Article

Pupil dependence assessment with multifocal intraocular lenses through visual acuity and contrast sensitivity defocus curves

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Abstract

Purpose: To identify the most sensitive visual performance metric for evaluating the pupil-dependency of a multifocal intraocular lens (MIOL) and to determine the pupil measurement method most correlated with such metric. Methods: Twenty-seven right eyes implanted with a MIOL were included in the analysis. Three pupil size measurements were obtained preoperatively and at 1 month after surgery with the Keratograph 5M system: photopic (PP), mesopic (MP), and the average from both (AP). Pupil was also measured with a rule (RP) under the same light conditions of postoperative visual performance measurements that included, corrected visual acuities (VA) at three distances (far, 67 cm and 40 cm), visual acuity (VADC) and contrast sensitivity defocus curves for optotype sizes of 0.3 logMAR (CSDC3) and 0.7 logMAR (CSDC7). Differences in visual performance were also analyzed for eyes with RP > 3 mm (Group A) and RP ⩽ 3 mm (Group B). Results: PP diameter decreased after surgery by 16% (p = 0.001), whereas MP (p = 0.013) and AP (p = 0.008) decreased by 10%. The best agreement with RP was obtained for AP. Group B showed a trend to better performance than Group A for all the included metrics (p > 0.05). From the three types of defocus curves, CSDC3 obtained generally highest statistical power for testing differences between groups. The strongest statistically significant correlations between pupil size and CSDC3 were obtained for RP and AP. Conclusion: The CSDC3 was the most sensitive metric to detect MIOL pupil-dependency. PR and AP were more correlated with CSDC3 than PP and MP.

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... Pupil diameter is a relevant variable to be measured in the preoperative evaluation of candidates for cataract surgery. When implanting multifocal IOLs, pupil diameter is crucial to predict the visual performance that can be achieved, especially with those multifocal IOL designs on which light energy distributions vary with pupil size, 22,23 and to understand its possible influence on adverse events such as dysphotopsia. 8 Only postoperative measurements of pupil diameter were included in this study because the aim was to evaluate the distribution of pupil size in patients already implanted with multifocal IOLs. ...
... 8 Only postoperative measurements of pupil diameter were included in this study because the aim was to evaluate the distribution of pupil size in patients already implanted with multifocal IOLs. The change in pupil diameter after surgery was not included in the analysis because it was already covered in previous studies by our research group, 15,22 with conclusions in agreement with other authors. 15,22,[24][25][26] Studies have reported a statistically significant reduction of the pupil diameter at 3 days postoperatively. ...
... The change in pupil diameter after surgery was not included in the analysis because it was already covered in previous studies by our research group, 15,22 with conclusions in agreement with other authors. 15,22,[24][25][26] Studies have reported a statistically significant reduction of the pupil diameter at 3 days postoperatively. 27 The pupil diameter increased up to 1 month, with some authors reporting significant 24 and non-significant 27 differences in comparison to the preoperative values. ...
Article
PURPOSE: To evaluate the distribution of pupil size in patients implanted with multifocal intraocular lenses (IOLs) and to assess the variations according to age. METHODS: A total of 168 eyes that had implantation of several multifocal IOLs and were measured at the 3-month follow-up visit were included in the analysis. The Keratograph 5M (Oculus Optikgeräte) was used to measure the photopic and mesopic pupil size, as well as the average between both (average pupil size). Eyes were stratified in four groups by age: 50 years or younger, 51 to 60 years, 61 to 70 years, and older than 70 years. RESULTS: Considering the total sample, 84.5% and 95.8% of eyes had a photopic pupil size of 3 and 3.5 mm or less, respectively. The mesopic pupil size was greater than 4.5 mm in 39.3% and greater than 5 mm in 16.7% of eyes. The average pupil size was 3.5 and 4 mm or less in 54.2% and 85.1% of eyes, respectively. Mesopic pupil size resulted in a steeper decrease with age than photopic pupil size: 0.028 versus 0.015 mm/year, respectively. Statistically significant differences were found among the four age groups (P < .0005). No significant mean differences were found between multifocal IOL models for photopic pupil size, mesopic pupil size, or average pupil size (P > .05). CONCLUSIONS: Eyes implanted with multifocal IOLs had a photopic pupil size of 3.5 mm or less and mesopic pupil size of 5 mm or less. Mesopic and photopic pupil size decreased 0.28 and 0.15 mm per decade, respectively. This information can help surgeons to understand the general functioning of multifocal IOLs whose performance varies with pupil size.
... For apodized diffractive IOLs, the near reading will become difficulty due to light energy goes more to distance in dim illumination. It suggested eyes implanted with multifocal IOLs should have a photopic pupil size of 3.5 mm or less and mesopic pupil size of 5 mm or less [38]. The average pupil size of photopic and mesopic are correlated with contrast sensitivity defocus curve [38]. ...
... It suggested eyes implanted with multifocal IOLs should have a photopic pupil size of 3.5 mm or less and mesopic pupil size of 5 mm or less [38]. The average pupil size of photopic and mesopic are correlated with contrast sensitivity defocus curve [38]. The photophobia phenomenon like glare and halo also more complained in the large pupil patients. ...
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Premium multifocal IOLs are a popular option for cataract or presbyopia patients today. Patients can achieve high levels of success and satisfaction after these advanced technology IOLs implantation. However, adequate preoperative clinical evaluation including patient selection, optical and anatomical examination is crucial to reach a success case. Based on the preoperative diagnosis including the corneal astigmatism, biometry measurement, IOL power calculation, presbyopia correcting IOLs’ indications and contraindications should be assessed for IOL selection strategy. Surgical procedure should be technically optimized to achieve the best outcomes. Adequate management of both satisfied and unsatisfied patients will improve the benefit of current premium IOLs.
... In other words, their expanded depth of focus might support useful intermediate and near vision with the onset of presbyopia but with a small loss of optical quality for distance viewing. This multifocality and its influence on intermediate and near vision will obviously depend on pupil size, 34 retinal illuminance, 35 and other psychophysical factors such as tolerance to reduced contrast, photic phenomenon (glare, stray light, forward scatter), [36][37][38] and compromised stereopsis. 39 Furthermore, multifocal lens designs have been shown to influence the accommodative response in young nonpresbyopes, 40,41 and it is conceivable that a similar influence is seen on the accommodative and the cross-coupled vergence response of the patient undergoing refractive surgery, [42][43][44] at least up until the onset of presbyopia (typically over a decade for an average patient of keratorefractive surgery). ...
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... The number of required Nd:YAG capsulotomies has been reported to be higher in multifocal than in monofocal IOLs at 22 months of followup [6], due to patient's complaints of poor visual quality rather than a decrease on CDVA. Contrast sensitivity is more sensitive to detect this "poor quality" complaint than visual acuity and defocus curves based on contrast sensitivity might help to take future decisions based on the visual performance along all the defocus range instead of a particular distance [13,22]. In this study, the PCO subjective grading at 12 months after the implantation of two trifocal hydrophilic IOLs and its impact on CSDC, visual function, and satisfaction was evaluated, as well as the incidence of required treatment of Nd:YAG for PCO considering a longer period of time. ...
Article
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Although there are inherent differences between corneal and IOL-based refractive surgery procedures, the aim of the procedure is the same in each case, so it makes sense that the 9 standard graphs be applied unaltered to corneal laser refractive surgery, phakic IOL implantation, and RLE. Cataract surgery is a different scenario that warrants a simplified version of the standard graphs. By considering these issues, we hope to standardize the quality of reporting for lens-based procedures from its current level and strive to encourage authors to go beyond these basic graphs to match the standard of studies reporting outcomes of corneal refractive surgery that now have good adherence to the standard graphs. Only by homogenizing the reporting of outcomes as a first step can we hope to glean comparative information among published studies.
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Purpose: To compare the optical quality under large apertures among three multifocal intraocular lenses (IOLs): the TECNIS Symfony ZXR00 (Abbott Laboratories, Abbott Park, IL), the AT LISA tri 839MP (Carl Zeiss Meditec, Jena, Germany), and the Finevision (PhysIOL, Liège, Belgium). Methods: The in vitro optical quality of each lens was assessed with an instrument that measured the modulation transfer function (MTF). The optical quality of each lens was described in terms of MTF and through focus average MTF. The Strehl ratio, cut-off frequency, area of visibility, and percentage energy were calculated to objectively describe the optical quality of each lens. These metrics were assessed for the best lens distance focus and at four vergences (from -1.50 to -3.00 D in 0.50-D steps) at a 4.5-mm aperture. Results: The through focus average MTF of the AT LISA and Finevision IOLs showed three mean areas corresponding to distance, intermediate, and near vision. The TECNIS Symfony IOL showed two main areas corresponding to distance and intermediate vision. All metrics revealed that the Finevision IOL showed the best optical quality at distance vision, the TECNIS Symfony IOL at intermediate vision, and the AT LISA IOL at near vision. The TECNIS Symfony IOL showed the most homogeneous light distribution between its best vision foci. Conclusions: The TECNIS Symfony IOL is less vergence dependent than the AT LISA and Finevision IOLs under dim conditions. These results may help clinicians to choose the proper lens depending on the patient's visual requirements. [J Refract Surg. 2015;31(10):666-672.].
Article
To evaluate the effect of pupil size on image quality of a sectorial multifocal intraocular lens (IOL), the Lentis Mplus (Oculentis GmbH, Berlin, Germany), and the Acri.LISA IOL (Carl Zeiss Meditec, Jena, Germany). The authors measured the MTFs of the Lentis Mplus LS-312 IOL and the Acri.LISA 366D IOL with three different sizes of pupil diameters: 3, 4, and 5 mm. The MTF was calculated from the cross-line spread function recorded with the OPAL Vector System (Image Science Ltd., Oxford, UK) by using fast Fourier-transform techniques. In distance focus, the image quality provided by the Lentis Mplus IOL was better than that of the Acri. LISA IOL with all pupil diameters. In near focus, the MTF of the Acri.LISA IOL was better with a 3-mm pupil, but poor with larger pupils. The aberration effect was equal in both IOLs in distance focus, but in near focus and with a 3-mm pupil, the Acri.LISA IOL was less affected by the aberration than the Lentis Mplus IOL. The Lentis Mplus IOL provides better distance image quality than the Acri.LISA IOL, whereas the near image quality of the Acri.LISA IOL is better with small-pupil diameter. The sectorial design makes this IOL more suitable for patients with a pupil diameter greater than 3 mm. [J Refract Surg. 2015;31(4):230-235.]. Copyright 2015, SLACK Incorporated.
Article
Purpose: To compare postoperative changes in apparent photopic and mesopic pupil size and centration in relation to cornea reflection landmarks after cataract surgery. Setting: LaserVision.gr Clinical and Research Eye Institute, Athens, Greece. Design: Prospective consecutive case study. Methods: Pupils were imaged for pupil size and corneal vertex location before and 1-month after cataract surgery. Digital analysis of pupil images was used to determine the Cartesian coordinates (nasal-temporal, horizontal axis, superior-inferior, vertical axis) of the first Purkinje reflection point (approximating the corneal intersection of the visual axis [corneal vertex]) to the pupil geometric center (approximating the corneal intersection of the line of sight [corneal apex]). Pupil size changes were measured, and the correlation between vertex-to-apex shift changes and postoperative pupil centroid shift was evaluated. Results: The study evaluated 40 eyes. The pupil size (diameter) change corresponded to a relative reduction of -9.8% for photopic pupils and -9.1% for mesopic pupils; the difference was statistically significant (P = .045 and P = .011, respectively). Also, there was a reduction in the centroid shift (all eyes) from a mean of 0.12 mm preoperatively to 0.05 mm postoperatively as a result of the postoperative minus temporal horizontal difference between the corneal vertex and the apex. Conclusions: Cataract extraction surgery appears to affect pupil size and centration. Specifically, a smaller pupil and less temporal shift were recorded. These data may have clinical relevance in targeted intraoperative intraocular lens centration. Financial disclosure: Dr. Kanellopoulos is a consultant to Alcon Surgical, Inc., Wavelight Laser Technologie AG, Allergan, Avedro, Inc., and i-Optics Corp. No author has a financial or proprietary interest in any material or method mentioned.
Article
To analyze the symptoms, etiology, and treatment of patient dissatisfaction after multifocal intraocular lens (IOL) implantation. Department of Ophthalmology, Maastricht University Medical Center, The Netherlands. Case series. In this retrospective chart review, the main outcome measures were type of complaints, uncorrected and corrected distance visual acuities, uncorrected and distance-corrected near visual acuities, refractive state, pupil diameter and wavefront aberrometry measurements, and type of treatment. Seventy-six eyes of 49 patients were included. Blurred vision (with or without photic phenomenon) was reported in 72 eyes (94.7%) and photic phenomena (with or without blurred vision) in 29 eyes (38.2%). Both symptoms were present in 25 eyes (32.9%). Residual ametropia and astigmatism, posterior capsule opacification, and a large pupil were the 3 most significant etiologies. Sixty-four eyes (84.2%) were amenable to therapy, with refractive surgery, spectacles, and laser capsulotomy the most frequent treatment modalities. Intraocular lens exchange was performed in 3 cases (4.0%). The cause of dissatisfaction after implantation of a multifocal IOL can be identified and effective treatment measures taken in most cases.
Article
In clinical measurement comparison of a new measurement technique with an established one is often needed to see whether they agree sufficiently for the new to replace the old. Such investigations are often analysed inappropriately, notably by using correlation coefficients. The use of correlation is misleading. An alternative approach, based on graphical techniques and simple calculations, is described, together with the relation between this analysis and the assessment of repeatability.
Article
To observe pupil sizes with near and distance vision under different lighting conditions in different Japanese age groups. Department of Ophthalmology, Tokyo Dental College Suidobashi Hospital, Tokyo, Japan. Using an open view-type infrared video pupillometer, the horizontal and vertical pupil sizes were measured prospectively with subjects gazing at 30 cm or 3 m targets under photopic (illumination 500 lux) and mesopic (illumination 5 lux) conditions. The results were analyzed by age, and the benefits with various multifocal IOLs were evaluated. The study comprised 140 eyes (70 subjects; 14 to 94 years). The mean +/- standard deviations of photopic vertical pupil sizes when gazing far/near decreased from 3.77 +/- 0.23/3.50 +/- 0.33 mm (<20 years) to 2.20 +/- 0.30/1.95 +/- 0.20 mm (over 80 years), with pupil sizes stabilizing after 60 years. The mesopic vertical pupil sizes when gazing far/near decreased from 6.35 +/- 0.11/6.27 +/- 0.14 mm (<20 years) to 3.42 +/- 0.30/3.21 +/- 0.28 mm (over 80 years). The pupil sizes decreased with age until 60 years and stabilized (1-way analysis of variance, P<.05). Fewer than 50% of subjects over 60 years of age had pupil sizes conducive to the near zone of refractive multifocal intraocular lenses. Photopic and scotopic pupil sizes decreased with age up to 60 years. The pupil was smaller when gazing at a near target than previously reported.
Article
To see whether there is a correlation between pupillary area or intraocular lens (IOL) decentration and tilt and the visual acuity (VA) at all distances for eyes with a zonal-progressive multifocal IOL or a monofocal IOL. Comparative, nonrandomized, interventional study. Fifty-five eyes of 55 patients undergoing five-zone refractive multifocal IOL implantation and 55 eyes of 55 age-matched patients undergoing monofocal IOL implantation. All eyes underwent phacoemulsification and IOL implantation. The VAs from far to near distances were examined using an all-distance vision tester at 1 month after surgery. The pupillary area was also measured using an infrared pupillometer, and the degrees of IOL decentration and tilt were measured using a Scheimpflug videophotography system. Univariate associations between VA and the pupillary area and IOL decentration or tilt were evaluated statistically. The mean intermediate VAs and contrast sensitivities at all spatial frequencies in the multifocal IOL group were worse than those in the monofocal IOL group, whereas near VA was better in the multifocal group. In the multifocal group, smaller pupillary area was associated significantly with worse near logarithm of the minimum angle of resolution (LogMAR) VA (r = 0.636), but not with far or intermediate VAs. When pupil diameter was 4.5 mm or greater, near mean VA reached 20/63. A greater degree of IOL decentration was associated significantly with worse far and intermediate LogMAR VAs (r = 0.460 at 5.0 m and 0.527 at 1.0 m) but not with near VA. When decentration was 0.9 mm or greater, distance mean VA did not reach 20/32. However, the correlation between tilt and VA was not statistically significant. In the monofocal group, no significant correlation was found between pupillary area, IOL decentration, or tilt and the VA. Smaller pupil size is correlated significantly with worse near VA, whereas greater decentration is correlated with worse distance and intermediate VA in eyes with refractive multifocal IOLs. Specifically, a pupil diameter of less than 4.5 mm cannot provide useful near VA, and decentration of 0.9 mm is the maximum allowable limit for adequate distance VA. However, pupil size and IOL decentration do not influence VA in eyes with monofocal IOLs.
Article
To determine whether pupil size is correlated with visual acuity and contrast sensitivity at all distances in eyes with an apodized diffractive intraocular lens (IOL). Private Clinic, Oviedo, Spain. Six months after surgery, the best corrected distance visual acuity, best distance-corrected near visual acuity, intermediate visual acuity, and distance contrast sensitivity under photopic (85 cd/m2) and mesopic (5 cd/m2) conditions were measured in 670 eyes of 335 consecutive patients who had implantation of the AcrySof ReSTOR Natural IOL (SN60D3, Alcon). Pupil diameters in distance vision were measured using a pupillometer. The logMAR best corrected distance acuity was significantly better with larger pupils (r = 0.297; P = 1.36 x 10(-8)), whereas logMAR best distance-corrected near acuity was significantly worse with larger pupils (r = 0.276, P = 1.02 x 10(-7)). For all pupil diameters, intermediate visual acuity worsened significantly as the distance of the test increased (P<.01). Statistically significant differences in photopic and mesopic contrast sensitivity at all spatial frequencies were found between the small-pupil and large-pupil groups (P<.01). Distance photopic contrast sensitivity and mesopic contrast sensitivity were better in patients with large pupils than in patients with small pupils. A larger pupil was correlated significantly with better distance visual acuity and with worse near visual acuity. For all pupil diameters, intermediate visual acuity worsened significantly as the distance of the test increased. Distance contrast sensitivity was better with larger pupils at all spatial frequencies in bright-light and dim-light conditions.
Refractive Analysis v.1.0.3. A Matlab toolbox for the analysis of refractive results in anterior segment surgery
  • M Rodríguez-Vallejo
Rodríguez-Vallejo M. Refractive Analysis v.1.0.3. A Matlab toolbox for the analysis of refractive results in anterior segment surgery, http://test-eye.com/index.php/en/refractiveanalysis (2020, accessed 1 January 2019).
Validation of a new clinical system for the fast measure of defocus curves with iPad
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Fernández J, Rodríguez-Vallejo M, Tauste A, et al. Validation of a new clinical system for the fast measure of defocus curves with iPad. In: Paper presented at the XXXV Congress of the ESCRS, Lisbon, 7-11 October 2017.
Visual acuity conversion chart
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Special report: American Academy of Ophthalmology task force consensus statement for extended depth of focus intraocular lenses
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