preoperative measured variables included mean corneal power (Km), corneal regular astigmatism (RA), anterior chamber depth (ACD), axial length (AXL), total irregular astigmatism (IA), spherical aberration (SA) and distance from pupil center to vertex normal (µ). Same variables were retrieved from the three month visit follow-up in addition to the actual lens position (ALP), the calculated effective addition (EA), the IOL centration from vertex normal (d), and the visual acuity defocus curve. The area under the defocus curve was computed along the total curve (TAUC) and ranges for far (FAUC), intermediate (IAUC) and near vision (NAUC). The sample was split in two groups of 17 eyes with TAUCs above and below the mean, and the differences among groups for different ocular parameters were assessed.

RESULTS

The group of eyes above TAUC of 2.03 logMAR*m-1 showed significantly lower Km and greater AXL and SA. Km was negatively correlated with TAUC and NAUC. NAUC was negatively correlated with IA and positively with d. A multiple lineal regression model including Km, d, and IA predicted NAUC (r-square = 34%). No significant differences between IA and SA were found between preoperative and postoperative values but µ significantly decreased after surgery.

CONCLUSIONS

The mean corneal power, irregular astigmatism, and centration from vertex normal should be considered for optimizing the near visual performance with this MIOL.

Systematic Study on the Biomechanical Stability of C-Loop Intraocular Lenses: Approach to an Optimal Design of the Haptics

To study the main design parameters that affect the mechanical stability of C-loop intraocular lenses, leading to an optimal design that minimizes the axial displacement, tilt and rotation. A total of 144 geometrical variations were studied on a 1-piece, non-angulated, C-loop hydrophobic acrylate intraocular lens. The study was performed in a finite element modeling simulation. The suitable set of variations was determined using a mixed-factorial analysis, allowing to analyse the impact of the different designs on the mechanical stability of the lens (compression force, axial displacement, tilt and rotation). The design parameters under study were: the length, width, thickness and opening angle of the haptic, the haptic-optic junction and the start of the haptic curvature. The compression (or reaction) force is affected by the haptic width, the haptic-optic junction, and the interaction between both. The axial displacement is mainly affected by the width and thickness of the haptic, and the size of the haptic-optic junction as well. The tilt is affected by the haptic thickness and the interaction between the haptic curvature and the haptic-optic junction. The rotation is affected by the start of the haptic curvature, the haptic-optic junction and the haptic width. The haptic-optic juntion is one of the most influential parameters affecting the four responses studied of the C-Loop IOL. The smaller the haptic-optic juntion, the better biomechanical stability.

Nationwide Prospective Cohort Study on Cataract Surgery With Multifocal Intraocular Lens Implantation in Japan

PURPOSE

To conduct a nationwide prospective cohort study of multifocal intraocular lens (mfIOL) implantation to determine clinical outcomes and patient satisfaction and assess factors affecting patient satisfaction.

DESIGN

Prospective, multicenter cohort study.

METHODS

Setting: institutional; patient population: a total of 1051 consecutive patients (1631 eyes) who underwent cataract surgery with mfIOL implantation at 65 Japanese institutions from January 2017 to June 2018. The inclusion criteria were patient age of 20 years and older and cataract surgery with mfIOL implantation. The exclusion criteria were the absence of informed consent, completed postoperative questionnaires, and no record of the IOL models implanted.

OBSERVATION PROCEDURES

the uncorrected and corrected distance visual acuities (UDVAs and CDVAs) at 5 m; uncorrected VAs at 50, 40, and 30 cm; and questionnaires regarding subjective visual symptoms, spectacle independence, and surgical satisfaction were assessed 3 months postoperatively.

MAIN OUTCOME MEASURE

odds ratios for the overall surgical satisfaction were computed for the preoperative/postoperative factors.

RESULTS

We analyzed data from 1384 eyes of 871 patients. The UDVAs and CDVAs, respectively, improved significantly at 3 months postoperatively. The intermediate and near VAs varied with the IOL models; 68.4% of patients were almost or totally spectacle-independent; 3.9% of patients reported surgical dissatisfaction. In patients implanted bilaterally with the same mfIOLs, postoperative blurred vision and/or decreased contrast was the most important factor in the overall surgical satisfaction.

CONCLUSIONS

MfIOLs provided good visual outcomes and high satisfaction rates in this large patient cohort. The difference in the outcomes with the extended depth-of-focus IOLs did not differ significantly from the bifocal IOLs. The postoperative blurred vision is important to the overall surgical satisfaction.

The Effect of a Spectral Filter on Visual Quality in Patients with an Extended-Depth-Of-Focus Intraocular Lens

PURPOSE

Wavelength dependence of diffractive intraocular lenses (IOLs) was recognized in vitro but not yet assessed in vivo. By examining pseudophakic patients who had extended-depth-of-focus diffractive implants, this spectral effect on their vision was measured clinically and the lens was tested in vitro.

DESIGN

Cross-sectional study with laboratory investigation.

METHODS

Twelve pseudophakic patients (23 eyes) with a Symfony lens (Johnson & Johnson Vision) were measured monocularly under red and white light at far, intermediate, and near distances. Corrected distance visual acuity (CDVA), distance-corrected intermediate visual acuity (DCIVA), and distance corrected near visual acuity (DCNVA) were assessed. Contrast sensitivity was examined at several spatial frequencies. The in vitro lens modulation transfer function was measured under different spectral conditions by using an IOL metrology device.

RESULTS

CDVA was comparable under red and white light. DCIVA and DCNVA were significantly better under white light by 0.06 and 0.09, respectively. Contrast sensitivity was slightly better with a red filter at far distance but was worse at intermediate distance, although differences were significant only at 1 frequency. Near contrast sensitivity was better under polychromatic than red light, which was significant at 3 frequencies. The in vitro analysis confirmed Symfony's wavelength dependence: performance was improved at far distance but was worse at intermediate and near distances.

CONCLUSIONS

Symfony's spectral dependence was observed to affect visual acuity and contrast sensitivity. Although the red filter did not improve distance vision, it caused visual deterioration at near distance. One should take this effect into account when optimizing the reading performance of patients with diffractive IOLs.

Presbyopia Correction Using Multifocal Soft Contact Lenses in Patients With Monofocal Intraocular Lenses

OBJECTIVES

To investigate the effectiveness of presbyopia correction using multifocal soft contact lenses (MF SCLs) for pseudophakic subjects with monofocal intraocular lenses (IOLs).

METHODS

In 11 subjects, after monofocal IOL implantation, disposable MF SCLs (Dailies Total 1 Multifocal, Alcon) were daily used for 3 months. Binocular visual acuity between 0.3 and 5 m was measured using an all-distance vision tester (AS-15, Kowa) at 1 and 3 months and compared before and during MF SCL wear. Binocular contrast sensitivity testing was conducted under mesopic and photopic illuminations at 1 month.

RESULTS

The mean manifest refraction spherical equivalent before MF SCL wear was -0.36 D. The add powers of used MF SCLs were +1.25, +2.00, and +2.50 D in 1, 16, and 5 eyes, respectively. The mean binocular visual acuities during MF SCL wear were 20/20 or better between 0.5 and 5 m and significantly improved at 0.7 m or less (P<0.025). There was no change in the mesopic contrast sensitivity, whereas the photopic contrast sensitivity at 18 cycles per degree was degraded during MF SCL wear.

CONCLUSIONS

The use of MF SCL was effective for presbyopia correction in pseudophakic subjects with monofocal IOL, and favorable binocular vision would be obtained in a range from distance to intermediate.

One-year clinical evaluation of rotationally asymmetric multifocal intraocular lens with +1.5 diopters near addition

We conducted a one-year prospective, multicenter study to assess clinical outcomes after implantation of segmented, rotationally asymmetric multifocal intraocular lenses (IOLs) with +1.5 diopters (D) near addition. In this phase III clinical trial, 120 eyes of 65 patients undergoing phacoemulsification and implantation of Lentis Comfort LS-313 MF15 (Oculentis GmbH) were included. The ophthalmological examinations were performed before and 1 day, 1 week, 1, 3, 6, 9, and 12 months after surgery. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, uncorrected (UIVA) and distance-corrected (DCIVA) intermediate visual acuity at 70 cm, and uncorrected (UNVA) and distance-corrected (DCNVA) near visual acuity at 30 cm were measured. A defocus curve was obtained and patients were asked about the severity of photic phenomena. Postoperative distance and intermediate visual acuity was excellent, with UDVA, CDVA, UIVA, and DCIVA of approximately 20/20, 20/16, 20/25, 20/25 were attained, respectively. The level of near visual acuity was lower; UNVA and DCNVA remained at around 20/60 and 20/70, respectively. The defocus curve indicated that postoperative uncorrected visual acuity of 20/25 and 20/40 was obtained at as close as 67 cm and 50 cm, respectively. Contrast sensitivity was within the normal range, with a minimal level of subjective symptoms and high patient satisfaction. The rotationally asymmetric multifocal IOLs with +1.5 D near addition provided excellent distance and intermediate vision, but near vision was not enough for reading small prints. Contrast sensitivity was high, with very low incidences of photic phenomena and a high level of patient satisfaction.

Correlation and predictability of ocular aberrations and the visual outcome after quadrifocal intraocular lens implantation: a retrospective longitudinal study

Background

To evaluate the correlating and predicting factors of visual outcome after implantation of newly developed diffractive quadrifocal intraocular lens (IOL).

Methods

A retrospective longitudinal study was conducted. Patients who underwent diffractive quadrifocal IOL implantation with a follow-up period longer than six months and records of wavefront aberrometer within one week perioperatively were enrolled. Accordingly, a total of 73 eyes from 73 patients were included. The postoperative distance and near visual acuity, ocular aberrations and postoperative symptoms were collected. The correlation and predictability between ocular aberrations and the postoperative visual outcome were evaluated.

Results

The corrected distance visual acuity (CDVA) one month postoperatively was significantly better than the preoperative status, and insignificant improvement was found six months postoperatively. Preoperative Tracey refraction spherical equivalent (TRSE), angle alpha, and spherical aberration (SA) were significantly correlated with postoperative CDVA and near corrected visual acuity (NCVA). For postoperative ocular aberrations, TRSE, angle alpha, and SA were significantly correlated with CDVA six months postoperatively and NCVA, while the trefoil, internal higher order aberration (HOA) and total HOA were associated with NCVA. Preoperative angle alpha could predict all postoperative visual performances, while postoperative TRSE and angle alpha could predict the CDVA six months postoperatively and NCVA. A large angle alpha is associated with visual disturbance and dissatisfaction.

Conclusion

The angle alpha preoperatively and postoperatively was correlated with the postoperative vision and could predict visual outcome in patients who had diffractive quadrifocal IOL implanted. Furthermore, the majority of ocular aberrations were also associated with certain postoperative vision.

AcrySof IQ PanOptix Intraocular Lens Versus Extended Depth of Focus Intraocular Lens and Trifocal Intraocular Lens: A Clinical Overview

AcrySof IQ PanOptix Model TFNT00 (Alcon Laboratories, Fort Worth, TX) is a 1-piece aspheric hydrophobic presbyopia-correcting intraocular lens (IOL) launched in 2015. Unlike traditional trifocal IOLs that usually have an intermediate focal point of 80 cm, the PanOptix IOL is designed to have an intermediate focal point of 60 cm (arms-length), a more natural and comfortable working distance to perform functional tasks on computers, laptops, mobiles, among others. The non-apodized PanOptix IOL uses the ENhanced LIGHT ENergy (ENLIGHTEN; Alcon Laboratories, Fort Worth, TX) optical technology that provides high (88%) utilization of light energy, low dependence on pupil size in all lighting conditions, and a more comfortable near-to-intermediate range of vision than traditional trifocal IOLs. This review provides an overview of the clinical performance of the PanOptix IOL and discusses it in the context of other commercially available trifocal IOLs, FineVision Micro F (PhysIOL, Liege, Belgium), the AT LISA tri 839MP (Carl Zeiss Meditec AG, Jena, Germany) and the extended depth of focus IOL, TECNIS Symfony (Abbott Medical Optics, Santa Ana, CA). A literature search was performed in the PubMed database to identify studies that have assessed the visual and other clinical outcomes with the PanOptix IOL. In total, 12 studies were included in this review article. Overall, the clinical evidence suggests that in general good visual outcomes, along with a high degree of spectacle independence, are achieved in patients implanted with the PanOptix, FineVision, AT LISA and Symfony IOLs. However, every MIOL has its benefits and limitations, which along with patient's needs and clinical conditions are important factors to consider while selecting an IOL to achieve best possible post-operative outcomes.

Clinical and aberrometric evaluation of a new extended depth-of-focus intraocular lens based on spherical aberration

PURPOSE

To compare the refractive, visual, and aberrometric results with a new extended depth-of-focus intraocular lens (EDOF IOL) based on alternating positive and negative spherical aberration in the central 3.0 mm optical zone and an aspheric monofocal IOL of the same platform.

SETTING

Ophthalmology, University Hospital of Verona, Italy.

DESIGN

Prospective case series.

METHODS

Cataract patients free from other ocular disease had bilateral implantation of the EDOF Mini Well IOL or the monofocal Mini IOL. Four to 6 weeks after second-eye surgery, the refraction, visual acuity, defocus curve, contrast sensitivity, and photic symptoms were assessed. Wavefront analysis was performed. The primary endpoint of was the amplitude of the dioptric interval for 0.1 logarithm of the minimum angle of resolution (logMAR) visual acuity. The secondary endpoint was an aberration comparison between the two IOLs.

RESULTS

The study comprised two groups of 25 patients each. The corrected distance visual acuity was better with the monofocal IOL by 0.02 logMAR (P = .03). The 0.1 logMAR dioptric interval was 2.0 diopters (D) for the EDOF IOL and 1.0 D for the monofocal IOL (P < .001). The mean CDVA at -2.0 defocus was 0.15 logMAR ± 0.08 (SD) and 0.52 ± 0.14 logMAR, respectively (P < .001). There was no difference in contrast sensitivity or photic symptoms. The optical aberrations at 4.0 mm and 6.0 mm aperture diameters were similar in the two groups.

CONCLUSION

The EDOF IOL based on spherical aberration provided greater depth of focus than the aspheric monofocal IOL without increasing optical aberrations and with few photic symptoms.

Visual performance of an extended depth of focus intraocular lens for treatment selection

PURPOSE

To evaluate the visual performance of an extended depth of focus (EDOF) intraocular lens (IOL) for patient selection.

METHODS

This prospective non-comparative case series evaluated fifty-two eyes (26 patients) after bilateral implantation of the Tecnis Symfony IOL. Exclusion criteria were previous ocular surgeries, corneal astigmatism of >1.5 diopter, and ocular pathologies or corneal abnormalities. Uncorrected (UCVA) and distance-corrected (DCVA) visual acuity (VA) in 4 m, 80 cm, 60 cm and 40 cm (logMAR), defocus curve, contrast sensitivity (CS) and a questionnaire on subjective quality of vision (QoV) were assessed after 3 months.

RESULTS

UCVA was -0.02 ± 0.071 logMAR at 4 m, 0.01 ± 0.077 logMAR at 80 cm, 0.08 ± 0.187 logMAR at 60 cm and 0.22 ± 0.153 logMAR at 40 cm. Defocus curve testing showed a flat VA range from 0.00 to -1.50 D (-0.05-0.02 logMAR). At near distance from -2.0 to -2.5 D a dip of DCVA was observed (0.14-0.28 logMAR). CS under photopic and mesopic conditions without and with glare was 1.56 logCS, 0.86 logCS, 0.78 logCS, respectively. Spectacle independence was achieved in 100% for distance and intermediate vision and 71% of patients at near distance.

CONCLUSION

This EDOF IOL provides excellent intermediate and far (<0.1 logMAR) and acceptable near UCVA (<0.3 logMAR). Defocus curve testing confirmed an EDOF between far and intermediate distance and showed a dip at near distance. It provides good QoV, CS, high spectacle independence, perception of few optical phenomena, and particularly good night-driving capabilities.

Short-term outcomes of combined pars plana vitrectomy for epiretinal membrane and phacoemulsification surgery with multifocal intraocular lens implantation

Purpose

The purpose of this study was to evaluate the functional and anatomical outcomes of combined phacovitrectomy with multifocal intraocular lens (mfIOL) implantation.

Methods

Retrospective, interventional, non-comparative case series of six eyes that received a combined phacoemulsification surgery with apodized, diffractive mfIOL implantation for cataract and pars plana vitrectomy (PPV) with membrane peeling for epiretinal membrane (ERM). Outcome measures included distance and near visual acuities (DVA and NVA), central macular thickness (CMT), intraocular pressure (IOP), and disruption of external limiting membrane (ELM) or inner-segment outer-segment (IS/OS) junction.

Results

Mean logMAR glare DVA improved from 0.40 (Snellen 20/50) preoperatively to a mean uncorrected DVA of 0.038 (Snellen 20/22) (P=0.004) at 6 months after surgery. All eyes achieved NVA of J2 or better by 12 months postoperatively. Median CMT improved by 10 µm and mean IOP increased by 1 mmHg at 12 months postoperatively. Percentage of patients with ELM or IS/OS disruptions decreased from 66.7% to 33.3%. Two eyes demonstrated residual metamorphopsia on Amsler grid testing postoperatively. Postoperatively, four eyes required laser capsulotomy and one required LASEK for refractive correction.

Conclusion

Combined phacovitrectomy, membrane peeling, and mfIOL implantation improved VA in patients with idiopathic ERM. Multifocality was achieved, but final visual outcome was delayed due to posterior capsular opacification and macular healing.

Binocular Visual Function With Staged Implantation of Diffractive Multifocal Intraocular Lenses With Three Add Powers

PURPOSE

To evaluate the binocular visual function and depth of focus after staged implantation of diffractive multifocal intraocular lenses (MIOLs) with 3 different add powers following cataract removal.

DESIGN

Prospective comparative case series.

METHODS

Setting: Institutional.

STUDY POPULATION

Both eyes of 56 patients that underwent staged implantation of bifocal IOLs.

INTERVENTION

In the first eye, MIOLs with a +4.0-diopter (D) add power were implanted. Based on outcomes at 1 week postoperatively and patient preference for near vision, 1 of 3 near add powers-+4.0 D (group MM), +3.25 D (group ML), or +2.75 D (group MK)-was implanted in the fellow eye.

MAIN OUTCOME MEASURE(S)

Three months postoperatively, the binocular uncorrected and distance-corrected visual acuities (BUCVA and BDCVA, respectively) at 5.0, 1.0, 0.5, 0.4, and 0.3 meters; binocular defocus curves; contrast sensitivity; and near stereopsis were measured.

RESULTS

The MM, ML, and MK groups included 21, 18, and 17 patients, respectively. The mean BUCVA in the MM group was significantly (P = .003) worse than that in the MK group at 0.5 meter. The BDCVAs at 0.5 meter in the ML and MK groups were significantly (P < .02) better than that in the MM group. The defocus curves with the -2.0 D refraction differed significantly (P < .001) between the MM and MK groups. The binocular contrast sensitivity and stereopsis values did not differ significantly.

CONCLUSIONS

Staged implantation of different add powers obtained better binocular intermediate visual acuity without degradation of visual function.

Effect of Crystalline Lens Aberrations on Adaptive Optics Simulation of Intraocular Lenses

PURPOSE

To evaluate the impact of the lens aberrations on the adaptive optics visual simulation of pseudophakic intraocular lens (IOL) profiles.

METHODS

In 20 right phakic eyes, lens higher order aberrations (HOAs) were calculated as the whole eye minus the corneal aberrations. Visual simulation using low and high contrast corrected distance visual acuity (CDVA) testing was carried out with the VAO instrument (Voptica, SL, Murcia, Spain), considering three optical conditions of the lens: removing HOA (no lens-HOA), removing spherical aberration (no lens-SA), and with lens HOA (natural condition). In addition, a through-focus visual simulation of a trifocal diffractive IOL profile with high contrast CDVA was also measured in two conditions: no lens-HOA and natural condition. Three different pupil sizes (3, 4.5, and 6 mm) were tested for all conditions.

RESULTS

There were no significant intersubject differences between the three optical conditions and in the IOL simulation for all pupil sizes (P > .05). For 4.5- and 6-mm pupils, mean VA values of the no-lens SA and no lens-HOA conditions were similar and slightly worse than those of the natural condition. Individual differences between the no lens-HOA condition and the other two optical conditions, estimated as 95% limits of agreement, were acceptable for 3-mm pupil but worse as pupil diameter increased.

CONCLUSIONS

The effect of lens aberrations on visual simulation is imperceptible for a small pupil diameter of 3 mm. Although the increment of pupil size increases the probability of patients with significant visual impact of lens HOAs, the mean intersubject VA differences are negligible. [J Refract Surg. 2019;35(2):126-131.].

Long-Term Clinical Outcomes after Mix and Match Implantation of Two Multifocal Intraocular Lenses with Different Adds

Purpose

To compare long-term clinical outcomes between patients with bilateral implantation of +3.0 diopter (D) multifocal intraocular lenses (IOLs) and mix and match implantation of +2.5 D and +3.0 D multifocal IOLs.

Material and Methods

This retrospective observer-masked cohort study comprised 66 eyes of 33 patients with two different strategies of binocular multifocal IOLs implantation: bilateral +3.0 D (17 patients) (bilateral group) and mix and match +2.5 D and +3.0 D (16 patients) (blended group). Patients were recruited 1 year (±3 months) after second-eye surgery. The primary effectiveness endpoint was binocular uncorrected intermediate visual acuity (UCIVA) at 70 cm. The secondary assessments included binocular visual quality tests and quality-of-vision questionnaire.

Results

The blended group showed clinically better UCIVA (0.10 ± 0.07 logMAR) at 70 cm than the bilateral group (0.26 ± 0.09 logMAR) with a difference of 0.16 ± 0.08 logMAR (P < 0.001). Similar binocular visual acuities were achieved between the two groups at the near and far distance. The binocular defocus curves showed better performance in the blended group from 50 cm to 1 m. The mean binocular contrast sensitivities under the photopic conditions with or without glare and mesopic condition without glare were clinically better in the blended group. Both the groups reported low rate of visual phenomena, high rate of spectacle independence, and satisfaction.

Conclusions

Comparing with bilateral implantation of +3.0 D multifocal IOLs during the cataract surgery, mix and match implantation of +2.5 D and +3.0 D multifocal IOLs provides a wider depth of binocular focus, especially for intermediate distances, and better binocular visual quality.

Evaluation of quality of life after implantation of a new trifocal intraocular lens

PURPOSE

To evaluate the vision-related quality of life (QOL) after implantation of a new trifocal intraocular lens (IOL), by using the National Eye Institute Visual Function Questionnaire-14 (VF-14 QOL questionnaire).

SETTING

Baskent University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey.

DESIGN

Prospective noncomparative case series.

METHODS

Consecutive patients who had a new trifocal IOL (PanOptix) bilaterally implanted were included in the study. The vision-related QOL was assessed 3 months after the surgery in the second eye. The VF-14 QOL questionnaire was used, with a grading scale of 0, no difficulty; 1, a little difficulty; 2, moderate difficulty; 3, quite difficult; 4, impossible to perform. A subgroup of 14 patients, with an interval of at least 3 months between the surgery in the first eye and the surgery in the fellow eye, were also interviewed 3 months after the monocular IOL implantation. In this subgroup, the QOL with monocular and binocular implantation was compared.

RESULTS

The study comprised 48 patients. Reading small print, driving at night, and doing fine handwork were the most difficult tasks to perform, with the mean values of the VF-14 QOL questionnaire being 0.94 ± 0.81 (SD), 0.89 ± 0.68, and 0.64 ± 0.67, respectively. Binocular implantation was associated with improvement in vision-related QOL when compared with monocular implantation, with significant differences in doing fine handwork such as sewing (P = .02) and using a computer (P = .03).

CONCLUSIONS

With mean values of 1.00 or lower for each question, the results of the VF-14 QOL questionnaire indicated that patients who have the new trifocal IOL bilaterally implanted have an overall high satisfaction rate and a high vision-related QOL.

Intraocular lens correction of presbyopia

The continued development of intraocular lens (IOL) technology has led to a dramatic improvement in refractive outcomes. New and innovative ways of achieving the desired postoperative refractive goals continue to be developed. This article aims to review the currently available IOL modalities for correction of presbyopia at the time of cataract surgery, including reference to high-quality comparative studies, where available, and discussion of strengths as well as limitations of the currently available IOL technologies. It has been shown that multifocal compared to monofocal IOL was associated with higher rates of spectacle independence, but higher rates and severity of symptomatic glare as well as reduced contrast sensitivity. Within multifocal IOLs, diffractive compared to refractive IOLs tended to have better near vision and a lower rate of symptomatic glare. Extended depth-of-focus IOLs compared to diffractive multifocal IOL demonstrated equal or superior intermediate visual acuity, with less than or equal rates of glare. Accommodative IOLs represent a broad range of technologies that continue to develop, and new technologies offering opportunities for postoperative adjustment of refractive outcome are emerging.

Near Vision Improvement with the Use of a New Topical Compound for Presbyopia Correction: A Prospective, Consecutive Interventional Non-Comparative Clinical Study

Introduction

To report the outcomes in near vision, optical quality and pupil diameter of a new pharmacological therapy (FOV tears) for presbyopia.

Methods

This was a prospective, consecutive, interventional, non-comparative clinical study in which 117 presbyopic patients were given one drop of the novel therapy (FOV tears) in each eye, followed 2 h after the instillation of the eye drop by an evaluation of the binocular uncorrected near visual acuity (UNVA) and uncorrected distance visual acuity. The objective scatter index and pupil diameter under photopic and scotopic conditions before and after instillation were also assessed. The patients were divided into two groups according to their age, with group 1 patients being 41 and 50 years old and group 2 patients, between 51 and 65 years old.

Results

The mean age of the patients was 50.2 years. The mean UNVA before the use of the eye drop was 0.35 LogMAR, which improved to 0.16 LogMAR at 2 h after the use of the eye drop (p = 0.000). Nine patients did not show an improvement in UNVA, but no patient showed a loss of lines. Fourteen patients (11.9%) reported headaches as a side effect of the therapy.

Conclusion

This pharmacological therapy improved near vision by one or more lines (mean improvement 0.18 lines) in 92.3% of the patients at 2 h following the instillation of the eye drops. The group with the youngest patients gained more lines than the group with the oldest patients.

Presbyopia: Effectiveness of correction strategies

Presbyopia is a global problem affecting over a billion people worldwide. The prevalence of unmanaged presbyopia is as high as 50% of those over 50 years of age in developing world populations, due to a lack of awareness and accessibility to affordable treatment, and is even as high as 34% in developed countries. Definitions of presbyopia are inconsistent and varied, so we propose a redefinition that states "presbyopia occurs when the physiologically normal age-related reduction in the eye's focusing range reaches a point, when optimally corrected for distance vision, that the clarity of vision at near is insufficient to satisfy an individual's requirements". Strategies for correcting presbyopia include separate optical devices located in front of the visual system (reading glasses) or a change in the direction of gaze to view through optical zones of different optical powers (bifocal, trifocal or progressive addition spectacle lenses), monovision (with contact lenses, intraocular lenses, laser refractive surgery and corneal collagen shrinkage), simultaneous images (with contact lenses, intraocular lenses and corneal inlays), pinhole depth of focus expansion (with intraocular lenses, corneal inlays and pharmaceuticals), crystalline lens softening (with lasers or pharmaceuticals) or restored dynamics (with 'accommodating' intraocular lenses, scleral expansion techniques and ciliary muscle electrostimulation); these strategies may be applied differently to the two eyes to optimise the range of clear focus for an individual's task requirements and minimise adverse visual effects. However, none fully overcome presbyopia in all patients. While the restoration of natural accommodation or an equivalent remains elusive, guidance is given on presbyopic correction evaluation techniques.

Unilateral Multifocal Intraocular Lens Implantation in a Patient with Adie's Pupil

Purpose

To report a case of a patient with unilateral Adie's pupil who underwent bilateral cataract extraction with multifocal and monofocal posterior chamber intraocular lens (IOL) implantation.

Methods

A 74-year-old woman presented to our institution complaining of worsening near vision. Gross examination revealed a 6-mm fixed pupil on the right eye (OD) and a 5-mm pupil reacting to 3 mm with light on the left eye (OS). Slit lamp examination revealed a tonic pupil with an exaggerated pupillary constriction to dilute pilocarpine OD. Dilated exam revealed 2–3+ nuclear and cortical lens changes bilaterally. The patient's active lifestyle, personality, and biometry measurements made her a good candidate for multifocal IOL (MfIOL) implantation OS. Femtosecond laser-assisted cataract extraction with a ReSTOR +3 ADD (SN60D1) implantation was performed OS. Monofocal lens implantation (SN60WF) was performed OD 6 months later.

Results

One year postoperatively, our patient had an uncorrected visual acuity (VAsc) of 20/15 for distance and J10 for near OD. Her VAsc was 20/25 +1 for distance and J1 for near OS. Visual acuity when using both eyes was 20/15 for distance and J1 for near.

Conclusion

Optimizing success for MfIOL implantation is a multifactorial process. Large pupils preoperatively are of particular concern, as this may lead to increased dysphotopsia with pupil-dependent MfIOLs. Thus, patients with unilateral mydriasis, such as Aide's pupil, may have a beneficial outcome combining multifocal-monofocal implantation after bilateral cataract extraction, especially if they are not a candidate for monovision but desire spectacle independence.

Premium intraocular lenses: The past, present and future

Purpose

To present potential benefits as well as limitations of premium intraocular lens (IOL) use, and provide insight in future of premium cataract surgery.

Methods

Bibliographic research was performed in PubMed/Medline database, and the most recently updated papers were evaluated. Keywords used were: premium intraocular lens, multifocal intraocular lens, toric intraocular lens, toric multifocal intraocular lens, accommodative intraocular lens, and the respective brand names.

Results

Multifocal IOLs provide uncorrected distance visual acuity (UDVA) of 0.03 logMAR in 82.3%–95.7% of patients and overall spectacle independence in 81%–85% of patients. Toric IOLs provide UDVA of 0.3 logMAR in 70%–95% of patients, residual astigmatism of 1 D or less is noted in 67%–88% of patients, and spectacle independence is reported in 60%–85% of patients. Toric multifocal IOLs provide UDVA of 0.3 logMAR in 92%–97% of patients, and spectacle independence is reported in 79%–90% of patients. Accommodative IOLs represent intensively developing field in ophthalmology, and the results are still variable depending on the IOL model.

Conclusions

Premium IOL technology and advanced surgical techniques have significantly improved postoperative visual outcomes. Future developments will potentiate development of new premium IOL designs that will provide spectacle independence and excellent visual outcomes after cataract surgery.

Clinical outcomes with a diffractive trifocal intraocular lens

PURPOSE

To evaluate clinical and visual outcomes, quality of near vision, and intraocular optical quality of patients bilaterally implanted with a trifocal PanOptix intraocular lens.

METHODS

In this prospective consecutive case-series study, 52 eyes of 26 bilateral patients (mean age, 60.2 ± 7.4 years) were implanted with the AcrySof IQ Panoptix intraocular lens. Visual acuity, defocus curve, contrast sensitivity (Pelli-Robson test), near activity visual questionnaire, and internal aberrations with Osiris were evaluated. A prototype light-distortion analyzer was used to quantify the postoperative light-distortion indices. The follow-up was 6 months after surgery.

RESULTS

Uncorrected, corrected distance, and uncorrected near visual acuities improved with the surgery (p ≤ 0.02). Distance corrected near visual acuity was 0.13 ± 0.10, 0.13 ± 0.13, and 0.13 ± 0.08 at 1, 3, and 6 months after surgery, respectively (p = 0.82). Distance corrected intermediate visual acuities were 0.09 ± 0.13, 0.13 ± 0.15, and 0.12 ± 0.12 at 1, 3, and 6 months, postoperatively. Binocular contrast sensitivity was 1.86 ± 0.15 Log Units. Defocus curve provided a visual acuity equal or better to 0.30 LogMAR between defocus levels of +0.50 to -3.00 D. The near activity visual questionnaire scores improved significantly with the surgery (p < 0.01).

CONCLUSION

The AcrySof IQ Panoptix intraocular lens is able to restore visual function with an acceptable intermediate and near vision after cataract surgery with good contrast sensitivity and an improvement in the near activity visual questionnaire.

Inferior Decentration of Multifocal Intraocular Lenses in Myopic Eyes

PURPOSE

To investigate the tilt and decentration of multifocal intraocular lenses (MfIOLs) implanted in myopic eyes.

DESIGN

A prospective cohort study.

METHODS

Twenty-eight myopic eyes and 56 emmetropic eyes were evaluated. Phacoemulsification with Tecnis ZMB00 MfIOL (Abbott Medical Optics, Santa Ana, California, USA) implantation was performed. At 1 year post-surgery, routine postoperative examinations were performed, and tilt and decentration of the MfIOLs, high-order aberrations, and modulation transfer function (MTF) were evaluated using the OPD-Scan III aberrometer (Nidek Co, Ltd, Gamagori, Japan). Subjective symptoms were assessed with a Quality of Vision questionnaire.

RESULTS

Postoperative uncorrected distance visual acuity (VA), best-corrected distance VA, and uncorrected near VA did not differ between the 2 groups. The mean IOL tilt and horizontal decentration were not different between the control and myopic groups. However, the myopic group presented significantly inferior decentration in the capsular bag compared with the control group (-0.03 ± 0.22 mm vs -0.21 ± 0.29 mm, P = .002). The overall decentration values were 0.32 ± 0.14 mm in the controls and 0.40 ± 0.18 mm in the myopic group (P = .023). Axial length was negatively correlated with vertical decentration (r = -0.268, P = 0.014) and positively correlated with overall decentration (r = 0.334, P = .002). Worse aberration data, poorer MTF, and more subjective symptoms were also found in the myopic group than in the controls.

CONCLUSION

Greater inferior decentration of MfIOLs and a consequent decrease in visual quality were found in myopic eyes, indicating that the increasing incompatibility between IOL and capsular bag size with axial length elongation should not be underestimated.