Effectivity and safety of trifocal intraocular lenses and capsular tension rings implantation for cataract patients with axial high myopia

●AIM:To assess effectivity and safety of trifocal intraocular lenses(IOLs)and capsular tension rings in treating cataract patients with axial high myopia.●METHODS:A prospective nonrandomized controlled clinical trial was conducted.Totally 98 eyes(74 patients)who underwent femtosecond laser-assisted cataract surgery(FLACS)with trifocal IOLs were enrolled in the study and followed up for 2y after surgery:46 eyes(33 patients)with capsular tension ring implantation in the long axial lengths(AL)group(26<AL<29 mm)and 52 eyes(41 patients)in the normal AL group(22<AL<24.5 mm).Postoperative outcomes about effectivity and safety,including the subjective and objective visual quality,and postoperative complications were assessed.●RESULTS:Uncorrected distance visual acuity at 5 m and uncorrected intermediate visual acuity at 60 and 80 cm in the long AL group were significantly worse than those in the normal AL group at 3mo postoperatively(P<0.05).The differences in reading speed,spectacle independence and potential visual complaints between the two groups were not statistically significant(P>0.05).The dysfunctional lens index and total modulation transfer function(MTF)average height were similar between the two groups.The postoperative internal coma aberrations in the axial high myopia eyes were significantly higher than that in the normal AL group(P<0.05).The total satisfaction score in the long AL group(91.32±2.76)was slightly higher than that in the normal AL group(90.36±3.47),but there was no difference(P=0.136).A statistically negative correlation was found between corrected distance visual acuity(CDVA)and dysfunctional lens index(r=-0.382,P=0.009),and between CDVA and the total MTF average height(r=-0.374,P=0.01).But there was no significant correlation between CDVA and total satisfaction score(r=0.059,P=0.696).Postoperative complications mainly presented as posterior capsular opacity(PCO),retinal detachment and cystoid macular edema.There was no difference in the incidence of fundus disease(6.5%vs 3.8%,P=0.663)or PCO(17.4%vs 7.7%,P=0.217)between the two groups at two years.●CONCLUSION:The utilization of trifocal IOL and capsular tension ring implantation is beneficial for cataract patients with axial high myopia undergoing FLACS.This approach not only ensures excellent subjective feelings and objective visual quality,but also does not increase the incidence of postoperative complications.

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 extendeddepth-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.

Sutured scleral fixation of existing subluxated/dislocated acrylic one-piece intraocular lenses

AIM:To evaluate the visual and refractive outcomes in cases after sutured scleral fixation of existing subluxated or dislocated acrylic one-piece intraocular lenses(IOLs).METHODS:This study retrospectively enrolled a consecutive series of patients who underwent a surgery of sutured existing subluxated or dislocated IOLs from October 2018 to June 2020.All patients underwent comprehensive preoperative and postoperative ophthalmologic examination,and data were collected including age,sex,surgical indications,best-corrected visual acuity,refractive error,intraocular pressure.Presence of intraoperative and postoperative surgical complications was documented.RESULTS:A total of 20 consecutive cases were enrolled for analysis with mean final follow-up period 9.8±5.3mo.Visual acuity improved from a mean of 0.35(0.46±0.32 logMAR)preoperatively to 0.61(0.21±0.18 logMAR)at the 3-month follow-up(P=0.002).The mean amount of preoperative keratometric astigmatism and total postoperative refractive astigmatism was-1.24±0.80 diopters(D)and-1.42±0.97 D,respectively.There was no statistically significant difference between preoperative and postoperative astigmatism(P=0.156).The mean IOL-induced astigmatism was-0.23±0.53 D.The mean spherical equivalent at the 3-month follow-up was-0.1±0.94 D.No major complications were noted during the follow-up period.CONCLUSION:Surgical techniques using sutured scleral fixation of existing subluxated or dislocated acrylic one-piece IOLs result in favorable visual and refractive outcomes without major complications.

A new software for automated counting of glistenings in intraocular lenses in vivo

AIM:To assess the performance of a bespoke software for automated counting of intraocular lens(IOL)glistenings in slit-lamp images.METHODS:IOL glistenings from slit-lamp-derived digital images were counted manually and automatically by the bespoke software.The images of one randomly selected eye from each of 34 participants were used as a training set to determine the threshold setting that gave the best agreement between manual and automatic grading.A second set of 63 images,selected using randomised stratified sampling from 290 images,were used for software validation.The images were obtained using a previously described protocol.Software-derived automated glistenings counts were compared to manual counts produced by three ophthalmologists.RESULTS:A threshold value of 140 was determined that minimised the total deviation in the number of glistenings for the 34 images in the training set.Using this threshold value,only slight agreement was found between automated software counts and manual expert counts for the validating set of 63 images(κ=0.104,95%CI,0.040-0.168).Ten images(15.9%)had glistenings counts that agreed between the software and manual counting.There were 49 images(77.8%)where the software overestimated the number of glistenings.CONCLUSION:The low levels of agreement show between an initial release of software used to automatically count glistenings in in vivo slit-lamp images and manual counting indicates that this is a non-trivial application.Iterative improvement involving a dialogue between software developers and experienced ophthalmologists is required to optimise agreement.The results suggest that validation of software is necessary for studies involving semi-automatic evaluation of glistenings.

Rotational stability of plate haptic toric intraocular lenses after combined 25-gauge vitrectomy and cataract surgery

AIM:To evaluate the postoperative intraocular lens(IOL)rotational stability and residual refractive astigmatism following combined 25-gauge vitrectomy and cataract surgery with implantation of a plate haptic toric IOL.METHODS:In this retrospective case series,32 eyes of 32 patients underwent a combined 25-gauge vitrectomy and phacoemulsification for vitreoretinal diseases and cataract with regular corneal astigmatism of at least 1 diopter(D).A plate haptic toric IOL(AT Torbi 709M,Carl Zeiss Meditec AG)was implanted in all eyes.The outcome measures were rotational stability and refractive astigmatism up to 6mo postoperatively as well as the best corrected visual acuity(BCVA).RESULTS:Preoperative refractive astigmatism was 2.14±1.17 D,which was significantly reduced to 0.77±0.37 D six to eight weeks postoperatively and remained stable throughout the observation period(0.67±0.44 D at three months and 0.75±0.25 D at six months;for all groups:P<0.0001 compared to baseline).BCVA improved significantly from 0.36±0.33 logMAR preoperatively to 0.10±0.15 logMAR following surgery(P=0.02).Mean IOL axis deviation from the target axis was 3.4°±2.9°after six to eight weeks and significantly decreased over time(2.4°±2.6°six months after surgery;P=0.04).In one patient IOL,re-alignment was performed.CONCLUSION:Corneal astigmatism is significantly reduced following combined 25-gauge vitrectomy and cataract surgery.The plate haptic toric IOL position and axis remain stable during the observation period of six months.

Flapless one-knot suture:a novel surgical technique for transscleral fixation of C-loop intraocular lenses

AIM:To describe a novel suture approach for transscleral fixation of C-loop intraocular lenses(IOL)and to compare the surgical outcomes with the four-haptics posterior chamber(PC)-IOL technique.METHODS:We retrospectively analyzed 16 eyes of 16 patients who underwent transscleral fixation of C-loop PCIOLs using a flapless one-knot suture technique,which were followed up for longer than 17mo.In this technique,the capsulorless IOL was suspended using a single suture for transscleral fixation of four feet.Then we compared its surgical outcomes and complications with the four-haptics PC-IOLs using the Student's t test and Chi-square test.RESULTS:Sixteen patients of 16 eyes with a mean age of 58.3±10.1y(42-76y)who received transscleral C-loop IOL implantation due to trauma,vitrectomy,or cataract surgery with inadequate capsule support showed improved visual acuity.The difference was not significant between two IOLs except the surgery time(P>0.05).The mean operation times of C-loop IOL surgery was 24.1±1.83min and 31.3±4.47min of the four-haptics PC-IOL method(P<0.0001).In the C-loop IOLs group,there was statistical difference between the preoperative and the postoperative UCVA(log MAR,1.20±0.50 vs 0.57±0.32,P=0.0003).There was no statistical difference between the preoperative and the postoperative BCVA(log MAR,0.66±0.46 vs 0.40±0.23,P=0.056).However,there was no statistically significant difference in postoperative UCVA and BCVA between the two IOLs(P>0.05).We did not detect any optic capture,IOL decentration or dislocation,suture exposed,or cystoid macular edema in patients underwent C-loop IOLs surgery.CONCLUSION:The novel flapless one-knot suture technique for transscleral fixation of C-loop IOL is a simple,reliable,and stable technique.

Considerations in the management of single-piece intraocular lenses outside the capsular bag

AIM: To investigate the outcomes of off label singlepiece acrylic intraocular lenses(SPA-IOL) ciliary sulcus placement compared to three-piece IOL(3P-IOL). METHODS: The charts of eight consecutive eyes of patients who received sulcus-placed SPA-IOLs between 2006 and 2009 were reviewed. None of the patients underwent IOL exchange. Charts of six age-matched patients who received sulcus placed 3P-IOLs were reviewed as a control group. RESULTS: Mean follow up was 16 mo for SPA-IOL and 23 mo for 3P-IOL. Five of 8 patients in the SPA-IOL group required chronic use of IOP lowering medications at final follow up. Of these, one patient needed glaucoma implant surgery for uncontrolled IOP. One patient in the 3P-IOL group used chronic aqueous suppression pre- and postoperatively. Four of eight eyes with SPAIOL were treated with chronic topical steroids and or non-steroidal anti-inflammatory drugs for cystoid macu-la edema, chronic uveitis, pigment dispersion syndrome or a combination of the above, compared to none in the control group. Mean best-corrected visual acuity was 20/35 in the SPA-IOL group and 20/47 in the 3PIOL group.CONCLUSION: Sulcus placed SPA-IOLs are associated with increased ocular morbidity. In select cases good visual acuity may be achieved. Due to postoperative rotation of sulcus placed toric SPA-IOLs stable astigmatism correction cannot be achieved. Alternative intraocular lenses should be considered when in-the-bag placement of SPA-IOL is not possible.

Study on the surface properties of surface modified silicone intraocular lenses

AIM: To prepare a new-type soft intraocular lens (IOL) that silicone intraocular lenses (IOLs) were modified by surface modification technique to assess IOLs biocompatibility. METHODS: With the technique of ion beam combined with low temperature and low pressure plasma, the surface characteristics of the IOLs including physical and optical properties were determined by the instruments of IOLs resolution, UV/VIS scanning spectrophotometer, contact angle measurement system, electron spectroscopy for chemical analysis (ESCA) and scanning electron microscope (SEM). RESULTS: The color of titanium (Ti) modified IOLs was light yellow and that of titanium nitride (TiN) modified IOLs was light brown. The absorptive degree of ultraviolet rays and the hydrophilicity of the surfaces of modified IOLs were increased, and appeared suitable chemical compositions. The resolution of unmodified and modified IOLs reached normal standard. The surfaces of unmodified and Ti-modified IOLs appeared uniform. The surfaces of TIN-modified IOLs presented fine porcelain structure. CONCLUSION: The optical properties of all IOLs and the surface morphology of the modified IOLs were not affected by modification processes. The surface properties of the modified IOLs were improved.

F-heparin modified intraocular lenses in Rhesus monkeys

AIMIn order to improve the biocompatibility of intraocular lenses (IOL), the polymethylmethacrylate (PMMA) IOL was modified with F-heparin.

Cauterization technique for suture erosion in transscleral fixation of intraocular lenses

Transscleral suturing is a commonly applied technique to fix intraocular Implants in the sulcus.A major problem after transscleral implantation is suture erosion that normally happens in the late post-surgery period and may result In an Increased incidence of endophthalmitis.Here we describe an original cauterization method by using a glass rod to melt the exposed suture end without damaging the suture knot in the sclera to avoid suture exposure in sclera-fixed IOL implantation.This is a simple,quick and effective technique that can be performed without conjunctiva incisions and will help to reduce suture erosion related complications.

Above-average defocus curves in photopic and mesopic vision with multifocal intraocular lenses after laser assisted in situ keratomileusis

I am Dr. David P Pifiero from the Department of Optics, Pharmacology and Anatomy of the University of Alicante and from the Department of Ophthalmology of Vithas Medimar （Oftalmar） and Vithas Virgen del Carmen （Qvision） hospitals in Spain.

Visual function and higher order aberration after implantation of aspheric and spherical multifocal intraocular lenses:a meta-analysis

AIMTo assess the visual outcomes of aspheric multifocal intraocular lenses (IOLs) compared with spherical multifocal IOL after cataract surgery.

Visual outcome and optical quality after bilateral implantation of aspheric diffractive multifocal, aspheric monofocal and spherical monofocal intraocular lenses: a prospective comparison

·AIM: To evaluate the visual function after bilateral implantation of aspheric diffractive multifocal Tecnis ZMA00, aspheric monofocal ZA9003 versus spherical monofocal Akreos Adapt intraocular lenses (IOLs). ·METHODS: Tecnis ZMA00, Tecnis ZA9003 or Akreos Adapt IOLs were bilaterally implanted in 180 eyes from 90 patients. The following parameters were assessed 3 months postoperatively: monocular and binocular uncorrected visual acuity (UCVA) and distance-corrected visual acuity (DCVA) for distance, intermediate and near, spherical aberration (SA), contrast and glare sensitivity, near point refractive power, uncorrected and best corrected near stereoscopic acuity (NSA). Patient satisfaction was assessed by a questionnaire. ·RESULTS:Threemonthspostoperatively,themonocular and binocular UCVA and DCVA at near of Tecnis ZMA00 were significantly better than other two groups. The mean SA for 5.0mm optical zone in Tecnis ZMA00 and Tecnis ZA9003 was significantly lower than that in Akreos Adapt. Mean contrast sensitivity and glare sensitivity were better for Tecnis ZA9003 group than for other two groups. Patients with Tecnis ZMA00 had higher monocular and binocular near point refractive power and uncorrected NSA than monofocal groups. The patients in Tecnis ZMA00 had higher mean values for halo compared with other two groups. ·CONCLUSION: Tecnis ZMA00 provided better near VA and uncorrected NSA and higher near point refractive power than monofocal IOLs and patients were spectacle independent. The IOLs with Tecnis aspheric design improved contrast and glare sensitivity. Patients with Tecnis ZMA00 reported more disturbances on visual phenomena of halo. ·

Higher order aberration comparison between two aspherical intraocular lenses: MC6125AS and Akreos advanced optics

AIM: To compare higher order aberrations in two aspherical intraocular lenses(IOLs): Akreos advanced optics(AO) and Dr. Schmidt Microcrystalline 6125 aspheric anterior surface(MC6125AS) with each other. METHODS: Forty eyes of 39 patients underwent phacoemulsification and Akreos AO and MC6125 AS were implanted in their eyes in a random manner. Three months post-operatively, higher order aberrations including spherical aberration, coma aberration, and total aberrations were measured and compared.RESULTS: The total aberration was 0.24±0.17 in eyes with Dr. Schmidt and 0.20 ±0.01 in eyes with Akreos AO(P =0.361). The mean of coma aberration was 0.17 ±0.21 and 0.09 ±0.86 in Dr. Schmidt and Akreos lenses,respectively(P =0.825). Total spherical aberration was almost the same in both groups(mean: 0.05, P =0.933).Best corrected visual acuity in Akreos AO(0.10±0.68) and Dr. Schmidt(0.09±0.67) did not differ significantly(P =0.700). CONCLUSION: There is no statistically significant difference in the higher order aberrations between these two aspherical lenses.

Effect of four different intraocular lenses on posterior capsule opacification

AIM: To evaluate the impact of 4 different intraocular lenses(IOLs) on posterior capsule opacification(PCO) by comparing the neodymium: yttrium-aluminum-garnet(Nd:YAG) laser capsulotomy rates.METHODS: This retrospective study included 4970 eyes of 4013 cataract patients who underwent phacoemulsification and IOL implantation between January 2000 and January 2008 by the same surgeon at one clinic. Four different IOLs were assessed. The outcome parameter was the incidence of Nd:YAG laser posterior capsulotomies.· RESULTS: An Nd:YAG laser posterior capsulotomy was performed in 153(3.07%) of the 4970 eyes. The mean follow-up time was 84 mo for all of the IOL groups. The percentage of eyes developing PCO was significantly greater for the acrylic hydrophilic IOLs than for the hydrophobic IOLs, although eyes with acrylic hydrophilic IOLs did not require Nd:YAG laser capsulotomy as soon as eyes with acrylic hydrophobic IOLs. There was no difference between the long-term PCO rates when 1-and 3-piece acrylic hydrophobic IOLs were compared or when IOLs made of the same material but with different haptic angles were compared.· CONCLUSION: In this study, eyes with acrylic hydrophilic IOLs were more likely to develop PCO than those with acrylic hydrophobic IOLs. The lens design(1-piece versus 3-piece and varying haptic angles) did not affect the PCO rate.

Potential of video games for the promotion of neuroadaptation to multifocal intraocular lenses: a narrative review

Multifocal intraocular lenses(IOLs) are currently usually implanted for the treatment of cataracts because they have been proved to be superior to monofocal IOLs with respect to spectacle independence. In turn, they are associated with a higher prevalence of dysphotopsia symptoms that is one of the most common causes of patient dissatisfaction. Neuroadaptation seems to play a major role in the optimal adaptation to multifocal IOLs. In this context, the development of strategies that facilitate the neuroadaptation process to multifocality might be an effective strategy to reduce patients' dissatisfaction. Video games have been proved to be effective for the improvement of visual acuity and for the promotion of neuroplasticity in elderly subjects and other populations with cortical-related visual impairment. This narrative review highlights the physiological potential of video games as a perceptual strategy to improve visual acuity and promote neuroplasticity in patients using multifocalIOLs, although research is still needed to confirm these benefits in this specific population, with only one comparative study to this date providing evidence of them.

Rainbow halos occur less following implantation of extended range of vision one-piece intraocular lenses vs diffractive bifocal intraocular lenses

AIM:To evaluate clinical outcomes following implantation of an extended range of vision intraocular lens(IOL),the ZXR00,and a diffractive multifocal IOL with+2.75 diopters(D)add power,the ZKB00.METHODS:Totally 30 patients who underwent either bilateral implantation of the ZXR00 IOL with intended emmetropia(ZXR00 emmetropia group:20 eyes)and intended micromonovision(ZXR00 monovision group:20 eyes),or bilateral implantation of the ZKB00 IOL with intended emmetropia(ZKB00 group:20 eyes)were included in this study.Visual acuity at 4 m,80,and 40 cm;and the types of halos(misty,fine,and rainbow)were analyzed at one and three months after surgery.RESULTS:There were no significant differences in distance visual acuity among the three groups.The mean uncorrected intermediate visual acuity was better in the ZXR00 emmetropia and monovision groups(0.02 logMAR and 0.02 logMAR,respectively)than in the ZKB00 group(0.14 logMAR).The mean uncorrected near visual acuity was worse in the ZXR00 emmetropia group(0.26 logMAR)than in the ZXR00 monovision and ZKB00 groups(0.12 logMAR and 0.10 logMAR,respectively).There was an increased incidence of rainbow halos in the ZKB00 group vs in either ZXR00 group(P=0.033).CONCLUSION:Implantation of the ZXR00 IOL with intended micromonovision provide superior visual acuity than implantation of the ZXR00 IOL with intended emmetropia.The ZXR00 IOLs tend to show a lower incidence of rainbow halos than did the ZKB00 IOL.

New two-point scleral-fixation technique for foldable intraocular lenses with four hollow haptics

The study was to report a new two-point scleralfixation technique for foldable intraocular lenses with four haptics.Lenses were slid into the anterior chamber from a 2.8 mm corneal incision and fixed under two sclera flaps at two opposite points.The postoperative best-corrected visual acuities（BCVAs） of all patients were significantly better than their preoperative BCVA.The results demonstrate that two-point,scleral fixations of foldable,intraocular lenses might be practicable and effective.

Analysis of glistenings in hydrophobic acrylic intraocular lenses on visual performance

AIM:To assess patients’ visual performance with glistenings in one piece soft hydrophobic acrylic intraocular lenses(IOLs)(Alcon)2y postoperatively.METHODS:This cross section trial included 120 eyes with one piece IOL at 2y postoperatively.Glistening was classified in 4 groups,ranging from 0(none)to 3(most evident)according to their severity in IOLs optics observed under a slit lamp.All eyes underwent a uncorrected and best-corrected visual acuity evaluation(UCVA and BCVA,LogMAR scale),a complete clinical examination,a contrast sensitivity(CS)evaluation by F.A.C.T chart,and a visual field test by Humphrey Field AnalyzerⅡ(HFA).One-way ANOVA was used for quantitative data,while Pearsonχ2test was used for qualitative data to analyze the visual function of 4glistening groups.RESULTS:Totally 120 eyes were enrolled with 30 eyes in each glistening group.There was no statistical correlation between glistening grades and patients’age,IOLs power,postoperative UCVA and BCVA(P】0.05).Quantificationally,CS values among each group were not statistically different.However,qualitative analysis showed there were more eyes in grade 3 group than in grade 0 group having abnormally declined CS at high spatial frequency(10%vs 36.7%at 18 cpd,P=0.029;6.7%vs 26.7%at 12 cpd,P=0.013).Mean deviation(MD)of the visual field test was-2.14±2.31,-1.97±2.23,-3.02±3.17,-4.12±3.38 in group 0 to 3 respectively.There was a significant decrease in the most serious glistenings group(P=0.018).CONCLUSION:Glistenings may potentially have an impact on contrast sensitivity at high spatial frequency and MD in visual field test.

Visual performance with accommodating and multifocal intraocular lenses

AIM： To compare the visual functional outcomes with accommodating and multifocal intraocular lenses（IOLs）.METHODS： Our retrospective comparative study included 51 patients（60 eyes） received implantation of an accommodating IOL（Tetraflex;16 patients,20 eyes）,a refractive multifocal IOL（Re Zoom;18 patients,20 eyes）,or a diffractive multifocal IOL（ZMA00;17 patients,20 eyes）.Subjective refraction,visual acuity,contrast sensitivity（CS）,intraocular aberration,and subjective photic phenomena were detected at 3mo after surgery.RESULTS： The spherical equivalent in the three groups was-0.38±0.54 D,0.14±0.56 D,and 0.35±0.41 D,respectively.No statistically significant differences were found in uncorrected and corrected distance visual acuity and uncorrected intermediate visual acuity among the groups（P=0.39）.The Re Zoom group had significantly better distance-corrected intermediate visual acuity than the ZMA00 group（P=0.003）.The ZMA00 group had significantly better near visual acuity than the other groups（P〈0.05）.Better contrast sensitivity values were observed in the Tetraflex group under most of the spatial frequencies conditions（P=0.025）.The total aberration was lowest in the ZMA00 group（P=0.000）,and the spherical aberration was highest in the Tetraflex group（P=0.000）.The three groups had similar frequency of ghosting and glare,and the Tetraflex group had a low rate of halos（P=0.01）.CONCLUSION： Both accommodating and multifocal IOLs can successfully restore distance and uncorrected intermediate visual acuities.Tetraflex accommodating IOLs perform better in CS and with less halos of photic phenomena.Re Zoom refractive multifocal IOLs havebetter performance in distance-corrected intermediate visual acuity than ZMA00 diffractive multifocal IOLs,and the latter achieved better near visual acuity and efficiently decreased the optical aberration.