Cataract Classification Systems: A Review.

Cataract is among the leading causes of visual impairment worldwide. Innovations in treatment have drastically improved patient outcomes, but to be properly implemented, it is necessary to have the right diagnostic tools. This review explores the cataract grading systems developed by researchers in recent decades and provides insight into both merits and limitations. To this day, the gold standard for cataract classification is the Lens Opacity Classification System III. Different cataract features are graded according to standard photographs during slit lamp examination. Although widely used in research, its clinical application is rare, and it is limited by its subjective nature. Meanwhile, recent advancements in imaging technology, notably Scheimpflug imaging and optical coherence tomography, have opened the possibility of objective assessment of lens structure. With the use of automatic lens anatomy detection software, researchers demonstrated a good correlation to functional and surgical metrics such as visual acuity, phacoemulsification energy, and surgical time. The development of deep learning networks has further increased the capability of these grading systems by improving interpretability and increasing robustness when applied to norm-deviating cases. These classification systems, which can be used for both screening and preoperative diagnostics, are of value for targeted prospective studies, but still require implementation and validation in everyday clinical practice.

Optical Quality and Higher Order Aberrations of Refractive Extended Depth of Focus Intraocular Lenses.

PURPOSE: To compare the optical quality and higher order aberrations of four different refractive extended depth of focus intraocular lens (EDOF IOL) models (Lentis Comfort [Teleon Surgical BV], MiniWell (SIFI), LuxSmart [Bausch & Lomb], and AcrySof IQ Vivity [Alcon Laboratories, Inc]) and a monofocal IOL (Tecnis ZCB00; Johnson & Johnson Surgical Vision, Inc). METHODS: An optical metrology instrument (OptiSpheric IOL PRO2; Trioptics GmbH) was used to study image quality metrics of the different IOLs. The modulation transfer function (MTF) was measured at pupil sizes 1 to 5 mm in 1-mm steps. Area under the MTF and simulated visual acuity were calculated for different pupil diameters. Wavefront aberrations were measured with the SHS Ophthalmic device (Optocraft GmbH), which features a Hartmann-Shack sensor. RESULTS: All EDOF lenses yielded a simulated far visual acuity of 0.00 logMAR (20/20 Snellen) or better. At the 0.20 logMAR visual acuity level, the EDOF IOLs showed an increased depth of focus of at least 0.75 diopters compared to the monofocal IOL. Pupil dependency was more pronounced with the MiniWell, LuxSmart, and Vivity, whereas the Lentis showed a more consistent behavior at different apertures. The wavefront measurement revealed increased central aberrations for the MiniWell, LuxSmart, and Vivity IOL compared to the monofocal control. CONCLUSIONS: All EDOF IOLs demonstrated increased depth of focus while maintaining good simulated visual acuity at the far focus. Pupil dependency differed between the IOL models. The wavefront analysis revealed the complex design of the different EDOF IOLs with several zones with varying aberrations. [J Refract Surg. 2023;39(10):668-674.].

Chromatic aberration and spectral dependency of extended-range-of-vision intraocular lens technology.

This study compared the optical quality and chromatic performance of refractive-diffractive intraocular lenses (IOLs) that are designed to extend the range of vision of pseudophakic patients and alter chromatic aberration. Five IOLs were evaluated, Tecnis Synergy and Triumf POD L GF, both intended to compensate for eye's chromatism, as well as Acriva Trinova Pro C-a lens that increases chromatic aberration, and AT Lisa Tri and AcrySof IQ PanOptix. An optical setup composed of a corneal model inducing monochromatic and chromatic aberrations and incorporating various spectral conditions was employed. The two chromatic-aberration correcting IOLs demonstrated the lowest far-focus dispersion, but it was negative only, with the Synergy indicating its ability to reduce eye's chromatic aberration. Although the Trinova increased far-point chromatism, it was close to the level of the PanOptix, but higher than that of the AT Lisa. All the studied models demonstrated varying optical quality in response to light color. Still, the strongest spectral dependency was associated with achromatizing technology. Therefore, chromatic aberration and wavelength dependency should be considered in IOL optimization and predicting visual function, particularly in non-white spectral conditions.

Impact of Phacoemulsification Parameters on Central Retinal Thickness Change Following Cataract Surgery.

Cataract surgery can lead to inflammatory processes in the retina due to its invasive nature, resulting in prolonged recovery times and reduced functional outcomes. The aim of the current study is to explore the impact that phacoemulsification parameters have on macular thickness following surgery. This prospective single-center study enrolled 46 healthy patients (46 eyes) who underwent uneventful cataract surgery. Retinal thickness was assessed using optical coherence tomography (OCT) preoperatively, as well as 1, 4, and 12 weeks after surgery. The macula was divided into a central (CMT), inner (IMT), and outer ring (OMT). Cataract density was automatically determined using an anterior segment OCT and a custom MATLAB script. Corrected distance visual acuity (CDVA), intraocular pressure (IOP) as well as cumulative dissipated energy (CDE), ultrasound time (UT), and fluids used during phacoemulsification were recorded. Retinal thickness and volume increased significantly following cataract surgery, reaching its maximum 4 weeks post-operatively. Statistically significant correlations were found between the CDE and IMT, OMT and retinal volume change (rIMT = 0.356, rOMT = 0.298, rvolume = 0.357 with p < 0.05) as well as between the ultrasound time and IMT, OMT, and retinal volume change (rIMT = 0.369, rOMT = 0.293 and rvolume = 0.409 with p < 0.05). Changes in CMT did not correlate with any surgical metrics. Additionally, no correlation was found to the amount of fluid used, whether CDVA or IOP. However, a link between nuclear cataract density and changes in OMT (r = 0.310, p < 0.05) was established. How ultrasound energy impacts the choroidea, and to what extent retinal metabolism changes after surgery, needs to be explored in future studies.

In vivo comparison of implantation behavior and laboratory analysis of two preloaded intraocular lens injectors.

PURPOSE: We evaluated implantation behavior and injector damage of two different IOL injector systems, the Multisert and the AutonoMe. DESIGN: Prospective, randomized, comparative study with laboratory investigation. METHODS: We examined used injectors from 48 bilateral cataract cases and assessed video recordings of each Implantation. All eyes were intraindividually randomized for treatment with one of the two IOL injectors. Implantation videos were reviewed for inadvertent events and the time for different implantation steps was determined. The injector nozzle tips were examined using light and scanning electron microscopy (SEM). Damage was graded using the Heidelberg Score for IOL injector damage (HeiScore). Three months postoperatively, IOLs were assessed for material changes. RESULTS: Implantation was without critical events in 96 of 96 eyes. Mean implantation time was 41.90 ± 7.11 s with the Multisert and 52.22 ± 12.06 s with the AutonoMe. In the AutonoMe group, we observed 4 eyes (8.3%) with a failed docking attempt, 28 eyes (58.3%) with a haptic adherence, one case (2.1%) of straight leading haptic and 2 cases (4.2%) of intrawound IOL manipulation. There were no events observed in the Multisert group. The mean HeiScore values were 0.87 ± 0.61 and 3.68 ± 0.47 for the AutonoMe and Multisert. 3 months postoperatively, IOL material changes were absent. CONCLUSIONS: Both injectors allowed safe and controlled implantation. Using Multisert, implantation behavior was more consistent. The injectors showed different damage profiles with a higher damage score for the Multisert.The study is registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien; reference number: DRKS00007837).

Rotational Stability of Toric Capsular Bag-Fixated Intraocular Lenses in Duet Procedure for Reversible Trifocality.

PURPOSE: To evaluate the long-term rotational stability of capsular bag-fixated toric intraocular lenses (IOLs) in polypseudophakic eyes of patients who underwent duet procedure for reversible trifocality. DESIGN: Retrospective interventional case series. METHODS: We included 34 eyes of 20 patients who underwent duet procedure with implantation of a monofocal toric IOL (RayOne toric, Hoya XY1AT, or a Tecnis ZCT800) into the capsular bag and a trifocal-diffractive Sulcoflex IOL into the ciliary sulcus. All toric IOLs were implanted with image-guided navigation. The manifest refraction and uncorrected and distance corrected visual acuity at far, intermediate, and near distance were measured. The position of the axis of the toric IOL was determined with the Pentacam device (Oculus GmbH) by evaluating retroillumination images. The results were compared with the preoperatively planned axis position. RESULTS: The median follow-up was 27 months. The spherical equivalent of manifest refraction was -0.04 ± 0.34 diopters (D) postoperatively, and the refractive cylinder was -0.14 ± 0.22 D on average. Binocular uncorrected and corrected distance visual acuity were 0.05 ± 0.11 logMAR and 0.02 ± 0.09 logMAR, respectively. The mean deviation from the calculated cylinder axis was 3.8° ± 3.5° with a median of 2.8° and a maximum deviation of 15.0°. Ninety-four percent of all eyes showed a deviation of less than 10°. CONCLUSIONS: The long-term axial alignment of capsular bag-fixated toric IOLs in polypseudophakic eyes was comparable to the results reported for single implantation of toric IOLs. The polypseudophakic approach did not affect the rotational stability of capsular bag-fixated IOLs.

Change in Subfoveal Choroidal Thickness following Cataract Surgery Imaged with Enhanced Depth Imaging Optical Coherence Tomography.

BACKGROUND: Due to its invasive nature, cataract surgery can lead to inflammatory processes in the posterior segment, which can result in prolonged recovery times, reduced functional outcomes, and late-onset complications. The aim of the current study was to identify wherever phacoemulsification parameters play a role in choroidal thickness change following cataract surgery. METHODS: This prospective single-center study enrolled 31 patients (31 eyes) scheduled to undergo routine cataract surgery. Patients with previous ocular surgeries, pathologies or general disorders affecting vision were excluded. Patients were examined preoperatively, as well as 1, 4, and 12 weeks after surgery. Corrected distance visual acuity (CDVA), intraocular pressure (IOP) as well as cumulative dissipated energy (CDE), ultrasound time (UT), and fluids used during surgery were recorded. Subfoveal choroidal thickness was measured manually by two masked independent experts using enhanced depth imaging (EDI) optical coherence tomography (OCT). Furthermore, cataract density was automatically calculated using a custom MATLAB script and an anterior segment OCT. RESULTS: Subfoveal choroidal thickness increased significantly (p < 0.001, Student's paired sample t-test) and continuously during the 12-week-long follow-up period. Both the nuclear lens density and the improvement in CDVA correlated significantly with this increase (r = 0.413, p = 0.021 and r = 0.421, p = 0.018, respectively). Neither the CDE (r = 0.334, p = 0.071), the UT (r = 0.102, p = 0.629), the amount of fluid used (r = 0.237, p = 0.27) nor the decrease in IOP (r = - 0.197, p = 0.288) showed any significant correlation with the choroidal swelling. CONCLUSION: Cataract surgery leads to an increase in subfoveal choroidal thickness. While no statistically significant correlation to the phacoemulsification parameters could be established, this might be because of a selection bias due to the technological constraints of the OCT. Nevertheless, the choroid might play a central role in early- and late-onset complications.

Spherical Aberration of Astigmatic Corneas in a Cataract Population.

PURPOSE: To study the distribution of spherical aberration (SA) in astigmatic corneas in a cataract population and the relationship between magnitude of corneal astigmatism and fourth-order corneal SA. METHODS: Data routinely collected using a Scheimpflug camera (Pentacam; Oculus Optikgeräte GmbH) were retrospectively analyzed. Patients with a minimum age of 60 years were included. Total corneal SA (from anterior and posterior corneal surface) was obtained for a 6-mm cor-neal area aligned with the pupil center. Exclusion criteria were insufficient measurement quality, total deviation index (Belin/Ambrósio Deviation) greater than 1.60, and corneal thickness at the thinnest point of less than 490 µm. One eye per patient was chosen randomly. Eyes were divided into low (≤ 1.00 diopters [D]), moderate (> 1.00 to ≤ 2.00 D), and high (> 2.00 D) astigmatism groups according to the Scheimpflug measurements. RESULTS: A total of 528 eyes were included in this analysis. Low astigmatism was found in 129 patients, moderate astigmatism in 265 patients, and high astigmatism in 134 patients. Mean astigmatism was 0.68 ± 0.24, 1.45 ± 0.28, and 2.91 ± 0.95 D in the low, moderate, and high astigmatism groups, respectively. Mean corneal SA in patients with moderate and high astigmatism was higher than in the low astigmatism group. The difference reached the significance level for the comparison of low and high astigmatism groups (P = .023). The fourth-order SA increased gradually with the magnitude of astigmatism with a slope of 0.015. CONCLUSIONS: SA was significantly larger in the cataract population with high corneal astigmatism. The increase of positive sign SA with the magnitude of astigmatism suggests that patients with moderate to high astigmatism may benefit more from intraocular lenses with negative sign SA correction. [J Refract Surg. 2023;39(8):532-538.].

Possible Advantages of Minimal-Invasive Approaches in Rectal Cancer Surgery: A Nationwide Analysis.

(1) Background: Laparoscopic resection for colon and rectal cancer was introduced in the early 1990s; the aim of this analysis was to show possible advantages of minimal-invasive approaches in rectal cancer surgery. (2) Methods: From 2016 to 2020, all patients undergoing open, laparoscopic or robotic-assisted rectal cancer surgery in Germany were retrospectively analyzed regarding sex distribution, conversion rates and in-hospital mortality rates according to nationwide hospital billing data based on diagnosis-related groups (DRGs). (3) Results: In total, 68,112 patients were analyzed, and most commonly, low anterior rectal resections with primary anastomosis (n = 25,824) were performed with an increase of minimal-invasive procedures over the years (open: 51% to 27%; laparoscopic: 47% to 63% and robotic: 2% to 10%). In-hospital mortality rate was 2.95% (n = 2012). In total, 4.61%, 1.77%, 1.14% and 3.95% of patients with open, laparoscopic, robotic and converted-to-open surgery died during hospital stay, respectively (open vs. laparoscopic p < 0.0001; open vs. robotic p < 0.00001; laparoscopic vs. robotic p = 0.001). Conversion rates were significantly more favorable in the robotic compared to the laparoscopic group. (11.94% vs. 2.53%; p < 0.0001). (4) Conclusion: Minimal-invasive rectal cancer surgery might have some advantages in terms of a reduced in-hospital mortality, and an improved conversion rate for the robotic approach.

Functional outcomes after bilateral refractive lens exchange with a continuous-range-of-vision intraocular lens.

PURPOSE: To clinically evaluate a diffractive continuous-range-of-vision intraocular lens (IOL) that combines bifocal and extended depth-of-focus technologies in refractive lens exchange (RLE) patients. SETTING: University eye clinic. DESIGN: Prospective interventional clinical study. METHODS: Bilateral implantation of the TECNIS Synergy IOL was performed during a RLE procedure in 28 patients. At 3 months postoperatively, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, uncorrected (UIVA) and distance-corrected (DCIVA) intermediate visual acuities at 80 cm, and uncorrected (UNVA) and distance-corrected (DCNVA) near visual acuities at 40 cm were assessed. Defocus curve testing and contrast sensitivity testing were also performed. RESULTS: Binocular UDVA and CDVA of 56 eyes (28 patients) were -0.06 ± 0.07 logMAR and -0.13 ± 0.05 logMAR, respectively. UIVA and DCIVA were -0.06 ± 0.05 logMAR and -0.08 ± 0.06 logMAR, and UNVA and DCNVA were -0.01 ± 0.07 logMAR and -0.04 ± 0.07 logMAR. The defocus curve revealed a visual acuity of 0.10 logMAR or better from +0.50 to -3.00 diopters (D). Photopic contrast sensitivity at spatial frequencies 3.0, 6.0, 12.0, and 18.0 was 1.68 ± 0.20, 1.77 ± 0.19, 1.45 ± 0.18, and 1.02 ± 0.19 log units, respectively. Mesopic contrast sensitivity at the same frequencies was 1.56 ± 0.20, 1.44 ± 0.25, 0.92 ± 0.38, and 0.44 ± 0.37, respectively. CONCLUSIONS: The Synergy IOL provided very good distance, intermediate, and near visual outcomes. A visual acuity of 0.10 logMAR or better was achieved from +0.50 to -3.0 D. Contrast sensitivity was within the normal range.

Aetiology and Management of IOL Dislocations. / Ursachen und Management von IOL-Dislokationen.

Early (< 3 months) intraocular lens (IOL) dislocation occurs due to insufficient fixation in the capsular bag, while late dislocation (≥ 3 months) is due to increasing insufficiency of the zonular apparatus. Iris-fixated IOL (IFIOL) and suture- or sutureless-fixated scleral IOL (SFIOL) are currently the most commonly used methods when IOL exchange is indicated. Different methods of scleral fixation with or without sutures have been described. The most important techniques are summarised in this paper. IFIOL and SFIOL allow comparable visual outcomes but differ in their risk profile. The decision of which method to use should be made case by case and in accordance with the surgeon's preference.

Reversible Multifocality Achieved Through Polypseudophakia. / Reversible Multifokalität durch Polypseudophakie.

Simultaneous implantation of a monofocal or monofocal toric intraocular lens (IOL) into the capsular bag and a multifocal IOL into the ciliary sulcus, referred to as duet procedure, allows us to create multifocality that is more easily reversible than the implantation of a capsular bag-fixated multifocal IOL. The optical quality and results after the duet procedure are equivalent to those of a capsular bag-fixated multifocal IOL. Patients who cannot tolerate the side effects of multifocal optics or who develop an ocular condition leading to loss of function such as age-related macular degeneration (AMD) or glaucoma in the course of their lives may benefit from the reversibility of the procedure.

Comparison of a Presbyopia-Correcting Supplementary Intraocular Lens Combination and a Capsular-Bag Lens: An In Vitro Study.

We evaluated the optical quality of two approaches to trifocality: polypseudophakia versus monopseudophakia. The combination (polypseudophakia) of a monofocal Basis Z B1AWY0 and AddOn Trifocal A4DW0M intraocular lens (IOL) was compared to using one Basis Z Trifocal B1EWYN IOL, all from 1stQ GmbH. In both approaches, we measured modulation transfer function (MTF) and Strehl Ratio (SR) values at 3.0 and 4.5 mm pupil sizes. We determined the through-focus (TF) MTF at 25, 50 and 100 lp/mm for the 3 mm aperture. United States Air Force (USAF) target images were recorded. MTF measurement of the trifocal lens and the combined monofocal and trifocal AddOn IOL showed good performance at the far and near focus for the 3 mm aperture. For the 4.5 mm aperture the MTF improved for the far focus but decreased for the intermediate and near focus. TF MTF showed better contrast at the far focus for the polypseudophakic setup but at the expense of the efficiency at the near focus. However, the USAF chart images revealed only minimal differences between both approaches. The optical quality of the polypseudophakic approach was not affected by the presence of two IOLs instead of one and proved to be comparable with the performance of one capsular-bag-fixated trifocal IOL. Differences between the single vs. two-lens approach seen in the TF MTF analysis could be attributed to the optical design that varied between the trifocal models.

Comparison of Five Presbyopia-Correcting Intraocular Lenses: Optical-Bench Assessment with Visual-Quality Simulation.

Presbyopia correction through implantation of a trifocal intraocular lens (IOL) is a modality offered to both cataract and refractive-lens exchange patients. To maximize postoperative satisfaction, IOL selection needs to be made based on patients' requirements aligned with the available technology. Five Trifocal IOLs were assessed in this study, and their differentiating features were identified: Triumf POD L GF, AT Lisa Tri, Tecnis Synergy, AcrySof IQ PanOptix, and Acriva Trinova Pro C. The optical quality was assessed using the modulation-transfer-function principle. Simulated defocus curves were derived from a non-linear formula. Far-focus simulated visual acuity (simVA) was 0.03 logMAR or better for all the studied IOLs, showing minimal differences. However, each IOL's intermediate focus position differed across a range from 61 cm to 80 cm; and for the near focus, it was 36 cm to 44 cm. Triumf demonstrated improved intermediate point at the expense of the near focus resulting in a lower predicted near VA. PanOptix exhibited the shortest range of vision without a clear distinction between intermediate and near-point. The remaining lenses presented three foci of comparable optical quality and, thus, simVA performance. Each model, however, revealed a different aperture-change response. Trinova function improved at intermediate but was worse at near for larger pupils. The opposite was observed for AT Lisa. Synergy's optical quality change was predominantly associated with lower pupil diameter. In conclusion, the trifocal IOLs can be differentiated according to their secondary-foci position, light-energy distribution, and pupil-size-related behavior. The observed differences may translate directly into a clinical effect showing that the trifocal IOLs vary in their ability to deliver optimal vision at different distances, with some providing improved intermediate while others favor reading distance. The knowledge gained through this objective testing can support IOL selection, postoperative patient counselling and increase the chance of spectacle independence after surgery.

Clinical Evaluation of Reading Performance in Refractive Lens Exchange With a Diffractive Continuous-Range-of-Vision Intraocular Lens.

PURPOSE: Evaluation of reading performance with a novel presbyopia correcting intraocular lens (IOL) in refractive lens exchange using an electronic reading desk. DESIGN: Prospective interventional before-and-after clinical study. METHODS: In total, 56 eyes of 28 patients were included. Bilateral implantation of the TECNIS Synergy IOL (Johnson & Johnson Surgical Vision) during a bilateral delayed sequential refractive lens exchange procedure. Uncorrected and distance corrected reading acuity, reading distance, reading speed, and the smallest print size that could be read effectively at a set (40 cm/80 cm) and subjectively chosen near and intermediate distance were assessed using the Salzburg Reading Desk preoperatively and 6 months after surgery. RESULTS: Uncorrected near reading acuity increased from 0.61 ± 0.16 logarithm of the minimum angle of resolution (logMAR) preoperatively to 0.05 ± 0.09 logMAR postoperatively at the set near distance (40 cm) and from 0.60 ± 0.11 logMAR to 0.07 ± 0.08 logMAR at the subjectively preferred distance (39.6 ± 5.3 cm and 37.7 ± 4.3 cm). Uncorrected intermediate reading acuity was 0.39 ± 0.19 logMAR preoperatively and 0.08 ± 0.07 logMAR postoperatively at the set intermediate distance (80 cm) and 0.43 ± 0.21 logMAR preoperatively and 0.07 ± 0.08 logMAR postoperatively at the preferred intermediate distance (73.5 ± 9.5 cm and 73.3 ± 5.9 cm). CONCLUSIONS: Uncorrected intermediate and near reading function considerably improved after bilateral implantation of the TECNIS Synergy IOL. Patients preferred a closer near and intermediate distance to the set distances. However, reading function was comparable for the set and subjectively preferred distances.

Enlargement of main corneal incision: clinical intraindividual comparison of two preloaded intraocular lens injectors.

PURPOSE: To compare the enlargement of the clear corneal incision from IOL implantation with 2 different intraocular lens (IOL) injectors: the AutonoMe preloaded with the Clareon IOL and the Multisert preloaded with the Vivinex IOL. SETTING: The David J. Apple Center for Vision Research, Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany. DESIGN: Prospective randomized clinical comparative study. METHODS: 96 eyes of 48 patients with cataract were intraindividually randomized to treatment with 1 of the 2 injectors. For Multisert eyes, the insert shield (IS) was used in the advanced position in 23 eyes. The initial incision was 2.2 mm, and intraoperative measurements of the incision size were made before and after IOL injection. 3 months postoperatively, keratometry and uncorrected (UDVA) and corrected (CDVA) distance visual acuities were assessed. RESULTS: Results are reported for 96 eyes of 48 patients. The mean incision enlargement was 0.213 ± 0.068 mm in the Multisert with the IS group, 0.265 ± 0.055 mm in the fellow eyes (AutonoMe) ( P < .05), 0.272 ± 0.060 mm in Multisert eyes treated without the IS, and 0.296 ± 0.066 mm for the fellow eyes (AutonoMe) ( P > .05). The mean absolute surgically induced astigmatism was 0.42 ± 0.23 diopters (D), 0.50 ± 0.25 D, and 0.44 ± 0.18 D in the Multisert with the IS, Multisert without the IS, and AutonoMe group, respectively ( P > .05). The UDVA and CDVA were comparable in all groups. CONCLUSIONS: The Multisert was associated with less wound enlargement than the AutonoMe. All groups had comparable functional outcomes. Therefore, the observed difference in incision enlargement may be of limited clinical relevance.

Visualization of Ray Propagation through Extended Depth-of-Focus Intraocular Lenses.

Extended depth-of-focus (EDoF) presbyopia-correcting intraocular lens (IOL) models differ in their optical design and performance. In the laboratory, we compared the ray propagation and light intensity profiles of four IOLs: the non-diffractive AcrySof IQ Vivity (Alcon Inc., Fort Worth, TX, USA) and two diffractive models, Symfony ZXR00 (Johnson & Johnson Vision, Jacksonville, FL, USA) and AT Lara 829 MP (Carl Zeiss Meditec, Berlin, Germany). A fourth lens, the monofocal AcrySof IQ SN60WF (Alcon Inc.) acted as the control. We projected a 520 nm laser light through each submerged lens in a bath of fluorescein solution. A camera mounted on a microscope captured the light that emerged from the IOL. We recorded the IOLs' point spread function (PSF) to determine the presence of unwanted visual effects. The ray propagation visualization and light intensity profile of the monofocal control showed one distinct focus, while the AcrySof IQ Vivity demonstrated an extended focus area. We observed two distinct foci with each diffractive IOL. We found a lower level of light spread beyond the PSF center for the AcrySof IQ Vivity compared to the diffractive IOLs. In conclusion, we could confirm the extended range of focus for all the EDoF IOL models. However, the non-diffractive AcrySof IQ Vivity appears to have a smoother transition from a far to an intermediate range. We discuss whether, in clinical use, the higher level of spurious light we found in the diffractive designs may translate into increased dysphotopsia.

Traumatic iridodialysis and mydriasis: Surgical reconstruction of the iris-lens-diaphragm with an iris implant and Intraocular lens.

Purpose: We present the case of a severe golf related ocular injury that affected the anterior and posterior segment. Treatment included primary surgical closure of the traumatic wound and secondary reconstruction of the iris-lens-diaphragm to correct aphakia and traumatic mydriasis and iridodialysis. Observations: A 62-year-old woman presented to our clinic with severe ocular contusion after she had been hit by a golf ball in the right eye. We observed iridodialysis, traumatic mydriasis and luxation of the crystalline lens into the vitreous body as well as Berlin's edema and retinal tears. The patient underwent primary surgical closure of the traumatic wound and, 6 months later, combined Intraocular lens (IOL) and Customflex ArtificialIris (AI, HumanOptics, Erlangen, Germany) implantation. Uncorrected distance visual acuity was hand movement after primary surgical closure of the traumatic wound. After secondary reconstruction of the iris-lens-diaphragm, corrected distance visual acuity was 0.30 logMAR. Subjective impairment from glare could effectively be reduced and the patient was very satisfied with the aesthetic result. Conclusions and Importance: Combined AI and IOL implantation can successfully restore visual acuity and reduce sensitivity to glare while providing an excellent aesthetic result in patients with a history of severe blunt ocular trauma, even in cases with a poor visual acuity prognosis.

Clinical Outcomes in Patients After Duet Procedure for Reversible Trifocality Using a Supplementary Trifocal Intraocular Lens.

PURPOSE: We report the clinical outcomes of patients who had primary lens implantation in the capsular bag and subsequently a supplementary trifocal lens implanted in the ciliary sulcus (duet procedure) to create reversible trifocality. DESIGN: Retrospective interventional case series. METHODS: This single-center clinical study included 25 patients who had undergone either refractive lens exchange for presbyopia correction or cataract surgery. All had lens removal by phacoemulsification and duet procedure to achieve reversible trifocality. Preoperatively and 3 months postoperatively, uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were assessed, as well as uncorrected near visual acuity (UNVA), distance corrected near visual acuity (DCNVA), and corrected near visual acuity (CNVA). At the postoperative examination, uncorrected intermediate visual acuity (UIVA), distance corrected intermediate visual acuity (DCIVA), and corrected intermediate visual acuity (CIVA), defocus curve testing, and dysphotopsia evaluation were also performed. RESULTS: Monocular UDVA and CDVA improved from 0.71 ± 0.43 logarithm of the minimum angle of resolution (logMAR) and 0.12 ± 0.16 logMAR preoperatively to 0.04 ± 0.10 logMAR and -0.01 ± 0.09 logMAR postoperatively. Monocular UNVA and DCNVA were both 0.06 ± 0.08 logMAR and UIVA and DCIVA 0.00 ± 0.10 logMAR and -0.02 ± 0.10 logMAR postoperatively. Monocular defocus curve testing revealed a visual acuity of 0.2 logMAR or better from +0.75 to -3.5 diopters. CONCLUSIONS: Duet procedure using a trifocal supplementary intraocular lens provided excellent results for far, near, and intermediate distance, comparable to those reported for capsular bag fixated trifocal intraocular lenses. The duet procedure offers the advantage of an exit strategy in cases with a future loss of function or side effects associated with the optics.