Extended Depth-of-Field Intraocular Lenses: An Update

Stereopsis Following Implantation of Presbyopia-Correcting Intraocular Lenses: A Narrative Review

Recent advancements in cataract surgery have broadened its scope from mere vision restoration to include correction of refractive errors and presbyopia. This evolution has introduced multifocal and extended depth-of-focus (EDOF) intraocular lenses (IOLs), allowing enhanced vision across multiple distances. However, the influence of these advanced IOLs on stereopsis remains controversial. Factors influencing stereopsis after surgery include visual acuity, interocular differences, residual astigmatism, and the type of IOL, etc. Binocular vision integration and neuroadaptation further affect stereopsis, especially in cases of presbyopia-correcting IOLs. It is widely acknowledged that bilateral implantation of presbyopia-correcting IOLs yield superior stereopsis compared to unilateral implantation. However, there remains no consensus on whether binocular implantation of multifocal or monofocal IOLs provides superior stereopsis. Most studies suggest no significant difference in stereopsis between these two types of implants. Among different types of multifocal IOLs, refractive multifocal IOLs may offer better stereopsis than diffractive multifocal IOLs when implanted bilaterally. Emerging EDOF and hybrid multifocal-EDOF IOLs also demonstrate promising postoperative stereopsis. Additionally, a mix-and-match strategy with different types of IOLs implanted in each eye may result in interocular differences in visual acuity at certain distances, potentially affecting stereopsis. Nevertheless, with appropriate selection, most patients can achieve satisfactory postoperative stereopsis. This review synthesizes current literature on the effects of presbyopia-correcting IOLs on postoperative stereopsis recovery following cataract surgery. Studies on stereopsis outcomes with different IOLs have yielded mixed results, urging further investigation for optimized surgical strategies and patient outcomes.

BCLA CLEAR presbyopia: Management with intraocular lenses

Cataract surgery including intraocular lens (IOL) insertion, has been refined extensively since the first such procedure by Sir Harold Ridley in 1949. The intentional creation of monovision with IOLs using monofocal IOL designs has been reported since 1984. The first reported implantation of multifocal IOLs was published in 1987. Since then, various refractive and or diffractive multifocal IOLs have been commercialised. Most are concentric, but segmented IOLs are also available. The most popular are trifocal designs (overlaying two diffractive patterns to achieve additional focal planes at intermediate and near distances) and extended depth of focus designs which leave the patient largely spectacle independent with the reduced risk of bothersome contrast reduction and glare. As well as mini-monovision, surgical strategies to minimise the impact of presbyopia with IOLs includes mixing and matching lenses between the eyes and using IOLs whose power can be adjusted post-implantation. Various IOL designs to mimic the accommodative process have been tried including hinge optics, dual optics, lateral shifts lenses with cubic-type surfaces, lens refilling and curvature changing approaches, but issues in maintaining the active mechanism with post-surgical fibrosis, without causing ocular inflammation, remain a challenge. With careful patient selection, satisfaction rates with IOLs to manage presbyopia are high and anatomical or physiological complications rates are no higher than with monofocal IOLs.

Visual outcomes and rotational stability of a new non-diffractive extended-vision toric intraocular lens

OBJECTIVE

To evaluate visual outcomes and intraocular lens (IOL) rotational stability of patients undergoing immediate sequential bilateral cataract surgery with a non-diffractive extended-depth-of-focus toric IOL.

DESIGN

Non-comparative single-centre cohort study.

PARTICIPANTS

Twenty patients (40 eyes) with significant cataracts and corneal astigmatism who underwent immediate sequential bilateral cataract surgery with the AcrySof IQ Vivity Extended Vision Lens (Alcon Laboratories Inc, Fort Worth, Tex.).

METHODS

Binocular uncorrected visual acuities (UCVA) and monocular best-corrected visual acuities (BCVA) were assessed at distance (6 m), intermediate (66 cm), and near (40 cm) postoperatively at 1 week and 3 months. The rotational stability of each IOL was assessed at 1 day, 1 week, and 3 months postoperatively. A validated questionnaire (Questionnaire for Visual Disturbances [QUVID]) was used for patient-reported subjective visual disturbances preoperatively at a 3-month follow-up.

RESULTS

Binocular distance, intermediate, and near UCVAs (mean ± SD) were 0.00 ± 0.16, 0.09 ± 0.08, and 0.14 ± 0.11 logMAR at 1 week and 0.01 ± 0.06, 0.08 ± 0.08, and 0.14 ± 0.07 logMAR at 3 months postoperatively, respectively. Distance monocular BCVA improved from 0.22 ± 0.23 logMAR preoperatively to 0.02 ± 0.06 logMAR at 3 months. Monocular BCVAs at 3 months were 0.08 ± 0.08 logMAR at intermediate distance and 0.05 ± 0.08 logMAR at near distance. IOL rotation from the intended placement axis was 2.5 ± 1.7 degrees at 1 week and 1.7 ± 1.7 degrees at 3 months postoperatively.

CONCLUSIONS

The AcrySof IQ Vivity Extended Vision IOL achieved good UCVAs and BCVAs for distance, intermediate, and near vision. This IOL also provided excellent rotational stability for astigmatism correction.

Changes in visual performance after implantation of different intraocular lenses

AIM

To evaluate the trending visual performance of different intraocular lenses (IOLs) over time after implantation.

METHODS

Ninety-one patients received cataract surgery with implantations of monofocal (Mon) IOLs, segmental refractive (SegRef) IOLs, diffractive (Dif) IOLs, and extended-depth-of-focus (EDoF) IOLs were included. The aberrations and optical quality collected with iTrace and OQAS within postoperative 6mo were followed and compared.

RESULTS

Most of the visual parameters improved over the postoperative 6mo. The postoperative visual acuity (POVA) of the Mon IOL, SegRef IOL, and EDoF IOL groups achieved relative stability in earlier states compared with the Dif IOL group. Nevertheless, the overall visual performance of the 3 IOLs continued to upturn in small extents within the postoperative 6mo. The optical quality initially improved in the EDoF IOL group, then in the Mon IOL, SegRef IOL, and Dif IOL groups. POVA and objective visual performance of the Mon IOL and EDoF IOL groups, as well as POVA and visual quality of the Dif IOL group, improved in the postoperative 1mo and stabilized. Within the postoperative 6mo, gradual improvements were observed in the visual acuity and objective visual performance of the SegRef IOL group, as well as in the postoperative optical quality of the Dif IOL group.

CONCLUSION

The visual performance is different among eyes implanted with different IOLs. The findings of the current study provide a potential reference for ophthalmologists to choose suitable IOLs for cataract patients in a personalized solution.

The Preoperative Factors for the Undercorrection of Myopia in an Extend Depth-of-Focus Intraocular Lens: A Case-Control Study

We aim to investigate the potential risk factors for undercorrection in those who have received extend depth-of-focus (EDOF) intraocular lens (IOL) implantation. A retrospective case-control study was conducted in which patients who had received one type of EDOF IOL implantation were included. The patients were divided into the residual group and non-residual group according to the final postoperative sphere power. The preoperative data include the refractive, topographic, endothelial, and biometric parameters obtained. A generalized linear model was generated to yield the adjusted odds ratio (aOR) and 95% confidence interval (CI) of each parameter of the residual myopia. One month postoperatively, the UDVA was better in the non-residual group than in the residual group (p = 0.010), and the final SE was significantly higher in the residual group than in the non-residual group (p < 0.001). In the multivariable analysis, the high preoperative cycloplegia sphere power, higher TCRP, higher corneal cylinder power, and longer AXL significantly correlated to the presence of postoperative residual myopia (all p < 0.05). Furthermore, the higher preoperative cycloplegia sphere power, higher TCRP, higher corneal cylinder power, longer AXL, larger ACD, and larger WTW were significantly associated with postoperative residual myopia in the high-myopia population (all p < 0.001), while the higher preoperative cycloplegia sphere power, higher TCRP, and longer AXL were related to postoperative residual myopia in the low-myopia population (all p < 0.05). In conclusion, high preoperative myopia and corneal refractive power correlate to high risk of residual myopia after EDOF IOL implantation, especially in the high-myopia population.

A New Methodology for Evaluating the Potential Impact of Residual Refractive Astigmatism in Pseudophakic Patients

Purpose

To validate a new methodology to evaluate the impact of astigmatism in pseudophakia using an astigmatic defocus curve.

Setting

Hospital Oftalmológico de Brasilia, Brazil.

Design

Non-randomized cohort study.

Methods

For every point of the defocus curve, from -2.00 to +3.00 with 0.50D intervals, visual acuity was assessed with optically induced astigmatism (0.50D, 1.00D and 1.50D at 90 and 180 degrees) in pseudophakic patients implanted with a refractive-enhanced intraocular lens.

Results

Twelve patients were analyzed. A statistically significant difference was found between the 90° (ATR) and 180°(WTR) axis with 1.50D astigmatism, providing better visual acuity in ATR astigmatism (p < 0.05).

Conclusion

This new methodology is reproducible, useful and may predict residual astigmatism tolerance in pseudophakic patients, which may help with surgery planning and IOL decision-making.

Current Status of Shared Decision-Making in Intraocular Lens Selection for Cataract Surgery: A Cross-Sectional Study

Purpose

To explore 1) the level of shared decision-making (SDM) participation in intraocular lens (IOL) selection in cataract patients and the factors that influence this participation and 2) the relationships between preparation for decision-making (PrepDM)and the level of SDM participation and satisfaction with the decision (SWD). Provide guidance for improving SDM in ophthalmology.

Patients and Methods

176 cataract patients were asked to complete the PrepDM scale, the 9-item Shared Decision Making Questionnaire (SDM-Q-9) and the SWD instrument in IOL decision-making process. Multiple linear regression was used to analyze the influencing factors of the level of SDM. The Process program and bootstrap sampling method was used to test whether the level of participation in SDM was a mediating variable among the three.

Results

The SDM-Q-9 median score was 77.78 (IQR 31.11-88.89). Patients with a history of surgery in the operative eye (P=0.022) or PrepDM <60 points (P<0.001) had lower SDM-Q-9 scores than patients with no history of surgery in the operative eye or PrepDM ≥60 points. Patients with an education level lower than primary school had lower SDM-Q-9 scores than patients with other education levels (P<0.05). The PrepDM of cataract patients was positively correlated with the level of SDM (r=0.768, P<0.001) and with the SWD (r=0.727, P<0.001), and the level of SDM was positively correlated with the SWD (r=0.856, P<0.001). The level of SDM fully mediated PrepDM and SDW, with a mediating effect value of 0.128 and a mediating effect of 86.66% of the total effect.

Conclusion

The SDM of cataract patients involved in IOL selection was in the upper middle range. Education, history of surgery in the operated eye, and PrepDM were factors that influenced the level of SDM. The level of participation in SDM fully mediated the relationship between PrepDM and SWD.

Extended-depth-of-field imaging with an ultra-thin folded lens

Optical systems with extended depth of field (EDOF) are crucial for observation and measurement applications, where achieving compactness and a substantial depth of field (DOF) presents a considerable challenge with conventional optical elements. In this paper, we propose an innovative solution for the miniaturization of EDOF imaging systems by introducing an ultra-thin annular folded lens (AFL). To validate the practical feasibility of the theory, we design an annular four-folded lens with an effective focal length of 80.91 mm and a total thickness of only 8.50 mm. Simulation results show that the proposed folded lens has a DOF of 380.55 m. We further developed an AFL-based test system exhibiting a resolution of 0.11 mrad across a wide wavelength range of 486-656 nm. Additionally, we present experimental results from a miniature compact prototype, which further highlights the promising potential of folded lenses for long-range EDOF imaging.

Clinical Outcomes after Bilateral Implantation of a Wavefront-Shaping Extended Depth of Focus (EDOF) IOL with Mini-Monovision

Background: To compare the visual outcomes and optical quality of patients who underwent bilateral implantation of EDOF (AcrySof® IQ Vivity IOL, DFT015) for mini-monovision, trifocal (AcrySof® IQ PanOptix, TNFT00), or monofocal (AcrySof® IQ IOL, SN60WF) IOL. Methods: The monocular-corrected and uncorrected distance visual acuities (CDVA and UDVA, respectively) were evaluated postoperatively at 1 and 3 months. The binocular visual acuity by distance, the binocular defocus curve, contrast sensitivity, and patient satisfaction were examined 3 months postoperatively. All patients were asked to complete questionnaires regarding their satisfaction, visual symptoms, and spectacle dependency. Results: This study included 178 eyes from 89 patients. The postoperative binocular UDVA did not differ significantly among the three groups. In the defocus curve, the Vivity group showed better visual acuity over a range of far and intermediate (60 cm) than the other two IOLs groups. In near-vision, the PanOptix group showed the best near-vision, and the Vivity group showed significantly better vision than the IQ group. The Vivity group showed contrast sensitivity and optical quality comparable to the IQ group. Conclusions: The bilateral implantation of AcrySof® IQ Vivity IOL with the mini-monovision approach provided excellent distance and intermediate visual acuity with good near-vision, resulting in high satisfaction.

Risk Factors for Corneal Monochromatic Aberrations and Implications for Multifocal and Extended Depth-of-Focus Intraocular Lens Implantation

PURPOSE

To discuss factors influencing corneal aberrations that might influence the optical quality after intraocular lens (IOL) implantation.

METHODS

PubMed and Scopus were the main resources used to search the medical literature. An extensive search was performed to identify relevant articles concerning factors influencing the level of corneal aberrations as of August 27, 2023. The following keywords were used in various combinations: corneal, aberrations, defocus, astigmatism, spherical aberration, coma, trefoil, quadrafoil, intraocular lens, and IOL.

RESULTS

Conclusive evidence is lacking regarding the correlation between age and changes in corneal aberrations. Patients with astigmatism have greater corneal higher-order aberrations than those with minimal astigmatism, particularly concerning trefoil and coma. Increased levels of corneal higher-order aberrations are noted following contact lens wear, in patients with dry eye disease, and with pterygium. Increased higher-order aberrations have been reported following corneal refractive surgery and for 3 months following trabeculectomy; regarding intraocular lens surgery, the results remain controversial.

CONCLUSIONS

Several factors influence the level of corneal higher-order aberrations. Multifocal and extended depth-of-focus IOLs can share similarities in their optical properties, and the main difference arises in their design and performance with respect to spherical aberration. Preoperative evaluation is critical for proper IOL choice, particularly in corneas with risk of high levels of aberrations. [J Refract Surg. 2024;40(6):e420-e434.].

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.

Optical and aberrometric evaluation of a new enhanced monofocal intraocular lens with isofocal optic design

PURPOSE

To evaluate the optical and aberrometric outcomes of an enhanced monofocal intraocular lens (ISOPure) compared with those of a standard monofocal lens (MicroPure) having the same platform and material.

METHODS

A prospective, comparative and randomised clinical study. A total of 28 eyes of 28 patients were randomly assigned to either group. Monocular visual acuity (VA) was measured at distance and intermediate under photopic and mesopic conditions. Aberrometry was analysed for 3.0-, 4.0-, 4.5- and 5.0 mm pupils. The contrast sensitivity defocus curve was measured for 3.0- and 4.5-mm pupils, while the modulation transfer function (MTF) and Strehl ratio (SR) were assessed with a double-pass system. All measurements were performed monocularly 3 months after surgery.

RESULTS

No significant differences were found for distance VA. Under photopic conditions, intermediate VA was better with the ISOPure lens, while no significant differences were found between the lenses under mesopic conditions. Internal and total aberrations were higher for the ISOPure lens. No significant differences were found for corneal aberrations. Additionally, both the contrast sensitivity defocus curve and optical quality showed similar behaviour for each lens, with the MTF cut-off frequency exceeding 30 c/deg in both cases.

CONCLUSION

The isofocal ISOPure lens enhanced intermediate VA without affecting distance VA under photopic conditions. Moreover, there were no significant differences in visual quality between the ISOPure and MicroPure lenses, despite the former exhibiting higher internal and total aberrations than the monofocal model.

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.

Comparison of modal and zonal wavefront measurements of refractive extended depth of focus intraocular lenses

Extended depth-of-focus (EDoF) intraocular lenses (IOLs) are typically evaluated using commercially available aberrometers. Given the intricate optical design of these IOLs, employing an appropriate wavefront reconstruction method with a sufficient sampling resolution of the aberrometer is crucial. A high-resolution Shack-Hartmann wavefront sensor was developed by magnifying the pupil aperture by a factor of five onto a lenslet array (pitch: 133 µm) and utilizing a full-frame CMOS sensor (24 by 36 mm), resulting in a 26.6 µm sampling resolution. Zonal wavefront reconstruction was used and compared with Zernike-based modal wavefront reconstruction to retain detailed local slope irregularities. Four refractive EDoF IOLs with a power of 20D were examined, and the wavefront difference between the zonal and modal methods, expressed as the root mean squared error (RMSE), remained significant for two of the IOLs up to the 16th-order Zernike spherical aberrations (SAs). Conversely, a negligibly small RMSE was observed for the other two IOLs, as long as the Zernike SAs were higher than the 6th order. The raytracing simulation results from the zonal wavefronts exhibited a stronger correlation with the results of recent optical bench studies than those from the modal wavefronts. The study suggests that certain recent refractive EDoF IOLs possess a complex optical profile that cannot be adequately characterized by limited orders of SAs.

Refractive extended depth-of-focus lens design based on periodic power profile for presbyopia correction

PURPOSE

Limitations of existing diffractive multifocal designs for presbyopia correction include discrete foci and photic phenomena such as halos and glare. This study aimed to explore a methodology for developing refractive extended depth-of-focus (EDoF) lenses based on a periodic power profile.

METHODS

The proposed design technique employed an optical power profile that periodically alternated between far, intermediate and near distances across the pupil radius. To evaluate the lens designs, optical bench testing was conducted. The impact on visual performance was assessed using a spatial light modulator-based adaptive optics vision simulator in human subjects. Additionally, the effects of pupil size change and lens decentration on retinal image quality were examined. A comparative performance analysis was carried out against a typical diffractive trifocal design and a monofocal lens.

RESULTS

The proposed design method was found to be effective in uniformly distributing light energy across all object distances within the desired depth of focus (DoF). While trade-offs between overall image quality and DoF still exist, the EDoF lens design, when tested in human subjects, provided a continuous DoF spanning over 2.25 D. The results also revealed that the EDoF design had a slightly higher dependence on changes in pupil size and lens decentration than the diffractive trifocal design.

CONCLUSION

The proposed design method showed significant potential as an approach for developing refractive EDoF ophthalmic lenses. These lenses offer a continuous DoF but are slightly more susceptible to variations in pupil size and decentration compared with the diffractive trifocal design.

Cataract surgery with new monofocal intraocular lens enhanced for intermediate vision and standard monofocal intraocular lens for retinal disorder

AIM

To investigate the difference in the initial surgical results between a new monofocal intraocular lens (IOL) with enhanced intermediate vision and the standard monofocal IOL in patients with retinal disease.

METHODS

We retrospectively reviewed the medical records of patients with retinal disease who underwent cataract surgery due to accompanying cataracts. Types of retinal diseases were investigated and best-corrected distant visual acuity, distant uncorrected visual acuity (UCVA), intermediate UCVA, near UCVA, and spherical equivalent were recorded at each visit. The surgical results were investigated at 1 day, 1 week, and 1 month after surgery.

RESULTS

Seventeen eyes treated with a new monofocal IOL enhanced for intermediate vision (ICB00 group) and 18 eyes treated with the standard monofocal IOL (AAB00 group) were included in this study. There were no significant differences in the baseline characteristics, including the type of underlying retinal disease, between the groups. There were no significant differences between the groups in terms of distant, intermediate, or near UCVA at day 1 and week 1 after surgery. However, at 1 month after surgery, the ICB00 group showed a significantly better intermediate vision improvement than the AAB00 group (p = 0.001).

CONCLUSION

Even in patients with cataract accompanied by retinal disease, the use of the ICB00 IOL showed significant improvement in intermediate vision compared to the use of the AAB00 (standard monofocal) IOL. The ICB00 IOL might be a good option for patients with cataract and retinal disease in the era of increased intermediate vision needs in daily life.

Visual performance and patient preference with bilateral implantation of an extended depth of focus or combined implantation of an extended depth of focus/trifocal intraocular lens

PURPOSE

Evaluate postoperative visual performance in patients with bilaterally implanted AT LARA or AT LARA/AT LISA tri (Carl Zeiss AG, Jena, Germany) intraocular lenses.

METHODS

Multicentered, comparative, open-label, retrospective/prospective study. Post-IOL implantation, patients were prospectively enrolled into this study; preoperative patient data were collected retrospectively. Follow-up was at 2-4 and 5-8 months post-surgery. The primary endpoint was binocular best corrected distance visual acuity (CDVA). The study was retrospectively registered on clinicaltrials.gov (#NCT05462067).

RESULTS

Seventy-one patients (142 eyes) were enrolled; 67 patients (134 eyes) have 5-8 months data. The mean binocular CDVA at 2-4 months was -0.10 ± 0.06 logMAR in the bilateral AT LARA group ("bilateral") and -0.11 ± 0.09 logMAR in the combined implantation AT LARA/ AT LISA tri group ("combined implantation"); (P = 0.4856). At 5-8 months, mean binocular CDVA was -0.13 ± 0.06 logMAR in the bilateral group and -0.11 ± 0.09 in the combined implantation group (P = 0.4003). At 5-8 months, more eyes in the bilateral group attained 0.2 logMAR or better binocular uncorrected intermediate VA (UIVA; 67 cm) than those in the combined implantation group (100% vs. 94%, respectively). The bilateral group achieved a mean of 0.24 ± 0.11 logMAR in uncorrected near VA (UCNVA), compared to a mean of 0.16 ± 0.12 logMAR in the combined implantation group at 5-8 months (P = 0.0041).

CONCLUSIONS

A combined implantation approach (AT LARA in the distance dominant eye/AT LISA tri in the non-dominant eye) produced similar CDVA outcomes but better UCNVA as bilateral implantation with the AT LARA. UIVA was comparable between groups. No new safety concerns were reported.

Extended Depth-of-Focus Intraocular Lens Implantation in Patients with Age-Related Macular Degeneration: A Pilot Study

Purpose

To assess visual outcomes of the implantation of a non-diffractive extended depth of focus (EDOF) intraocular lens (IOL) in patients with age-related macular degeneration (AMD).

Setting

Ophthalmology practice, Sydney, Australia.

Design

Retrospective chart review.

Methods

Patients with AMD undergoing cataract surgery and receiving non-diffractive EDOF AcrySof IQ Vivity IOL implantation over a 2-year period were identified. Corrected distance visual acuity (CDVA), distance-corrected near visual acuity (DCNVA; 50 cm), contrast sensitivity, central foveal thickness, VF-14 questionnaire results, and quality of life where available were analyzed.

Results

A total of 28 sequential patients (51 eyes) were included in this pilot study (46% male, mean age 77.4 years). Of 27 eyes that had late AMD, 17 (63%) had wet AMD. Mean patient preoperative CDVA was logMAR 0.32±0.29. Postoperative monocular CDVA and DCNVA were logMAR 0.20±0.25 and N9±5 (range N5-N36), respectively. Eyes achieving postoperative CDVA of Snellen 6/5-6/12 (n=42, 82%), 6/15-6/24 (n=7, 14%), and greater than 6/24 (n=2, 4%) achieved a mean DCNVA of N8 (range N5-N10), N13 (range N10-N18), and N27 (range N18-N36), respectively. Eyes achieving CDVA of Snellen 6/5-6/12 showed contrast sensitivity within the normal range. On postoperative VF-14 questionnaire, patients with CDVA of Snellen 6/5-6/12 reported minimal visual impairment, while patients with CDVA greater than 6/15 reported mild impairment. A majority of patients (96%, n=27) were satisfied with the improvement in quality of life postoperatively. No intraoperative complications were reported.

Conclusion

The EDOF AcrySof IQ Vivity IOL provides improved near vision proportional to distance vision in patients with early AMD.

The BVI ISOPURE® 123 intraocular lens: a new hydrophobic preloaded extended monofocal IOL with intermediate vision correction

The BVI ISOPURE® intraocular lens (IOL) (PhysIOL, Liege, Belgium) is a fully refractive, aspherical, monofocal lens based on isofocal technology. Isofocal technology provides cataract patients distance vision quality combined with improved unaided intermediate vision by accentuating the extended depth of field/focus (EDOF) effect whilst inducing minimal photic phenomena.

Methods

PubMed, Web of Science, Scopus, and Google Scholar searches were conducted for published research articles featuring the ISOPURE 123 IOL.

Results

Excellent uncorrected and corrected binocular distance visual acuity of at least 20/25 can be achieved; uncorrected binocular intermediate vision of 20/25 or better in 81% and 50% at 80 cm and 66 cm, respectively, and 42% binocular near vision of 20/40 or better can be achieved. The defocus curve showed good visual acuity at far and intermediate distances with a depth of focus value of 1.50 D. Photic phenomena are minimal compared to other EDOF IOLs. Excellent contrast sensitivity was maintained compared to a standard monofocal IOL.

Conclusion

Studies show that this isofocal optic design IOL provides excellent visual performance for far vision and functional intermediate vision with an increased range of vision with few photic phenomena. This lens is an effective option for providing functional intermediate vision and correcting aphakia.

Functional Classification of Intraocular Lenses Based on Defocus Curves: A Scoping Review and Cluster Analysis

PURPOSE

To explore a potential functional classification of intraocular lenses (IOLs) based on monocular visual acuity defocus curves (VADCs) as a primary end-point.

METHODS

A systematic literature search was conducted using PubMed. Two independent reviewers screened the literature for inclusion and data extraction. Inclusion criteria were full-text primary clinical studies of IOLs, published in English from 2010 onward, involving patients undergoing cataract or refractive lens exchange. A cluster analysis was conducted to explore similarities in the range of field (RoF) and increase of visual acuity from intermediate to near (ΔVA).

RESULTS

A total of 107 studies were ultimately included from the 436 identified in the systematic search, with an additional 5 studies added through the snowballing technique search. The cluster analysis was conducted using 69 reports that included monocular VADCs. Two main categories were identified based on the achieved RoF for 0.2 and 0.3 logMAR: full (FRoF) and partial (PRoF) RoF IOLs. Three subcategories were identified for FRoF depending on ΔVA: continuous (FRoF-C), smooth (FRoF-Sm), and steep (FRoF-St). On the other hand, PRoF IOLs shared the characteristic of monotonous decrease in visual acuity and were subclassified into two subcategories depending on the achieved RoF: narrowed (PRoF-N) and extended (PRoF-Ex). An additional subcategory was added to PRoF, enhanced (PRoF-En), for 7 reports alternating between PRoF-N and PRoF-Ex depending on the use of 0.2 or 0.3 logMAR as a cut-off for calculating the RoF.

CONCLUSIONS

IOLs can be functionally classified into six types depending on the RoF and shape of the monocular VADC. [J Refract Surg. 2024;40(2):e108-e116.].

Clinical outcomes after implantation of a new monofocal intraocular lens with enhanced intermediate function in patients with preperimetric glaucoma

Purpose

We evaluated the clinical outcomes after implantation of a new monofocal intraocular lens (IOL) with enhanced intermediate function in patients with preperimetric glaucoma and compared those with patients without retinal nerve fiber layer (RNFL) defects.

Methods

All patients were implanted bilaterally a new monofocal IOL with enhanced intermediate function. Patients with bilateral RNFL defects and no glaucomatous visual field defects were classified as the preperimetric glaucoma group. A total of 60 eyes of 30 patients with preperimetric glaucoma were compared with 60 eyes of 30 patients without RNFL defects. Uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), uncorrected near visual acuity (UNVA), defocus curve, contrast sensitivity, and questionnaire were evaluated 1 month and 3 months after surgery.

Results

No difference in binocular UDVA, UIVA, and UNVA was evident between the two groups at 1 and 3 months postoperatively. Additionally, there were no significant differences between the two groups regarding the proportion of severe or very severe photic phenomena, such as glare and halos, or the overall satisfaction.

Conclusion

Bilateral implantation of a new monofocal IOL with enhanced intermediate function in patients with preperimetric glaucoma demonstrated commensurate clinical outcomes and could be considered a feasible alternative.

Patient Perception and Self-Reported Outcomes with Presbyopia-Correcting Intraocular Lenses (PCIOLs): A Social Media Listening Study

INTRODUCTION

Presbyopia-correcting intraocular lens (PCIOL) implantation is a popular treatment option for cataract surgery patients who desire spectacle independence. This study aimed to understand patient perception and outcomes with PCIOLs by analyzing patient social media posts.

METHODS

This was a non-interventional retrospective study that used predefined search strings to identify publicly available social media data discussing patient perceptions and outcomes with seven PCIOLs (three trifocal, one multifocal with continuous range of vision, and three extended depth-of-focus [EDOF] PCIOLs). Relevant posts were searched from Reddit, YouTube, and Facebook and patient forums Patient.info, Medicine.net, Optiker-Forum, and Medizin Forum from September 2020 to October 2022 in four languages (English, German, French, and Spanish).

RESULTS

A total of 2237 posts were included, all in English, with 68% of posts identified on Patient.info. The themes most discussed by patients were quality of vision (69% of total posts), patient experience after PCIOL implantation (30%), patient perception before PCIOL implantation (26%), and visual disturbances (24%). Most discussed PCIOLs were Vivity® (58% of total posts), PanOptix® (38%), Synergy® (26%), and Symfony® (13%). Patient perception of PCIOLs was most frequently influenced by healthcare professionals, online reading, and online videos (31%, 18%, and 15% of posts, respectively). A total of 215 posts (10% of total) discussed glasses use after PCIOL surgery: for EDOF and trifocal/multifocal PCIOLs, 37% and 56% of posts discussing glasses use stated being glasses free, respectively. A total of 537 posts discussed visual disturbances: halos/rings (66%) and starbursts (36%) were the most discussed visual disturbances for all lens types. Being glasses free after PCIOL implantation appeared to be a key driver of patient satisfaction.

CONCLUSION

Social media provides a rich source of information on patient perception, experience, and overall satisfaction of PCIOLs that can be used to complement and guide the collection of further evidence generated through controlled trials.

Applications of the pinhole effect in clinical vision science

The pinhole effect is commonly used to discriminate uncorrected refractive error from ocular diseases. A small aperture limits the width of light beams entering the eye, thus increasing the depth of focus. The pinhole effect has also been used in spectacles, contact lenses, corneal inlays, and intraocular lenses (IOLs) to improve reading by compensating for loss of accommodative function. Pinhole spectacles improve near visual acuity, but reduce reading speed, increase interblink interval, and decrease tear break-up time. For contact lenses and IOLs, pinhole devices are usually used in the nondominant eye, which allow compensation of various refractive errors and decrease spectacle dependence. Pinhole corneal inlays are implanted during laser in situ keratomileusis or as a separate procedure. Pinhole IOLs are gaining popularity, particularly as they do not bring a risk of a local inflammatory reaction as corneal inlays do. Disadvantages of using the pinhole effect include high susceptibility to decentration, decrease in retinal luminance levels, and difficulties in performing fundus examinations or surgery in eyes with implanted devices. There are also concerns regarding perceptive issues with different retinal illuminances in the 2 eyes (the Pulfrich effect).

Vehicle Headlight Halo Simulation of Presbyopia-Correcting Intraocular Lenses

Purpose

This optical bench study was designed to evaluate and compare the halos generated by presbyopia-correcting intraocular lenses (PCIOLs) and monofocal intraocular lenses (IOLs), with or without lens decentration, using an optical bench to simulate the headlight of a distant vehicle in mesopic conditions.

Methods

Halos generated by six nondiffractive and 10 diffractive IOLs with different dioptric add powers were evaluated using a high dynamic range bench system. Halo intensities were compared by assessing the area under the measured intensity profile curve to compute the relative halo magnitude (RHM).

Results

Nondiffractive PCIOLs produced smaller and less intense bench halo images than diffractive ones. RHM measurements ranged from 964 to 1896. Monofocal IOLs produced lower RHM values, whereas diffractive PCIOLs generated higher ones. When decentered by 0.5 mm with respect to the system aperture, more obviously asymmetric halo image profiles were observed in diffractive compared with nondiffractive PCIOLs.

Conclusions

Simulated bench halos of nondiffractive PCIOLs are smaller and less intense than those of diffractive PCIOLs. Additional clinical studies assessing standardized patient-reported outcomes measures are required to correlate these bench results with patient satisfaction.

Translational Relevance

This study contrasts the design-related simulated bench halos of nondiffractive and diffractive PCIOLs, aiming to elucidate their impact on halo perception.

Descemet membrane endothelial keratoplasty combined with presbyopia-correcting and toric intraocular lenses - a narrative review

Fuchs endothelial corneal dystrophy (FECD) is the leading indication for EK and may coexist with cataract and presbyopia. Notably, the outcomes of phacoemulsification in FECD patients are not as favorable as those in eyes without this condition. Historically, only monofocal intraocular lenses (IOLs) were recommended for these patients. However, recent reports have described the implantation of Premium-IOLs (such as Multifocal IOLs, Enhanced Depth of Focus IOLs, and Toric IOLs) in FECD eyes undergoing cataract surgery and Descemet membrane endothelial keratoplasty (DMEK). While the results are encouraging, they are not as optimal as those from unoperated eyes, especially when comparing simultaneous procedures to sequential ones. It's advised to perform the DMEK first to improve the accuracy of IOL calculations. Still, even successfully operated eyes may experience secondary graft failure or graft rejection after DMEK. The success rate of a secondary DMEK is typically lower than that of the initial procedure. Furthermore, if the postoperative thickness after DMEK is less than anticipated, laser enhancements might not be an option. There's a pressing need for more controlled and randomized clinical trials to ascertain the safety and effectiveness of Premium-IOLs for FECD eyes. This narrative review aims to collate evidence on the use of Premium IOL technologies in eyes receiving EK and to underscore key points for surgeons performing EK combined with cataract surgery.

Comparison of the optical behaviour of five different multifocal diffractive intraocular lenses in a model eye

The purpose of this study was to investigate and compare the optical performance of five trifocal intraocular lenses (IOLs) following the ISO 11979-2 standards, analysing the impact of tilt and decentration. Five different diffractive trifocal IOLs were evaluated in this experimental study: Acriva Trinova (VSY-Biotechnology) (AT), FineVision HP (PhysIOL) (FVHP), AT LISA tri 839 MP (Zeiss) (ATLT), PanOptix TFNT00 IOL (Alcon) (PO), and Tecnis Synergy (J&J Vision) (TS). In-vitro optical quality analysis of them was performed with the Lambda PMTF system that has an aberration neutral cornea model (Lambda-X Ophthalmics). Measurements were performed on-axis, with 5º of IOL tilt and with 0.5 mm of IOL decentration using 543-nm monochromatic light. Finally, IOL dimensions and diffractive disk profile inspection was performed using the VisIOLA system (Rotlex). On-axis measurements showed a far through-focus MTF > 0.3 at 3 mm aperture, except for TS. FVHP and PO showed better far MTFs for larger apertures (3.75 mm and 4.5 mm) while AT showed good intermediate and near vision for such apertures. With 5º of IOL tilt, the better optical performance at all distances was found with AT for medium-sized pupils (3 mm) and an important reduction of MTF was found for ATLT and PO, especially in the intermediate focus. The induction of 0.5 mm of IOL decentration especially affected the intermediate focus of ATLT and TS and the far focus of FVHP and PO. IOL dimensions and diffractive profile were consistent with those described by the manufacturer. In conclusion, there are differences in the optical performance according to the pupil aperture of the five trifocal IOLs evaluated and this should be considered in clinical practice when selecting the most appropriate implant in each specific case. IOL tilt and decentration can affect significantly in most of the designs evaluated the performance of the IOL at intermediate vision range. It should be noted that measurements were made with an aberration-free cornea, being necessary future studies analysing the impact of different levels of corneal aberrations.

A comparative evaluation of three extended depth of focus intraocular lenses

PURPOSE

To compare the refractive and visual performance of three Extended Depth of Focus (EDOF) intraocular lenses (IOLs) after uncomplicated cataract surgery.

SETTING

Centre IRIDIS, Albi, France.

DESIGN

Comparative retrospective study.

METHODS

Patients with cataracts and without other eye diseases were enrolled for monocular implantation of EDOF IOLs on the dominated eye by the same surgeon between 2018 and 2021, using either the IsoPure (BVI-PhysIOL, Belgium), the Synthesis+ (Cutting Edge, France), or the Lucidis (SAV-IOL, Swiss). Refraction, Uncorrected Distance Visual Acuity (UDVA), Corrected Distance VA (CDVA), Uncorrected Near VA (UNVA), Distance-Corrected Near VA (DCNVA), 25% Contrast CDVA, and Defocus Curve were assessed 3-months postoperatively.

RESULTS

A total of 64 eyes of 64 patients were included in this study (IsoPure n = 22; Synthesis+ n = 20, Lucidis n = 22). CDVA, 25% Contrast CDVA and DCNVA were significantly better for Lucidis than IsoPure or Synthesis+. No significant difference was observed for CDVA and 25% Contrast CDVA between IsoPure and Synthesis+. DCNVA was significantly better for Lucidis and Synthesis+ with respectively 0.08 LogMAR ± 0,09 and 0.29 LogMAR ± 0.13, compared to 0.40 LogMAR ± 0.17 for IsoPure (p < 0.05).

CONCLUSIONS

Lucidis showed more efficient distance, low contrast, and near vision than IsoPure and Synthesis+. Synthesis+ seems to be more efficient in intermediate vision than other groups. Each EDOF IOLs provided good distance vision without creating spontaneous complaints of photic phenomena. Refractive EDOF IOLs, especially Lucidis, are efficient for patients wishing to improve their vision without dysphotopsia.

Extended depth of focus intraocular lens versus a new monofocal intraocular lens: A prospective comparative and interventional study

PURPOSE

To compare the visual outcome findings between a new monofocal intraocular lens (IOL) (Tecnis Eyhance) and extended depth of focus (EDOF) IOL (Appasamy Supraphob Infocus).

METHODS

This prospective comparative interventional study evaluated 31 patients after implantation of Tecnis Eyhance (15 patients) and Supraphob EDOF IOL (16 patients). The uncorrected and corrected distance and intermediate and near visual acuity were measured at postoperative day 1, 1 week, 4 week, and 3 months. Contrast sensitivity, incidence of halos and glares, and patient satisfaction were assessed at 3 months postoperatively.

RESULTS

The Tecnis Eyhance (n = 15) and Supraphob EDOF (n = 16) group were comparable with respect to all preoperative parameters including biometry, visual acuity, and cataract status. The average age distribution of participants was 56 ± 6 years. Postoperatively, both groups had similar distance and intermediate vision, but the near vision was significantly better in the EDOF group (P < 0.01) as compared to Tecnis Eyhance at 3 months. The contrast sensitivity and patient satisfaction were similar in both the groups. The incidence of halos and glares was present in the EDOF group, but it was statistically insignificant.

CONCLUSION

The Tecnis Eyhance and Supraphob EDOF both were effective in improving distance and intermediate vision, but the near vision was significantly better in the EDOF group. Both the groups retained good contrast sensitivity and the majority of patients were satisfied.

Visual performance and subjective experience 3 months and 12 months after combined implantation of 2 new complementary continuous phase multifocal intraocular lenses

PURPOSE

To assess the 3-month and 12-month postoperative visual performance and subjective quality of vision (QoV) after combined implantation of complementary continuous phase multifocal intraocular lenses (IOLs).

SETTING

Private practice, United Kingdom.

DESIGN

Case series.

METHODS

The study enrolled 44 patients undergoing phacoemulsification with implantation of an Artis Symbiose Mid in the dominant eye and an Artis Symbiose Plus in the nondominant eye. Refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity, uncorrected intermediate visual acuity (UIVA), uncorrected near visual acuity (UNVA), electronic reading desk, and a QoV questionnaire were evaluated at 3 months and 12 months postoperatively.

RESULTS

The mean binocular UDVA was -0.06 ± 0.08 logMAR and -0.07 ± 0.06 logMAR at 3 months and 12 months ( P = .097), respectively. The mean binocular UIVA was 0.03 ± 0.13 logMAR and 0.03 ± 0.10 logMAR ( P = 1.0), respectively. The mean binocular UNVA was 0.07 ± 0.10 logMAR and 0.07 ± 0.08 logMAR ( P = .875), respectively. There was a significant improvement in QoV for both day and night between 3 and 12 months, with a significant reduction in halos at 12 months. Spectacle independence was reported in 93.2% of cases at 12 months.

CONCLUSIONS

The Artis Symbiose Mid and Plus IOL combined implantation provided an excellent range of uncorrected vision at 3 and 12 months. There was a significant improvement in QoV and less halos at 12 months. This IOL combination provided very high rates of complete spectacle independence.

Spherical aberrations and their role in modern ophthalmology

Spherical aberration is an imperfection of the optical system of the human eye. The role of spherical aberration of the human eye in the quality of vision and pseudoaccommodation is reviewed. Spherical aberration is an imperfection of the optical system of the human eye. In most cases, due to well-developed neuroadaptation, it is insignificant for the perception of the image. Nevertheless, its role in modern ophthalmology is far from straightforward. On the one hand, there are clinical scenarios in which an excess of spherical aberration degrades the retinal image and leads to a high dissatisfaction rate among patients.©Recently, there is a growing interest in the modulation of spherical aberration in the clinical setting. Modern intraocular lenses as well as laser refractive procedures are aimed at interfering with spherical aberrations of the optical system in order to increase range of pseudoaccommodation. Here, we review the role of spherical aberration of the human eye in the quality of vision and pseudoaccommodation.

The Novel Optical Design and Clinical Classification of a Wavefront-Shaping Presbyopia-Correcting Intraocular Lens

Purpose

To evaluate the clinical rationale of wavefront-shaping technology, describe how intraocular lenses (IOLs) using wavefront-shaping technology are differentiated from refractive or diffractive optical presbyopia-correcting designs, and describe the mode of action of this technology.

Methods

Extended depth of focus (EDoF) IOLs are the latest class of presbyopia-correcting IOLs addressing the growing demand of patients for reduced spectacle dependence. These use various optical technologies, including diffractive designs (eg, TECNIS Symfony ZXR00 and AT LARA 29 MP) and non-diffractive designs such as small aperture (eg, IC-8 IOL and XtraFocus Pinhole Implant), spherical aberration (eg, MINI WELL Ready and LuxSmart), and wavefront shaping (eg, AcrySof IQ Vivity DFT015 and Clareon Vivity CNWET0). Despite some improvement in visual acuity at intermediate and near distances, these technologies can still be associated with increased rate of visual disturbances or poorer distance vision compared with monofocal IOLs. One way to overcome such limitations is using a wavefront-shaping optical principle.

Results

Clinical data show that wavefront-shaping technology results in a continuous EDoF compared with a monofocal IOL while exhibiting a minimal halo, similar to an aspheric monofocal IOL. Clinically, this translates to a lens that has proven to exceed the American National Standards Institute/American Academy of Ophthalmology criteria for an EDoF IOL.

Conclusion

The novel wavefront-shaping optic technology allows patients to achieve a continuous range of vision from distance to functional near with low levels of visual disturbances comparable with aspheric monofocal IOLs.

Real-world visual outcomes of cataract surgery based on population-based studies: a systematic review

BACKGROUND/AIMS

Quantity of cataract surgery has long been an important public health indicator to assess health accessibility, however the quality of care has been less investigated. We aimed to summarise the up-to-date evidences to assess the real-world visual outcomes after cataract surgery in different settings.

METHODS

A systematic review was undertaken in October 2021. Population-based cross-sectional and longitudinal studies reporting vision-related outcomes after cataract surgery published from 2006 onward were included. A meta-analysis was not planned.

RESULTS

Twenty-six cross-sectional studies from low-income and middle-income countries (LMICs) and five cross-sectional studies from high-income countries (HICs) were included. The proportions of participants with postoperative presenting visual acuity (VA) ≥0.32 (20/60) were all over 70% in all HICS studies, but mostly below 70% in LMICS studies, ranging from 29.9% to 80.5%. Significant difference in postoperative VA was also observed within countries. The leading causes for postoperative visual impairment (defined mostly as presenting VA <20/60) mainly included refractive error, ocular comorbidities and surgical complications including posterior capsule opacification, except for one study in Nigeria wherein the leading cause was aphakia. Only four population-based cohort studies were included with 5-20 years of follow-up time, generally demonstrating no significant changes in postoperative visual outcomes during the follow-up.

CONCLUSIONS

We observed large inequality in the visual outcomes and principal causes of visual impairment after cataract surgery among different countries and regions. Structured quality control and enhancement programmes are needed to improve the outcomes of cataract surgery and reduce inequality.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Results of an Extended Depth-of-Focus Intraocular Lens Implantation in the Second Eye of Monofocal Pseudophakic Patients: A Pilot Study

PURPOSE

The purpose of this study was to investigate the visual results and patient satisfaction after implantation of an extended depth-of-focus (EDOF) intraocular lens (IOL) in the second eye of patients implanted previously with a monofocal IOL in the first eye.

METHODS

The medical records and self-reported questionnaires from patients who were implanted with monofocal IOLs in the first eye and EDOF IOLs in the second eye (group A) and from patients implanted bilaterally with EDOF IOLs (group B) were compared for visual acuity (VA), spectacle independence, patient satisfaction, and photic phenomena.

RESULTS

Group A (23 eyes of 23 patients) had similar distance uncorrected VA and intermediate uncorrected VA compared with group B (72 eyes of 36 patients) (0.03±0.05 vs. 0.04±0.16; P =0.136 and 0.660, respectively). There was a tendency toward a better near uncorrected VA in group A compared with group B (0.15±0.14 vs. 0.23±0.17; P =0.074). Patients' perception of their VA was similar between groups. Spectacle independence for distance vision was reported by 16/17 (94.1%) and 35/36 (97.2%) patients ( P =0.543), 13/17 (76.5%) and 32/36 (88.9%) patients ( P =0.252) for intermediate vision, and 4/17 (23.6%) and 22/36 (61.1%) patients for near vision ( P =0.011), in groups A and B, respectively. There was no difference in complaints of photic phenomena between groups.

CONCLUSIONS

Patients previously implanted with a monofocal IOL in 1 eye who are interested in improving their spectacle independence can be considered for an EDOF IOL implantation in the second eye and may have similar results to those implanted bilaterally with EDOF IOLs.

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

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

Impact of Light Conditions on Visual Performance following Premium Pseudophakic Presbyopia Corrections

The primary objective of this study was to objectively compare the visual performance of patients following premium pseudophakic presbyopia corrections in different light combinations for near- and intermediate-vision activities of daily living (ADLs). This is a prospective, comparative study. A total of 75 patients populated three study groups: G1-patients with bilateral trifocal implantation, G2-patients with bilateral bifocal implantation, and G3-patients with bilateral monofocal implantation. All participants addressed 10 ADLs in nine combinations of light temperature (3000 K, 4000 K, and 6000 K) and light intensity (25 fc, 50 fc, and 75 fc) and declared their subjectively optimal light combination while reading. G2 and G3 had the best total ADL scores in 6000 K/75 fc, while G1 had the best total ADL score in 4000 K/75 fc. Total ADL, easy ADL, and moderate difficulty ADL scores were significantly better in G2, while difficult ADL score was significantly better in G1. The majority of all groups selected 6000 K/75 fc as the most comfortable light combination, and no group selected 3000 K and 25 fc. In conclusion, trifocal patients benefit from intense daylight, while bifocal and monofocal patients benefit from intense, cold lighting. Trifocal patients present superior near-vision capacity in difficult near-vision daily tasks, while bifocal patients present superiority in easy and moderate-difficulty ADLs.

Automated and subjective refraction with monofocal, multifocal, and EDOF intraocular lenses: review

Automated refraction (Scheiner principle) is universally used to start a visual examination. Although the results are reliable in eyes implanted with monofocal intraocular lenses (IOLs), they may be less precise with multifocal (mIOL) or extended depth-of-focus (EDOF) IOLs and can even indicate a refractive error that does not clinically exist. Autorefractor results with monofocal, multifocal, and EDOF IOLs were investigated through literature search analyzing the papers reporting the difference between automated and clinical refraction. The average difference ranged between -0.50 diopter (D) and -1.00 D with most mIOL and EDOF IOLs. The differences in astigmatism were generally much lower. Autorefractors using infrared light cannot measure eyes with high technology IOLs precisely because of the influence of the refractive or of the diffractive near add. The systematic error induced with some IOLs should be mentioned in the IOL label to prevent possible inappropriate refractive procedures to treat apparent myopia.

Enhanced Monofocal Intraocular Lenses: A Retrospective, Comparative Study between Three Different Models

The purpose of this study was to compare the visual performance and optical quality between three new enhanced monofocal intraocular lenses (IOLs). This retrospective study included patients affected by cataracts with corneal astigmatism less than 0.75 D and no ocular comorbidities who underwent cataract surgery with bilateral implantation of Tecnis Eyhance ICB00 (Johnson & Johnson Vision Care, Inc., Jacksonville, FL, USA), Vivinex Impress XY1-EM (Hoya Surgical Optics, Singapore) or IsoPure 123 (PhysIOL, Liege, Belgium) IOLs. Three months postoperatively, monocular and binocular uncorrected and corrected distant, and intermediate and near visual acuities were measured. Binocular defocus curve, photopic contrast sensitivity, Point Spread Function (PSF), low order aberrations (LOAs), high order aberrations (HOAs), objective scatter index (OSI), halo and glare perception were also evaluated. This study included a total of 72 eyes from 36 patients. Visual acuity outcomes, PSF, LOAs, HOAs and OSI were similar between groups. There were no statistically significant differences in terms of photopic contrast sensitivity, halo or glare perception. In patients without ocular comorbidities, the Eyhance ICB00 IOL, the Vivinex Impress IOL and the Isopure IOL-even though based on different optical properties-provided similar results in terms of visual acuity, contrast sensitivity and intraocular aberrations, with no influence on photic phenomena.

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

PURPOSE

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

SETTING

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

DESIGN

Prospective clinical study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusions

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

How Reliable Is Pyramidal Wavefront-Based Sensor Aberrometry in Measuring the In Vivo Optical Behaviour of Multifocal IOLs?

Cataract or refractive lens surgery, along with the implantation of multifocal intraocular lenses (MF-IOL), enables a complete range of functional far, near and intermediate vision. Refractive, diffractive and extended depth of focus (EDoF) or combination of these principles represent the technology used to obtain this multifocality. Aberrometry makes it possible to study the aberrations induced by MF-IOLs. Among the different optical principles available to measure ocular aberrations, pyramidal wavefront-based sensor (PWS) aberrometry shows the highest resolution with MF-IOLs. Retinal image quality measured by a PWS aberrometer differed significantly according to the technology of the implanted lens. Monofocal and diffractive lenses showed the highest values of far-distance retinal image quality, followed by refractive and EDoF lenses; however, retinal image quality analysed in diffractive lenses appears to be more dependent on residual refractive error. Considering this limitation, PWS-aberrometry could be used to compare diffractive lenses. Nevertheless, further studies are needed to provide additional information about the clinical retinal image quality of MF-IOLs and to help surgeons in the important preoperative selection of IOLs.

Positioning of enhanced monofocal intraocular lenses between conventional monofocal and extended depth of focus lenses: a scoping review

BACKGROUND

New intraocular lenses (IOLs) have emerged since the originally coined monofocal and multifocal IOLs. The extended depth of focus (EDoF) and enhanced monofocal IOLs (mono-EDoF) that have appeared in the last decade have caused some confusion in their classification. The aim of this review was to summarize the outcomes provided by mono-EDOF IOLs and to determine which of the endpoints, described by the American National Standard (ANSI) for EDoF IOLs, are fulfilled.

METHODS

The MEDLINE, EMBASE, and WEB OF SCIENCE databases were searched. Two independent reviewers screened the studies for inclusion and data extraction. The search strategy was limited to studies published between 2020 and 2022, but not by language. The results are presented as a narrative summary accompanied by tables, in alignment with the objectives of this scoping review. Compliance with the endpoints for clinical outcomes described in the American National Standard Z80.35-2018 (ANSI) for EDoF lenses was checked and additional endpoints were defined.

RESULTS

Two systematic reviews, 13 laboratory, 21 clinical, and two mixed studies were included. Tecnis Eyhance was the mono-EDOF with the highest volume of evidence to date. Although laboratory studies included other IOLs, clinical evidence for them is still scarce, with only one study of IsoPure compared to a standard monofocal IOL. Evidence in comparison to EDoF lenses is also scarce, even for Tecnis Eyhance, with only three studies including this lens in comparison to an EDoF lens. After evaluation of the ANSI criteria, agreement was found in the failure for the increase in depth of field equal to or greater than 0.5 D for a visual acuity (VA) level of 0.2 logMAR and none of the studies supported that the median monocular VA at intermediate distance was at least 0.2 logMAR.

CONCLUSIONS

Additional clinical evidence is required for other mono-EDOF IOLs beyond Tecnis Eyhance. Until the arrival of a standard classification, mono-EDOF should be better still classified as monofocal because the ANSI standards were not fully met.

Clinical Retinal Image Quality of a Non-diffractive Wavefront-Shaping Extended Depth of Focus (Vivity) Intraocular Lens

PURPOSE

To evaluate clinical retinal optical image quality following implantation of an extended depth of focus intraocular lens (EDOF IOL) (Vivity; Alcon Laboratories, Inc), and to compare it with a monofocal and a trifocal IOL.

METHODS

This prospective, comparative, case-control study included 88 eyes implanted with: (1) 19 monofocal IOLs (AcrySof SA60AT; Alcon Laboratories, Inc); (2) 38 EDOF IOLs (AcrySof IQ Vivity); and (3) 31 trifocal IOLs (AT LISA tri 839MP; Carl Zeiss Meditec AG). Total root mean square, ocular lower (LOA) and higher (HOA) order aberrations, point spread function (PSF) Strehl ratio (PSF with LOA), and PSF Strehl ratio excluding LOA (PSF without LOA) were analyzed using a Pyramidal WaveFront-based sensor aberrometer Osiris (Costruzione Strumenti Oftalmici) at two different pupil sizes (3 and 4 mm).

RESULTS

The trifocal IOL showed the highest PSF without LOA at both pupil sizes (0.52 ± 0.12 and 0.31 ± 0.07, respectively), followed by the AcrySof SA60AT (0.39 ± 0.10 and 0.27 ± 0.07) and AcrySof IQ Vivity (0.34 ± 0.11 and 0.24 ± 0.09) (P < .001). The AcrySof IQ Vivity and monofocal IOLs were comparable (P > .05). Despite the comparable postoperative low spherical equivalent among the IOL groups, the AT LISA tri 839MP retinal image quality (PSF with LOA) was the most severely affected by such residual refractive errors (dropped to 0.26 ± 0.06 at 3 mm; P < .001) compared to the monofocal AcrySof SA60AT (0.24 ± 0.07 at 3 mm) and EDOF Acrysof IQ Vivity (0.23 ± 0.06 at 3 mm) groups. The PSF with LOA was comparable (P > .05) among the three groups at both the 3-and 4-mm pupil size.

CONCLUSIONS

Although trifocal IOLs provided significantly better retinal image quality if influence of LOA is excluded, they also demonstrated to be the most sensitive to residual refractive errors. Both the EDOF Acrysof IQ Vivity and mono-focal AcrySof SA60AT IOLs showed a comparable retinal image quality, and they are also comparable with trifocal IOLs when considering the clinically real PSF (PSF with LOA). [J Refract Surg. 2023;39(2):103-110.].

Presbyopia: What We Do Know and What We Do Not Know in 2022

The subject of presbyopia has accompanied clinical ophthalmic practices around the world for centuries [...].

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.