Clinical outcomes with a low add multifocal and an extended depth of focus intraocular lenses both implanted with mini-monovision

Trifocal versus extended depth of focus (EDOF) intraocular lenses after cataract extraction

BACKGROUND

Cataract, defined as an opacity of the lens in one or both eyes, is the leading cause of blindness worldwide. Cataract may initially be treated with new spectacles, but often surgery is required, which involves removing the cataract and placing a new artificial lens, usually made from hydrophobic acrylic. Recent advancements in intraocular lens (IOL) technology have led to the emergence of a diverse array of implantable lenses that aim to minimise spectacle dependence at all distances (near, intermediate, and distance). To assess the relative merits of these lenses, measurements of visual acuity are needed. Visual acuity is a measurement of the sharpness of vision at a distance of 6 metres (or 20 feet). Normal vision is 6/6 (or 20/20). The Jaegar eye card is used to measure near visual acuity. J1 is the smallest text and J2 is considered equivalent to 6/6 (or 20/20) for near vision.

OBJECTIVES

To compare visual outcomes after implantation of trifocal intraocular lenses (IOLs) to those of extended depth of focus (EDOF) IOLs. To produce a brief economic commentary summarising recent economic evaluations that compare trifocal IOLs with EDOF IOLs.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE, Embase, and three trial registries on 15 June 2022. For our economic evaluation, we also searched MEDLINE and Embase using economic search filters to 15 June 2022, and the NHS Economic Evaluation Database (EED) from 1968 up to and including 31 December 2014. We did not use any date or language restrictions in the electronic searches.

SELECTION CRITERIA

We included studies comparing trifocal and EDOF IOLs in adults undergoing cataract surgery. We did not include studies involving people receiving IOLs for correction of refractive error alone (or refractive lens exchange in the absence of cataract).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Two review authors working independently selected studies for inclusion and extracted data from the reports. We assessed the risk of bias in the studies, and we assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies that compared trifocal and EDOF lenses in people undergoing cataract surgery. Three trifocal lenses (AcrySof IQ PanOptix, ATLISA Tri 839MP, FineVision Micro F) and one EDOF lens (TECNIS Symfony ZXR00) were evaluated. The studies took place in Europe and North America. Follow-up ranged from three to six months. Of the 239 enroled participants, 233 (466 eyes) completed follow-up and were included in the analyses. The mean age of participants was 68.2 years, and 64% of participants were female. In general, the risk of bias in the studies was unclear as methods for random sequence generation and allocation concealment were poorly reported, and we judged one study to be at high risk of performance and detection bias. We assessed the certainty of the evidence for all outcomes as low, downgrading for the risk of bias and for imprecision. In two studies involving a total of 254 people, there was little or no difference between trifocal and EDOF lenses for uncorrected and corrected distance visual acuity worse than 6/6. Sixty per cent of participants in both groups had uncorrected distance visual acuity worse than 6/6 (risk ratio (RR) 1.06, 95% confidence intervals (CI) 0.88 to 1.27). Thirty-one per cent of the trifocal group and 38% of the EDOF group had corrected distance visual acuity worse than 6/6 (RR 1.04, 95% CI 0.78 to 1.39). In one study of 60 people, there were fewer cases of uncorrected near visual acuity worse than J2 in the trifocal group (3%) compared with the EDOF group (30%) (RR 0.08, 95% CI 0.01 to 0.65). In two studies, participants were asked about spectacle independence using subjective questionnaires. There was no evidence of either lens type being superior. One further study of 60 participants reported, "overall, 90% of patients achieved spectacle independence", but did not categorise this by lens type. All studies included postoperative patient-reported visual function, which was measured using different questionnaires. Irrespective of the questionnaire used, both types of lenses scored well, and there was little evidence of any important differences between them. Two studies included patient-reported ocular aberrations (glare and halos). The outcomes were reported in different ways and could not be pooled; individually, these studies were too small to detect meaningful differences in glare and halos between groups. One study reported no surgical complications. Three studies did not mention surgical complications. One study reported YAG capsulotomy for posterior capsular opacification (PCO) in one participant (one eye) in each group. One study reported no PCO. Two studies did not report PCO. One study reported that three participants (one trifocal and two EDOF) underwent laser-assisted subepithelial keratectomy (LASEK) to correct residual myopic refractive error or astigmatism. One study reported a subset of participants who were considering laser enhancement at the end of the study period (nine trifocal and two EDOF). Two studies did not report laser enhancement rates. No economic evaluation studies were identified for inclusion in this review.

AUTHORS' CONCLUSIONS

Distance visual acuity after cataract surgery may be similar whether the lenses implanted are trifocal IOLs or EDOF (TECNIS Symfony) IOLs. People receiving trifocal IOLs may achieve better near vision and may be less dependent on spectacles for near vision. Both lenses were reported to have adverse subjective visual phenomena, such as glare and halos, with no meaningful difference detected between lenses.

Comparative efficacy and safety of all kinds of intraocular lenses in presbyopia-correcting cataract surgery: a systematic review and meta-analysis

PURPOSE

To assess the efficacy and safety of various intraocular lenses (IOLs), including standard monofocal, bifocal, trifocal, extended depth of focus (EDOF), and enhanced monofocal IOLs, post-cataract surgery through a network meta-analysis.

METHODS

A systematic search of PubMed, Cochrane Library, and Web of Science was conducted to identify relevant studies from the past 5 years. Parameters such as binocular visual acuities, spectacle independence, contrast sensitivity (CS), and optical quality were used to evaluate efficacy and safety. Data from the selected studies were analyzed using Review Manager 5.4 and STATA 17.0 software.

RESULTS

Twenty-eight Randomized Controlled Trials (RCTs) comprising 2465 subjects were included. Trifocal IOLs exhibited superior uncorrected near visual acuity (UNVA) compared to monofocal IOLs (MD: -0.35; 95% CI: -0.48, -0.22). Both trifocal (AcrySof IQ PanOptix IOLs group MD: -0.13; 95% CI: -0.21, -0.06) and EDOF IOLs (MD: -0.13; 95% CI: -0.17, -0.09) showed better uncorrected intermediate visual acuity (UIVA) than monofocal IOLs. Trifocal IOLs ranked highest in spectacle independence at various distances (AT LISAtri 839MP group: SUCRA 97.5% for distance, 80.7% for intermediate; AcrySof IQ PanOptix group: SUCRA 83.0% for near).

CONCLUSIONS

For cataract patients who want to treat presbyopia, trifocal IOLs demonstrated better visual acuity and spectacle independence at near distances. Different types of trifocal IOL characteristics differ. EDOF and enhanced monofocal IOLs have improved visual quality at intermediate distances.Therefore, It is very important to select the appropriate IOLs based on the lens characteristics and patient needs.

Refraction and defocus curves in eyes with monofocal and multifocal intraocular lenses

Several clinical techniques have been described to evaluate visual performance and optical quality with intraocular lenses (IOL). However, subjective refraction remains one of the most important methods for assessing post-surgery results, taking decisions about retreatments, advanced spectacle prescription and the refinement of the constant for the formula used in the IOL power calculation. Beyond clinical refraction, defocus curve measurement has been described as a complementary tool for assessing visual performance and taking clinical decisions. However, to date, there are no clinical guidelines or evidence-based protocols published in the scientific literature recommended for pseudophakic patients implanted with either monofocal or multifocal IOLs. This narrative review highlights the importance of clinical refraction in pseudophakic eyes, its utility in the decision of different types of IOL implantation, and describes a clinical refraction protocol for eyes implanted with monofocal and multifocal IOLs.

Effectiveness of SMILE Combined with Micro-Monovision in Presbyopic Patients: A Pilot Study

Binocular summation along all defocus range after a micro-monovision procedure has scarcely been studied. The aim of this pilot study was to evaluate the efficacy of SMILE combined with different levels of micro-monovision in presbyopic patients and to assess the binocular summation effect on contrast sensitivity defocus curves (CSDC) at the 6-month follow-up. Efficacy was assessed on the basis of visual acuity (VA) and stereopsis at far, intermediate, and near distances. Patient-reported outcomes (PROs) and binocular CSDC were also evaluated. Six patients completed the study with a programmed median anisometropia of 0.81 Diopter. The median binocular uncorrected VA was better than 0 logMAR at the three evaluated distances, and stereopsis was not impaired in any patient, achieving a median of ≤119 arcsec at any distance. CSDC increased binocularly after surgery, significantly in the range of -2 to -3 D (p < 0.05). No clinically relevant changes were observed in PROs compared with the preoperative period, and all patients achieved spectacle independence at intermediate/near distance and were likely or very likely to undergo the same surgery. In conclusion, micro-monovision with SMILE could be an effective procedure, with results that might be comparable to other laser correction techniques specifically designed for presbyopia correction.

Clinical Outcomes of a New Non-Diffractive Extended Depth-of-Focus Intraocular Lens Targeted for Mini-Monovision

Purpose

To assess visual acuity, binocular defocus curve, spectacle independence, and photic phenomena after bilateral same-day cataract surgery with implantation of an extended depth-of-focus intraocular lens (IOL) with mini-monovision.

Methods

Single-center retrospective study including 124 eyes from 62 patients who underwent bilateral implantation of an isofocal EDOF lens [Isopure® (BVI)] with mini-monovision (-0.50 D). Refraction, visual acuity at different distances, binocular defocus curves, spectacle independence, and subjective ratings of picture-referenced photic phenomena were assessed one to two months postoperatively.

Results

The mean postoperative refractive spherical equivalent was -0.15±0.41D in the dominant eyes and -0.46±0.35D in the mini-monovision eyes (p<0.01). Overall, 98.4% and 87.7% of the eyes were within ±1.00D and ±0.50D of the target refraction, respectively. Postoperative monocular corrected distance visual acuity was -0.04±0.07 logMAR. Binocular uncorrected visual acuity was -0.02±0.07, 0.13±0.11and 0.40±0.20 logMAR for far, intermediate and near, respectively. At the visual acuity threshold of 0.20 logMAR (or better) the defocus curve ranged from -1.6D to +0.9D. Reported spectacle-independence was 96% for far distance, 95% for intermediate, and 34% for near. Five percent of patients reported halos, 16% starburst, and 16% glare. Only 7% of all patients considered them bothersome.

Conclusion

In patients undergoing same-day bilateral cataract surgery, an isofocal EDOF lens provided an extended range of functional vision, up to 63 cm, resulting in useful uncorrected near vision, good uncorrected intermediate vision, and excellent uncorrected distance vision. Subjective patient satisfaction in terms of spectacle independence and photic phenomena was high.

Small Aperture IC-8 Extended-Depth-of-Focus Intraocular Lens in Cataract Surgery: A Systematic Review

The aim of this paper is to evaluate the visual outcomes and patient satisfaction of small aperture IC-8 IOLs in cataract patients with or without prior ocular events. A systematic review of full-length original English studies reporting the visual results of small aperture IC-8 IOL implantation after cataract surgery in three databases, PubMed, Web of Science and Scopus, was performed according to the PRISMA statement. The Quality Assessment Tool for case series studies from the National Heart, Lung, and Blood Institute was used to analyze the quality of the studies selected. The search provided 543 articles, of which 22 were included in this systematic review. Significant improvements in uncorrected distance visual acuity (UDVA); uncorrected intermediate visual acuity (UIVA); uncorrected near visual acuity (UNVA); perception of photic phenomena; and patient satisfaction have been reported. Unilateral and bilateral small aperture IC-8 IOL implantation reduces photic phenomena and provides good vision for all distances with high patient satisfaction and minimal postoperative complications. Therefore, the implantation of this IOL may be recommended for patients with cataracts, corneal irregularities and ocular trauma with partial aniridia.

Clinical Performance of Extended Depth of Focus (EDOF) Intraocular Lenses – A Retrospective Comparative Study of Mini Well Ready and Symfony

Purpose

Extended depth of focus intraocular (EDOF) IOLs form a bridge between single- and multifocal IOL design. This study aimed to compare clinical outcomes obtained after implanting two different optical designs of EDOF IOLs: the Mini Well Ready (SIFI Medtech, Catania, Italy) and Tecnis Symfony (Abbott Laboratories, Illinois, USA).

Methods

The retrospective observational study included 61 patients (122 eyes) who underwent bilateral implantation of the Mini Well Ready IOL (32 patients) or the Tecnis Symfony IOL (29 patients). The following preoperative and postoperative parameters were evaluated: spherical equivalent, anterior astigmatism, pupil size, monocular and binocular uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), monocular and binocular uncorrected intermediate visual acuity (UIVA) and distance-corrected intermediate visual acuity (DCIVA), monocular and binocular uncorrected near visual acuity (UNVA) and distance-corrected near visual acuity (DCNVA). In the 6 months postoperative period, defocus curve, contrast sensitivity, photopic phenomena, and posterior capsule opacification were assessed.

Results

The patients receiving the Tecnis Symfony had slightly better monocular and binocular UDVA and CDVA than with the Mini Well Ready IOL, the differences were not statistically significant. Whereas the UIVA, DCIVA, UNVA, DCNVA, UNVA and DCNVA values were higher in the Mini Well Ready group, the differences were not significant. There were no significant between-group differences regarding the defocus curve for the vast majority of tested vergences. Dysphotopsias postoperatively were assessed at 6 months.

Conclusion

Patients receiving both the Mini Well Ready and Symfony IOLs had excellent visual acuity outcomes and spectacle independence.