Pseudophakic monovision is an important surgical approach to being spectacle-free

Intraocular lens selection in diabetic patients: How to increase the odds for success

The incidence of cataracts is significantly higher in diabetic individuals, particularly in younger age groups, with rates quadrupled in those under 65 and doubled in those over 65 compared to non-diabetics. Cataract surgery in diabetic patients poses many challenges: Poor epithelial healing, decreased corneal sensitivity, increased central corneal thickness, decreased endothelial cell count, variable topography, poor pupillary dilatation, anterior capsular phimosis, posterior capsular opacification (PCO), chances of progression of diabetic retinopathy (DR), zonular weakness, and vitreous prolapse and diabetic macular edema. Selection of an appropriate intraocular lens (IOL) is crucial for visual rehabilitation and monitoring DR. The choice of IOL in diabetic cataract patients is a challenging scenario. Square-edge IOLs are favored for their capacity to mitigate PCO, whereas hydrophilic counterparts may incur calcification in the setting of proliferative DR. The advisability of premium IOLs for achieving spectacle independence warrants judicious evaluation, particularly in the presence of advanced retinopathy. Optimal IOL placement within the capsular bag is advocated to minimize postoperative complications. Rigorous preoperative assessment and informed patient counseling regarding IOL options are indispensable for optimizing surgical outcomes. This review article covers various aspects regarding the choice of IOLs in different case scenarios and complications in the diabetic population.

Mix-and-match vs bilateral trifocal and bilateral EDOF intraocular lens implantation: the spline curve battle

PURPOSE

To compare the postoperative visual acuity curves following 3 pseudophakic presbyopic correction techniques.

SETTING

Department of Ophthalmology, University Hospital of Alexandroupolis, Alexandroupolis, Greece.

DESIGN

Prospective, randomized, comparative trial.

METHODS

For this study, patients with stage 2 Lens Opacities Classification System III cataract were divided into 3 study groups: (1) premium monovision group, including patients who received the Panoptix intraocular lens (IOL) in the recessive eye and Vivity IOL in the dominant one; (2) bilateral trifocal group, including those who received bilaterally the Panoptix IOL; and (3) bilateral xEDOF group, including patients who received bilaterally the Vivity IOL. Postoperative bilateral uncorrected distance visual acuity was measured at 25.5, 28, 33, 40, 50, 66, 100, 200, and 300 cm distances. Spline curve fitting was attempted, and areas of the curves (AOCs) and curvature k were calculated. All patients responded to the National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ-25).

RESULTS

90 patients were equally divided into the 3 groups. Premium monovision and bilateral trifocal implantations delivered similar visual acuity (all AOC P > .05); however, the trifocal patients suffered from drops in vision acuity in certain distance ranges as expressed by negative curvature values. Bilateral xEDOF patients demonstrated worse near vision acuity ( P < .05). Premium monovision patients reported better scores in NEI-VFQ 25 ( P = .03) and in the near activities ( P = .02) and distant activities ( P = .04) subscales.

CONCLUSIONS

All surgical options provided impressive outcomes. Premium monovision appeared to deliver the best results.

Ocular dominance in cataract surgery: research status and progress

Ocular dominance (OD), a commonly used concept in clinical practice, plays an important role in optometry and refractive surgery. With the development of refractive cataract surgery, the refractive function of the intraocular lens determines the achievement of the postoperative full range of vision based on the retinal defocus blur suppression and binocular monovision principle. Therefore, OD plays an important role in cataract surgery. OD is related to the visual formation of the cerebral cortex, and its plasticity suggests that visual experience can influence the visual system. Cataract surgery changes the visual experience and transforms the dominant eye, which confirms the plasticity of the visual system. Based on the concept and mechanism of OD, this review summarizes the application of OD in cataract surgery.

IRIS® Registry (Intelligent Research In Sight) Analysis of the Incidence of Monovision in Cataract Patients with Bilateral Monofocal Intraocular Lens Implantation

Purpose

To determine the incidence of pseudophakic monovision among patients bilaterally implanted with monofocal intraocular lenses (IOLs) and to characterize the distribution of myopic offsets achieved.

Patients and Methods

This retrospective database study included data on patients receiving care from ophthalmologists who contributed to the Academy IRIS® (Intelligent Research In Sight) Registry. Anonymized data were collected, including patient age, ethnicity, procedure data (CPT code, date, laterality), and postoperative manifest refractive spherical equivalent (MRSE) in both eyes implanted with monofocal or monofocal toric IOLs. No data regarding IOL manufacturer, model, or power were collected. One primary outcome measure was the percentage of patients achieving monovision (defined as emmetropia within ±0.25 diopters [D] in one eye and a myopic offset of ≥0.50 D in the fellow eye) among all patients receiving bilateral monofocal IOLs at the time of cataract surgery between January 1, 2016, and September 1, 2019, with at least 90 days of follow-up. Other primary outcomes included the distribution and frequency of myopic offsets (anisometropia) between eyes.

Results

Of the 16,765 people receiving bilateral monofocal IOLs within the study period, 4796 (28.6%) achieved emmetropia in at least one eye, as defined by an MRSE within ± 0.25 D. The incidence of monovision among these patients was 34.2% (1638/4796). One-quarter (24.7%; 405/1638) of patients who achieved monovision had a myopic offset between 0.50 and 0.74 D, with more than one-third (35.2%; 576/1638) falling within 0.75-1.24 D and 18.0% within 1.25-1.74 D. A myopic offset ≥1.75 D was observed in 22.1% (362/1638) of patients who achieved monovision.

Conclusion

Pseudophakic monovision for presbyopia correction was achieved in ~34% of patients in the IRIS Registry bilaterally implanted with monofocal IOLs, with myopic offsets typically ranging from 0.5 to 1.24 D.

Comparison of binocular visual quality in six treatment protocols for bilateral cataract surgery with presbyopia correction: a prospective two-center single-blinded cohort study

OBJECTIVE

To compare the postoperative binocular visual quality in six treatment protocols for bilateral age-related cataract surgery with presbyopia correction for clinical decisions.

MATERIALS AND METHODS

In this prospective two-center single-blinded cohort study, participants from North or South China who underwent bilateral phacoemulsification and intraocular lens implantation were divided into six protocols: monovision, diffractive bifocal, mixed, refractive bifocal, trifocal, and micro-monovision extended range of vision (EROV). Binocular visual quality was evaluated at 3 months postoperatively, including binocular uncorrected full-range visual acuity, binocular defocus curves (depth of focus [DoF] and area under the curve [AUC]), binocular visual function (fusion function and stereopsis), binocular subjective spectacle independence rates, visual analog scale (VAS) of overall satisfaction, 25-item visual function questionnaire (VFQ-25), and binocular dysphotopsia symptoms.

RESULTS

Of the 300 enrolled patients, 272 (90.7%; 544 eyes) were analyzed. The trifocal protocol showed excellent binocular full-range visual acuity and the best performance for most DoFs and AUCs. The monovision protocol presented the worst binocular visual quality in most perspectives, especially in convergence, distance, and near stereopsis (p < 0.001). The full-range subjective spectacle independence rates were sorted from highest to lowest as follows: trifocal (84.8%), refractive bifocal (80.9%), EROV (80.0%), mixed (73.3%), diffractive bifocal (65.2%), and monovision (32.6%) protocols, with no statistically significant differences between the former five protocols (p > 0.05). The EROV protocol achieved the highest VAS and VFQ-25 scores. The incidence of postoperative binocular dysphotopsia symptoms was comparable in all protocols.

CONCLUSIONS

The trifocal protocol showed the best performance, and the monovision protocol presented the worst performance in most perspectives of binocular visual quality for presbyopia correction. The refractive bifocal, mixed, or EROV protocols can provide an approximate performance as a trifocal protocol. Ophthalmologists can customize therapies using different protocols.

Ten-year outcomes of pseudophakic mini-monovision correction of hyperopic presbyopia

PURPOSE

To evaluate long-term efficacy, safety, and spectacle independence after the treatment of hyperopic presbyopia with pseudophakic mini-monovision using standard monofocal intraocular lenses (IOLs) after bilateral cataract surgery.

SETTING

Private practice in Barcelona, Spain.

DESIGN

Retrospective, noncomparative case series.

METHODS

Patients with hyperopic presbyopia underwent bilateral cataract surgery with pseudophakic mini-monovision using standard monofocal IOLs between 2008 and 2018. Main outcomes analyzed were uncorrected distance visual acuity (UDVA), uncorrected near distance visual acuity (UNVA), and rates of spectacle independence at postoperative day 1 (POD1), months 1, 6 and 12, and at 5 and 10 years (Y10) postoperatively.

RESULTS

The study enrolled 463 patients. Both UDVA and UNVA significantly improved postoperatively ( P < .05). The mean binocular UDVA improved from 0.47 ± 0.3 logMAR preoperatively to 0.096 ± 0.14 at POD1 to 0.16 ± 0.2 at Y10 ( P = .0033). The binocular UNVA was 0.05 logMAR at Y10, whereas in preoperative visits, all patients needed spectacles. The mean UDVA for the dominant eye ≤0.20 logMAR was achieved in 84.29% at the Y10. Self-reported and measured complete spectacle independence for near vision was achieved in 79.61% of patients at POD1 and 71.92% at Y10 postoperatively. For distance, respectively, in 86.29% of patients at POD1 and 78.43% at Y10. The achieved results were stable. No serious events were reported, as well as no photic phenomena.

CONCLUSIONS

Pseudophakic mini-monovision in hyperopic presbyopes is a safe, effective, and low-cost approach for the long-term correction of presbyopia. It significantly reduces spectacle dependence and fulfils patients' expectations after bilateral cataract surgery.

Visual outcomes of binocular implantation of a new extended depth of focus intraocular lens

Purpose:

To evaluate the visual outcomes of bilateral implantation of a new hydrophobic foldable extended depth of focus (EDOF) IOL.

Methods:

All cases undergoing phacoemulsification with bilateral implantation of Supraphob Infocus IOL between December 2017 and July 2018 at a tertiary eye care center were recruited in this prospective interventional study. The primary outcome measures were uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), and uncorrected near visual acuity (UNVA). Postoperative follow-up was done on day 1, 1 week, 1 month, and 3 months.

Results:

One hundred and four eyes of 52 patients with a mean age of 58.4 ± 9.3 years were included. The mean UDVA improved from 0.84 ± 0.32 logMAR preoperatively to 0.11 ± 0.08 logMAR at 3 months following surgery. At the final follow-up, the binocular UDVA, UIVA, and UNVA was 0.03 ± 0.07, 0.14 ± 0.06, and 0.36 ± 0.05 logMAR, respectively. The mean CS was 1.47 ± 0.06 logCS. The distance and near stereopsis was 90.2 ± 24.8 s of arc (arcsec) and 62.5 ± 19.4 arcsec, respectively. The mean total higher-order aberration (HOA), point spread function, and modulation transfer function were 0.30 ± 0.13, 0.07 ± 0.08, and 0.26 ± 0.07, respectively.

Conclusion:

The Supraphob Infocus EDOF IOL provides good unaided visual acuity for distance, intermediate, and near along with a high quality of vision as assessed by contrast sensitivity, HOAs, and stereoacuity. It may be a potential alternative to the currently available EDOF IOLs in providing good visual acuity at variable distances.

Visual and Refractive Outcomes and Patient Satisfaction Following Implantation of Monofocal IOL in One Eye and ERV IOL in the Contralateral Eye with Mini-Monovision

Title

Visual and refractive outcomes and patient satisfaction following implantation of monofocal intraocular lens in one eye and ERV intraocular lens in the contralateral eye with mini-monovision.

Purpose

To evaluate the outcomes following implantation of monofocal intraocular lens in one eye and ERV intraocular lens in the contralateral eye with mini-monovision.

Methods

Twenty-five subjects underwent bilateral cataract surgery, wherein the dominant eye received monofocal Tecnis-1 IOL, while in the contralateral eye received the Tecnis Symphony ERV IOL. The dominant eye was targeted for emmetropia and the non-dominant eye for myopia of −0.50 to −0.75D. Binocular uncorrected and corrected distance (UDVA, CDVA), intermediate (UIVA, CIVA), and near (UNVA, DCNVA) visual acuity; reading speeds, defocus curve and contrast sensitivity were studied at 6 months post-operatively.

Results

At 6 months post-operatively the mean binocular UDVA, CDVA, UNVA and DCNVA were 0.007±0.07, −0.13±0.06, 0.26±0.09 and 0.44±0.10 LogMAR, respectively. Binocular UIVA and DCIVA at 60 cm were 0.22±0.10 and 0.18±0.08 LogMAR and at 80 cm was 0.16±0.11 and 0.15±0.10 LogMAR, respectively. Mean uncorrected reading speeds evaluated with SRD at 40, 60 and 80 cm were 114.4±6.9, 126.4±7.9 and 123.16±5.8 words per minute. Contrast sensitivity values did not show significant difference for any spatial frequency tested. At 6 months, only 12% (3 patients) reported mild halos. Spectacle independence satisfaction scores were 96%, 100% and 88% for distance, intermediate and near.

Conclusion

Implantation of monofocal intraocular lens in one eye and ERV intraocular lens in the contralateral with mini-monovision resulted in good outcomes for far and intermediate, and satisfactory outcomes for near vision, with good tolerance to mini-monovision at the end of 6 months.

Cataract surgery in Kinshasa-Is there a place for "Monovision"?

OBJECTIVES

Monovision is a method of correcting presbyopia where one eye is focused for far and the other for near vision. It is a simple, cost-effective approach to overcome the loss of accommodation with age and to become spectacles independent.

METHODOLOGY

About 50 patients, where bilateral cataract extraction was indicated, were included in this study performed at the St. Joseph's Eye Hospital in Kinshasa (DR Congo). Small incision cataract surgery technique (SICS) was applied with the implantation of 6 mm PMMA lenses in the capsular bag. IOL refractive power choice was made to achieve a post-operative refraction of -0.5 dpt for the eye selected for far vision. The second eye received an implant heading for a post-operative myopia of -1.5 dpt suitable for intermediated and near vision. According to the literature, monovision criteria have been regarded as fulfilled when (a) far vision was 0.5 (logMAR) or better and (b) near vision was P3 (0.40, Decimal 32 cm) or better. Spectacle dependence after bilateral cataract surgery heading for monovision was analysed using a dedicated questionnaire.

RESULTS

Out of all 50 patients 22 (44%) fulfilled the above defined criteria of monovision in terms of post-operative refraction and visual acuity. About 19 out of these 22 (86.3%) patients were happy without glasses. Two of them used bifocal spectacles, whereas the remaining patient refused spectacles. About 28 patients did not fulfill monovision criteria. Out of these 28 patients, however, 9 (32.1%) of them are happy without glasses.

CONCLUSION

In view of the described local circumstances aiming for monovision after bilateral cataract surgery is a suitable approach to optimise cataract surgical outcomes with no extra costs for surgery but considerable improvement of patient's visual performance in daily life.

Contact lenses, the reverse Pulfrich effect, and anti-Pulfrich monovision corrections

Interocular differences in image blur can cause processing speed differences that lead to dramatic misperceptions of the distance and three-dimensional direction of moving objects. This recently discovered illusion-the reverse Pulfrich effect-is caused by optical conditions induced by monovision, a common correction for presbyopia. Fortunately, anti-Pulfrich monovision corrections, which darken the blurring lens, can eliminate the illusion for many viewing conditions. However, the reverse Pulfrich effect and the efficacy of anti-Pulfrich corrections have been demonstrated only with trial lenses. This situation should be addressed, for clinical and scientific reasons. First, it is important to replicate these effects with contact lenses, the most common method for delivering monovision. Second, trial lenses of different powers, unlike contacts, can cause large magnification differences between the eyes. To confidently attribute the reverse Pulfrich effect to interocular optical blur differences, and to ensure that previously reported effect sizes are reliable, one must control for magnification. Here, in a within-observer study with five separate experiments, we demonstrate that (1) contact lenses and trial lenses induce indistinguishable reverse Pulfrich effects, (2) anti-Pulfrich corrections are equally effective when induced by contact and trial lenses, and (3) magnification differences do not cause or impact the Pulfrich effect.

Spectacle Independence And Patient Satisfaction With Pseudophakic Mini-Monovision Using Aberration-Free Intraocular Lens

Purpose

To assess spectacle independence and patient satisfaction with pseudophakic mini-monovision in patients undergoing routine bilateral cataract surgery with implantation of an aspherical aberration-free intraocular lens (Akreos AO, Bausch and Lomb, USA).

Methods

This study was a retrospective analysis that included 60 eyes of 30 consecutive patients between 2016 and 2018. The included patients had undergone sequential bilateral routine phacoemulsification after choosing the mini-monovision option. Test for ocular dominance was done using a sighting test. Emmetropia was aimed at in the dominant eye, while in the non-dominant eye the aim was myopia between -1 D and -1.5 D. The main outcome parameters were uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), and data reported from a questionnaire given to the patients at 3 months postoperative visit.

Results

The study included 60 eyes of 30 consecutive patients. The mean binocular UDVA was 0.09 ± 0.07 logMAR. Twenty-eight patients (93%) had binocular UDVA of 0.2 logMAR or better. The mean binocular uncorrected intermediate distance visual acuity (at 65 cm) was 0.16 ± 0.12 logMAR. Twenty-six patients (87%) had binocular uncorrected intermediate distance visual acuity of 0.2 logMAR or better. The mean binocular UNVA (at 35 cm) was 0.30 ± 0.21 logMAR. Fourteen patients (47%) had binocular UNVA of 0.2 logMAR or better. The patients score in the questionnaire was significantly higher in far and intermediate vision than near vision (p = 0.022). The patients score was significantly higher in day vision than night vision (p = 0.031). The mean overall patient satisfaction was good (9.1 ± 1.54). Twenty-eight patients (93%) reported high spectacle independence for far vision (score 8, 9, or 10).

Conclusion

Pseudophakic mini-monovision shows good results for spectacle independence and high patient satisfaction. It is a safe and inexpensive option after bilateral cataract surgery for correcting distance and intermediate vision. However, it might show lower results with near and night vision which is generally acceptable. Using aberration-free monofocal IOL allows for the residual normal positive corneal aberration that may augment the effect of monovision.

A systematic review of pseudophakic monovision for presbyopia correction

A systematic review of the recent literature regarding pseudophakic monovision as a reliable methods for presbyopia correction was performed based on the PubMed, MEDLINE, Nature and the American Academy of Ophthalmology databases in July 2015 and data from 18 descriptive and 12 comparative studies were included in this narrative review. Pseudophakic monosvision seems to be an effective method for presbyopia with high rates of spectacles independence and minimal dysphotopsia side-effects, that should be considered by the modern cataract surgeons.

Combination of Toric and multifocal intraocular lens implantation in bilateral cataract patients with unilateral astigmatism

AIM

To assess the binocular visual function in bilateral cataract patients with unilateral astigmatism after combined implantations of Toric with multifocal intraocular lens (IOL), and to compare with that of Toric and monofocal IOL implantation.

METHODS

All the 30 patients with unilateral astigmatism suffered bilateral cataract were randomly divided into two groups: Toric plus multifocal IOL group and Toric plus monofocal IOL group. Uncorrected and corrected visual acuity at distance (5.0 m), intermediate distance (0.6 m), and near (0.33 m), contrast sensitivity, and stereopsis were assessed 6mo after surgery. Patients were also surveyed for visual disturbances and spectacle dependence.

RESULTS

Binocular uncorrected visual acuity (LogMAR) of Toric/multifocal IOL eyes at distance, intermediate, near were 0.05±0.05, 0.24±0.10, and 0.14±0.06 respectively. The values of Toric plus monofocal IOL eyes were 0.06±0.07, 0.26±0.08, and 0.37±0.10 respectively. These values did not indicate significant differences between two groups with exception of near visual acuity. In the photopic condition (with or without glare), the contrast sensitivity of multifocal IOL eyes was significant lower than the monofocal IOL eyes in 18 cpd. In the mesopic condition, the contrast sensitivity of multifocal group was significant lower than monofocal group in 12 cpd, and in mesopic glare condition, this significant difference was found both in 6 cpd and 12 cpd. The stereopsis of Toric/multifocal IOL eyes decreased slightly (100±80 seconds of arc, t=2.222, P=0.136). Mean near vision for patient satisfaction was statistically significantly higher in Toric/multifocal IOL group patients versus than that in Toric/monofocal IOL group (80% vs 25.5%, P=0.000). Visual disturbance was not noticed in either group.

CONCLUSION

Although the combination of Toric and multifocal IOL implantation results in compromising stereoacuity, it can still provide patients with high levels of spectacle freedom and good overall binocular visual acuity.

Visual and Refractive Outcomes of Phacoemulsification with Implantation of Accommodating versus Standard Monofocal Intraocular Lenses

Purpose:

To compare distant and near visual function after cataract surgery with implantation of Crystalens HD or Tek-Clear as accommodating intraocular lenses (IOLs), versus SA60AT as a standard IOL.

Methods:

The study included 62 eyes of 58 patients divided into three groups using three different IOLs: Crystalens HD (Bausch and Lomb, NY, USA), Tek-Clear (Tekia, CA, USA) and SA60AT (Alcon, TX, USA) were implanted in 23, 14 and 25 eyes, respectively. Corrected distant visual acuity (CDVA), uncorrected and distance corrected near visual acuities (UCNVA and DCNVA), near point of accommodation (NPA), spectacle freedom and patient satisfaction were assessed six months postoperatively and compared between the three groups.

Results:

After 6 months, all patients showed significant improvement in CDVA with no significant difference among the study groups. However, UCNVA and DCNVA were significantly better in patients implanted with accommodating IOLs. NPA was closest in the Crystalens HD group, followed by Tek-Clear and monofocal SA60AT (P < 0.001). Patients with accommodating IOLs were more likely to become spectacle free and satisfied with their near vision as compared to subjects receiving a monofocal IOL.

Conclusions:

Accommodating IOLs (Crystalens HD and Tek-Clear) effectively reduce the necessity for spectacles after cataract surgery.

Cataract

Cataract is the leading cause of reversible blindness and visual impairment globally. Blindness from cataract is more common in populations with low socioeconomic status and in developing countries than in developed countries. The only treatment for cataract is surgery. Phacoemulsification is the gold standard for cataract surgery in the developed world, whereas manual small incision cataract surgery is used frequently in developing countries. In general, the outcomes of surgery are good and complications, such as endophthalmitis, often can be prevented or have good ouctomes if properly managed. Femtosecond laser-assisted cataract surgery, an advanced technology, can automate several steps; initial data show no superiority of this approach over current techniques, but the results of many large clinical trials are pending. The greatest challenge remains the growing 'backlog' of patients with cataract blindness in the developing world because of lack of access to affordable surgery. Efforts aimed at training additional cataract surgeons in these countries do not keep pace with the increasing demand associated with ageing population demographics. In the absence of strategie that can prevent or delay cataract formation, it is important to focus efforts and resources on developing models for efficient delivery of cataract surgical services in underserved regions. For an illustrated summary of this Primer, visit: http://go.nature.com/eQkKll.

Binocular visual function of modified pseudophakic monovision

PURPOSE

To compare binocular visual function of pseudophakic patients having modified monovision (0.75 diopter [D] anisometropia) with that of patients having conventional monovision (1.75 D anisometropia).

DESIGN

Prospective observational study.

METHODS

Eighty-two patients that underwent bilateral implantation of a monofocal intraocular lens were recruited at 3 months postoperatively. Modified monovision was simulated by adding a +0.75 D spherical lens to the nondominant eye, while conventional monovision was simulated by adding a +1.75 D spherical lens. Binocular corrected visual acuity (VA) at various distances, binocular contrast VA (contrast VA) and that with glare (glare VA), and stereoacuity were evaluated.

RESULTS

With modified monovision, mean binocular corrected intermediate VA at 1.0 m was 20/19 and near VA at 0.3 m was 20/51, and stereoacuity was 125 ± 100 seconds of arc. Mean binocular intermediate VA at 1.0 m was significantly better with modified monovision than with conventional monovision (P = .0001), while near VA and intermediate VA at 0.5 m were significantly worse (P < .0001). Mean binocular photopic and mesopic contrast VA and glare VA tended to be better with modified monovision than with conventional monovision, but the difference was not significant. Mean stereoacuity was significantly better with modified monovision than with conventional monovision (P = .0020).

CONCLUSIONS

Modified pseudophakic monovision provided excellent binocular VA from far to intermediate distances, although near VA was worse than that with conventional monovision. Contrast VA with and without glare tended to be better and stereoacuity was significantly better with modified monovision, suggesting that this method is useful for correcting presbyopia without marked impairment of binocular function.

Comparison of conventional versus crossed monovision in pseudophakia

AIMS

To compare the visual performances and patient satisfactions of conventional monovision, which corrects the dominant eye for distance vision, and crossed monovision, which corrects the non-dominant eye for distance vision in patients with pseudophakia.

METHODS

This prospective randomised study was conducted in 59 patients who underwent implantation of different targets of monofocal intraocular lens for each eye at Konkuk University Medical Center between November 2009 and August 2012. The following were examined before bilateral cataract surgery and 2 months after the surgery: refractive error, binocular uncorrected distance visual acuity (UCDVA), uncorrected near visual acuity (UCNVA), best corrected visual acuity (BCVA) and stereopsis. Questionnaires to evaluate postoperative spectacle dependence and patient satisfaction were completed by all patients.

RESULTS

The conventional monovision group and the crossed monovision group were composed of 28 and 31 patients, respectively. There were no significant differences in postoperative UCDVA, UCNVA, BCVA and stereopsis between the two groups. In addition, patient satisfaction with near and distant vision and spectacle dependence were not significantly different in the two groups.

CONCLUSIONS

The clinical results of the crossed monovision were not significantly different from the results of conventional monovision. Therefore, crossed monovision can also be a valuable option for correcting postoperative presbyopia in patients considering bilateral cataract surgery.

TRIAL REGISTRATION NUMBER

KCT0001065.

Feasibility of multifocal intra-ocular lens exchange and conversion to the bag-in-the-lens implantation

PURPOSE

Our purpose was to evaluate the surgical outcome after intra-ocular lens exchange in patients who presented impairing visual complaints after primary multifocal intra-ocular lens (MIOL) implantation. In particular, the study was undertaken to look at the number of eyes that could be equipped with the bag-in-the-lens (BIL) IOL after MIOL exchange.

METHODS

This series consisted of 30 eyes of 21 consecutive patients scheduled for MIOL exchange. In 15 out of the 30 eyes, IOL misalignment was measured on slit lamp anterior segment photo's after defining the mathematical centres of the IOL optic, pupil and limbus.

RESULTS

Diffractive MIOL was more frequently explanted (25; 83%) when compared with refractive MIOL (4; 13%) and progressive optic IOL (1; 4%). In 21 out of the 30 eyes (70%) a bag-in-the-lens could be implanted. In 7 out of the 30 eyes (23%), the capsule was not considered sufficiently stable to accommodate an IOL. An iris-fixated IOL or a sulcus-fixated IOL was then implanted. In 2 out of the 30 eyes (6%) the remaining capsular bag could accommodate a traditional lens-in-the-bag only. Eyes that underwent Nd:YAG laser capsulotomy prior to the MIOL exchange needed anterior vitrectomy peroperatively (11 eyes; 37%). Visual acuity improved postoperatively in 13 out of the 30 eyes and remained stable in 17 out of the 30 eyes.

CONCLUSIONS

Since the BIL technique requires a very well-preserved capsular bag for the purpose of the IOL implantation, the success rate of BIL implantation after MIOL is a good indicator to evaluate the degree of difficulty to exchange MIOL.

Randomized trial of multifocal intraocular lenses versus monovision after bilateral cataract surgery

OBJECTIVE

To compare spectacle independence in patients randomized to receive bilateral multifocal intraocular lenses (IOLs) or monofocal IOLs with the powers adjusted to produce monovision.

DESIGN

Randomized, multicenter clinical trial.

PARTICIPANTS

A total of 212 patients with bilateral, visually significant cataract.

METHODS

Before bilateral sequential cataract surgery, patients were randomized (allocation ratio 1:1) to receive bilateral Tecnis ZM900 diffractive multifocal lenses (Abbott Medical Optics, Santa Ana, CA) or Akreos AO monofocal lenses (Bausch & Lomb, Rochester, NY) with the powers adjusted to target -1.25 diopters (D) monovision. Outcomes were assessed 4 months after the second eye underwent operation.

MAIN OUTCOME MEASURES

The primary outcome was spectacle independence. Secondary outcomes included questionnaires (VF-11R, dysphotopsia symptoms, and satisfaction) and visual function measures (near, intermediate, and distance logarithm of minimum angle of resolution [logMAR] visual acuity, stereoacuity, contrast sensitivity, and forward light scatter).

RESULTS

A total of 212 patients were randomized, and 187 patients (88%) returned for assessment 4 months after surgery. Uniocular distance refractions in the monovision arm showed a mean spherical equivalent of +0.075 D in the distance eye and -0.923 in the near eye. In the multifocal arm, the mean distance spherical equivalents were -0.279 D and -0.174 D in the right and left eyes, respectively. A total of 24 of 93 patients (25.8%) in the monovision arm and 67 of 94 patients (71.3%) in the multifocal arm reported never wearing glasses (P<0.001, Fisher exact test). The adjusted odds ratio of being spectacle free was 7.51 (95% confidence interval, 3.89-14.47). Binocular uncorrected acuities did not differ significantly for distance (0.058 logMAR for monovision vs. 0.076 for multifocal, P = 0.3774) but were significantly worse in the multifocal arm for intermediate acuity (0.149 vs. 0.221, P = 0.0001) and in the monovision arm for near acuity (0.013 vs. -0.025, P = 0.037). In the first postoperative year, 6 patients (5.7%) in the multifocal arm underwent IOL exchange (4 had a bilateral and 2 had a unilateral exchange). No patients in the monovision arm underwent IOL exchange.

CONCLUSIONS

Patients randomized to bilateral implantation with the diffractive multifocal Tecnis ZM900 were more likely to report being spectacle independent but also more likely to undergo IOL exchange than those randomized to receive monofocal implants (Akreos AO) with the powers adjusted to give low monovision.