Monovision LASIK Versus Presbyopia-Correcting IOLs: Comparison of Clinical and Patient-Reported Outcomes

Comparative Analysis of Clinical and Patient-Reported Outcomes of a New Enhanced Monofocal IOL and a Conventional Monofocal IOL

Purpose

To compare the outcomes of the Tecnis Eyhance ICB00 IOL, designed to enhance intermediate vision, to a conventional Tecnis Monofocal ZCB00 IOL.

Methods

This retrospective analysis compared two cohorts of patients undergoing lens replacement surgery with bilateral implantation of the Tecnis ICB00 or the Tecnis ZCB00 IOL (383 patients in each group). Monocular and binocular uncorrected distance (UDVA), intermediate (UIVA; 66cm), and near (UNVA; 40cm) visual acuities, refractive predictability, and patient-reported outcomes were compared. A sub-analysis of patients with the Eyhance IOL was performed to compare patients who achieved bilateral emmetropia to those with mini-monovision. One-month postoperative outcomes were analyzed.

Results

Both groups had comparable UDVA outcomes. On average, both monocular and binocular UIVAs were approximately one Snellen line better in patients implanted with Eyhance IOL (monocular UIVA: ICB00 0.23 ± 0.18 logMAR, ZCB00 0.33 ± 0.19 logMAR; binocular UIVA: ICB00 0.18 ± 0.18 logMAR, ZCB00 0.26 ± 0.20 logMAR, p < 0.01). Likewise, the mean UNVA was also one Snellen line better with the ICB00 model (monocular UNVA: ICB00 0.51 ± 0.20 logMAR, ZCB00 0.61 ± 0.18 logMAR; binocular UNVA: ICB00 0.42 ± 0.19 logMAR, ZCB00 0.51 ± 0.22 logMAR, p < 0.01). There was no difference between the two groups in overall satisfaction or visual phenomena. A subgroup of patients who achieved mini-monovision with Eyhance IOL had, on average, one Snellen line better UIVA and UNVA compared to patients with bilateral emmetropia.

Conclusion

Patients receiving the enhanced monofocal IOL had better intermediate and near vision compared to those receiving the conventional monofocal IOL, with similar levels of patient-reported photic phenomena in both groups.

Comparison of objective and subjective visual quality after flapless laser vision correction for mild to moderate myopia: SMILE vs PRK

PURPOSE

To investigate the differences in surgical results and the objective and subjective quality of vision (QoV) of patients after small incision lenticule extraction (SMILE) versus alcohol-assisted photorefractive keratectomy (PRK).

METHODS

Medical records of patients treated with SMILE and PRK were retrospectively examined. Visual quality, biometric parameters, Strehl ratio (SR), and corneal higher-order aberrations (HOAs) within a 6.0 mm area were recorded. The effective optical zone (EOZ) and decentration were measured using a tangential pre-post operation difference map. Subjective QoV and operation satisfaction were evaluated 6 months postoperatively using the Quality of Vision questionnaire.

RESULTS

The study comprised 100 eyes treated with SMILE (preoperative mean spherical equivalent (SE), - 4.52 ± 0.81 dioptres (D)) and 69 eyes with PRK (mean SE, - 4.21 ± 1.25 D). Six months postoperatively, the EOZ reduction was significantly larger in the PRK group (P < 0.001). Decentrations were comparable between the groups. Regarding visual symptoms, monocular diplopia was more common following PRK (P = 0.02), and 98 (98.00%) SMILE-treated and 67 (97.10%) PRK-treated patients were satisfied with the QoV. Both groups demonstrated significant increases in total HOAs, coma, and spherical aberration (SA) at 6 months postoperatively compared to preoperatively (P < 0.001); these values were significantly higher in the PRK (P < 0.05) compared to the SMILE group. SR increased significantly only in the PRK group (P < 0.05).

CONCLUSION

Although EOZ was more consistent with anticipated treatment and HOAs were fewer in SMILE, high patient-reported satisfaction and good corneal optical quality were achieved in both groups, indicating that both SMILE and alcohol-assisted PRK are excellent options for mild to moderate myopia correction.

Long-term follow-up for monovision surgery by Implantable Collamer Lens V4c implantation for myopia correction in early presbyopia

Purpose

To investigate the long-term safety and efficacy of monovision surgery using implantable collamer lens V4c (ICL V4c) implantation in myopic patients with early presbyopia.

Setting

Eye and ENT Hospital of Fudan University, Shanghai, China.

Design

Prospective case series study.

Methods

This study included 64 eyes of 32 patients with early presbyopia, who underwent bilateral ICL V4c implantation for myopia correction. Parameters, including mean spherical equivalent (SE), uncorrected distance visual acuity, corrected distance visual acuity, intraocular pressure, endothelial cell density, presbyopic add power, visual acuity (logMAR) of dominant eyes (D-eye), nondominant (nD-eye) eyes, and both eyes (Bi) at 0.4 m, 0.8 m, and 5 m were recorded at the last follow-up.

Results

All surgeries were uneventful. At the last follow-up, the safety indices were 1.23 ± 0.18 (D-eyes) and 1.21 ± 0.18 (nD-eyes) (p > 0.05); the efficacy indices were 0.95 ± 0.27 (D-eyes) and 0.92 ± 0.28 (nD-eyes) (p < 0.05), the SE was -0.62 ± 0.47 D (D-eyes); and − 1.21 ± 0.78D (nD-eyes) (p < 0.05), presbyopic add power was 1.31 ± 0.58 D. The visual acuity (logMAR) of D-eyes, nD-eyes, and binocular (Bi) at 5.0 m were: 0.06 ± 0.15 (D-eye), 0.21 ± 0.18 (nD-eye), (p < 0.01), and 0.04 ± 0.13 (Bi); 0.8 m: 0.03 ± 0.18 (D-eye), 0.08 ± 0.16 (nD-eye), (p > 0.05), and − 0.02 ± 0.11 (Bi); 0.4 m: 0.08 ± 0.09 (D-eye), − 0.02 ± 0.08 (nD-eye), (p < 0.001), and − 0.03 ± 0.09 (Bi). Subjects were very satisfied or felt excellent with their visual acuity at near (81.25%) and far distances (87.50%), respectively (versus preoperative, p < 0.001).

Conclusion

Monovision surgery using ICL V4c implantation is safe and practicable for correction of myopes with presbyopia, with long-term efficacy at near and far distances and patient satisfaction.

Presbyopia - A Review of Current Treatment Options and Emerging Therapies

Presbyopia is a common age-related vision disorder characterized by a progressive inability to focus on near objects. If uncorrected or under-corrected, presbyopia can significantly impact patients' quality of life. Presbyopia represents an area of considerable unmet need due to its rising prevalence worldwide as the population ages, the high proportion of under-treated individuals in some parts of the world, and the limitations of currently available corrective methods. Progressive or bifocal spectacles are associated with peripheral blur, a restricted visual field and impaired depth perception, which have been linked to an increased risk of falls in the elderly. Contact lens options can be difficult to maintain due to the development of age-related dry eye symptoms and reduced manual dexterity. Other corrective methods involve surgical interventions that modify the optics of the cornea, replace the crystalline lens, or attempt to restore active accommodation. While patients undergoing surgery report satisfactory outcomes post-operatively, many of them eventually require reading glasses. Non-invasive therapies with novel mechanisms of action are currently being investigated; these include miotic agents and UNR844, a lipoic acid choline ester. In this narrative review, available evidence on presbyopia prevalence, quality of life impact and risk factors are described, with a focus on observational studies in non-clinical settings. The diagnosis pathway and patient journey in presbyopia are outlined, and various treatment options are analyzed. The data reviewed herein reveals significant gaps in the provision of vision correction for this common condition, with a paucity of effective, non-invasive treatment options broadly accessible to presbyopic individuals.

Performance and Safety of the Extended Depth of Focus Implantable Collamer® Lens (EDOF ICL) in Phakic Subjects with Presbyopia

Purpose

To evaluate the performance and safety of the Extended Depth of Focus Implantable Collamer^® Lens (EDOF ICL) for improvement of uncorrected near, intermediate and distance visual acuity in phakic subjects with myopia and presbyopia.

Design

Prospective multicenter study.

Methods

Presbyopic subjects who required an EDOF ICL in the range of −0.50 D to −18.00 D, exhibited ≤ 0.75 D refractive astigmatism and required from +1.00 to +2.50 D reading add were implanted bilaterally. Assessments at 6 months included uncorrected near, intermediate and distance visual acuities, defocus curves, contrast sensitivity, responses to the National Eye Institute Refractive Error Quality of Life Questionnaire and a Task Assessment Questionnaire.

Results

A total of 34 subjects completed the study. Investigators targeted emmetropia in all eyes. Mean binocular uncorrected near, intermediate and distance visual acuities measured logMAR −0.01 ± 0.05 (20/20), −0.02 ± 0.08 (20/19) and 0.07 ± 0.10 (20/23), respectively. Mean monocular uncorrected near, intermediate and distance visual acuities measured logMAR 0.068 ± 0.09 (20/23), 0.062 ± 0.10 (20/23) and 0.16 ± 0.12 (20/29). There were no clinically or statistically significant differences in contrast sensitivity between baseline and 6 months under any testing conditions. Subjects reported significant improvements in measures of vision-related quality of life and ability to perform tasks at all distances without glasses or contact lenses. Overall, satisfaction with the EDOF ICL was high: postoperatively, 91.2% of subjects were satisfied with their vision.

Conclusion

This multicenter, prospective clinical investigation demonstrated the ability of the EDOF ICL to correct myopia and presbyopia, resulting in improvement of uncorrected near, intermediate and distance visual acuity without compromising the quality of vision. The EDOF ICL allowed subjects to perform tasks of daily living without glasses or contact lenses. Subjects reported significant improvements in quality of life with high levels of spectacle independence and satisfaction.

Optimization of the Light Sword Lens for Presbyopia Correction

Purpose

We propose and evaluate the modifications of a light sword lens (LSL) to obtain better performance for distance vision while maintaining good operation for near and intermediate vision.

Methods

The modifications consisted of assigning angular or circular windows for distance vision while rescaling the LSL profile in the remaining area of the element. The objective performance of the redesigned LSLs was verified numerically by the Strehl ratio and experimentally using correlation coefficients and Michelson contrast. Subjective assessments were provided by monocular visual acuity (VA) and contrast sensitivity (CS) through-focus curves for six patients with paralyzed accommodation. The tested object vergence range was [-4.0, 0.0] diopters (D). All experiments were conducted in a custom-made monocular visual simulator.

Results

Computational simulations and objective experiments confirmed the better performance of the modified LSL for the imaging of distant objects. The proposed angular and radial modulations resulted in flat VA and CS through-focus curves, indicating more uniform quality of vision with clearly improved distance vision. The VA provided by the modified LSL profiles showed a maximal improvement of 1.5 lines of acuity with respect to the VA provided by the conventional LSL at distance vision.

Conclusions

Optimized LSLs provide better imaging of distant objects while maintaining a large depth of focus. This results in comparable and acceptable quality for distance, intermediate, and near vision. Therefore, the modified LSLs appear to be promising presbyopia correctors.

Translational Relevance

The new design of LSL reveals an improved performance for all ranges of vision and becomes a promissory element for a real presbyopia correction in clinical applications.

Varifocal Versus Monofocal LASIK in Presbyopic Hyperopic Eyes

PURPOSE

To compare varifocal (SupraCor; Technolas Perfect Vision GmbH, Munich, Germany) to monofocal (Zyoptix TissueSaving; Bausch & Lomb, Rochester, NY) LASIK in patients with hyperopic presbyopia.

METHODS

In this prospective, non-randomized, comparative case series, consecutive patients with hyperopia, presbyopia, and emmetropia as target refraction were bilaterally treated with varifocal (8 patients) or monofocal (7 patients) LASIK. The study was designed for 35 patients, but was terminated early after interim analysis. Outcomes (preoperative and 1 day, 1 week, 1 month, and 3 months postoperative) were: monocular and binocular uncorrected near visual acuity (UNVA), distance-corrected near visual acuity (DCNVA), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), low-contrast UDVA and CDVA, efficacy, and safety.

RESULTS

Preoperative data were similar in both groups. Monocular and binocular UNVA were not significantly different between both groups at any follow-up visit. At 3 months, mean monocular UNVA was 0.40 logMAR in both groups. Monocular DCNVA and binocular CDVA were not significantly different between groups. Monocular mean CDVA was 0.00 ± 0.06 logMAR after varifocal LASIK and -0.06 ± 0.04 logMAR after monofocal LASIK. The efficacy index was 0.9 after vari-focal LASIK and 0.88 after monofocal LASIK (not significant). The safety index was 1.08 after varifocal LASIK and 1.125 after monofocal LASIK (not significant).

CONCLUSIONS

With emmetropia as target refraction, varifocal ablations yielded no additional benefit compared to monofocal ablations in hyperopic presbyopic LASIK. The authors speculate that epithelial remodeling masks the impact of a varifocal ablation pattern and that a myopic postoperative refraction (modified monovision) may be necessary to further improve near and intermediate vision. These results demonstrate the value of a control group in studies evaluating presbyopia corrections. [J Refract Surg. 2019;35(7):459-466.].

Initial Clinical Outcomes of a New Extended Depth of Focus Intraocular Lens

PURPOSE

To evaluate clinical and patient-reported outcomes of a new extended depth of focus intraocular lens (IOL).

METHODS

Data of patients treated between September 2017 and September 2018 who underwent a refractive lens exchange/cataract surgery with an implantation of the AT LARA 829MP IOL (Carl Zeiss Meditec AG, Jena, Germany) and attended the 1-week, 1-month, and 3-month follow-up visit were reviewed.

RESULTS

At 3 months, the percentage of eyes within ±0.50 diopters (D) of emmetropia was 86.7%. The mean binocular uncorrected distance visual acuity was -0.05 ± 0.09 logMAR and the mean binocular unaided near vision was 0.26 ± 0.14 logMAR. Of all patients, 90.3% were satisfied with their vision. The percentage of patients spectacle-free for near and distance vision was 83.6% and 95.4%, respectively. On a scale from 1 (no difficulty) to 7 (severe difficulty), there was an average 1.2 to 1.4 units increase in glare, halo, and starburst between the preoperative and 1-month visit, and a decrease of 0.2 to 0.3 units between the 1- and 3-month visit.

CONCLUSIONS

The new extended depth of focus IOL provided reasonable unaided near and distance vision, as well as spectacle independence and patient satisfaction. Some optical side effects were reported in the early postoperative period. [J Refract Surg. 2019;35(7):426-433.].

Determinants of subjective patient-reported quality of vision after small-incision lenticule extraction

PURPOSE

To characterize patient-reported long-term quality of vision (QoV) after small-incision lenticule extraction (SMILE), and to identify potential clinical parameters that might predispose to experiencing deteriorated visual quality.

SETTING

University Eye Hospital, Ludwig-Maximilians-University, Munich, Germany.

DESIGN

Prospective cross-sectional study.

METHODS

For the assessment and scoring of visual symptoms, the Quality of Vision questionnaire was employed, which constitutes a clinically validated, linear-scaled 30-item instrument providing a QoV score on three scales (symptom frequency, severity, and bothersome). Subgroup analyses were performed for patient subgroups stratified by baseline characteristics (eg, age) and treatment parameters (eg, surgical refractive correction) as well as refractive outcomes (eg, residual refraction) and visual outcomes (eg, uncorrected distance visual acuity [UDVA]).

RESULTS

The study comprised 394 eyes of 197 patients (117 women [59.4%], 80 men [40.6%]) were included with a mean postoperative follow-up of 24.4 months ± 14.1 (SD). The QoV scores for symptom frequency, severity, and bothersome were 34.63 ± 13.69, 29.60 ± 12.38, and 24.56 ± 16.00, respectively. Patients with a preoperative binocular corrected distance visual acuity (CDVA) of 20/12.5 or better, patients who lost 1 or more lines of UDVA as compared with preoperative CDVA, patients older than the age of 40, and patients with inadvertent anisometropia more than 0.375 diopters reported worse QoV scores.

CONCLUSION

The relationship between objective clinical parameters and patient-reported subjective QoV after SMILE seems complex. Defined prognostic factors that convey a higher risk for experiencing visual disturbances were identifiable and should be discussed with patients seeking SMILE treatment during preoperative counseling.

Comparison of visual outcomes after bilateral implantation of two intraocular lenses with distinct diffractive optics

Purpose

The aim of this study was to compare the visual outcomes and subjective visual quality between bilateral implantation of an extended depth of focus intraocular lens, J&J Vision Tecnis Symfony^® ZXR00 (Group A) and bilateral implantation of a diffractive trifocal intraocular lens, Alcon Acrysof IQ PanOptix^® TNFT00 (Group B).

Methods

This prospective, nonrandomized, comparative study of consecutive cases assessed 52 eyes of 26 patients operated on by the same surgeon (WTH) and binocularly implanted with multifocal intraocular lenses between May 2016 and July 2018. Binocular visual acuity for far, intermediate and near was tested in all cases. Ophthalmological evaluation included the measurement of binocular uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected near visual acuity (UNVA) at 40 cm, uncorrected intermediate visual acuity (UIVA) at 70 cm, monocular visual defocus curve and the quality of life (QoL) questionnaire, National Eye Institute Visual Functioning Questionnaire - 25 ( NEI-VFQ 25).

Results

Postoperative UDVA was 0.00 and 0.09 logMAR (P<0.001), UIVA was 0.20 and 0.39 logMAR (P<0.001) and UNVA was 0.16 and -0.01 logMAR (P<0.001) in groups A and B, respectively; postoperative CDVA was -0.05 and 0.06 logMAR (P<0.001) in groups A and B, respectively.

Conclusion

Both groups reported good subjective quality of vision regarding long, intermediate and short distances. Group A had a better performance for binocular UDVA, UIVA at 70 cm and CDVA, while regarding the monocular defocus curve, Group A outperformed Group B for long distances. Furthermore, Group B surpassed it in the short to very short distances, between the range of ≥2.00 D to 5.00 D of vergence. While Group A had a better performance regarding the vergences between 0.00 and 1.00 D (P<0.05) and at the vergence of +2.50 D (P=0.007). Group B outran Group A for UNVA at 40 cm.

Patient satisfaction and self-reported dry eye symptoms in hyperopic patients treated with femtosecond laser in situ keratomileusis

Purpose

To study self-reported patient satisfaction and dry eye symptoms in hyperopic correction with femtosecond laser-assisted in situ keratomileusis (FS-LASIK).

Patients and methods

Ninety-eight eyes (53 patients) were treated with FS-LASIK for hyperopia. Patients’ self-reported dry eye symptoms and satisfaction with near and far vision were graded on the visual analog scale (VAS) preoperatively and 1 month postoperatively.

Results

Ninety-one percent of the eyes with the plano target (54 eyes) achieved an uncorrected distance visual acuity of 20/20 or better. Predictability, defined as spherical equivalent refraction within ±0.5 D of target, was 88% of all eyes. None of the eyes lost two or more Snellen lines of corrected distance visual acuity. There was no significant change in the self-reported dry eye sensation (VAS score from 2.7±2.0 to 2.8±2.0; P=0.66). In 44 monovision patients, satisfaction with both far vision (from 71.2±19.8 to 89.2±8.7; P<0.0001) and near vision (from 51.7±26.2 to 89.3±13.2; P<0.0001) increased significantly. In nine emmetropic patients, satisfaction with neither far vision nor near vision was significantly improved, although there was a clear tendency (from 73.7±23.7 to 86.9±15.3; P=0.22, and from 58.9±29.1 to 81.6±17.4; P=0.11, respectively). In the monovision patient group, far vision satisfaction decreased when dry eye symptoms increased. Monovision patients, as predicted, were more satisfied with their near vision, when postoperative spherical equivalent from target was on the myopic side.

Conclusion

FS-LASIK correction of hyperopia significantly improved patient satisfaction with both near and far vision in monovision patients. Hyperopic patients had no significant changes in postoperative dry eye symptoms compared to preoperative values.

Presbyopic Excimer Laser Ablation: A Review

PURPOSE

To provide an overview of the efficacy and safety of available presbyopic excimer laser ablation profiles.

METHODS

Literature review.

RESULTS

Monovision with excimer laser traditionally applies near correction to the non-dominant eye. Different excimer laser presbyopic approaches include the increase in depth of focus, through the controlled change of spherical aberration or asphericity, or multifocal ablation patterns with central or peripheral near vision zones. The studies investigating different excimer laser ablation patterns applied in previously myopic eyes revealed high levels of efficacy with all ablation profiles (between 68% and 99% achieving binocular uncorrected distance visual acuity [UDVA] of 20/25 or better, and between 70% and 100% achieving uncorrected near visual acuity [UNVA] presenting J3 or better). In hypermetropic eyes, most of the studies revealed high levels of efficacy with different platforms (between 78% and 100% achieving binocular UDVA of 20/25 or better and between 70% and 100% achieving UNVA presenting J3 or better). Loss of two or more lines of corrected distance visual acuity varied between 0% and 10% in the myopic eyes and between 0% and 14% in the hyperopic eyes.

CONCLUSIONS

There is evidence that excimer laser presbyopic strategies accomplish spectacle independence at reasonable levels. There are reliable and safe options for both myopic and hyperopic eyes with satisfactory outcomes regarding near and distance vision. [J Refract Surg. 2018;34(10):698-710.].

Monocular Clinical Outcomes and Range of Near Vision following Cataract Surgery with Implantation of an Extended Depth of Focus Intraocular Lens

Importance

A full range of near and intermediate vision has not been clinically evaluated for the Symfony extended depth of focus intraocular lens (EDOF IOL).

Background

To evaluate the monocular range of near visual acuity with an EDOF IOL.

Design

Retrospective case series.

Participants

Consecutive patients of a single surgeon from January 2017 through March 2018.

Methods

Phacoemulsification with implantation of an EDOF IOL.

Main Outcome Measures

Uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), corrected distance visual acuity (CDVA), distance-corrected near visual acuity (DCNVA), range of DCNVA, and optimal near focal length.

Results

Seventy-six eyes of 48 patients (34 or 71% female, mean age: 68 years) were included with a mean follow-up of 68 days. Mean values were as follows: logarithm of the minimum angle of resolution (logMAR) UDVA 0.02 ± 0.09, logMAR UNVA 0.12 ± 0.09 at a mean distance of 51 cm, logMAR CDVA -0.05 ± 0.07, logMAR DCNVA 0.08 ± 0.07 at a mean distance of 51 cm, and a spherical equivalent of -0.16 diopters ±0.35. Percentage of eyes achieving DCNVA of 20/30 were 84% at 36 cm, 92% at 41 cm, 99% at 51 cm, 93% at 61 cm, and 74% at 71 cm. DCNVA of 20/40 or better was achieved in nearly 100% of eyes over a range of 35 cm.

Conclusions and Relevance

The Symfony EDOF IOL achieved excellent distance visual acuity while providing a 35 cm range of near visual acuity at levels useful for many tasks in nearly all patients.