Comparison of Patient Outcomes following Implantation of Trifocal and Extended Depth of Focus Intraocular Lenses: A Systematic Review and Meta-Analysis

Visual Performance After Bilateral Implantation of a New Enhanced Monofocal Hydrophobic Acrylic Intraocular Lens Targeted for Mini-Monovision

BACKGROUND

The aim of this study was to evaluate visual outcomes and patient satisfaction after bilateral implantation of a new hydrophobic acrylic intraocular lens called Clareon (Alcon) using the mini-monovision technique.

METHODS

A single-center, prospective, nonrandomized study was conducted in Tandil (Buenos Aires, Argentina), including patients scheduled for cataract surgery. To achieve mini-monovision, the spherical equivalent was calculated between -0.25 and +0.25 D for the dominant eye, and between -0.75 and -1.00 D for the non-dominant eye. The main outcomes were uncorrected distance visual acuity (UDVA) and uncorrected intermediate visual acuity (UIVA) evaluated at 66 cm. A secondary outcome, patient satisfaction, was assessed using the CatQuest-9SF questionnaire.

RESULTS

The mean binocular UDVA was 0.01 ± 0.05 logMAR three months after surgery, while the mean binocular UIVA was 0.20 ± 0.06 logMAR. The postoperative mean spherical equivalent in the dominant eye was -0.27 ± 0.12, and in the non-dominant eye was -0.87 ± 0.25. Before surgery, the CatQuest-9SF questionnaire revealed that 83.33% of patients were dissatisfied with their vision during daily activities. Over 50% reported significant difficulties with reading newspapers, sewing, and reading TV subtitles. Additionally, 66.6% struggled with recognizing faces, 50% with seeing product prices, and 50% with walking on uneven ground. Post-surgery, most patients experienced improved vision for daily tasks, with no reports of high dissatisfaction or significant difficulties. Patients were quite satisfied with their vision for hobbies and TV subtitles, and very satisfied (90%) with seeing supermarket prices.

CONCLUSIONS

patients implanted with a new enhanced monofocal IOL using the mini-monovision technique showed improved distance and intermediate visual acuity, reduced need for glasses, and expressed a high degree of satisfaction.

Clinical Outcomes of Enhanced Monofocal (Mono-EDOF) Intraocular Lenses with the Mini-Monovision Technique versus Trifocal Intraocular Lenses: A Comparative Study

Objectives

It was aimed to compare the clinical results of the mini-monovision technique (MMV) with enhanced monofocal intraocular lens (IOL) and trifocal IOL applications and to evaluate the intereye differences in the MMV group.

Materials and Methods

This retrospective observational study evaluated the results of cataract surgeries performed on 48 eyes of 24 patients. Surgeries in Group I were performed for MMV using the RayOne EMV IOL targeting emmetropia in dominant eyes (Group IA) and -0.70 diopter (D) myopia in non-dominant eyes (Group IB), while those in Group II were performed with the AcrySof® IQ PanOptixTM TNFT00 IOL targeting emmetropia. After the surgeries, uncorrected and corrected distance, intermediate, and near distance visual acuities, contrast sensitivity measurements, and defocus curves were determined. Subjective evaluation was made with the National Eye Institute Visual Function Questionnaire (NEI VFQ-25). The groups were compared statistically.

Results

Postoperative refraction mean spherical equivalent was -0.25±0.22 D, -0.67±0.33 D, and -0.16±0.31 D in the three groups, respectively. A statistical difference was identified in favor of Group IA for uncorrected distance vision and in favor of Group IB for near vision (p<0.05). There was no difference in bilateral uncorrected visions in Groups I and II (p>0.05). While contrast sensitivity was better in Group I at all spatial frequencies (p<0.05), better vision was achieved in the defocus curve at distance in Group IA and at near in Group IB. In the binocular evaluation, it was seen that Groups I and II had similar results. In the subjective evaluation, NEI-VFQ-25 scores were 94.1±4.2/100 in Group I and 91.5±3.0/100 in Group II at 6 months (p>0.05). Photic complaints were significantly more common in Group II.

Conclusion

With the MMV technique, it was observed that enhanced monofocal lenses provided better visual acuity at all distances and less dysphotopsia than trifocal lenses, whereas trifocal lenses were better at providing independence from glasses.

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.

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.

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.].

Head-to-Head Comparison of Intermediate Vision of Two Monofocal Intraocular Lenses

Purpose

To compare intermediate visual outcomes in patients previously implanted with bilateral Clareon monofocal IOLs versus bilateral Eyhance IOLs.

Methods

This was a non-interventional, single-center, examiner-masked, comparative study. Participants were cataract patients presenting at least 3 months after uncomplicated, bilateral implantation of either Clareon or Eyhance non-toric and toric IOLs. Outcomes measures included binocular distance-corrected intermediate visual acuity (DCIVA), binocular corrected distance visual acuity (CDVA), binocular best-corrected defocus curve, postoperative mean residual spherical equivalent (MRSE), and residual astigmatism.

Results

A total of 620 eyes of 310 subjects (155 subjects per group) were evaluated. The mean difference in DCIVA was 0.05 logMAR between the Eyhance and Clareon IOLs which was significant (p < 0.01), but within the 0.1 logMAR non-inferiority margin. Mean CDVA of the Clareon group was 0.01 ± 0.03 logMAR compared to 0.02 ± 0.03 logMAR of the Eyhance Group (p > 0.05). Defocus curves from +1.0 D to -3.0 D were not clinically nor statistically different between the Clareon and Eyhance groups (p > 0.05).

Conclusion

The results of this study show that bilateral implantation of Clareon monofocal IOLs and Eyhance monofocal IOLs lead to similar distance and intermediate visual outcomes.

Premium Intraocular Lenses in Glaucoma-A Systematic Review

The incidence of both cataract and glaucoma is increasing globally. With increasing patient expectation and improved technology, premium intraocular lenses (IOLs), including presbyopia-correcting and toric IOLs, are being increasingly implanted today. However, concerns remain regarding the use of premium IOLs, particularly presbyopia-correcting IOLs, in eyes with glaucoma. This systematic review evaluates the use of premium IOLs in glaucoma. A comprehensive search of the MEDLINE database was performed from inception until 1 June 2023. Initial search yielded 1404 records, of which 12 were included in the final review of post-operative outcomes. Studies demonstrated high spectacle independence for distance and good patient satisfaction in glaucomatous eyes, with positive outcomes also in post-operative visual acuity, residual astigmatism, and contrast sensitivity. Considerations in patient selection include anatomical and functional factors, such as the type and severity of glaucomatous visual field defects, glaucoma subtype, presence of ocular surface disease, ocular changes after glaucoma surgery, and the reliability of disease monitoring, all of which may be affected by, or influence, the outcomes of premium IOL implantation in glaucoma patients. Regular reviews on this topic are needed in order to keep up with the rapid advancements in IOL technology and glaucoma surgical treatments.

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.].

Dysphotopsias or Unwanted Visual Phenomena after Cataract Surgery

Dysphotopsias are unwanted visual phenomena that occur after cataract surgery. They represent some of the most common reasons for patient dissatisfaction after uncomplicated surgery for cataract phacoemulsification with in-the-bag intraocular lens (IOL) implantation. Depending on the form of the optical phenomenon and the effect it poses on vision, dysphotopsias are divided into positive and negative type. Positive dysphotopsias are usually described by patients as glare, light streaks, starbursts, light arcs, rings, haloes, or flashes of light. Negative dysphotopsias are manifested as an arc-shaped shadow or line usually located in the temporal part of the visual field, similar to a temporal scotoma. In addition to their different clinical manifestations, positive and negative dysphotopsia also have different risk factors. Even though up to 67% of patients may experience positive dysphotopsia immediately after surgery, only 2.2% of the cases have persistent symptoms up to a year postoperatively. Surgical intervention may be indicated in 0.07% of cases. The incidence of negative dysphotopsias is up to 26% of all patients; however, by one year postoperatively, the symptoms usually persist in 0.13 to 3% of patients. For both types of dysphotopsia, preoperative patients' education, accurate preoperative diagnostics, and use of an appropriate IOL design and material is mandatory. Despite all these measures, dysphotopsias may occur, and when noninvasive measures fail to improve symptoms, a surgical approach may be considered.

Depth of field and visual performance after implantation of a new hydrophobic trifocal intraocular lens

Purpose

To assess the depth of field (DOF) by means of defocus curve analysis applying different visual acuity criteria in patients following cataract surgery and bilateral implantation of a new trifocal diffractive intraocular lens (IOL).

Methods

Fifty eyes of 25 consecutive patients who underwent implantation of the Asqelio™ trifocal IOL (AST Products Inc., USA) were enrolled in this observational prospective study. Monocular subjective DOF was obtained from defocus curves with absolute and relative criteria of tolerance for different visual acuities values. Patient’s visual satisfaction, postoperative refraction and visual acuity at far, intermediate (67 cm) and near (40 cm) distances were also measured at 1 and 3-months post-surgery. Analysis of variance was used to assess differences in refractive error after the surgical procedure, and paired t-tests were used to assess differences in VA. Patient satisfaction results were reported as percentages.

Results

Spherical equivalent was 0.05 ± 0.23 D and residual cylinder 0.01 ± 0.23 D 3-months after the surgery. Absolute DOF obtained was 3.29 ± 0.91 D considering 0.1 LogMAR as cut-off value, and 4.82 ± 0.69 D when 0.3 logMAR as cutoff value. Relative DOF considering a drop of 0.1 logMAR from maximum visual acuity was 2.57 ± 0.82 D, and 1.27 ± 0.70 D when a drop of 0.04 logMAR was considered. Visual acuities obtained 3-months after the surgery were 0.03 ± 0.13, − 0.05 ± 0.06, 0.03 ± 0.08 and 0.04 ± 0.08 logMAR for uncorrected and best-corrected for distance, and best distance-corrected for intermediate and near distances, respectively. Average response to visual satisfaction queries was 8.24/10 at distance, 8.04/10 at intermediate, and 7.88/10 at near.

Conclusions

Patients implanted with this trifocal IOL showed a significant improvement in visual acuity at different distances providing wide absolute and relative DOF values. The outcomes demonstrate that this lens is predictable yielding good patient satisfaction rates.