Multifocal versus monofocal intraocular lenses after cataract extraction

BACKGROUND: Good unaided distance visual acuity is now a realistic expectation following cataract surgery and intraocular lens (IOL) implantation. Near vision, however, still requires additional refractive power, usually in the form of reading glasses. Multiple optic (multifocal) IOLs are available which claim to allow good vision at a range of distances. It is unclear whether this benefit outweighs the optical compromises inherent in multifocal IOLs. OBJECTIVES: The objective of this review was to assess the effects of multifocal IOLs, including effects on visual acuity, subjective visual satisfaction, spectacle dependence, glare and contrast sensitivity, compared to standard monofocal lenses in people undergoing cataract surgery. METHODS: Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register), The Cochrane Library 2012, Issue 2, MEDLINE (January 1946 to March 2012), EMBASE (January 1980 to March 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 6 March 2012. We searched the reference lists of relevant articles and contacted investigators of included ...

Multifocal versus monofocal intraocular lenses after cataract extraction.

BACKGROUND: Good unaided distance visual acuity is now a realistic expectation following cataract surgery and intraocular lens (IOL) implantation. Near vision, however, still requires additional refractive power, usually in the form of reading glasses. Multiple optic (multifocal) IOLs are available which claim to allow good vision at a range of distances. It is unclear whether this benefit outweighs the optical compromises inherent in multifocal IOLs. OBJECTIVES: The objective of this review was to assess the effects of multifocal IOLs, including effects on visual acuity, subjective visual satisfaction, spectacle dependence, glare and contrast sensitivity, compared to standard monofocal lenses in people undergoing cataract surgery. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register), The Cochrane Library 2012, Issue 2, MEDLINE (January 1946 to March 2012), EMBASE (January 1980 to March 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 6 March 2012. We searched the reference lists of relevant articles and contacted investigators of included studies and manufacturers of multifocal IOLs for information about additional published and unpublished studies. SELECTION CRITERIA: All randomised controlled trials comparing a multifocal IOL of any type with a monofocal IOL as control were included. Both unilateral and bilateral implantation trials were included. DATA COLLECTION AND ANALYSIS: Two authors collected data and assessed trial quality. Where possible, we pooled data from the individual studies using a random-effects model, otherwise we tabulated data. MAIN RESULTS: Sixteen completed trials (1608 participants) and two ongoing trials were identified. All included trials compared multifocal and monofocal lenses but there was considerable variety in the make and model of lenses implanted. Overall we considered the trials at risk of performance and detection bias because it was difficult to mask patients and outcome assessors. It was also difficult to assess the role of reporting bias. There was moderate quality evidence that similar distance acuity is achieved with both types of lenses (pooled risk ratio, RR for unaided visual acuity worse than 6/6: 0.98, 95% confidence interval, CI 0.91 to 1.05). There was also evidence that people with multifocal lenses had better near vision but methodological and statistical heterogeneity meant that we did not calculate a pooled estimate for effect on near vision. Total freedom from use of glasses was achieved more frequently with multifocal than monofocal IOLs. Adverse subjective visual phenomena, particularly haloes, or rings around lights, were more prevalent and more troublesome in participants with the multifocal IOL and there was evidence of reduced contrast sensitivity with the multifocal lenses.

Opportunistic infections of the retina in patients with aquaporin-4 antibody disease.

IMPORTANCE: Patients with neuromyelitis optica who have aquaporin-4 antibodies are being identified and receiving immunosuppressant treatment earlier and more aggressively as a result of increasing awareness of the importance of preventing relapses responsible for the high morbidity and mortality associated with the disease. To our knowledge, opportunistic retinal infection in patients with aquaporin-4 antibodies who are receiving immunosuppressants has not been reported to date. OBSERVATIONS: We describe 2 patients with aquaporin-4 antibodies who were receiving conventional doses of first-line immunosuppressive therapy. Both patients presented with vision loss that was initially thought to be optic neuritis attacks. The subsequent diagnoses were ocular toxoplasmosis and cytomegalovirus retinitis. CONCLUSIONS AND RELEVANCE: Retinal opportunistic infections can occur in patients with aquaporin-4 antibodies who are receiving relatively low levels of immunosuppression, may mimic optic neuritis, and are a potentially reversible cause of vision loss when treated promptly.

Multifocal versus monofocal intraocular lenses after cataract extraction.

BACKGROUND: Good unaided distance visual acuity is now a realistic expectation following cataract surgery and intraocular lens (IOL) implantation. Near vision, however, still requires additional refractive power, usually in the form of reading glasses. Multiple optic (multifocal) IOLs are available which claim to allow good vision at a range of distances. It is unclear whether this benefit outweighs the optical compromises inherent in multifocal IOLs. OBJECTIVES: The objective of this review was to assess the effects of multifocal IOLs, including effects on visual acuity, subjective visual satisfaction, spectacle dependence, glare and contrast sensitivity, compared to standard monofocal lenses in people undergoing cataract surgery. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 2), MEDLINE (January 1946 to March 2012), EMBASE (January 1980 to March 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 6 March 2012. We searched the reference lists of relevant articles and contacted investigators of included studies and manufacturers of multifocal IOLs for information about additional published and unpublished studies. SELECTION CRITERIA: All randomised controlled trials comparing a multifocal IOL of any type with a monofocal IOL as control were included. Both unilateral and bilateral implantation trials were included. DATA COLLECTION AND ANALYSIS: Two authors collected data and assessed trial quality. Where possible, we pooled data from the individual studies using a random-effects model, otherwise we tabulated data. MAIN RESULTS: Sixteen completed trials (1608 participants) and two ongoing trials were identified. All included trials compared multifocal and monofocal lenses but there was considerable variety in the make and model of lenses implanted. Overall we considered the trials at risk of performance and detection bias because it was difficult to mask patients and outcome assessors. It was also difficult to assess the role of reporting bias. There was moderate quality evidence that similar distance acuity is achieved with both types of lenses (pooled risk ratio (RR) for unaided visual acuity worse than 6/6: 0.98, 95% confidence interval (CI) 0.91 to 1.05). There was also evidence that people with multifocal lenses had better near vision but methodological and statistical heterogeneity meant that we did not calculate a pooled estimate for effect on near vision. Total freedom from use of glasses was achieved more frequently with multifocal than monofocal IOLs. Adverse subjective visual phenomena, particularly haloes, or rings around lights, were more prevalent and more troublesome in participants with the multifocal IOL and there was evidence of reduced contrast sensitivity with the multifocal lenses. AUTHORS' CONCLUSIONS: Multifocal IOLs are effective at improving near vision relative to monofocal IOLs. Whether that improvement outweighs the adverse effects of multifocal IOLs will vary between patients. Motivation to achieve spectacle independence is likely to be the deciding factor.

Adherent ocular bandage for clear corneal incisions used in cataract surgery.

PURPOSE: To assess an adherent ocular bandage for clear corneal incisions (CCIs) in cataract surgery using optical coherence tomography (OCT). SETTING: Prince Charles Eye Unit, Windsor, United Kingdom. DESIGN: Case-control study. METHODS: Patients having coaxial microincision cataract surgery (MICS) were allocated to an adherent ocular bandage group or to a control group. The CCIs were examined postoperatively within 2 hours and at 24 hours and 7 days using OCT imaging and a slitlamp fluorescein 2% Seidel test. RESULTS: The ocular bandage group comprised 22 eyes and the control group, 23 eyes. The mean intraocular pressure (IOP) in the immediate postoperative period was significantly lower in the control group (13.4 mm Hg ± 5.28 [SD]; range 5 to 23 mm Hg) than in the bandage group (19.4 ± 5.94 mm Hg, range 11 to 29 mm Hg) (P<.001, t test). In the bandage group, all incisions were Seidel negative. In the control group, 1 main incision was Seidel positive. In 2 cases, the bandage successfully captured a micro-leak and thus maintained an intact anterior chamber. Differences in OCT architectural features between the bandage group and control group were noted. CONCLUSIONS: The adherent ocular bandage protected the incisions, selectively adhering to deepithelialized areas and rapidly clearing from reepithelialized areas. The bandage helped maintain a more desirable IOP in the immediate postoperative period, likely by preventing micro-leaks.

Optical coherence tomography of the effects of stromal hydration on clear corneal incision architecture.

PURPOSE: To evaluate the effects of stromal hydration on clear corneal incision (CCI) architecture immediately after surgery using anterior segment optical coherence tomography (AS-OCT). SETTING: Department of Ophthalmology, Royal Berkshire Hospital, Reading, United Kingdom. METHODS: Clear corneal incisions in adult eyes were examined using a Visante AS-OCT imaging system within 1 hour of surgery. Half the CCIs had stromal hydration with a balanced salt solution and half did not. Incisions were made with a 2.75 mm steel keratome. Intraocular pressure (IOP) was measured within 90 minutes after surgery. The CCI length and corneal thickness at the CCI site were measured using software built into the AS-OCT system. RESULTS: Thirty CCIs were evaluated. Stromal hydration significantly increased the measured CCI length (P<.05, t test); this was the result of a trend toward increased corneal thickness at the CCI site with hydration (P<.1, t test). The mean CCI length was 1.69 mm +/- 0.27 (SD) (range 1.31 to 2.32 mm) with hydration and 1.51 +/- 0.23 mm (range 1.30 to 1.95 mm) without hydration. The mean IOP was 20.9 +/- 8.18 mm Hg and 15.8 +/- 8.20 mm Hg, respectively. The IOP tended to be higher with hydration (P<.1, t test). Local detachment of Descemet membrane was more likely with stromal hydration (63%) than without (25%). CONCLUSION: Stromal hydration significantly increased CCI length and tended to leave the eye with a higher early postoperative IOP, showing the importance of taking stromal hydration into account when designing similar OCT studies of CCI architecture.

Clear corneal incision architecture in the immediate postoperative period evaluated using optical coherence tomography.

PURPOSE: To investigate clear corneal incision (CCI) architecture in the immediate postoperative period using optical coherence tomography (OCT). SETTING: Prince Charles Eye Unit, King Edward VII Hospital, Windsor, United Kingdom. METHODS: Thirty-four CCIs in 34 adult eyes were examined prospectively using the Carl Zeiss Visante anterior segment OCT imaging system within 1 hour of uneventful phacoemulsification cataract surgery. The CCIs were created using 4 widths of stainless steel blades (2.20 mm, 2.50 mm, 2.75 mm, and 3.20 mm). Immediately afterward, a Seidel test, an inverse Seidel test, and intraocular pressure (IOP) measurements were performed independently. The OCT images were randomized and masked before evaluation. Approval was obtained from appropriate research and ethics committees. RESULTS: The mean CCI length was 1.61 mm +/- 0.26 (SD) (range 1.10 to 2.25 mm). The mean incision angle was 40.7 +/- 9.43 degrees (range 24 to 56 degrees). Five CCI architectural features were noted with the following frequencies: epithelial gaping (12%), endothelial gaping (41%), endothelial misalignment (65%), local detachment of Descemet's membrane (62%), and loss of coaptation (9%). A reduction in wound apposition up to 20% was caused by endothelial gaping and up to 25%, by loss of coaptation, in a bidimensional image. The mean postoperative IOP was 16.1 +/- 9.02 mm Hg (range 3 to 46 mm Hg). The IOP was lower with local detachment of Descemet's membrane (P<.1). Other CCI architectural features varied predicatively with IOP, but not with blade width. CONCLUSIONS: Optical coherence tomography architectural features of endothelial gaping and loss of coaptation theoretically reduce CCI structural integrity in the immediate postoperative period. These features appeared to be more common at low IOP and could represent significant risk factors for endophthalmitis.