Refractive expectations of patients having cataract surgery

Tolerance to refractive error with a new extended depth of focus intraocular lens

PURPOSE

To evaluate the tolerance to refractive errors of a new purely refractive extended depth of focus (EDF) intraocular lens (IOL) using preclinical and clinical metrics.

METHODS

Preclinical evaluation included computer simulations of visual acuity (sVA) and dysphotopsia profile of different IOL designs (refractive EDF, diffractive EDF, multifocal, standard, and enhanced monofocals) using an appropriate eye model with and without ±0.50 D defocus and/or +0.75 D of astigmatism. Patients bilaterally implanted with a refractive EDF (Model ZEN00V) or an enhanced monofocal (Model ICB00) IOL from a prospective, randomized study were included. At the 6-month postoperative visit, uncorrected and corrected distance vision (UDVA and CDVA), visual symptoms, satisfaction and dependency on glasses were evaluated in a subgroup of patients with absolute residual refractive error of >0.25 D in one or both eyes.

RESULTS

In the presence of defocus and astigmatism, sVA was comparable for all except the multifocal IOL design. The refractive EDF was more tolerant to myopic outcomes and maintained a monofocal-like dysphotopsia profile with defocus. Binocular logMAR UDVA was -0.03 ± 0.08 for ZEN00V and -0.02 ± 0.11 for ICB00. 100% ZEN00V and 97% ICB00 patients did not need glasses and were satisfied with their distance vision. Monocular CDVA, contrast sensitivity and visual symptoms were also similar between both groups.

CONCLUSIONS

The clinical outcomes of the refractive EDF IOL demonstrated high quality distance vision and dysphotopsia comparable to a monofocal IOL, even in the presence of refractive error, thus matching the design expectations of the EDF IOL.

Determination of the toric axis by using internal astigmatism axis in non-dilated eyes

PURPOSE

To determine the toric intraocular lens (IOL) axis by using internal astigmatism axis obtained from Optical Path Difference (OPD) Scan III (Nidek Co.) in non-dilate eyes.

METHODS

The eyes of patients who underwent toric IOL implantation for astigmatic correction were investigated. Patients who have ocular surface disorder, keratoconus, posterior capsule opacification were excluded. The IOL axis measured in non-dilated eyes in mesopic conditions by OPD scan III device and the IOL axis measured by using classical slit lamp biomicroscopy method in dilated eyes were detected at postoperative 1st and 6th months. Results were compared with correlation and linear regression analysis.

RESULTS

Totally, 26 eyes of 18 patients were included. The difference between biomicroscopic IOL axis and OPD internal astigmatism axis was 4.96 ± 4.41 degrees at the 1st month and 3.62 ± 3.5 degrees at the 6th month. There was a significant and high correlation between biomicroscopic IOL axis and OPD internal astigmatism axis at both 1st month (r = 0.992 p < 0.001) and 6th month (r = 0.995 p < 0.001). According to regression analysis, the results of two measurement methods were significantly compatible with each other at 1st month (R Sq = 0.984 p < 0.001) and 6th month (R Sq = 0.990 p < 0.001) and there was a close to ideal linear (R Sq = 1) relationship between two methods.

CONCLUSIONS

In eyes with toric IOL implantation, the IOL axis and IOL rotation according to target IOL axis can be detected easily and effectively in a short time by OPD scan internal astigmatism axis without the need to dilate the pupil.

Comparative Analysis of Tolerance to Experimentally Induced Astigmatism with Three Types of Multifocal Intraocular Lenses

Purpose

The effect of residual astigmatism and its axis on distance and near visual acuities (VAs) with multifocal intraocular lenses (IOLs) has not been studied extensively. This study compared the tolerance to experimentally induced residual astigmatism among bifocal, trifocal, and extended depth-of-focus (EDOF) IOLs.

Patients and Methods

This retrospective, comparative study included 70 eyes of 70 patients implanted with bifocal, trifocal, or EDOF IOLs. Distance and near VAs were assessed with experimentally induced astigmatism by placing positive cylindrical lenses in increments of 0.50 diopters to 2.00 diopters at 90° and 180° axes over the best distance correction.

Results

Both distance and near VAs worsened with increasing magnitudes of experimentally induced astigmatism except in the EDOF group, in which the near VA remained within a clinically acceptable limit, ie, within one line from the best corrected VA under all ranges of experimentally induced astigmatism. Furthermore, the EDOF group showed the highest astigmatic threshold for losing VA lines following experimental astigmatic induction at both distance and near. The distance VA was generally better at with-the-rule (WTR) than against-the-rule (ATR) astigmatism for all three IOL groups. On the other hand, the near VA was generally better at WTR than ATR astigmatism in the bifocal group, comparable between WTR and ATR astigmatism in the trifocal group, and generally better at ATR than WTR astigmatism in the EDOF group.

Conclusion

The EDOF IOL demonstrated the highest tolerance to experimentally induced astigmatism at both distance and near. VA was generally less affected by WTR astigmatism than ATR astigmatism, especially at distance. We proposed the residual astigmatism thresholds for clinically acceptable VA reduction in all three IOL groups.

Comparison of Patients With Emmetropia and Presbyopia and Different Accommodation Who Undergo Unilateral or Bilateral Implantation of a Trifocal IOL

PURPOSE

To compare visual outcomes and satisfaction in patients with emmetropia, presbyopia, and greater or lesser residual accommodation who undergo unilateral or bilateral implantation of a trifocal diffractive intraocular lens (IOL).

METHODS

A multicenter, multisurgeon study was performed to evaluate outcomes in patients with emmetropia and presbyopia who underwent refractive lens exchange followed by implantation of a FineVision trifocal IOL (PhysIOL). The inclusion criteria were as follows: emmetropia, sphere -0.25 to +0.50 diopters (D), cylinder less than 0.75 D, and manifest refractive spherical equivalent (MRSE) of -0.25 to +0.25 D. All patients also had to have an uncorrected distance visual acuity (UDVA) of Snellen 0.9 or better in each eye. The sample was divided into different clusters based on two variables: eyes operated on (monocular or binocular) and age either younger than 55 years or 55 years or older. Thus, four possible groups were created. Visual and refractive performance, patient satisfaction, and spectacle independence were assessed.

RESULTS

A total of 690 eyes from 431 patients were evaluated. There was no difference in postoperative uncorrected (UDVA) and corrected (CDVA) distance visual acuity between the groups. Binocular uncorrected near vision (UNVA) was better in patients who underwent surgery on both eyes regardless of age (median [interquartile range]: 0.00 [0.00; 0.10] vs 0.10 [0.00; 0.10] logMAR; P < .001). Binocular uncorrected intermediate vision (UIVA) was better in patients who underwent surgery on both eyes aged younger than 55 years than in those who underwent surgery in one eye aged 55 years or older (median [interquartile range]: 0.18 [0.10; 0.18] vs 0.30 [0.18; 0.30] logMAR; P < .001). The efficacy and safety indexes were 0.98 ± 0.09 and 1.01 ± 0.06, respectively. A total of 93.3% of eyes were within the 0.50 D range in postoperative MRSE. Visual dysphotopsia was worse in patients with both eyes operated on, although the differences were not statistically significant.

CONCLUSIONS

The study shows that after refractive lens exchange, patients with emmetropia and presbyopia who received a trifocal IOL in one or both eyes achieved good UNVA, UIVA, and UDVA. Regarding near binocular visual acuity, results were better for patients who underwent surgery on both eyes than for those who underwent surgery on one eye. Regarding binocular intermediate visual acuity, patients aged younger than 55 years with both lenses replaced had better results than those 55 years or older with only one lens replaced. However, no significant differences were observed in UDVA or patient satisfaction. [J Refract Surg. 2023;39(12):817-824.].

Comparing clinical outcomes of Optiwave Refractive Analysis, Lenstar, and surgeon's modified method for intraocular lens power calculation in Asian eyes

The study aimed to compare the accuracy of intraocular lens (IOL) calculation to predict postoperative refraction by Optiwave Refractive Analysis (ORA), Lenstar LS 900, and the surgeon's Modify method in normal Asian eyes. The IOL power of the Lenstar group was calculated according to Lenstar LS 900, whereas the surgeon's Modify group used topography, axial length (AL) of Lenstar, and Barrett Universal II online formula. Intraoperative aphakic measurements and IOL power calculations were obtained with the ORA system. From the results acquired through Lenstar, Modify, and ORA, the surgeon used his judgment to select the actual IOL power. Postoperative manifest refraction spherical equivalent (MRSE) was obtained 2 months after surgery. The prediction error (PE) was calculated as the difference between the postoperative MRSE and the target refraction proposed by three methods. AL, anterior chamber depth (ACD, measured from corneal endothelium to lens), lens thickness (LT), and ACD + 1/2LT were also included in the survey. In 67 eyes, the average real PE was smaller for the Lenstar (0.06 ± 0.44) and Modify (- 0.05 ± 0.40) than for the ORA group (- 0.25 ± 0.60, p < 0.05). The ORA system demonstrated the best results of IOL power selection in eyes with a normal range of ACD + 0.5 LT (5.2-5.6 mm) in Asian eyes.

Distance spectacle-wearing habits in older patients in England

PURPOSE

To report the proportion of older people in England who wear distance spectacles full time, part time and rarely, and to investigate factors that influence how much the distance vision (DV) correction is worn.

METHODS

A two-part questionnaire investigating the spectacle-wearing habits of older people was developed and completed by 322 participants (age 72 years ±7.7, range 60-94). A subcohort of 209 DV correction wearers with a mean spherical equivalent (MSE) of <±4.00DS was selected for a logistic regression to investigate which factors influence how much the DV correction is used.

RESULTS

In total, 43% of emmetropic, and 55% of pseudophakic, DV spectacle wearers wear their correction full time. Lens type, MSE and the age that participants first wore a DV correction significantly predicted DV correction wearing habit (adjusted R2  = 0.36), with lens type being the strongest predicting factor and progressive users wearing their spectacles 37% more than those using single vision lenses.

CONCLUSIONS

Many patients appear to consider convenience more important than being spectacle independent at distance, with lens type the most significant influencing factor of how much those with low/moderate refractive error wear their distance correction. Many emmetropes and pseudophakes choose to wear their progressive or bifocal spectacles full time, and the emmetropia provided by cataract surgery does not provide independence from full-time spectacle wear for many patients. The optometrist has a key role in discussing both choice of spectacle lens correction and the refractive outcome options of cataract surgery with patients.

Use of Spectacles after Cataract Surgery

PURPOSE

The goal of this study was to investigate the use of spectacles in everyday life after bilateral cataract surgery with a preoperative refractive target of emmetropia in both eyes. In addition, we analyzed the total cost of spectacles and the patient's visual satisfaction at least 6 months after surgery.

METHODS

Patients after bilateral cataract surgery with implantation of an aspheric monofocal IOL (Tecnis 1, Johnson & Johnson) with a preoperative refractive target of emmetropia in both eyes and a documented refractive outcome were included in this prospective observational study. In a phone interview ≥ 6 months after surgery, the following items were assessed: type of spectacles purchased and overall cost, type of activity with and duration of spectacle wear, and satisfaction with the visual situation.

RESULTS

Seventy patients were included in this study. Depending on their postoperative refraction, patients were divided into group A (n = 27) with perfect emmetropia in both eyes (i.e., spherical equivalent [SE] of ≥ - 0.25 D to ≤ + 0.25 D), group B (n = 21) with achieved emmetropia in one eye (i.e., SE of ≥ - 0.25 D to ≤ + 0.25 D) and a myopic refraction in the other eye (< - 0.25 D), and group C (n = 22) with bilateral myopic results (SE of < - 0.25 D). Overall, 84% of patients had purchased new spectacles, mostly varifocals (59%) or reading glasses (24%) at the median cost of 980 Swiss Francs (mean: CHF 912 ± 746). Despite patients' initial reasoning for their lens choice to require reading glasses only, varifocal glasses were worn for more than 50% or all of awake time by 48% of patients in group A, 43% in group B, and 68% in group C. Despite their regular spectacles use, patients' visual satisfaction was very high in all three groups.

CONCLUSIONS

Most patients who achieve perfect bilateral emmetropia after implantation of monofocal aspheric lenses buy varifocal spectacles within 6 months, and more than half of all patients use their varifocal spectacles for more than 50% of their awakening time. The costs for such spectacles are high.

Developing refractive management recommendations for patients undergoing cataract surgery: A Delphi study

PURPOSE

Currently, there are no UK optometric guidelines regarding the pre and postoperative refractive management of patients undergoing cataract surgery. This study used a Delphi method to gain consensus on best practice.

METHODS

Eighteen recommendations targeted areas of concern/variability in advice that were highlighted in an earlier focus group study of refractive management for patients who had received cataract surgery. These covered three topics: preoperative target refraction discussions, postoperative refractive management and driving advice postoperatively. The recommendations were then developed using evidence from optometry and ophthalmology clinical expertise and the research literature. Eighteen recommendations underwent a process of agreement and modification using a Delphi study consisting of a panel of 22 highly experienced optometrists (N = 11, 25 years mean clinical experience) and ophthalmologists (N = 11, 17 years mean clinical experience) who rated and commented upon the importance and feasibility of each recommendation. The responses were considered by the research team and the recommendations modified and/or removed prior to a second Delphi round of responses to a modified series of recommendations. Consensus of opinion was defined as greater than 80% of panellists 'agreed' or 'strongly agreed' on the recommendation for both importance and feasibility.

RESULTS

Fourteen of the 18 recommendations reached consensus in the first round. A second round of the Delphi method saw 17 modified recommendations scored and commented upon by 20 clinicians. Fifteen recommendations reached consensus after two rounds of the Delphi method.

CONCLUSIONS

Recommendations to guide the pre and postoperative refractive management of patients undergoing cataract surgery were agreed between highly experienced optometrists and ophthalmologists using a 2-round Delphi method. Patients would benefit from consistent target refraction discussions, postoperative refractive management and driving advice, and recommendations were of particular benefit to less experienced optometrists.

Comparison of visual performance between two aspheric monofocal intraocular lens models

CLINICAL RELEVANCE

It is important to distinguish between visual acuity, optical quality and quality of vision when outcomes obtained with intraocular lenses are evaluated. These parameters, that includeobjective and subjective tests, should be assessed to obtain results that are not biased.

BACKGROUND

To assess the difference in visual and optical quality between two monofocal intraocular lens models.

METHODS

: This was a prospective, parallel and randomised clinical study conducted at Miranza IOA, a private clinic in Madrid, Spain. Sixty patients were implanted bilaterally, 30 per group, with two aspheric IOLs with induced spherical aberration of -0.27 μm for Group A and -0.20 μm for Group B. Visual outcomes obtained at 1 and 3 months after surgery included both uncorrected (UCVA) and corrected monocular distance visual acuity (DCVA), objective scattering index (OSI), modulation transfer function (MTF) cut-off, Strehl Ratio (SR), contrast sensitivity defocus curve (CSDC), intraocular lens spherical aberration (SA), and longitudinal chromatic aberration of the eye. Activity limitations in daily life were assessed using CatQuest-9SF questionnaire.

RESULTS

There were statistically significant differences for DCVA (0.04 LogMAR; p = .008) and SR (0.03; p = .003) between groups. Outcomes related to CSDC showed statistically significant differences for vergences between -0.50 D and +1.00 D (3 mm pupil) and for vergences of 0.00 D and +0.50 D (4.5 mm pupil) between groups. Overall, Group A showed better results regarding visual and optical quality, including a lower longitudinal chromatic aberration result in comparison to Group B. Patient satisfaction evaluated with CatQuest-9SF showed that Group A achieved better outcomes, although the differences were statistically significant only for the 'Reading text on television' item (p = 0.027).

CONCLUSIONS

Both intraocular lens models showed excellent quantity of vision, optical and visual quality as well as high patient satisfaction. Despite this, the the Group A model provided slightly better outcomes than the Group B model.

Effectiveness of reducing corneal astigmatism after combined high-frequency LDV Z8 femtosecond laser-assisted phacoemulsification and arcuate keratotomy

Purpose: In this retrospective study, the efficacy of the FEMTO LDV Z8 Femtosecond Laser-Assisted Cataract Surgery (Femto Z8 FLACS) and the Femtosecond laser Arcuate Keratotomy (FSAK) in decreasing the corneal astigmatism was investigated.

Methods: During FLACS, FSAK was positioned with the help of the FEMTO LDV Z8 laser at a diameter of 8.5 mm and an 80% depth. Before and 3 months after surgery, the astigmatism of the cornea was measured with the aid of Pentacam. The variables influencing the efficacy of FSAK were assessed using the multiple regression analysis technique. Vector analyses were carried out. To determine the net corneal alterations, the with-the-wound and against-the-wound variations were computed along the FSAKs’ meridian.

Results: This study investigated 80 eyes from 62 participants. The average keratometric astigmatism value was 0.92 ± 0.44 diopters (D). The average keratometric astigmatism decreased to 0.61 ± 0.45 D 3 months following FSAK compared to preoperative corneal astigmatism (p &lt; 0.05). Additionally, there was a considerable decline in the percentage of eyes with ±0.5 D and ±1.0 D astigmatism, which reduced 3 months after surgery by 58% and 85%, respectively (p &lt; 0.05).

Conclusion: The FEMTO LDV Z8 laser can create an effective and precise arcuate keratotomy with an excellent safety profile, rapid recovery, and vision stability.

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.

Investigating target refraction advice provided to cataract surgery patients by UK optometrists and ophthalmologists

PURPOSE

To determine whether UK optometrists and ophthalmologists provide target refraction advice to patients prior to cataract surgery, and when this should first be discussed.

METHODS

Optometrists and ophthalmologists were asked to complete a survey of two clinical vignettes (both older patients with cataract; a pre-operative myope who routinely read without glasses and a patient using a monovision approach), plus multiple choice and short answer questions either using hard copy or online.

RESULTS

Responses were obtained from 437 optometrists and 50 ophthalmologists. Optometrists who reported they would provide target refraction advice were more experienced (median 22 years) than those who would leave this to the Hospital Eye Service (median 10 years). The former group reported it was in the patients' best interest to make an informed decision as they had seen many myopic patients who read uncorrected pre-operatively, and were unhappy that they could no longer do so after surgery. Inexperienced optometrists reported that they did not want to overstep their authority and left the decision to the ophthalmologist. The ophthalmologists estimated their percentage of emmetropic target refractions over the last year to have been 90%.

CONCLUSION

Currently, some long-term myopes become dissatisfied after cataract surgery due to an emmetropic target refraction that leaves them unable to read without glasses as they did prior to surgery. Although experienced optometrists are aware of this and attempt to discuss this issue with patients, less experienced optometrists tend not to. This suggests that target refraction needs greater exposure in university training and continuing professional development. To provide patients with the knowledge to make informed decisions regarding their surgery, we suggest an agreed protocol within funded direct referral schemes of initial target refraction discussions by optometrists to introduce the idea of refractive outcomes and outline options, with further discussion with the ophthalmologist to clarify understanding.

Prediction Error Stabilization and Long-Term Standard Results with a Monofocal Intraocular Lens

The aim of this study was to assess the stability and differences between objective (O-Rx) and subjective (S-Rx) refraction for the assessment of the prediction error (PE). A secondary aim was to report the results of a monofocal intraocular lens (IOL). 100 subjects were included for whom S-Rx and O-Rx were obtained for all visits, and for visual performance, posterior capsular opacification incidence and Nd:YAG rates at 12 months. Either S-Rx and O-Rx showed a hyperopic shift from 1 to 6 months (p < 0.05) and stabilization after 6 months. S-Rx was related with the axial length (rho = −0.29, p = 0.007), obtaining a major tendency towards hyperopia in short eyes implanted with high-power IOLs. O-Rx showed a myopic shift in comparison to S-Rx (p < 0.05). This resulted in a decrease of the number of eyes in ±0.50 D and ±1.00 D from 79 to 67% and from 94 to 90%, respectively. The median (interquartile range) uncorrected and corrected visual acuities were 0.1 (0.29) and 0 (0.12) logMAR, respectively, and seven eyes required Nd:YAG capsulotomy at 12 months. Some caution should be taken in PE studies in which O-Rx is used or S-Rx is measured in a 1-month follow-up. Constant optimization should be conducted for this IOL after S-Rx stabilization.

Visual outcomes after optic exchange of a modular intraocular lens

PURPOSE

To evaluate the effectiveness of the Harmoni Modular IOL (HMIOL).

SETTING

3 study sites.

DESIGN

Prospective, multicenter clinical study.

METHODS

HMIOL is a foldable, posterior chamber lens with separate base and exchangeable optic components. Eligible adults undergoing cataract surgery received HMIOL in the study eye (monovision target -1.50 diopters [D]) and standard monofocal IOL in contralateral eye (control). After 3 months, subjects could undergo optic exchange based on visual outcomes. End points included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manifest refractive spherical equivalent (MRSE). Follow-up was 12 months or greater postoperatively.

RESULTS

114 subjects had successful HMIOL implantation in study eye and control IOL in contralateral eye. At 3 months, subjects could undergo optic exchange if unsatisfied with monovision; 65 eyes had optic exchange (exchange cohort), and 49 eyes had no exchange (no exchange cohort). In exchange cohort, the proportion of eyes with UDVA of 20/40 or greater and of 20/20 or greater increased 3 months after optic exchange vs preexchange levels by 23% (97% vs 74%) and 40% (49% vs 9%), respectively. In all cohorts, 95% of subjects or greater achieved UDVA of 20/40 or greater after 12 months or greater. Control and no exchange cohorts achieved CDVA of 20/40 or greater by 3 months; 97% of eyes or greater had CDVA of 20/40 or greater at 12 months after optic exchange. In exchange cohort, the proportion of eyes with MRSE within ±0.50 D and ±1.00 D of target changed by 57% and 36%, respectively, from preexchange (20% and 59%, respectively) to 12 months postexchange (77% and 95%, respectively), reaching levels similar to control subjects (72% and 97%, respectively).

CONCLUSIONS

HMIOL provided visual outcomes comparable with standard monofocal IOLs.

Refractive Outcomes Using Intraoperative Aberrometry for Highly Myopic, Highly Hyperopic, and Post-refractive Eyes

PURPOSE

To evaluate whether intraoperative aberrometry improves the accuracy of refractive outcomes after cataract surgery in highly myopic, highly hyperopic, and post-refractive eyes.

METHODS

This single-center, retrospective review compared the spherical equivalent of postoperative refraction to that predicted by the Barrett Universal II formula versus Optiwave Refractive Analysis (ORA) (Alcon Laboratories, Inc) for highly myopic and hyperopic eyes and to the Barrett True K formula versus ORA for post-refractive eyes. The number and magnitude of lens changes were analyzed and used to determine in how many cases refractive surprises were affected by ORA, with additional subanalysis of outcomes based on average keratometry values.

RESULTS

ORA led to a change in the lens power implanted in 48% (96 of 198) of eyes, and prevented hyperopic surprise in 27% (15 of 55) and excess myopia in 46% (19 of 41). Steeper keratometry values correlated with more frequent changes on ORA-recommended implanted intraocular lens (P = .0031). ORA led to a similar percentage of eyes falling within ±0.50, ±0.75, and ±1.00 diopters compared to the Barrett Universal II and Barrett True K formulas. In post-refractive eyes, ORA led to a similar mean absolute error when compared to the Barrett True K formula (P = .62). For highly myopic eyes with an axial length of greater than 27 mm, ORA demonstrated a trend toward lower mean absolute error when compared to the Barrett Universal II formula (P = .076).

CONCLUSIONS

ORA demonstrated similar refractive results to the Barrett True K formula in post-refractive eyes and to the Barrett Universal II formula in highly myopic and hyper-opic eyes and may provide additional benefit for eyes with steeper corneas or an axial length of greater than 27 mm. [J Refract Surg. 2021;37(9):609-615.].

Use of a Machine Learning Method in Predicting Refraction after Cataract Surgery

The present study aims to describe the use of machine learning (ML) in predicting the occurrence of postoperative refraction after cataract surgery and compares the accuracy of this method to conventional intraocular lens (IOL) power calculation formulas. In total, 3331 eyes from 2010 patients were assessed. The objects were divided into training data and test data. The constants for the IOL power calculation formulas and model training for ML were optimized using training data. Then, the occurrence of postoperative refraction was predicted using conventional formulas, or ML models were calculated using the test data. We evaluated the SRK/T formula, Haigis formula, Holladay 1 formula, Hoffer Q formula, and Barrett Universal II formula (BU-II); similar to ML methods, we assessed support vector regression (SVR), random forest regression (RFR), gradient boosting regression (GBR), and neural network (NN). Among the conventional formulas, BU-II had the lowest mean and median absolute error of prediction. Therefore, we compared the accuracy of our method with that of BU-II. The absolute errors of some ML methods were lower than those of BU-II. However, no statistically significant difference was observed. Thus, the accuracy of our method was not inferior to that of BU-II.

The PanOptix Trifocal IOL vs the ReSTOR 2.5 Active Focus and ReSTOR 3.0-Add Multifocal Lenses: A Study of Patient Satisfaction, Visual Disturbances, and Uncorrected Visual Performance

Purpose

To compare spectacle independence, patient-reported outcomes (PROs), and dysphotopsia after multifocal intraocular lens (IOL) implantation with the AcrySof PanOptix trifocal or the ReSTOR +2.5/3.0 D or ReSTOR +2.5 D mini-monovision multifocal IOL.

Patients and Methods

Prospective, open-label, multicenter analysis of PROs, spectacle independence, and satisfaction among patients undergoing cataract surgery who had been implanted at least 1 month previously with AcrySof IQ PanOptix or PanOptix Toric trifocal (n = 59) IOLs bilaterally. Results were compared to outcomes from a similar study with the AcrySof ReSTOR 2.5/3.0 or the ReSTOR ActiveFocus 2.5 mini-monovision lens [n = 191]).

Results

Spectacle independence was significantly higher in the PanOptix cohort, with 83% of patients “never” needing glasses for any activity versus 36% in the ReSTOR 2.5 mini-monovision and 34% in the ReSTOR 2.5/3.0 cohorts. No significant differences in patient satisfaction rates were reported between the three cohorts. Glare and halo were rated “extremely” noticeable more with the PanOptix (10%) than with the ReSTOR 2.5 mini-monovision (1%) or ReSTOR 2.5/3.0 (3%). BCVA differences were not statistically significant, and no new safety concerns were reported.

Conclusion

The AcrySof PanOptix trifocal provides significantly greater spectacle independence across all measured activities than the AcrySof ReSTOR multifocal IOLs.

Successful Implementation of Femtosecond Laser-Assisted Cataract Surgery: A Real-World Economic Analysis

Purpose

To calculate the minimum number of Femtosecond laser-assisted cataract surgery (FLACS) procedures required per month to pay off the fixed investment cost over 5 years to achieve break-even.

Setting

A rural ophthalmology practice located in the mid-West United States.

Design

An economic analysis, based on real-world, retrospectively collected data over 12 months, from an ambulatory surgical care perspective.

Methods

FLACS was initiated in 2017 with the LenSx^® laser (Alcon Vision LLC., Fort Worth, TX). The incremental cost of FLACS, cases needed to break-even, return on investment (ROI), patient education, and marketing efforts were assessed. The financial analysis considered cataract volume, conversion rates, fixed (eg, principal) and variable (eg, supplies) costs, and revenue in the first 12 months.

Results

The clinic performed 2717 cataract surgeries in the 12-month period, with 1304 (48%) of patients converting to FLACS. Of FLACS procedures, 613 (47%) selected an advanced-technology intraocular lens (AT-IOL; eg, toric or lifestyle IOL), and the remaining patients selected a monofocal IOL with laser astigmatism correction. FLACS increased AT-IOL use by 113 procedures (23%) compared to volumes in the year prior to FLACS. Overall, FLACS was predicted to be profitable, with only 13 cases required per month to break even in 5 years. If both facility and physician fees are considered revenue, only eight cases per month are required to break-even in 5 years.

Conclusion

The practice experienced a greater-than-anticipated conversion to FLACS and increased selection of AT-IOLs, well above the break-even volume required, contributing to a rapid return on their investment.

Unilateral Versus Bilateral Refractive Lens Exchange With a Trifocal Intraocular Lens in Emmetropic Presbyopic Patients

PURPOSE

To compare visual outcomes and patient satisfaction between unilateral and bilateral trifocal diffractive intraocular lens (IOL) implantation in emmetropic patients with presbyopia.

DESIGN

Retrospective observational case series.

METHODS

This is a multicenter, multisurgeon study of emmetropic presbyopes who underwent refractive lens exchange (RLE) followed by an implantation of FineVision IOL (PhysIOL). Inclusion criteria were emmetropic eyes, with a sphere between -0.25 and +0.50 diopters (D), cylinder of less than 0.75 D and spherical equivalent (SE) between -0.25 and +0.25 D. In addition, uncorrected distance visual acuity (UDVA) had to be Snellen >0.9 in each eye. A total of 171 eyes of 122 patients were evaluated. This sample was divided into 2 groups depending on whether they have been operated monocularly or binocularly. Visual and refractive performance, patient satisfaction, and spectacle independence were evaluated.

RESULTS

UDVA and corrected distance visual acuity (CDVA) remained almost unchanged after monocular and binocular surgery. Binocular uncorrected intermediate (UIVA) and near visual acuity (UNVA) were better in those operated binocularly (0.3±0.12 vs 0.22±0.06, P < .063, and 0.09±0.08 vs 0.04±0.05, P < .027, respectively). Predictability and efficacy were higher in the binocular group, whereas safety was better in the monocular group. Visual dysphotopsia was worse and spectacle independence for all distances was higher in binocular group.

CONCLUSIONS

Our research shows that RLE with binocular implantation of a trifocal diffractive IOL in presbyopic emmetropic patients is more successful in UNVA than monocular implantation. However, no significant differences were observed in UDVA, UIVA, and patient satisfaction.

Subjective Opinions of Patients About Step-by-Step Cataract Surgery Preparation

Purpose

We analyzed the subjective feelings and opinions of patients regarding modified cataract phacoemulsification procedures.

Patients and Methods

A consecutive case series of patients undergoing phacoemulsification of cataracts, who completed questionnaires designed by the authors to evaluate their subjective opinions about hospital admission, medical examination, and intraoperative procedures carried out at the operating theater.

Results

Two hundred patients (82 men and 118 women) were included in the study. Subjects aged ≥65 years more often than younger respondents presented negative opinions about hospital admission procedures (15% vs. 2.5%, p=0.032) and were less satisfied with physicians’ explanations about the matter of phacoemulsification (71.3% vs. 92.5%, p=0.004), type of artificial lens to be implanted (43.8% vs. 85%, p<0.001), and potential complications (69.4% vs. 95%, p<0.001). The most unpleasant intraoperative experiences included venipuncture (35.5%), artificial lens implantation (30.5%), and peeling off of a sterile surgical drape (24%).

Conclusion

Persons aged ≥65 years presented with negative opinions about routine procedures related to phacoemulsification. Older age seems to be associated with less tolerance to time-consuming bureaucratic procedures and a lesser understanding of the specific stages of the surgery. Older patients should be notified in advance about all routine procedures to be carried out and provided with a rationale for these activities.

Trial Registration

The study was registered on clinicaltrials. gov (NCT04327856).

Evaluation of Safety Following Optic Exchange of a Modular Intraocular Lens

PURPOSE

To characterize safety of optic exchange using a modular lens.

SETTING

3 study sites (New Zealand, Philippines).

DESIGN

Prospective clinical study.

METHODS

Harmoni modular intraocular lens (HMIOL) with separate base and optic components was implanted in the study eye (monovision target -1.5 D). Contralateral eyes received standard monofocal lenses. Subjects could elect optic exchange 3 months after primary implantation. Adverse events (AEs) and endothelial cell loss (ECL) were assessed through 12-months follow-up.

RESULTS

114 subjects successfully received HMIOL and 114 received control lens in contralateral eye. At month 3, 65 HMIOL eyes had optic exchange due to unsatisfactory visual outcome from high monovision (Exchange cohort); 49 eyes received no exchange (No Exchange cohort). Exchange, No Exchange, and Control cohorts reported ocular AEs in 10 (15%), 6 (12%), and 14 (12%) eyes. No posterior capsular rupture occurred during optic exchange procedures. Short-term (12-month) posterior capsule opacification (PCO) evaluation showed all eyes had PCO grade ≤1 at month 12; no YAG capsulotomy was performed in the Exchange cohort. No Exchange and Exchange cohorts had similar ECL at 3 months versus preoperative baseline (-4.5%, n=48 and -4.0%, n=65). In the Exchange cohort, additional 2.7% ECL occurred 3 months after optic exchange compared with pre-exchange baseline; ECL was significantly below the 14% threshold (P<0.001) and was 5.8% at 12 months.

CONCLUSIONS

HMIOL safety outcomes were comparable with standard monofocal lenses; HMIOL may provide an effective method for correcting postoperative refractive errors.

A Comparative Evaluation of Visual, Refractive, and Patient-Reported Outcomes of Three Extended Depth of Focus (EDOF) Intraocular Lenses

Objective

To compare visual, refractive, and patient-reported outcomes of patients implanted with one of three types of extended depth of focus (EDOF) intraocular lenses.

Setting

Asian Eye Institute, Philippines.

Design

Retrospective cohort study.

Methods

Subjects implanted with Symfony (Johnson and Johnson, USA), IC-8 (AcuFocus, USA), and WIOL (Medicem, Czech Republic) EDOF intraocular lenses were recruited. Spherical equivalent, uncorrected and corrected visual acuity, defocus curve, and modulation-transfer function, Strehl ratio, and visual Strehl optical transfer function values, photic phenomena, and questionnaire answers were measured and assessed.

Results

A total of 32 eyes with the Symfony lens, 30 with the IC-8 lens, and 32 with the WIOL lens were included in the study. Mean postoperative spherical equivalent was -0.24 D for the Symfony, -0.17 D for the IC-8, and 0.27 D for WIOL. There were no significant differences in postoperative monocular and binocular uncorrected and corrected visual acuity. On a monocular defocus curve, the IC-8 and Symfony showed significantly better vision than WIOL. The Symfony had significantly better modulation-transfer function, Strehl ratio, and visual Strehl optical transfer function. No difference was seen among the three lenses with regard to glare or starburst, while patient satisfaction remained high in all groups for far, intermediate, and near vision.

Conclusion

All eyes implanted with the three EDOF designs achieved excellent far and intermediate vision, with acceptable near vision. The IC-8 and Symfony exhibited a better range of vision on defocus-curve testing. The Symfony showed superior results in quality of vision. Patient satisfaction was high in all three EDOF groups.

Refractive surprise after cataract surgery secondary to smeared optics of swept-source optical coherence tomography biometer: a case report

BACKGROUND

Inaccurate biometry can lead to the wrong intraocular lens implantation and result in refractive surprise following cataract surgery. It is important to be sceptical of biometry results that do not match the refractive or clinical picture and ask for it to be repeated.

CASE PRESENTATION

We present a unique cause of refractive surprise in a patient undergoing cataract surgery. Pre-operative refraction demonstrated hypermetropia, yet swept-source optical coherence tomography (SS-OCT) biometry repeatedly calculated the axial length as > 35.00 mm in both eyes. The patient underwent phacoemulsification and intraocular lens insertion using the provided biometry calculations, however post-operatively the patient had a + 14.00 dioptre refractive surprise. Analysis of biometry performed on the same day identified other patients with exaggerated axial lengths, supporting the theory that the biometer's smeared optical surface was responsible. Following servicing of the machine, repeat biometry of the patient calculated the axial length consistent with a hypermetrope (21.67 mm) and the intraocular lens exchange was successful in correcting the refractive error.

CONCLUSIONS

Ensure the optical surfaces of the biometer are cleaned regularly, and consider repeating biometry on separate days if repeat biometry still is not in keeping with the refractive or clinical picture. Additionally, re-confirm the axial length with another modality.

Experiences following cataract surgery - patient perspectives

PURPOSE

Most patients report being highly satisfied with the outcome of cataract surgery but there are variable reports regarding the impact of cataract surgery on some real-world activities, such as fall rates. We hypothesised that adaptations to changed refractive correction and visual function may cause difficulties in undertaking everyday activities for some patients and used a series of focus groups to explore this issue.

METHOD

Qualitative methods were used to explore patients' experiences of their vision following cataract surgery, including adaptation to vision changes and their post-surgical spectacle prescription. Twenty-six participants took part in five focus groups (Mean age = 68.2 ± 11.4 years), and the data were analysed using thematic analysis.

RESULTS

We identified three themes. 'Changes to Vision' explores participants' adaptation following cataract surgery. While several had problems with tasks relying on binocular vision, few found them bothersome and they resolved following second eye surgery. Participants described a trial and error approach to solving these problems rather than applying solutions suggested by their eyecare professionals. 'Prescription Restrictions' describes the long-term vision problems that pre-surgery myopic patients experienced as a consequence of becoming emmetropic following surgery and thus needing spectacles for reading and other close work activities, which they did not need before surgery. Very few reported that they had the information or time to make a decision regarding their post-operative correction. 'Information Needs' describes participant's responses to the post-surgical information they were given, and the unmet information need regarding when they can drive following surgery.

CONCLUSION

The findings highlight the need for clinicians to provide information on adaptation effects, assist patients to select the refractive outcome that best suits their lifestyle, and provide clear advice about when patients can start driving again. Patients need to be provided with better guidance from clinicians and prescribing guidelines for clinicians would be beneficial, particularly for the period between first- and second-eye surgery.

Prospective multicenter trial of a small-aperture intraocular lens in cataract surgery

PURPOSE

To evaluate the clinical acceptability of monocular implantation of the small-aperture (IC-8) intraocular lens (IOL) in 1 eye and an aspheric monofocal IOL in the fellow eye of bilateral cataract patients over 6 months postoperatively.

SETTING

Twelve clinics in Austria, Belgium, Germany, Italy, Spain, and Norway.

DESIGN

Prospective case series.

METHODS

The visual acuity, depth of focus, contrast sensitivity, patient satisfaction, visual symptoms, and adverse events were assessed in patients who had bilateral cataract surgery followed by implantation of the small-aperture IOL in 1 eye and an aspheric monofocal IOL in the fellow eye. Uncorrected distance (UDVA), intermediate (UIVA), and near (UNVA) visual acuities were reported in Snellen notation.

RESULTS

The study comprised 105 patients. At 6 months, the UDVA, UIVA, and UNVA in eyes with the small-aperture IOL were 20/23, 20/24, and 20/30, respectively. Ninety-nine percent, 95%, and 79% of patients achieved 20/32 or better binocular UDVA, UIVA, and UNVA, respectively. Ninety-three patients (95.9%) reported they would have the procedure again versus 4 patients (4.1%) who reported they would not have the procedure again. In eyes with the small-aperture IOL, the target-corrected defocus curve measured with 0.75 diopter (D) of myopia extended the range of functional near vision by an additional diopter without loss of distance vision compared with the distance-corrected defocus curves. The mean UIVA and UNVA remained at 20/25 and 20/32, respectively, for up to 1.5 D of residual astigmatism in eyes with the small-aperture IOL.

CONCLUSION

The small-aperture IOL showed excellent visual performance, safety, patient satisfaction, and tolerance to residual astigmatism 6 months after implantation.

Secondary intraocular lens implantation: Complication rates, visual acuity, and refractive outcomes

PURPOSE

To compare complication rates, visual acuity, and refractive outcomes of secondary intraocular lens (IOLs) implantation.

SETTING

Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA.

DESIGN

Retrospective case series.

METHODS

All secondary IOLs placed by the anterior segment service were reviewed. Preoperative data, operative reports, and data from each subsequent postoperative visit were evaluated. Patients were divided into 5 groups based on the final IOL position: (1) sulcus with optic capture, (2) sulcus without optic capture, (3) anterior chamber (AC), (4) iris-fixated, and (5) transscleral-sutured. Complication rates, visual acuity, and refractive outcomes were compared for each group.

RESULTS

The sulcus with and without optic capture groups had the lowest complication rates and best visual acuity outcomes. There was no difference in final corrected distance visual acuity (CDVA) between the transscleral-sutured IOL, iris-fixated IOL, and AC IOL groups, although the AC IOL group had the lowest rates of early postoperative complications and a significant improvement in vision. The transscleral-sutured IOL group had the highest complication rates, and 25% of patients in the iris-fixated IOL group lost 2 or more lines of CDVA.

CONCLUSIONS

When a secondary IOL cannot be placed within the capsular bag, sulcus with optic capture is the best alternative, followed by sulcus without optic capture. There was no difference in visual acuity outcomes between transscleral-sutured IOLs, iris-fixated IOLs, and AC IOLs. Anterior chamber IOLs resulted in fewer early complications.

Surgical removal of dystrophic calcification on a silicone intraocular lens in association with asteroid hyalosis

We present a case of successful removal of late calcium deposition on the posterior surface of a silicone intraocular lens (IOL) optic in association with asteroid hyalosis using a surgical technique that included pars plana vitrectomy, a lighted pick, and a modified silicone-tipped cannula. The lighted pick provided the most efficient and complete removal of calcium deposits. Postoperatively, the dystrophic calcification was removed and the IOL optic was clear at 6 months follow-up. The patient's symptoms resolved and uncorrected distance visual acuity returned to 20/20. This method can be considered in patients with dystrophic calcification of a silicone IOL in association with asteroid hyalosis and might avoid the need for IOL exchange and its associated complications and uncertain refractive outcomes.

Quality of images with toric intraocular lenses

PURPOSE

To objectively evaluate the image quality obtained with toric intraocular lenses (IOLs) when misaligned from the intended axis.

SETTING

University Eye Clinic and the Department of Industrial and Information Engineering, University of Trieste, Trieste, Italy.

DESIGN

Experimental study.

METHODS

An experimental optoelectronic test bench was created. It consisted of a high-resolution monitor to project target images and an artificial eye. The system simulates the optical and geometric characteristics of the human eye with an implanted toric IOL. A 3.00 diopters corneal astigmatism was simulated. Images reproduced by the optical system were captured according to different IOL axis positions. The quality of each image was analyzed using the visual information fidelity (VIF) criterion. The VIF reduction was calculated at each IOL rotational step.

RESULTS

A 5-degree IOL axis rotation from the intended position determined a decay in the image quality of 7.03%. Ten degrees of IOL rotation caused an 11.09% decay of relative VIF value. For a 30-degree rotation, the VIF decay value was 45.85%. Finally, the image decay with no toric correction was 56.70%.

CONCLUSIONS

The more the objective quality of the image decays progressively, the further the axis of the IOL is rotated from its intended position. The reduction in image quality obtained after 30 degrees of toric IOL rotation was less than 50% and after 45 degrees, the image quality was the same as that of no toric correction.

Posterior Segment Visualization in Eyes With Small-Aperture Intraocular Lens

PURPOSE

To evaluate the posterior segment visualization in patients with small-aperture intraocular lens (IOL) implantation.

METHODS

In this prospective, comparative case series, 15 patients who had unilateral implantation of the small-aperture IOL in their non-dominant eyes were recruited. Their fellow eyes were pseudophakic with a monofocal IOL in 14 patients and phakic in 1 patient. All underwent bilateral posterior segment clinical investigations including fundus photography, threshold perimetry, and optical coherence tomography of the posterior pole including optic nerve head. The results from these investigations were graded by a clinician masked to the laterality and type of IOL. Patient 11 developed postoperative endophthalmitis 4 weeks following cataract surgery with implantation of a small-aperture IOL and underwent pars plana vitrectomy. The intraoperative view of the posterior segment was subjectively evaluated by the retinal surgeon.

RESULTS

All 15 patients had successful image captures with all clinical investigative tools with no differences in image quality detected between the images obtained from the monofocal pseudophakic and small-aperture IOL eyes. The small-aperture IOL did not subjectively obstruct the intraoperative view for the retinal surgeon during pars plana vitrectomy.

CONCLUSIONS

Standard posterior segment investigations including non-mydriatic fundus photography, optical coherence tomography, and automated perimetry can be safely and effectively performed in eyes with small-aperture IOLs. There is no difference in the image quality. [J Refract Surg. 2019;35(8):538-542.].

Patients' Expectations in Lens Extraction Surgery: a Systematic Review

It is common knowledge that there are patients who have an uncomplicated cataract surgery with an actual improvement of their visual acuity, but they are dissatisfied with their final visual capacity. It is hypothesized that patients' preoperative expectations play a significant role in their postoperative perceptions. A systematic review of the recent literature regarding preoperative expectations of patients before lens extraction surgery and their postoperative perceptions as regards the visual outcome was performed based on the PubMed, Medline, Google Scholar, American Academy of Ophthalmology, Nature and Springer databases in September 2017 and data from 14 descriptive and 7 comparative studies were included in this narrative review. The objective of this review is the determination of the relationship between preoperative expectations and postoperative perception of visual outcome, as well as the investigation of predictors of patient satisfaction by understanding the factors that determine preoperative patient expectations. A considerable number of studies evaluate patient expectations before cataract surgery and compare them with postoperative patient perceptions. In conclusion, the final patient's postoperative perception could be affected both by the actual outcome of the operation and by patient preoperative expectations. Ocular and systemic comorbidity, unrealistic expectations, preoperative spectacle independence, the cost of surgery, and a previous cataract surgery as well as the level of health literacy and age could influence preoperative expectations and predict more accurately patient satisfaction. Taking these factors into consideration could allow surgeons to control the expectations with an extensive preoperative counseling.

Refractive outcomes following cataract surgery in patients who have had myopic laser vision correction

Objective

Prediction errors are increased among patients presenting for cataract surgery post laser vision correction (LVC) as biometric relationships are altered. We investigated the prediction errors of five formulae among these patients.

Methods and analysis

The intended refractive error was calculated as a sphero-cylinder and as a spherical equivalent for analysis. For determining the difference between the intended and postoperative refractive error, data were transformed into components of Long's formalism, before changing into sphero-cylinder notation. These differences in refractive errors were compared between the five formulae and to that of a control group using a Kruskal-Wallis test. An F-test was used to compare the variances of the difference distributions.

Results

22 eyes post LVC and 19 control eyes were included for analysis. Comparing both groups, there were significant differences in the postoperative refractive error (p=0.038). The differences between the intended and postoperative refractive error were greater in post LVC eyes than control eyes (p=0.012), irrespective of the calculation method for the intended refractive error (p<0.01). The mean difference between the intended and postoperative refractive error was relatively small, but its variance was significantly greater among post LVC eyes than control eyes (p<0.01). Among post LVC eyes, there were no significant differences between the mean intended target refraction and between the intended and postoperative refractive error using five biometry formulae (p=0.76).

Conclusion

Biometry calculations were less precise for patients who had LVC than patients without LVC. No particular biometry formula appears to be superior among patients post LVC.

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.

Patient-reported outcomes of multifocal and accommodating intraocular lenses: analysis of 117 patients 2-10 years after surgery

Purpose

The purpose of this study was to determine the satisfaction levels of patients at least 2 years after cataract surgery implantation with bilateral accommodating or bilateral multifocal intraocular lenses (IOLs) and to determine the relative rate of spectacle independence and adverse symptoms in that same time frame.

Design

Patient questionnaire administered in a single-center private practice at least 2 years after cataract surgery with presbyopia-correcting IOL implantation.

Methods

Patients who had undergone uncomplicated cataract surgery with an accommodating or multifocal IOL implant were eligible for inclusion. Patients with visually significant non-IOL-related postoperative morbidity were excluded. Patients with astigmatism or residual refractive error were not excluded. The main outcome measure was patient satisfaction at least 2 years after IOL implantation.

Results

Sixty-eight patients who received accommodating lenses and 49 patients who received multifocal lenses completed the questionnaire. The mean age of all patients was 75.7 years at the time of survey; the mean number of years since cataract surgery was 5.4 years. Overall, there were no significant differences between the two groups or within each group between the different lenses used. About 90% of patients in each group were “very satisfied” or “somewhat satisfied” with their vision at least 2 years after the initial surgery. Conversely, only one in eleven patients found his vision to be worse than expected.

Conclusions

The majority of patients who received either accommodating or multifocal IOLs remain satisfied with their lens of choice more than 5 years after the original surgery. Glare and halos remain more noticeable in patients who received multifocal lenses.

Small-aperture intraocular lens tolerance to induced astigmatism

Purpose

This prospective, single-site study aimed to assess the corresponding change in monocular visual acuity with induced astigmatic defocus in subjects implanted with a small-aperture intraocular lens (IOL).

Patients and methods

Ten subjects with a mean age of 65.1 years were recruited. Eleven eyes of these 10 subjects were implanted (9 unilaterally, 1 bilaterally) with an IC-8 small-aperture IOL. Baseline manifest refraction and best-corrected distance visual acuity were measured with a Snellen chart (Tumbling E chart). Astigmatic defocus was induced in the same axis as the manifest sphere-cylinder refraction or at 180° for a spherical refraction. Cylinder defocus was reduced in 0.50 D steps from −2.50 D, and distance visual acuity was measured at each level of defocus.

Results

Mean distance visual acuity was 0.08 logarithm of minimum angle of resolution (logMAR) ±0.08 (20/24) at 1.50 D of defocus, 0.18 logMAR ±0.08 (20/30) at 2.00 D of defocus, and 0.24 logMAR ±0.07 (20/35) at 2.50 D of defocus. Eight out of 10 subjects achieved 20/25 or better vision with 1.50 D of cylinder defocus, and all subjects were 20/30 or better. Ten out of 11 subjects were 20/40 or better with 2.50 D of defocus.

Conclusion

The IC-8 IOL shows good tolerance to astigmatic defocus with minimal effect on visual acuity. Overall, 20/25 or better distance acuity was maintained through 1.50 D cylinder defocus.

From Presbyopia to Cataracts: A Critical Review on Dysfunctional Lens Syndrome

Dysfunctional lens syndrome (DLS) is a term coined to describe the natural aging changes in the crystalline lens. Different alterations in the refractive properties and transparency of the lens are produced during the development of presbyopia and cataract, such as changes in internal high order aberrations or an increase in ocular forward scattering, with a potentially significant impact on clinical measures, including visual acuity and contrast sensitivity. Objective technologies have emerged to solve the limits of current methods for the grading of the lens aging, which have been linked to the DLS term. However, there is still not a gold standard or evidence-based clinical guidelines around these new technologies despite multiple research studies have correlated their results with conventional methods such as visual acuity or the lens opacification system (LOCS), with more scientific background around the ocular scattering index (OSI) and Scheimpflug densitometry. In either case, DLS is not a new evidence-based concept that leads to new knowledge about crystalline lens aging but it is a nomenclature change of two existing terms, presbyopia and cataracts. Therefore, this term should be used with caution in the scientific peer-reviewed literature.

Photorefractive keratectomy for correcting residual refractive error following cataract surgery with premium intraocular lens implantation

PURPOSE:

The aim of this study is to evaluate the effectiveness and predictability of photorefractive keratectomy (PRK) for correcting residual refractive error following cataract surgery with premium intraocular lens (IOL) implantation.

METHODS:

We conducted a retrospective review of the medical records of patients who received PRK for correcting residual hyperopia, myopia, and/or astigmatism due to unsatisfied uncorrected distance visual acuity (UDVA) after cataract extraction with implantation of aspheric, diffractive multifocal, or toric IOL from September 2011 to December 2017. Pre-cataract surgery, pre- and post-PRK data including UDVA, best-corrected distance visual acuity, and refractive status were analyzed.

RESULTS:

A total of 18 consecutive eyes in 17 patients were included in this study. The UDVA after PRK improved 1 line or more in 10 eyes, remained unchanged in five eyes, and decreased in three eyes. The overall improvement in the logarithm of minimal angle of resolution (logMAR) UDVA after PRK was significant (P < 0.05). While dividing patients into subgroups based on IOL type, significant improvement in logMAR UDVA was found in patients with aspheric IOL or diffractive multifocal IOL implantation (P < 0.05). No significant improvement of UDVA was found in patients with toric IOL implantation. All eyes achieved ± 1.00 D of the attempted spherical correction, demonstrating good predictability of PRK.

CONCLUSIONS:

PRK was a safe and effective procedure to correct residual refractive error following cataract extraction with premium IOL implantation. Although satisfactory for all patients, the outcome is better and more predictable in patients with aspheric and diffractive multifocal IOL implantation and is less satisfactory and unpredictable in patients with toric IOL implantation.

Predictability of Biometry in Patients Undergoing Cataract Surgery

PURPOSE

To compare measurements of axial length (AL), anterior chamber depth (ACD), keratometry (K), and the refractive predictability of the Aladdin and IOLMaster biometry devices in cataract surgery patients.

METHODS

A retrospective observational study of eyes undergoing cataract surgery. Data were retrieved on AL, ACD, and K measurements obtained by the Aladdin and the IOLMaster. Furthermore, the postoperative refractive prediction errors were compared between the devices.

RESULTS

The study included 127 consecutive eyes of 127 patients undergoing cataract surgery. Mean measurements of AL were not significantly different between the Aladdin (24.18 ± 1.89 mm) and IOLMaster (24.18 ± 1.89 mm) (p = 0.792). Mean K measurements were different between Aladdin (43.84 ± 1.56 D) and IOLMaster (43.97 ± 1.61 D) (p < 0.001). For AL, Aladdin measurements correlated strongly with IOLMaster measurements (r = 0.9997). For K, Aladdin measurements correlated strongly with IOLMaster measurements (r = 0.9912). Fifty-eight of the 127 eyes underwent cataract surgery with a monofocal intraocular lens. For these, mean absolute error (MAE) in predicting refraction relative to the measured postoperative refraction differed between Aladdin (MAE = 0.54 ± 0.40D) and IOLMaster (MAE = 0.49 ± 0.41D) (p = 0.001). After adjustment for the systematic difference in K measurements, the difference in MAE was no longer significant (p = 0.601). The ACD measurements did not differ significantly (p = 0.873) and were well correlated (r = 0.8327).

CONCLUSIONS

A very good correlation was found in AL, K, and ACD measurements between the Aladdin biometer and the IOLMaster. Minimal adjustment for the constant difference in keratometry measurements matched the refractive predictability of both devices.

Monovision Versus Multifocality for Presbyopia: Systematic Review and Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Refractive surgery in presbyopia tends to achieve spectacle independence with minimal optical disturbances. We compared monovision to multifocality procedures regarding these outcomes.

METHODS

We conducted a systematic review of published (till November 21, 2016) randomized controlled trials (RCTs) comparing any monovision to any multifocality method or comparing different monovision/multifocality methods to each other that enabled direct or indirect comparisons between particular monovision and particular multifocality procedures in presbyopic patients undergoing cataract-related or unrelated surgery in respect to spectacle independence, unaided binocular visual acuity (VA), contrast sensitivity (CS), and adverse events.

RESULTS

Three trials comparing monovision (monofocal lenses, LASIK) to multifocal intraocular lenses (MFIOLs; Isert refractive or Tecnis diffractive) and 6 comparing other MFIOLs to Tecnis were included (1-12 months duration). Spectacle independence. All reporting trials were of sufficient quality. Directly, pseudophakic monovision was inferior to Isert (1 trial, N = 75, RR = 0.49, 95% CI 0.28-0.80) and Tecnis (1 trial, N = 211, RR = 0.36, 95% CI 0.25-0.52) in cataract patients, and LASIK was comparable to Tecnis (1 trial, N = 100, RR = 0.93, 0.78-1.10) in refractive surgery. In network meta-regression (6 trials, 14 arms) pseudophakic monovision in cataract patients was inferior to Tecnis. Indirect data suggest also that it is inferior (ReZoom refractive, TwinSet diffractive) or tends to be inferior (Array refractive) to other MFIOLs. LASIK was comparable to Tecnis in refractive surgery. Indirect data suggest also that it tends to superiority vs. ReZoom or Array refractive MFIOLs. Adverse events. No pooling was possible (heterogeneity of assessment and reporting). One quality direct RCT indicated less glare/dazzle with pseudophakic monovision vs. Tecnis in cataract patients. Unaided VA and CS data were burdened with heterogeneity (assessment, reporting) and insufficient quality.

CONCLUSIONS

Randomized comparisons of monovision to multifocality are scarce. Existing estimates regarding spectacle independence (imprecision, indirectness) and particularly regarding unaided VA and CS (assessment/reporting heterogeneity, bias, imprecision, indirectness) are burdened with uncertainty. Dysphotopsia is less common with monovision, but estimate uncertainty is high (bias, imprecision).

Refractive and Visual Outcomes of Different Intraocular Lenses with Femtosecond Laser Cataract Surgery: The Expectation of Independence from Spectacles

PURPOSE

To evaluate the visual performance of different types of intraocular lens (IOL) in eyes submitted to femtosecond laser (FSL) cataract surgery and to analyze whether this technology could result in spectacles independence.

DESIGN

Retrospective comparative case series.

METHODS

Consecutive eyes that were scheduled for FSL cataract surgery were included in this study. After one month postoperative, patients were divided into two groups: cases that required prescription for eyeglasses and cases that did not require prescription. In addition, the patients were analyzed according to the type of IOL that was implanted (monofocal, monofocal toric, multifocal and multifocal toric).

RESULTS

Thirty-five cataract surgeries were analyzed. Twenty-three eyes had a monofocal IOL implanted, and 12 had a multifocal IOL implanted. After 1 month, 12 cases required prescription (Group 1), and 23 did not require prescription (Group 2). The proportion of eyes that did not require corrective lenses was significantly greater (P = 0.02) in eyes that received multifocal IOL (91.67%) compared with those that received monofocal IOL (47.83%). Additionally, 100% of eyes that received multifocal toric IOL did not require eyeglasses at one month postoperatively.

CONCLUSION

The FSL surgical precision associated with modern IOL technology may be an important factor related to vision satisfaction after cataract surgery.

[Clinical practice variation in cataract surgery]

PURPOSE

Cataract surgery rates have dramatically increased in the last two decades. However, clinical practice variation in cataract surgery has not been thoroughly studied. The aim of this review is to analyze clinical practice variation, including the causes and consequences of this phenomenon. Then, its role in health care planning and health care quality is focused, emphasizing the importance of reducing it and providing several practical strategies to accomplish it.

RECENT FINDINGS

The latest researches are presented in this article. They identify the development and implementation of clinical practice guidelines as the best tool to standardize care processes.

CONCLUSION

Managing unwarranted or unwanted variation would improve quality of care and may lead to a significant saving in health care spending.

Changes in corneal astigmatism among patients with visually significant cataract

OBJECTIVE

To determine the prevalence of corneal astigmatism, changes in astigmatism, and biometry measurements with age and to correlate fellow eye measurements of patients undergoing cataract surgery.

DESIGN

Prospective, observational study.

PARTICIPANTS

3498 eyes of 1814 patients undergoing cataract surgery.

METHODS

Setting was a single center teaching hospital. Preoperative biometry data measured by partial coherence interferometry (IOLMaster; Carl Zeiss Meditec, Jena, Germany) were collected and analyzed.

RESULTS

Mean age of the cohort was 74.52 ± 10.23 years. Mean corneal astigmatism was 1.04 ± 0.78 D OD and 1.04 ± 0.79 D OS. About 19.7% and 4.9% of eyes had corneal astigmatism greater than 1.5 and 2.5 D, respectively. The prevalence of against-the-rule astigmatism significantly increased with age bilaterally. Paired fellow eye analysis found a positive correlation for corneal astigmatism, axial length, anterior chamber depth, and white-to-white distance (p < 0.001). About 33.33% of right eyes with corneal astigmatism greater than 2.5 D had more than 2.5 D of astigmatism in the fellow eye. This is in comparison with only 1.5% of right eyes with corneal astigmatism of less than 1.5 D having corneal astigmatism greater than 2.5 D in the fellow eye.

CONCLUSIONS

Patients with high corneal astigmatism in 1 eye are more likely to have significant astigmatism in the fellow eye. This may necessitate the need for bilateral toric intraocular lens (IOL) implantation during cataract surgery. Against-the-rule astigmatism should be treated more aggressively during cataract surgery, because this is likely to worsen with age. Such information is useful when calculating toric IOL power at the time of surgery.

Corrective Techniques and Future Directions for Treatment of Residual Refractive Error Following Cataract Surgery

Postoperative residual refractive error following cataract surgery is not an uncommon occurrence for a large proportion of modern-day patients. Residual refractive errors can be broadly classified into 3 main categories: myopic, hyperopic, and astigmatic. The degree to which a residual refractive error adversely affects a patient is dependent on the magnitude of the error, as well as the specific type of intraocular lens the patient possesses. There are a variety of strategies for resolving residual refractive errors that must be individualized for each specific patient scenario. In this review, the authors discuss contemporary methods for rectification of residual refractive error, along with their respective indications/contraindications, and efficacies.

Technology and Intraocular Lenses to Enhance Cataract Surgery Outcomes-Annual Review (January 2013 to January 2014)

PURPOSE

This article is aimed to provide a clinical update on recent developments in cataract surgical techniques, with specific focus on femtosecond laser technology. The article also focuses on recent improvements in the technology used in implanting intraocular lenses (IOLs).

DESIGN

Literature review.

METHODS

The authors conducted a review of literature available in the last 12 months in the English language using PubMed. The period used to conduct the literature search was from January 1, 2013, to December 31, 2013. The following search terms were used during the PubMed search: phacoemulsification, femtosecond laser, toric IOLs, multifocal IOLs, multifocal toric IOLs, manual small-incision cataract surgery, outcomes, surgically induced astigmatism, rotational stability, trifocal IOLs, laser cataract surgery, safety, and efficacy.

RESULTS

This review incorporates selected original articles that provide fresh insights and updates on the fields of toric and multifocal IOLs, femtosecond laser cataract surgery, and manual small-incision cataract surgery. Particular attention has been paid to observational, randomized controlled clinical trials, experimental trials, and analyses of larger cohorts with prospective and retrospective study designs. Letters to the editor, unpublished works, and abstracts do not fall under the purview of this review.

CONCLUSIONS

This review is not designed to be all-inclusive. It highlights and provides insights on literature that is most useful and applicable to practicing ophthalmologists.