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Purpose To assess whether the combined implantation of a monofocal intraocular lens (IOL) and an artificial iris has an effect on the IOL's optical performance. Setting David J. Apple International Laboratory for Ocular Pathology, Heidelberg, Germany. Design In vitro laboratory study. Methods IOL optical quality was assessed using an OptiSpheric IOL Pro II to measure the IOL's modulation transfer function (MTF) at 3.0 mm pupil size and spatial frequency of 100 lp/mm. Three ASPIRA-aAY IOLs with different base powers, 10.0 diopter (D) (IOL A), 20.0 D (IOL B), and 30.0 D (IOL C) were measured before and after suturing the IOL to an ArtificialIris (AI). The degree of lens decentration in respect to the center of the AI was also evaluated. Results The mean MTF values prior to suturing were 0.57, 0.65, and 0.63 for IOLs A, B, and C, respectively. After suturing to the AI, the mean MTF values were 0.52, 0.54, and 0.55 for IOLs A, B, and C, respectively. The decentration values in vertical direction were 0.20 mm, 0.00 mm, and 0.02 mm for IOLs A, B, and C. In horizontal direction, the decentration values were 0.42 mm, 0.10 mm, and 0.03 mm for IOLs A, B, and C. Conclusions The MTF decreased slightly in all 3 IOLs after they were sutured to the AI. The small differences, however, should be clinically irrelevant. This laboratory assessment showed that suturing of the IOL to the AI can be done in a reliable and reproducible manner without deteriorating optical quality.

We describe a pupilloplasty procedure to prevent a captive iris and to narrow the pupillary aperture and its associated complications. We also describe 5 surgical techniques in combination—vertical glued IOL, peripheral iridectomy, anterior sclerotomy, pupilloplasty, and application of a trocar anterior chamber maintainer—performed in eyes with a large WTW diameter; that is, the quintet in glued IOL. Financial Disclosure Neither author has a financial or proprietary interest in any material or method mentioned.

Purpose To develop a rabbit model for continuous curvilinear capsulorhexis (CCC) instruction. Setting University of California San Francisco, San Francisco, California, USA. Design Experimental study. Methods Isolated rabbit lenses were immersed in 2% to 8% paraformaldehyde (PFA) fixative from 15 minutes to 6 hours. Rabbit eyes were treated by substituting aqueous with 2% to 4% PFA for 30 minutes to 6 hours, followed by washes with a balanced salt solution. Treated lenses and eyes were held in purpose-designed holders using vacuum. A panel of 6 cataract surgeons with 5 to 15 years of experience performed CCC on treated lenses and eyes and responded to a questionnaire regarding the utility of these models for resident teaching using a 5-item Likert scale. Results The expert panel found that rabbit lenses treated with increasing amounts of fixative simulated CCC on human lens capsules from the third to the seventh decade of life. The panel also found fixative-treated rabbit eyes to simulate some of the experience of CCC within the human anterior chamber but noted a shallower anterior chamber depth, variation in pupil size, and corneal clouding under some treatment conditions. Conclusions Experienced cataract surgeons who performed CCC on these rabbit models strongly agreed that isolated rabbit lenses treated with fixative provide a realistic simulation of CCC in human patients and that both models were useful tools for capsulorhexis instruction. Results indicate that rabbit lenses treated with 8% PFA for 15 minutes is a model with good fidelity for CCC training. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Purpose To evaluate visual outcomes and patient satisfaction after implantation of an aspheric apodized diffractive intraocular lens (IOL) or a spherical apodized diffractive IOL in cataract surgery. Setting Maastricht University Medical Center, The Netherlands. Design Nonrandomized clinical trial. Methods This prospective nonrandomized study with a 6-month follow-up compared the results of cataract surgery with implantation of an aspheric AcrySof ReSTOR SN6AD3 IOL and a spherical AcrySof ReSTOR SN60D3 IOL. Main outcome measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuities, uncorrected (UNVA) and distance-corrected (DCNVA) near visual acuities, straylight levels, incidence of glare and halos, and contrast sensitivity levels. Results The mean UDVA was 0.14 ± 0.15 logMAR in the aspheric group (47 eyes) and 0.14 logMAR ± 0.17 (SD) in the spherical group (45 eyes) and the mean CDVA, −0.01 ± 0.06 logMAR and 0.02 ± 0.10 logMAR, respectively. The mean UNVA was Jaeger (J) 1 in 83.0% of patients in the aspheric group and 55.5% of patients in the spherical IOL group (P = .003). The DCNVA was J1 in 95.7% and 71.1%, respectively (P = .001). There were no significant differences between the 2 groups in contrast sensitivity levels, intraocular straylight levels, incidence of night-vision symptoms, or subjective rating of vision. Conclusions Patients with the aspheric multifocal IOL had significantly better near vision than patients with the multifocal spherical IOL. The UDVA, CDVA, intraocular straylight, night-vision symptoms, and contrast sensitivity were similar between the 2 groups. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

PURPOSE: To determine whether letter sequences and/or lens-presentation order should be randomized when measuring defocus curves and to assess the most appropriate criterion for calculating the subjective amplitude of accommodation (AoA) from defocus curves. SETTING: Eye Clinic, School of Life & Health Sciences, Aston University, Birmingham, United Kingdom. METHODS: Defocus curves (from +3.00 diopters [D] to -3.00 D in 0.50 D steps) for 6 possible combinations of randomized or nonrandomized letter sequences and/or lens-presentation order were measured in a random order in 20 presbyopic subjects. Subjective AoA was calculated from the defocus curves by curve fitting using various published criteria, and each was correlated to subjective push-up AoA. Objective AoA was measured for comparison of blur tolerance and pupil size. RESULTS: Randomization of lens-presentation order and/or letter sequences, or lack of, did not affect the measured defocus curves (P>.05, analysis of variance). The range of defocus that maintains highest achievable visual acuity (allowing for variability of repeated measurement) was better correlated to (r = 0.84) and agreed best with ( 0.50 D) subjective push-up AoA than any other relative or absolute acuity criterion used in previous studies. CONCLUSIONS: Nonrandomized letters and lens presentation on their own did not affect subjective AoA measured by defocus curves, although their combination should be avoided. Quantification of subjective AoA from defocus curves should be standardized to the range of defocus that maintains the best achievable visual acuity.

Purpose To analyze the image quality with a refractive and 2 hybrid refractive–diffractive multifocal intraocular lenses (IOLs) in vitro to determine the IOL modulation transfer function (MTF) following the EN-ISO international standard for distance and near vision and to study the IOLs' behavior with different pupil sizes. Setting Fundacion Oftalmologica del Mediterraneo, Valencia, Spain. Methods This study evaluated 4 IOLs: the hybrid refractive–diffractive AcrySof ReSTOR SN60D3 (Alcon) and Tecnis ZM900 (AMO), the refractive ReZoom NXG (AMO), and the monofocal AcrySof SN60WF (Alcon). The MTF was calculated from the cross-line spread function recorded with the OPAL Vector System (Image Science Ltd.) using fast Fourier transform techniques. The artificial eye model simulated in vivo conditions of the anterior chamber and included an artificial cornea and physiological solution, in which the IOLs were positioned. The pupil sizes varied between 2.0 mm and 5.0 mm in steps of 0.5 mm. Results For distance vision and small pupils (2.0 to 3.5 mm), the refractive IOL provided better image quality than the 2 hybrid IOLs. When the pupil was larger, the distance vision was similar with all IOLs. The 2 hybrid IOLs gave better image quality than the refractive IOL for near vision with any pupil size. With the refractive IOL and pupils smaller than 3.5 mm, near focusing did not occur, resulting in poor image quality. Of the hybrid IOLs, the AcrySof ReSTOR SN60D3 provided better distance image quality and the Tecnis ZM900 provided better near image quality. Conclusions The refractive IOL gave better image quality than the hybrid IOLs at distance and with small pupils. With pupils larger than 3.5 mm, the quality was similar. Hybrid IOLs gave significantly better image quality for near vision with all pupil sizes. AcrySof ReSTOR SN60D3 IOLs give better distance vision than Tecnis ZM900 IOLs; the latter gave better near vision. The reference monofocal IOL provided better distance images than any multifocal IOL with all pupil sizes.

To evaluate the functional outcome after implantation of the Tecnis ZM900 multifocal intraocular lens (IOL) (AMO) and the Array SA40 multifocal IOL (AMO).Department of Ophthalmology, Bundesknappschaft s Hospital, Sulzbach, and the Department of Ophthalmology, Marienhospital, Aachen, Germany.In a prospective comparative 2-center trial, Tecnis ZM900 and the Array SA40 multifocal IOLs were bilaterally implanted in 50 patients (50 eyes Tecnis, 50 eyes Array) by 1 surgeon at each center. The following parameters were assessed 30 to 60 days and 120 to 180 days after surgery in both eyes: refraction, pupil size, uncorrected and best corrected visual acuities for distance and near at different contrast levels, and photopic and mesopic contrast sensitivity at different spatial frequencies. Patient satisfaction (spectacle independence, photic phenomena, overall satisfaction) was assessed by a questionnaire.The main differences between the 2 multifocal IOLs were the better uncorrected near visual acuity (P.001), distance-corrected near visual acuity (P.001), the mesopic contrast sensitivity at high spatial frequencies (P.05) as well as greater independence from spectacles in patients with the Tecnis multifocal IOL, resulting in higher levels of patient satisfaction.The aspherical diffractive Tecnis multifocal IOL gave better outcomes than the Array multifocal IOL.

Purpose To investigate the relationship between pupil size and the modulation transfer function (MTF) of a multifocal intraocular lens (IOL) in vitro and to predict the visual effects in vivo. Setting Department of Ophthalmology and Visual Science, Kitasato University Graduate School of Medical Sciences, Kitasato, Japan. Methods A refractive multifocal IOL (Array SA-40N, Allergan) and a monofocal IOL (PhacoFlex SI-40NB, AMO) were evaluated using the OPAL Vector system and a model eye with a variable effective aperture. With effective pupil diameters of 2.1, 3.0, 3.4, 3.9, 4.6, 5.1, and 5.5 mm, the in-focus and defocus MTFs were measured in the multifocal and monofocal IOLs. Results With increases in effective pupil diameter, the far MTF progressively decreased at all spatial frequencies. In contrast, the near MTF began to increase at effective pupil diameter 2.1 mm, showed a peak at 3.4 mm, and decreased at diameters greater than 3.4 mm. The ratio of near MTF to far MTF showed an increase with larger effective pupil diameters and at lower spatial frequencies. Conclusions With a zonal progressive multifocal IOL, the pupil size effected a trade-off between the far and near MTFs: The near MTF increased at the expense of the far MTF at large pupil sizes (effective pupil diameter >3.4 mm). To enhance near vision with a multifocal IOL, the desirable effective pupil diameter should be 3.4 mm or larger.

Purpose To study the theoretical optical performance of 3 intraocular lens (IOL) designs in the presence of IOL decentration. Setting Optics Center, Bausch & Lomb, Rochester, New York, USA. Methods A ray-tracing program was used to evaluate the effect of IOL decentration on the optical performance of 3 silicone IOLs (LI61U, Bausch & Lomb; Tecnis Z9000, Advanced Medical Optics; and a new aberration-free IOL [SofPort AO, Bausch & Lomb]) in an experimental model eye. The study was done using pupil diameters of 3.0 mm, 4.0 mm, and 5.0 mm and IOL decentrations of 0 mm, 0.25 mm, 0.50 mm, 0.75 mm, and 1.00 mm. The modulation transfer functions were computed and plotted. A Monte Carlo simulation analysis with 1000 trials with IOL decentration randomly varying for each pupil size was performed. Results Decentration of LI61U and Tecnis Z9000 IOLs led to asymmetrical higher-order aberrations that adversely affected the optical performance of the model eye; performance was not affected with the aberration-free IOL because it lacks inherent spherical aberration. Optical performance with the aberration-free IOL was better than with the LI61U IOL as the former has less spherical aberration and did not introduce other aberrations when decentered. Performance with the aberration-free IOL was better than with the Tecnis Z9000 IOL for 3.0 mm, 4.0 mm, and 5.0 mm pupils when decentration exceeded 0.15 mm, 0.30 mm, and 0.38 mm, respectively. Performance with the LI61U IOL was better than with the Tecnis Z9000 IOL for 3.0 mm, 4.0 mm, and 5.0 mm pupils when decentration exceeded 0.3 mm, 0.5 mm, and 0.5 mm, respectively. Monte Carlo simulations showed the expected postoperative results of the LI61U IOL and aberration-free IOL would be repeatable and predictable, whereas the outcomes with the Tecnis Z9000 IOL would vary widely. Conclusions The optical performance of the model eye was not affected by decentration of an aspheric IOL designed to have no inherent spherical aberration. With decentration, the performance with the new IOL was better than with a conventional spherical IOL and an aspheric IOL designed to offset the spherical aberration of an average cornea.

To compare 2 infrared pupillometers with a videokeratographer and 2 aberrometers for the determination of scotopic pupil size.Department of Ophthalmology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany.The pupil diameter was measured in 100 eyes of 51 patients after 2 minutes of dark adaptation using the following devices: digital infrared pupillometer (Procyon Instruments Ltd.), handheld infrared pupillometer (Colvard) (Oasis Medical), Zywave aberrometer (BauschLomb), Wasca aberrometer (Asclepion-Meditec-Zeiss), and Orbscan II topography system (BauschLomb Surgical). Measurements taken with the Procyon pupillometer were considered reference values for comparison with the other devices. Statistical evaluation was performed using the Bland-Altmann method for comparison of measurement techniques.The mean pupil size was 6.10 mm +/- 0.86 (SD) with the Procyon pupillometer, 5.68 +/- 1.07 mm with the Colvard pupillometer, 5.91 +/- 1.01 mm with the Zywave aberrometer with the fixating target turned off, 5.09 +/- 1.14 mm with the Zywave aberrometer with the fixating target turned on, 5.59 +/- 0.99 mm with the Wasca aberrometer, and 3.75 +/- 0.67 mm with the Orbscan topographer. The limits of agreement were smallest for measurements between Procyon and Colvard and largest for measurements between Procyon and Orbscan. The sign test revealed statistically significant differences for all devices compared with the Procyon pupillometer (P.001 in all cases) except the Zywave aberrometer with the fixating target turned off (P=.13).The Zywave wavefront sensor with the fixating target turned off using the study settings and light conditions provided measurements of scotopic pupil diameter that were closest to the reference values (Procyon). With the other devices (Colvard pupillometer, Zywave aberrometer with the fixating target switched on, Wasca aberrometer, and Orbscan topographer), the difference was statistically significant.

Purpose: To evaluate the effect of brimonidine tartrate 0.2% ophthalmic solution on pupil size under scotopic and photopic luminance conditions in persons considering laser refractive surgery. Setting: Ophthalmic Health Center, Tel Aviv, Israel. Methods: The pupil size was measured in 36 eyes of 36 participants under scotopic and photopic conditions using the Colvard pupillometer (Oasis Medical) before and after brimonidine tartrate drops were administered. The pupil size was subsequently measured after 30 minutes and 4 and 6 hours. Results: No difference was found in pupil size before brimonidine tartrate instillation in eyes with light or dark irides. Before instillation, the mean photopic pupil size was 4.81 mm ± 0.54 (SD) (range 4.0 to 6.0 mm). At 30 minutes, all pupils became miotic, with a mean size of 3.77 ± 0.51 mm (range 3.0 to 5.0 mm) ( P P Conclusions: Brimonidine tartrate caused significant miosis, especially under scotopic conditions, most likely from its α-2 adrenergic effect. Under photopic luminance conditions, the miotic effect was pronounced.

Purpose: To evaluate a digital photography method of pupil size estimation over a broad range of illumination conditions and to compare this method with common clinical techniques. Setting: College of Optometry, Ohio State University, Columbus, Ohio, USA. Methods: Two examiners measured the pupil diameter in 45 right eyes at 3 illumination levels

Purpose To evaluate the effect of pupil size, degree of intraocular lens (IOL) decentration, and rotation of 4 aspheric toric IOLs on the image quality. Setting Department of Ophthalmology, Seoul St. Mary's Hospital, Seoul, South Korea. Design Experimental study. Methods Four aspheric toric intraocular lenses (IOLs)—the Precizon (transitional conic toric IOL), AT Torbi 709M (bitoric IOL), SN6AT4 (posterior toric surface IOL), and ZCT225 (anterior toric surface IOL)—were evaluated using the optical bench metrology system. Measurements included changes in spherical aberrations, relative spherical equivalent (SE), and image quality at different pupil diameters and image quality degradation due to decentration and rotation of the IOLs. Results Change in relative SE with pupil size in aberration-free toric IOLs (transitional conic toric and bitoric IOLs) was greater than in negatively aspheric toric IOLs (posterior toric surface and anterior toric surface IOLs). In contrast, the aberration-free IOLs showed higher contrast than the negatively aspheric IOLs. When IOLs were decentered by 1.0 mm, the contrast reduction rates at 17.6 cycles per degree for the transitional conic toric IOL, bitoric IOL, posterior toric surface IOL, and anterior toric surface IOL were 5.1%, 3.1%, 12.2%, and 15.8%, respectively. Rotation-induced deterioration of contrast to 0.5 required a much higher rotation for the transitional conic toric IOL than for the other 3 IOLs. Conclusions The transitional conic toric IOL and bitoric IOL provided superior image quality despite pupil size changes and the presence of decentration. The transitional conic toric IOL demonstrated maximum rotation tolerance compared with the other IOLs. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

The objective of this review was to provide a summary of the peer-reviewed literature on the etiologies of negative dysphotopsia that occurs after routine cataract surgery. A search of PubMed, Google Scholar, and Retina Medical identified 59 reports. Negative dysphotopsia has been associated with many types of intraocular lenses (IOLs), including hydrophobic and hydrophilic acrylic, silicone, and 1-piece and 3-piece designs. Proposed etiologies include edge design, edge smoothness, edge thickness, index of refraction of the IOL, pupil size, amount of functional nasal retina, edema from the clear corneal incision, distance between the iris and IOL, amount of pigmentation of the eye, corneal shape, prominent globe and shallow orbit, and interaction between the anterior capsulorhexis and IOL. Treatments include a piggyback IOL, reverse optic capture, dilation of the pupil, constriction of the pupil, neodymium:YAG capsulotomy of the nasal portion of the anterior capsule, IOL exchange with round-edged optics, and time alone. This review summarizes the findings. Financial Disclosure Dr. Henderson is a consultant to Alcon Laboratories, Inc., Abbott Medical Optics, Inc., Bausch & Lomb, and Genzyme Corp. Neither author has a financial or proprietary interest in any material or method mentioned.

Purpose To measure miosis after femtosecond laser pretreatment of cataract surgery and determine correlative factors. Setting Department of Ophthalmology and Visual Science, Seoul St. Mary's Hospital, College of Medicine, and Catholic University of Korea, Seoul, South Korea. Design Cross-sectional study. Methods Images extracted from surgical videos of femtosecond laser pretreatment and phacoemulsification were used to measure the pupil area. Quantitative analysis of pupil constriction was performed by comparing consecutive images obtained at the initiation of each procedure. Potential factors related to pupil constriction were examined, including laser parameters and anatomic measurements. Results The study enrolled 56 eyes. The mean pupil area decreased by 29.7% during the time it took to shift between procedures (shifting time). The total laser treatment duration was highly correlated with the reduction in the pupil area ( r = −0.433, P = .001). The amount of intraoperative miosis was significantly correlated with the duration of lens fragmentation by the femtosecond laser ( r = −0.416, P = .001) and of primary incision creation ( r = −0.289, P = .031). Pupil constriction was correlated with patient age ( r = −0.398, P = .002) and the laser capsulotomy–pupil margin distance ( r = 0.395, P = .003), but not with suction-on time ( r = −0.012, P = .930) or shifting time ( r = −0.091, P = .506). Conclusions The pupil area decreased significantly after femtosecond laser pretreatment of cataract surgery. Intraoperative miosis was most significantly correlated with laser pretreatment duration and patient age. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

To evaluate the effect of brimonidine tartrate ophthalmic solution 0.2% (Alphagan) on pupil size in normal eyes. Three luminance conditions were used to assess the potential use of brimonidine in postoperative refractive patients who experience nighttime vision problems related to large pupil size.McDonald Eye Associates, Fayetteville, Arkansas, USA.Pupil size was measured in 16 eyes of 16 participants with the Colvard pupillometer under 3 luminance conditions. One drop of brimonidine 0.2% was administered to each patient. Pupil size was then measured using the same technique 30 minutes and 4 and 6 hours after drop administration.Under scotopic conditions, 100% of the pupils showed significant miosis at 30 minutes (P.05). The effect continued in all eyes for 4 hours. At 6 hours, a miotic effect was still present in 81.3%. However, under photopic luminance, there was no significant effect on pupil size in all 16 eyes (P.05). The pupil size in 5 eyes (31.2%) was not affected at 30 minutes or 4 or 6 hours. At 6 hours, 15 eyes (93.8%) had returned to their preinstillation size.Brimonidine tartrate 0.2% had a significant effect in decreasing pupil size under scotopic conditions. The results indicate that the drug can decrease night-vision difficulties such as halos, star bursts, glare, and monocular diplopia in postoperative refractive patients.

Purpose To prospectively measure the scotopic pupil diameter in a normal population and to compare 2 infrared pupillometers for these measurements. Setting Johann Wolfgang Goethe-University, Department of Ophthalmology, Frankfurt am Main, Germany. Methods The Colvard infrared pupillometer was compared to the Video Vision Analyzer (VIVA) infrared pupillometer under scotopic light conditions in 33 participants (aged 19 to 55 years). Reliability was assessed by 2 independent examiners (E1, E2). Statistical analysis was performed using a comparison method by Bland and Altman. Results Mean pupil diameter was 6.16 mm ± 1.20 (SD) (range 3.20 to 9.00 mm) with all measurements taken under scotopic illumination. The mean scotopic pupil diameter was 6.08 ± 1.16 mm (range 3.2 to 8.4 mm) with the Colvard pupillometer and 6.24 ± 1.28 mm (3.5 to 9.0 mm) with the VIVA pupillometer. The mean differences between the Colvard and VIVA were −0.27 mm (E1) and −0.05 mm (E2). Limits of agreement ranged from 1.4 (Colvard) to 2.4 (VIVA). The coefficients of repeatability ranged from 0.7 (Colvard) to 1.1 (VIVA). Conclusions A mean scotopic pupil diameter of 6.15 mm with a maximal pupil size of 9.00 mm can be expected in a normal population; this should be considered in refractive corneal and refractive lens surgery. Measurements with the Colvard pupillometer were more reliable and precise than those with the VIVA pupillometer.

Purpose: To compare contrast sensitivity (CS) after implantation of a diffractive bifocal intraocular lens (IOL) and a monofocal IOL of similar design. Setting: Seven European centers. Methods: In this randomized, prospective study, CS was tested 5 months after cataract and IOL implantation surgery in 115 patients with a diffractive bifocal IOL and 106 patients with a monofocal IOL. It was also tested in a subgroup of 38 patients who had bilateral implantation of a diffractive bifocal IOL. Contrast sensitivity was tested using the Vision Contrast Test System (VCTS). Results: In patients with a best corrected visual acuity (BCVA) of 1.0 or better, the CS at all spatial frequencies (1.5 to 18 cycles/degree), both at distance and near, was slightly lower in the bifocal IOL group than in the monofocal group. Mean values were within the normal range. In patients with a BCVA of less than 1.0, the CS was lower and the difference between the bifocal and monofocal groups was less. In patients with bilateral bifocal IOLs, CS was better when tested bilaterally than when testing the better eye alone. Pupil size affected the results to a small degree. Contrast sensitivity appeared to improve over time after implantation of a diffractive bifocal IOL. Conclusions: In patients with cataract and no other eye pathology, the diffractive bifocal IOL will slightly reduce the CS at all spatial frequencies. In those with reduced visual acuity after cataract surgery, CS will be reduced accordingly. In this situation, the reduction from the diffractive bifocal optic would be minor.

To study the relationship between pupil size and light intensity using the Procyon pupillometer.University based clinic.In this retrospective study, 20 consecutive patients had pupil size assessment with the Procyon pupillometer under 3 different light conditions--4, 0.4, and 0.04 lux. Correlation was established using the log unit of the light intensity and pupil size.The correlation coefficient for the association between pupil size and log unit of light intensity in all eyes was significant (P.001). The mean correlation coefficient for the association between pupil size and log unit of light intensity in all patients was 0.968 +/- 0.089 (SD) in the right eye and 0.970 +/- 0.031 in the left eye.The linear relationship between the pupil size and the log unit of the light intensity showed a tight correlation in all cases. These results can be useful in the comparing pupil size with pupillometers that work under different light conditions.

Purpose To compare changes in reading performance parameters after implantation of 4 multifocal intraocular lens (IOL) models and a monofocal IOL. Setting Department of Ophthalmology, Paracelsus Medical University, Salzburg, Austria. Design Prospective randomized controlled clinical trial. Methods Patients with bilateral cataract without additional ocular pathology were scheduled for bilateral implantation of Acri.Smart 48S monofocal, Acrysof Restor SN6AD3 apodized multifocal, AT LISA 366D diffractive multifocal, Tecnis ZMA00 diffractive multifocal, or Rezoom refractive multifocal IOLs. Bilateral corrected and uncorrected reading acuity, reading distance, mean and maximum reading speeds, and smallest log-scaled print size of a Radner reading chart were evaluated under bright lighting conditions (500 lux) using the Salzburg Reading Desk. Pupil size was not measured throughout the trial. The minimum follow-up was 12 months. Results The diffractive multifocal groups had significantly better uncorrected reading acuity and uncorrected smallest print size than the monofocal and refractive multifocal groups 1, 6, and 12 months postoperatively. The diffractive IOL groups had comparable uncorrected reading distance of approximately 32 cm, which was larger in the monofocal group (38.9 ± 8.4 cm) and refractive multifocal group (37.1 ± 7.3 cm) at the last visit. Patients with diffractive IOLs could read print sizes of approximately 0.74 to 0.87 mm, which was much better than in the monofocal and refractive multifocal groups. The diffractive AT LISA IOL provided the best reading speed values (mean and maximum, corrected and uncorrected). Conclusion Multifocal IOLs with a diffractive component provided good reading performance that was significantly better than that obtained with a refractive multifocal or monofocal IOL. Financial Disclosure Drs. Grabner and Dexl were patent owners of the Salzburg Reading Desk technology (now owned by SRD-Vision, LLC). No other author has a financial or proprietary interest in any material or method mentioned.

We conducted a bicenter study to evaluate the effect of pupil size and corneal astigmatism on best corrected contrast acuity (BCCA) in patients with the True Vista ™ bifocal intraocular lens (IOL) and compared the results with those in a matched group of monofocal patients. Best corrected contrast acuity was measured using the Regan Charts (96%, 50%, 25%, 11 %) at four pupil sizes (2.0, 2.5, 3.5, 6.0 mm) in three groups (Group 1: corneal astigmatism 0–0.50 D [n = 11]; Group 2: 0.75–1.50 D [n =11 ]; Group 3: 1.75–2.50 D [n = 4]). In monofocal eyes, BCCA between these astigmatic groups did not differ significantly at any contrast step or at any pupil size tested. However, BCCA decreased slightly with increasing pupil size in each group, and differences between 2.0 mm and 6.0 mm pupils were significant at each contrast level. In all bifocal groups, BCCA decreased significantly with increasing pupil size and also decreased with increasing corneal astigmatism; differences were significant at most pupil sizes and contrasts tested. In Group 1, BCCA was lower in eyes with bifocal IOLs than in eyes with monofocal IOLs at 25% and 11 % contrast with a 2.5, 3.5, and 6.0 mm pupil; with a 2.0 mm pupil it did not differ significantly. In Groups 2 and 3, BCCA in eyes with bifocal IOLs was lower at all contrast steps and all pupil sizes tested. Our results indicate that corneal astigmatism in excess of 0.50 D reduces quality of vision in eyes with bifocal IOLs, while eyes with monofocal IOLs are not affected. It may be important to minimize postoperative corneal astigmatism in patients with bifocal IOLs.

Purpose To quantify the current accuracy limits, analyze the residual errors, and propose the next steps for prediction accuracy improvements. Setting Eye hospitals in Germany, Denmark, and Austria. Method Numerical ray tracing using manufacturer's intraocular lens (IOL) data (vertex radii, central thickness, refractive index) was used for all calculations. Postoperative lens position was predicted by a simple scaling model based on measurements in 1 patient collective. The model was compared with 2 other approaches in 2 patient collectives at 2 hospitals (1121 eyes with 13 IOL models; 936 eyes with 2 models). Axial lengths were measured optically (IOLMaster, Zeiss). No parameter adjustments or individualization of IOL types or of surgeons/localizations were done. The prediction errors and measures of systematic bias for short or long eyes were used to quantify the outcome. Results The mean prediction errors in the 2 collectives were +0.13 diopter (D) and −0.13 D and the mean absolute errors were 0.44 D and 0.50 D without bias for long or short eyes, but depending on the IOL position model approach. The differences in the mean prediction errors for the IOL types were below the allowed manufacturing tolerances and below human recognition thresholds. Conclusions The need to individualize and fudge parameters decreases with better physical models of the pseudophakic eye. Further improvements are possible by individual topography to extract corneal asphericity and measured pupil size to calculate the best focus, by improved position predictions based on individual measurements of the crystalline lens and by smaller tolerances for IOL manufacturing.

Purpose To prospectively evaluate reading performance with of 3 types of multifocal intraocular lenses (IOLs) under different lighting conditions based on reading acuity and reading speed tests. Setting Augenklinik, Bad Hersfeld, Germany. Methods This randomized study comprised 60 cataract patients (120 eyes) randomly assigned to receive an SA40N IOL (AMO) (Group 1, 20 patients), Tecnis ZM001 IOL (AMO) (Group 2, 20 patients), or AcrySof ReSTOR SA60D3 IOL (Alcon) (Group 3, 20 patients). Pupil size and reading ability at near (visual acuity, reading speed) without correction, with best distance correction, and with best near correction were assessed 6 weeks postoperatively under low-light conditions (6 cd/m 2 ) and bright-light conditions (100 cd/m 2 ) using the Radner Reading Charts. Results Six weeks postoperatively, there was no significant difference between groups in pupil size measured under low-light (6 cd/m 2 ) or bright-light (100 cd/m 2 ) conditions. When assessed under low-light conditions, near visual acuity and reading speed with or without correction were generally better in Group 2 than in Groups 1 and 3; there were no significant difference between Groups 1 and 3. Under bright-light conditions, Groups 2 and 3 performed significantly better than Group 1 and Group 2 performed better than Group 3. Conclusions Under bright-light conditions, second-generation multifocal IOLs provided better reading performance than the Array SA40N IOL. However, when tested under low-light conditions, patients with the Tecnis ZM001 IOL had the best reading acuity and reading speed.

Purpose To compare 2 digital infrared pupillometers. Setting Anterior Segment Service, Moorfields Eye Hospital, London, England. Methods Eighty-eight eyes of 44 healthy subjects were recruited into the study. The scotopic pupil size was measured with 2 instruments, a digital pupillometer (Procyon) and a Hartman-Shack wavefront aberrometer (Visx WaveScan). Agreement between the instruments was assessed. Results There were 21 men and 23 women with a mean age 38.1 years ± 9.2 (SD) (range 23 to 62 years). The mean scotopic pupil diameter was significantly larger with the WaveScan (6.61 ± 0.92 mm) than with the Procyon pupillometer (6.40 ± 0.90 mm), P Conclusions There was good agreement in measurement of scotopic pupil size between the two instruments. The larger pupil diameter found with the Visx WaveScan than with the Procyon digital pupillometer probably represents the different illumination level used by each instrument, the effects of accommodation, and target fogging.

Purpose To evaluate the changes in pupil size before and after phacoemulsification surgery in nondiabetic and diabetic patients and determine whether there is an association between preoperative pupil size and postoperative pupil size. Setting Hayashi Eye Hospital, Fukuoka, Japan. Methods In this study, 315 nondiabetic patients and 71 diabetic patients scheduled for phacoemulsification were recruited consecutively. The pupil area and pupil diameter were measured preoperatively and approximately 3 days and 1 month postoperatively using an infrared pupillometer and Colvard pupillometer, respectively. The simple association between preoperative and postoperative pupil size and between pupil size and age were evaluated. Results The mean pupil area in the nondiabetic group and diabetic group decreased significantly 3 days postoperatively and returned to approximately preoperative levels at 1 month. Strong associations were found between preoperative pupil area and diameter and the area and diameter at 3 days and 1 month in both groups. Younger age was weakly associated with larger pupils in the nondiabetic group. The pupil size in the diabetic group was smaller than in the nondiabetic group, although the difference was not significant preoperatively. The pupil size became smaller with increasing severity of diabetic retinopathy. Conclusions Pupil size decreased immediately after phacoemulsification but returned to approximately preoperative levels by 1 month postoperatively in nondiabetic and diabetic patients. There was a strong association between preoperative and postoperative pupil size. The pupil size in diabetic patients was significantly smaller than in nondiabetic patients postoperatively.

Purpose: To determine the difference in pupil size measured with the Colvard pupillometer in mesopic and scotopic luminance and with the Rosenbaum pupil card in mesopic luminance between 2 examiners. Setting: Michel Pop Clinics, Montreal, Quebec, Canada. Methods: Two examiners used the Colvard pupillometer and the Rosenbaum card to measure pupil size in 58 eyes. The Colvard pupillometer was used in mesopic and scotopic light conditions. The Rosenbaum card was used in mesopic luminance only. Pupil size was evaluated with a 1.0 mm interval scale at the nearest half millimeter. Results: For the 3 sets of data, the limits of agreement and coefficient of interrater repeatability were calculated and a 2 × 2 factorial analysis of variance was performed. Because of interexaminer bias, measurements done in mesopic luminance with the Rosenbaum card were not statistically different from those with the Colvard pupillometer in scotopic luminance, although interrater repeatability of the Colvard pupillometer (0.8 mm) was superior to that of the Rosenbaum card (1.3 mm). Conclusions: Examiner bias was the greatest statistical bias in all sets of measures. Surgeons may want to opt for a "safe" limit of pupil size (ie, 0.5 to 0.8 mm greater than the measured size) when calculating optical zones in refractive surgery. Future devices for pupil measurement should be based on automatic adjustment sizing.

A technique using flexible iris retractors to manage small pupils during cataract extraction reduces iris trauma, allows adjustment of pupil size, and reduces intraoperative difficulty more than previously described techniques. This method is appropriate for extracapsular cataract extraction and phacoemulsification, as well as the posterior segment procedures for which it was originally described.

media (air and aqueous) that bound the cornea. The 1.336 value used in our formula is the refractive index of the aqueous and vitreous at body temperature. The original Hoffer formula was restated in the Hoffer Q paper referenced in our article. The original reference is shown below. Holladay recommended that we repeat our study by back-calculating the K values again using modern formulas (Hoffer Q, Holladay 1 and 2, SRK/T). While this exercise is interesting in theory, the results would be erroneous because each of these formulas calculates ELP based on biometric data and an A-constant or surgeon factor. It is not possible to rearrange the formulas to input a measured IOL position. We plan to work with Holladay and Oculus to refine the methods used to study the Pentacam and other Scheimpflug cameras, with the goal of improving the accuracy of these devices in post-keratorefractive surgery eyes. We applaud Oculus for producing the device and Holladay for his software contributions. We think the Pentacam is a remarkable piece of technology, but we also consider it a work in progress.dQiongyan Tang, MD, Kenneth J. Hoffer, MD, Michael D. Olson, OD, PhD, Kevin M. Miller, MD

A group of 40 postoperative cataract patients had Miller-Nadler glare testing performed before and after midpupillary pharmacologic dilation. The results indicated that pupillary enlargement is associated with increased glare disability. For that reason it is essential to maintain normal pupil shape and function after cataract surgery, a difficult task in cases with miotic pupils.

We performed glare tests on patients following uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens implantation and on noncataractous phaldc patients. Three types of lenses were implanted to compare the effect of optic asphericity and ultraviolet filtration on glare. Glare testing was performed using the Miller-Nadler GlareTester and Baylor Visual Function Tester. The glare scores of the pseudophaldc and phakic patients were statistically similar. In the pseudophaldc patients, factors associated with decreased glare performance were posterior capsular opacification and increased pupil size; the intraocular lens type did not significantly affect glare scores.