Which intraocular lens would ophthalmologists choose for themselves?

A survey of intraocular lens preferences of UK refractive surgeons for cataract surgery and refractive lens exchange

BACKGROUND

To explore intraocular lens (IOL) preferences of United Kingdom-based (UK) refractive surgeons in cataract and refractive lens exchange (RLE) surgery.

METHODS

An online survey on IOL preferences (and reasons for their choice) in cataract and RLE surgery was distributed. It also enquired about implementing mini-monovision with extended depth of field (EDoF) IOLs, about utilising IOL mix-and-match (different IOL types in each eye), and at what level of corneal astigmatism they prefer toric lenses.

RESULTS

Following an 81.6% response rate, thirty responses were analysed; median years of refractive surgery experience was 12.5. The most popular IOL choices for cataract surgery were EDoF lenses (30%), monofocals (20%), and trifocals (20%). The most cited reason for each was better overall visual outcomes (88.9%), fewer unwanted symptoms (66.7%) and best spectacle independence (66.7%), respectively. For RLE, EDoF remained most popular (36.7%), followed by trifocals (30%), and multifocals (16.7%) with the same reasons for choice cited above. Mini-monovision with EDoF lenses was well-regarded (83% recommend for most/select patients), unlike utilising IOL mix-and-match (60% did not recommend). 40% prefer toric IOLs for astigmatism of 1 dioptre (D) or higher, whilst 30% opt for them at < 1D.

CONCLUSIONS

Experienced UK refractive surgeons prefer newer IOLs with enhanced optics; ≥50% of respondents favoured either EDoF or trifocals for a 'typical' cataract or RLE patient. Notably, respondents have a low corneal astigmatism threshold for toric lenses. Mini-monovision with EDoF IOLs was well-regarded, whilst mix-and-match of different IOL types was less recommended.

BCLA CLEAR Presbyopia: Epidemiology and impact

The global all-ages prevalence of epidemiologically-measured 'functional' presbyopia was estimated at 24.9% in 2015, affecting 1.8 billion people. This prevalence was projected to stabilise at 24.1% in 2030 due to increasing myopia, but to affect more people (2.1 billion) due to population dynamics. Factors affecting the prevalence of presbyopia include age, geographic location, urban versus rural location, sex, and, to a lesser extent, socioeconomic status, literacy and education, health literacy and inequality. Risk factors for early onset of presbyopia included environmental factors, nutrition, near demands, refractive error, accommodative dysfunction, medications, certain health conditions and sleep. Presbyopia was found to impact on quality-of-life, in particular quality of vision, labour force participation, work productivity and financial burden, mental health, social wellbeing and physical health. Current understanding makes it clear that presbyopia is a very common age-related condition that has significant impacts on both patient-reported outcome measures and economics. However, there are complexities in defining presbyopia for epidemiological and impact studies. Standardisation of definitions will assist future synthesis, pattern analysis and sense-making between studies.

Effect of low-degree astigmatism on the objective visual quality

AIM

To evaluate the effect of low-degree astigmatism on objective visual quality through the Optical Quality Analysis System (OQAS).

METHODS

This study enrolled 46 participants (aged 23 to 30y, 90 eyes) with normal or corrected-to-normal vision. The cylindrical lenses (0, 0.5, 0.75, 1.0, and 1.25 D) were placed at the axial direction (180°, 45°, 90°, and 135°) in front of the eyes with the best correction to form 16 types of regular low-degree astigmatism. OQAS was used to detect the objective visual quality, recorded as the objective scattering index (OSI), OQAS values at contrasts of 100%, 20%, and 9% predictive visual acuity (OV100%, OV20%, and OV9%), modulation transfer function cut-off (MTFcut-off) and Strehl ratio (SR). The mixed effect linear model was used to compare objective visual quality differences between groups and examine associations between astigmatic magnitude and objective visual quality parameters.

RESULTS

Apparent negative relationships between the magnitude of low astigmatism and objective visual quality were observed. The increase of OSI per degree of astigmatism at 180°, 45°, 90°, and 135° axis were 0.38 (95%CI: 0.35, 0.42), 0.50 (95%CI: 0.46, 0.53), 0.49 (95%CI: 0.45, 0.54) and 0.37 (95%CI: 0.34, 0.41), respectively. The decrease of MTFcut-off per degree of astigmatism at 180°, 45°, 90°, and 135° axis were -10.30 (95%CI: -11.43, -9.16), -12.73 (95%CI: -13.62, -11.86), -12.75 (95%CI: -13.79, -11.70), and -9.97 (95%CI: -10.92, -9.03), respectively. At the same astigmatism degree, OSI at 45° and 90° axis were higher than that at 0° and 135° axis, while MTFcut-off were lower.

CONCLUSION

Low astigmatism of only 0.50 D can significantly reduce the objective visual quality.

Screening for multifocal intraocular lens implantation in cataract patients in a public hospital

PURPOSE

To identify the rate and characteristics of cataract surgery candidates suitable for multifocal intraocular lens implantation among patients undergoing preoperative evaluation in a public hospital.

MATERIALS AND METHODS

Screening was performed based on the patient's medical records, comprehensive ophthalmic examination, optical biometry (Zeiss, IOL Master 700) and optical coherence tomography (OCT) (Heidelberg, OCT Spectralis) in accordance with the relevant indications and contraindications mentioned in the pertinent literature. Patients were included in the present study if they were eligible for bilateral cataract surgery. The exclusion criteria were the presence of central nervous system or motility issues, prior refractive surgery, the presence of astigmatism greater than 1 dioptre and/or the presence of important ocular comorbidities in either eye.

RESULTS

The study evaluated 1200 consecutive patients. Four hundred thirty-two patients (36%) were not eligible for bilateral surgery and were excluded from the study. Of the 768 patients included in the present study, 346 (45.1%) were considered suitable candidates. Four hundred twenty-two patients (54.9%) were excluded for one or both eyes. Among them, 121 (28.7%) were excluded because of retinal disease, 120 (28.4%) because of regular astigmatism (> 1.0 D of corneal astigmatism), 32 (7.5%) because of pseudoexfoliation or zonular instability, and 30 (7.1%) because of glaucoma or ocular hypertension; in addition, 90 (21.3%) patients were excluded for multiple reasons. Suitable candidates were significantly younger (70 and 75 years, respectively) (p < 0.001). After being informed about the potential risks and benefits of MOIL implantation, 212 of 346 (83.8%) eligible patients provided consent.

CONCLUSION

Close to half of cataract patients in a public hospital were eligible for MOIL implantation, and the majority of patients would proceed to surgery. The most prevalent contraindication was macular disease.

Patient Utilization of Premium Intraocular Lenses Before and During the COVID-19 Pandemic

PURPOSE

To compare the choice of intraocular lens (IOL) and sociodemographic characteristics between patients who underwent elective cataract surgery before the COVID-19 pandemic and during the pandemic at the Wilmer Eye Institute.

METHODS

A retrospective chart review of patients who underwent cataract surgery before the COVID-19 pandemic (June 1 to November 30, 2019) and during the pandemic (June 1 to November 30, 2020) was conducted. Sociodemographic information, including age, sex, race, and insurance, and choice of IOL (premium or standard) were analyzed. The association between timing of surgery and choice of IOL was analyzed using multivariable logistic regression.

RESULTS

The study included 2,877 patients (3,946 eyes) before COVID-19 and 2,564 patients (3,605 eyes) during COVID-19. However, 9.0% (357/3,946) of surgeries before COVID-19 used premium IOLs compared with 11.1% (399/3,605) during COVID-19 ( P =0.004). There was no difference in the racial characteristics of patients between before and during COVID-19. After adjusting for time of surgery and demographics, the odds of choosing premium IOLs for black patients was 0.32 times the odds for white patients ( P <0.001). There was an increase in private-insured patients but a decrease in Medicare-insured patients during COVID-19. After adjusting for time of surgery and demographics, private-insured patients had higher odds of choosing premium IOLs ( P <0.001), whereas Medicaid-insured patients had lower odds ( P =0.007) when compared with Medicare-insured patients.

CONCLUSION

More patients chose premium IOLs during COVID-19 than before COVID-19, concurrent with change in insurance status. White patients were more likely to choose premium IOLs than black patients, as were private-insured patients compared with Medicare-insured patients.

Comparison of postoperative visual performance between trifocal intraocular lens and monofocal intraocular lens

OBJECTIVES

To compare the subjective and objective visual quality more comprehensively after surgery of the commonly used multifocal intraocular lenses (IOL) and monolocal IOL implants through long-term systematic clinical observation, providing reference and basis for clinical application.

METHODS

Non-randomized controlled trial. A total of 91 (138 eyes) patients between June 2020 and December 2020 were implanted trifocal IOL or monofocal IOL after phacoemulsification in a tertiary class hospital in Wuhan. Monocular testing 3 months after surgery included best-spectacles corrected and uncorrected visual at distant, intermediate, and near vision; spherical equivalent (SE); defocus curve; modulation transfer function (MTF); dysfunctional lens index (DLI); Strehl ratio (SR); mesopic contrast sensitivity function; quality-of-life, spectacles independence, visual disturbance, and surgical satisfaction surveys 3 months post-surgery.

RESULTS

There was statistically better uncorrected vision acuity with trifocal IOLs in all range, while monofocal IOL had statistically better mesopic contrast sensitivity at specific spatial frequencies and statistically worse defocus curves, spectacles independence, and surgical satisfaction. The trifocal IOL performed better in subjective quality of vision and life and spectacles independence questionnaires, and the objective quality of vision had no statistical significance.

CONCLUSION

Compared to monofocal IOL, trifocal IOL could provide a full range of clear vision for the majority of patients with simple cataracts, improve the rate of spectacles independence and patient satisfaction. And the objective quality of vision did not show any difference.

Factors associated with good near vision after cataract surgery with monofocal intraocular lens implantation at a tertiary eye hospital in southern India

PURPOSE

Although multifocal intraocular lenses (IOLs) are effective methods of dealing with surgical presbyopia, there are associated limitations (cost, technique, and patient-reported symptoms). Given their scalability challenge (due to economic factors), it is imperative to explore alternative low-cost and sustainable solutions to achieve good near vision postcataract surgery. This study aimed to determine the proportion of and the factors associated with good near vision in patients following cataract surgery with monofocal IOL implantation.

METHODS

We conducted a hospital-based cross-sectional study at a tertiary eye hospital in southern India from September 2019 to January 2020. Inclusion criteria: Uncomplicated postcataract surgery cases with monofocal IOL at least 30 days ago. Exclusion criteria: patients with any ocular condition (other than refractive errors) that could decrease the vision with best-corrected distance visual acuity < 0.18 Logarithm of the Minimum Angle of Resolution (LogMAR) units. Data collection: we assessed near vision (at 40 cm distance by using near vision card with Early Treatment of Diabetic Retinopathy Study format), distance visual acuity (uncorrected and best-corrected), refractive error (amount and type), type of astigmatism, pupil size, axial length, and contrast sensitivity. We considered a near vision of 0.2 LogMAR units or better as good near vision.

RESULTS

Of the 82 patients (82 eyes), 71 (86.59%) had good near vision. Multiple logistic regression analysis found found that the presence of myopia or myopic astigmatism was significantly associated with good near vision (adjusted odds ratio: 72.63; 95% confidence interval: 1.02-5193.5, p = 0.049).

CONCLUSION

About eight of every ten participants had good near vision postcataract surgery with monofocal IOL implantation. Myopia/myopic astigmatism was associated with good near vision.

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

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

Comparison of Clinical Outcomes, Visual Quality and Visual Function of Two Presbyopia-Correcting Intraocular Lenses Made from the Same Material, but with Different Design and Optics

This semi-prospective, parallel, comparative investigation evaluated the clinical outcomes and quality of vision (contrast sensitivity, visual function, dysphotopsia, spectacle use, overall satisfaction) after mono- or bilateral implantation of two presbyopia-correcting intraocular lenses (IOL)-the Liberty® 677MY or the AT LISA® tri 839M-in 50 eyes of 25 cataract patients. Clinical outcomes were assessed 3 and 12 months postoperatively. Eighty-nine percent of eyes implanted with the Liberty IOL and 59% of eyes implanted with the AT LISA IOL achieved a refractive outcome ±0.5 diopters of the target (emmetropia). Refractive outcomes were stable with both lenses. The proportions of eyes with 20/20 uncorrected distance visual acuity (UDVA) and 20/20 uncorrected near visual acuity (UNVA) were higher in the Liberty group than in the AT LISA group (UDVA: 56% vs. 41%; UNVA: 83% vs. 66%). Optical quality assessment results were comparable for the two IOLs. Superior photopic contrast sensitivity was found with the Liberty lens. The rate of Nd:YAG capsulotomy at the 12-month follow-up was 16.7% in the Liberty group and 40.6% for the AT LISA IOL. Considering that both lenses are made from the same material, we propose that the noted differences in clinical outcomes may derive from differences in design and optical surface between the two IOLs.

Iberoamerican Ophthalmologists IOL Selection for Use on Themselves: Survey Results

Purpose

To determine the preferred type of intraocular lens (IOL) that ophthalmologists would choose for themselves in case of cataract surgery.

Design

Prospective convenience questionnaire study.

Materials and Methods

We developed an electronic survey with seven (7) questions, combining multiple and open options. The following categories were established: monofocal (MonoIOL) without monovision (MonoIOL-SM) and with monovision (MonoIOL-CM) and multifocal (MultiIOL) that could be either a bifocal (MultiIOL-B), trifocal (MultiIOL-T) or extended focus (MultiIOL-E). The link for the survey was sent to ophthalmologists from Latin America and Spain through different ways. The 1209 responses were analyzed statistically.

Results

We received 1209 responses from 14 countries. The average age was 47.977 years (SD 11.711 years). Gender distribution was 839 males (72.8%) and 313 females (27.2%). Overall preference was MonoIOL-SM 23.90% (289), MonoIOL-CM 12.16% (147), MultiIOL-B 4.63% (56), MultiIOL-T 34.99% (423), MultiIOL-E 15.22% (110), and unsure 9.10% (110). Ophthalmologists that implant IOLs showed a greater preference for MultiIOL (64%) than those who did not implant IOLs (32.3%). Although all ophthalmologists preferred MultiIOL, anterior segment specialists chose them more frequently (59.1%) than posterior segment specialists (41%).

Conclusion

Ophthalmologists would prefer to receive a multifocal IOL implantation despite the lower frequency of multifocal IOL implantation observed in the general population. The frequency was greater among ophthalmologists who implant IOLs compared to those who do not implant them. It was also greater among those who identified themselves as anterior segment specialists compared to posterior segment specialists.

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