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Purpose: To evaluate subjective and objective outcomes after combined implantation of an extended depth-of-focus (EDOF) intraocular lens (IOL) and a combined technology multifocal lens (CT-IOL)., Setting: 2 clinical practices (Carolina Eyecare Physicians, Center For Sight) in the United States., Design: Prospective, unmasked, multicenter, nonrandomized bilateral eye study., Methods: Patients interested in reducing their dependence on spectacles were implanted with an EDOF IOL in the dominant eye and a CT-IOL in the nondominant eye. Refractive and visual acuity (VA) data at various distances (4 m, 66 cm, 40 cm, and 33 cm) were collected 3 months postsurgery, along with the distance-corrected binocular defocus curve and responses to questionnaires related to spectacle independence, visual disturbances, and overall visual function., Results: Data from 37 participants were analyzed. The distance-corrected binocular defocus curve showed a mean VA better than 0.1 logMAR (20/25) at all vergences from +1.00 to -2.50 diopters (D). 36 participants (97%) had an uncorrected binocular VA of 0.3 logMAR or better, at all test distances. 70% of participants (26/37) reported never wearing spectacles at any distance, and 84% (31/37) were "completely" or "mostly" satisfied with their overall vision after surgery. Halos were the disturbance reported most frequently and reported as most bothersome, with difficulty driving at night the most common visual function issue. Difficulty reading was the next most reported issue. Overall eyesight was rated as "excellent" or "good" by 92% (34/37) of participants., Conclusions: This combined EDOF/CT-IOL approach was well-tolerated by participants and provided some potential benefits relative to bilateral implantation of either lens., (Copyright © 2024 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To determine whether impaired or absent stereopsis affects the ability to perform simulated microsurgical tasks., Setting: University of Edinburgh, United Kingdom., Design: Prospective randomized cross-over study., Methods: Visual acuity and stereoacuity were measured. A band-pass filter was placed over the nondominant eye to reduce stereoacuity to 150 seconds of an arc (partial stereopsis), or the nondominant eye was completely occluded (absent stereopsis). Participants completed a computerized surgical simulator task 3 times with a randomized testing order (normal stereopsis, absent stereopsis, and partial stereopsis). The task involved using forceps to grasp and position objects in the anterior chamber. Outcomes included area of ocular injury, time to task completion, and overall score., Results: Ocular damage area was significantly worse with partial stereopsis (P = .002) and worse still when stereopsis was absent (P < .001 for normal vs absent stereopsis and P = .005 for partial vs absent stereopsis). The median ocular damage area was 3.55 mm (interquartile range [IQR], 1.21-5.88 mm) with normal stereopsis, increasing to 6.10 mm (IQR, 3.96-12.47 mm) with stereopsis reduced to 150 seconds of an arc and to 9.25 mm (IQR, 4.93-18.70 mm) with no stereopsis. Time taken to complete the task increased and overall score decreased as stereopsis was reduced. The overall score decreased from 53% (IQR, 22.5-82%) under normal stereopsis to 0% (IQR, 0-43.5%) with absent stereopsis., Conclusions: Impaired stereopsis was associated with worse microsurgical performance, which may have implications for surgical training. The absence of stereopsis resulted in worse performance than partial reduction in stereopsis.

Purpose: To compare the visual acuity and satisfaction outcomes of 2 different concepts of extended depth-of-focus intraocular lenses (EDOF IOLs)., Setting: University Eye Hospital Bochum, Germany., Design: Prospective randomized comparative clinical trial., Methods: Patients undergoing cataract surgery with the implantation of 2 different concept EDOF IOLs. In the first group (IC-8 Group), a monofocal 1-piece Tecnis Z B00 IOL (Johnson & Johnson Vision Care, Inc.) was implanted in the dominant eye, and an IC-8 IOL (AcuFocus) was implanted in the nondominant eye. In the second group (Symfony Group), a Tecnis Symfony IOL (Johnson & Johnson Vision Care, Inc.) was implanted in both eyes. The target refraction of the dominant eye was emmetropia and slight myopia (mini-monovision, -0.75 diopters) in the nondominant eye. Visual and refractive outcomes and patient satisfaction rates were evaluated 3 months postoperatively., Results: This study comprised 76 eyes of 38 patients. No intraoperative or postoperative complications occurred in either group. Target refraction was reached in both groups without statistically significant differences. The uncorrected distance visual acuity (UDVA, photopic and mesopic light conditions) was excellent in both groups with statistically significantly better results in the IC-8 goup (logarithm of the minimum angle of resolution; IC-8 Group (0.1 ± 0.07 logarithm of the minimum angle of resolution [logMAR]; Symfony Group 0.07 ± 0.1 logMAR, P value .02 [photopic]; IC-8 group 0.12 ± 0.09 logMAR, Symfony group 0.22 ± 0.1 logMAR, P value < .01 [mesopic]). Binocular uncorrected intermediate visual acuity (UIVA) and uncorrected near visual acuity (UNVA) were also good in both groups without statistically significant differences (UIVA: IC-8 Group, 0.01 ± 0.07 logMAR, Symfony Group 0.01 ± 0.08 logMAR, P value .35; UNVA: IC-8 Group 0.14 ± 0.11, Symfony Group 0.09 ± 0.08, P value .14). Subjective satisfaction was high in both groups., Conclusions: Both EDOF IOLs provided a very good UDVA with superior results in the IC-8 Group, and a good UIVA and UNVA under photopic light conditions. Subjective patient satisfaction was higher in the IC-8 Group.

The extended depth-of-focus (EDOF) intraocular lens (IOL) is an emerging technology that is designed to improve range of vision, especially at intermediate distances. In this review, we describe the clinical performance of 4 emerging EDOF IOL technologies; that is, small aperture, bioanalogic, diffractive optics, and nondiffractive optical manipulations. The American Academy of Ophthalmology generated a consensus statement for EDOF IOLs that provided benchmarks and recommendations for classifying an implant as an EDOF IOL as well as standardized testing criteria for evaluating performance. Although many types of EDOF technologies are being developed, there are important differences in their performance that require further testing and evaluation.

Purpose: To compare visual outcomes, reading ability, and visual quality between the Symfony extended depth-of-focus intraocular lens (IOL) and the trifocal AT LISA tri 839MP IOL., Setting: University Eye Clinic Maastricht, The Netherlands., Design: Prospective randomized controlled trial., Methods: Patients were randomly assigned to bilateral Symfony IOL or AT LISA tri 839MP IOL implantation. The primary outcome measure was uncorrected intermediate visual acuity (UIVA measured at 66 cm). Secondary outcomes included uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), reading ability, and comparison of defocus curves, contrast sensitivity, optical adverse effects, and quality of vision., Results: The study enrolled 60 eyes of 30 patients. The mean UIVA was -0.02 ± 0.03 (SD) vs 0.01 ± 0.03 logarithm of the minimal angle of resolution (logMAR) in the Symfony and AT LISA tri 839MP groups, respectively (P = .047). The UDVA was 0.01 ± 0.12 and -0.05 ± 0.07 logMAR (P = .11) and the UNVA was 0.09 ± 0.05 and 0.04 ± 0.07 logMAR (P = .052) in the Symfony and AT LISA tri 839MP groups, respectively. Reading ability was similar in both groups at 40 cm and 66 cm (P = .87 and P = .14, respectively). Less than 10% of patients in both groups experienced disabling glare. Patients experienced disabling halos in the AT LISA tri 839 MP group compared to the Symfony group in 39% and 21% of cases, respectively (P = .12). The mean score for visual functioning was 88.0 ± 14.1 n the trifocal group and 88.2 ± 10.9 for the EDOF group (P = .96)., Conclusions: The UIVA was better in the Symfony group than in the AT LISA tri 839MP group. No significant differences were seen in the binocular UNVA and UDVA, contrast sensitivity, reading ability, incidence of photopic phenomena, and patient satisfaction.

Purpose: To examine the 6-month outcomes of visual performance and positional stability of a capsule-fixated intraocular lens (IOL), FEMTIS Comfort MF15, extended depth-focus (EDOF) version, after cataract surgery performed using femtosecond laser-assisted cataract surgery capsulotomy., Setting: Vision Eye Institute, Sydney, Australia., Design: Prospective open-label postregistration data collection., Methods: Three-month and 6-month outcomes were measured including visual function, stability of IOL position, and quantitative measurement of glare and halo. Subjective patient satisfaction and spectacle independence rates were documented with a subjective questionnaire. A computer simulator was used to quantify the incidence and severity of unwanted visual phenomena allowing comparison with other EDOF and multifocal IOLs., Results: Forty-four eyes of 25 patients were included in the study. There were 19 bilateral cases. The median shift in IOL position over 6 months (from surgery to 6 months) was 0.095 ± 0.09 mm. There was a marked improvement in uncorrected and corrected distance visual acuity from the preoperative to the 6-month mark. Patient satisfaction and spectacle independence levels were high. There was no IOL enclevation, negative dysphotopsia, decentration, or capsular phimosis., Conclusions: To the authors' knowledge, this is the first study to report outcomes after insertion of the FEMTIS capsulorhexis-fixated EDOF IOL. This IOL offers excellent refractive predictability, functional range of vision, and minimal unwanted visual phenomena. The attachment to the anterior capsulorhexis is shown to be stable over time with no significant shift in the position or capsular phimosis. There was high patient satisfaction with spectacle independence.

Purpose: The use of monochromatic light in the assessment of intraocular lenses (IOLs) has been criticized for not representing the real-world situation. This study aimed to measure and compare the image quality of 3 extended depth-of-focus (EDOF) IOL models in monochromatic and polychromatic light., Setting: David J Apple Laboratory, Heidelberg, Germany., Design: In vitro study., Methods: An optical metrology instrument was used to study image quality metrics of diffractive IOLs with chromatic aberration correction (Symfony and AT Lara) and a refractive lens (Mini Well). The modulation transfer function (MTF) was measured in green and polychromatic light at a 2.0 mm, 3.0 mm, and 4.0 mm aperture. The EDOF IOL's tolerance to defocus was tested against a monofocal lens., Results: The mean MTF of the EDOF IOL at far distance was decreased in polychromatic compared with monochromatic light. The largest effect was found in the refractive lens; however, at intermediate distance, only small differences occurred. In their tolerance to defocus, the EDOF IOLs were superior to the monofocal IOL. The diffractive IOL had higher MTFs than that of the refractive IOL at 2 primary foci, the refractive IOL's optical quality varied less with defocus at 3.0 mm. The refractive lens was the most susceptible to changes in aperture size., Conclusion: The diffractive EDOF IOL was more resistant to chromatic effects than the refractive IOL. The EDOF IOLs provided an extended through-focus performance compared with the monofocal IOL, but differences in optical design, particularly pupil dependency, should be considered when refining IOL selection for patients.

Purpose: To compare kinetic visual acuity, stereopsis, ocular deviation, and fusion amplitude before and after implantable collamer lens (ICL) surgery., Setting: Sanno Hospital., Design: Retrospective analysis., Methods: The charts of adult patients who underwent implantation of an ICL with a central aquaport (V4c) for emmetropia were reviewed. The mean preoperative spherical equivalent and subjective astigmatism were -7.87 diopters (D) ± 3.13 (SD) and -0.75 ± 0.78 D, respectively. All measurements were obtained with full refraction before surgery and without spectacle correction after surgery. The kinetic visual acuity was measured with the AS-4D device. Stereopsis and ocular deviation were measured with the Titmus Stereotest and an alternate prism cover test, respectively. Fusion amplitude was determined from breakpoints measured using a prism., Results: The study comprised 29 adult patients (58 eyes). One month postoperatively, the mean safety and efficacy indices were 1.13 ± 0.20 and 0.96 ± 0.25, respectively, and 57 eyes (98.7%) were within ±0.5 D of the target correction. The mean kinetic visual acuity (logarithm of the minimum angle of resolution) was 0.30 ± 0.21 preoperatively and 0.20 ± 0.15 (Snellen 20/40 versus 20/32) postoperatively and the mean stereopsis (seconds of arc), 48.5 ± 1.6 versus 41.5 ± 1.1; both improved significantly (P < .001 and P = .012, respectively). The mean distance ocular deviation (-4.0 ± 3.8 prism diopters [Δ] versus 2.8 ± 3.6 Δ; P = .002) and near ocular deviation (-6.5 ± 6.7 Δ versus 5.4 ± 6.9 Δ; P = .04) decreased significantly. The fusion amplitude increased for near vision only., Conclusions: ICL implantation improved kinetic visual acuity and stereopsis, decreased ocular deviation, and increased near fusion amplitude., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the defocus curves of 4 presbyopia-correcting intraocular lenses (IOLs)., Setting: Department of Ophthalmology, Goethe University, Frankfurt, Germany., Design: Prospective case series., Methods: Patients included in the study had bilateral surgery with implantation of diffractive panfocal, diffractive trifocal, segmental refractive (SegRef), or extended-depth-of-focus (EDOF) presbyopia-correcting IOLs. The uncorrected (UDVA) and corrected (CDVA) distance visual acuities, uncorrected intermediate and near visual acuities, distance-corrected intermediate (DCIVA) and near (DCNVA) visual acuities, defocus curve, and spectacle independence were measured., Results: The UDVA and CDVA were not significantly different between groups (P > .05); however, the EDOF group had worse near CDVA (P < .001). The trifocal and EDOF groups showed better DCIVA than the panfocal and SegRef group at 80 cm (P < .001); the EDOF and panfocal groups had comparable DCIVA at 60 cm (P > .05). Defocus curves showed no significant between-group differences from 4 m to 2 m (P > .05). The EDOF group had better visual acuity from 1 m to 67 cm than the trifocal and SegRef groups and better visual acuity than the panfocal group at 1 m (P > .05). Compared with the other IOLs, the panfocal IOL yielded significantly better visual acuity at 50 cm (P < .001) and the EDOF IOL worse visual acuity at 40 cm (P < .01). There was a significant difference in spectacle independence between the panfocal group and EDOF group (P < .05) but no difference between the other groups., Conclusions: The 4 IOLs provided equally good CDVA. The EDOF IOL yielded slightly better DCIVA but worse DCNVA than the other IOLs. Only the panfocal IOL gave better DCIVA at 50 cm., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the refractive, visual, and aberrometric results with a new extended depth-of-focus intraocular lens (EDOF IOL) based on alternating positive and negative spherical aberration in the central 3.0 mm optical zone and an aspheric monofocal IOL of the same platform., Setting: Ophthalmology, University Hospital of Verona, Italy., Design: Prospective case series., Methods: Cataract patients free from other ocular disease had bilateral implantation of the EDOF Mini Well IOL or the monofocal Mini IOL. Four to 6 weeks after second-eye surgery, the refraction, visual acuity, defocus curve, contrast sensitivity, and photic symptoms were assessed. Wavefront analysis was performed. The primary endpoint of was the amplitude of the dioptric interval for 0.1 logarithm of the minimum angle of resolution (logMAR) visual acuity. The secondary endpoint was an aberration comparison between the two IOLs., Results: The study comprised two groups of 25 patients each. The corrected distance visual acuity was better with the monofocal IOL by 0.02 logMAR (P = .03). The 0.1 logMAR dioptric interval was 2.0 diopters (D) for the EDOF IOL and 1.0 D for the monofocal IOL (P < .001). The mean CDVA at -2.0 defocus was 0.15 logMAR ± 0.08 (SD) and 0.52 ± 0.14 logMAR, respectively (P < .001). There was no difference in contrast sensitivity or photic symptoms. The optical aberrations at 4.0 mm and 6.0 mm aperture diameters were similar in the two groups., Conclusion: The EDOF IOL based on spherical aberration provided greater depth of focus than the aspheric monofocal IOL without increasing optical aberrations and with few photic symptoms., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate stereopsis and visual quality after bilateral implantation of extended range of vision intraocular lenses (ERV IOLs)., Setting: R.P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India., Design: Prospective interventional study., Methods: Patients underwent phacoemulsification with bilateral implantation of ERV IOLs. The primary outcome measures were stereopsis (distance and near Randot) and visual quality (ray-tracing aberrometry). The secondary outcome measures were visual acuity and patient satisfaction. Follow-up was performed on day 1 and at 1, 3, 6, and 12 months postoperatively., Results: The study comprised 50 patients (100 eyes). The mean age of the patients was 58.9 years ± 8.9 (SD). At 1 year, the mean distance stereopsis was 103.6 ± 49.1 seconds of arc (arcsec) and near stereopsis was 21.1 ± 2.3 arcsec. Perfect near stereopsis of 20 arcsec was present in 80% of cases, and 82% had good distance stereopsis of 100 arcsec or better. Stereopsis correlated well with the patient satisfaction score (P < .001) and average internal modulation transfer function (MTF) (P < .015). The mean Strehl ratio was 0.029 ± 0.021, MTF was 0.24 ± 0.08, total higher-order aberrations were 0.62 ± 0.41 μm, and coma was 0.25 ± 0.18 μm. The mean binocular uncorrected decimal visual acuities were 0.98 ± 0.07 (distance), 0.82 ± 0.09 (intermediate) and 0.64 ± 0.08 (near). The mean patient satisfaction score was 9.08 ± 1.1, and no case required IOL explantation because of visually disturbing phenomena or patient dissatisfaction., Conclusion: Excellent stereoacuity was observed after bilateral implantation of ERV IOLs, which correlated well with patient satisfaction and quality of vision., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the visually weighted image quality and depth of focus achieved with small-pupil and multifocal strategies for expanding depth of focus of presbyopic or pseudophakic eyes., Setting: School of Optometry, Indiana University, Bloomington, USA., Design: Computational modeling., Methods: The visual Strehl ratio was computed from monochromatic optical transfer functions over a wide range of primary spherical aberration and defocus levels for pupil diameters ranging from 1.0 mm to 7.0 mm under high photopic light levels (retinal illuminance >900 trolands) and mesopic light levels (2 candelas/m 2 )., Results: Pupil miosis and added spherical aberration were effective at reducing the impact of spherical defocus. With high light levels at which Weber's law makes neural contrast sensitivity independent of retinal illuminance, small pupils (eg, 1.0 to 3.0 mm) generated higher peak image quality and more effective expansion of depth of focus than the small-pupil multifocal model. However, under low light levels at which the reduced retinal illuminance associated with pupil miosis lowered neural contrast sensitivity, the peak image quality was lower with small pupils (1.0 to 1.5 mm) at all aberration levels. Large pupils and high levels of spherical aberration were most effective at expanding the depth of focus under mesopic light levels., Conclusions: When reductions in retinal illuminance created by pupil miosis have no effect on neural contrast sensitivity, small pupils produced higher image quality and larger depth of focus than multifocal optics and large pupils. In general, the reverse was true under mesopic light conditions., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the quality of vision after excimer laser (MEL 80) correction of presbyopia using micromonovision and aspheric aberration patterns., Setting: Hospital Universitario QuirónSalud, Madrid, Spain., Design: Prospective case series., Methods: Patients were assigned to 1 of 3 groups based on the preoperative spherical equivalent. Visual acuity, spherical aberration, contrast sensitivity, quality of vision, and safety of the procedure were assessed preoperatively and at the end of the study. The dominant eye was treated for distance vision and the nondominant eye for near vision, with modulation of spherical aberration., Results: The study comprised 50 patients (100 eyes). The mean patient age was 46.84 years ± 4.17 (SD). Stereopsis at the end of the study improved in Group 3, from 215.29 ± 99.63 seconds of arc (arcsec) and 169.41 ± 71.10 arcsec (P = .025); no changes were seen in the other groups. Contrast sensitivity at 18 cycles per degree increased in Group 2 (P = .021), with no changes in the other groups. Group 1 and Group 2 had the best optical quality of vision after the surgery based on Optical Quality Analysis System frequency of the modulation transfer function values of 100%, 20%, and 9% and the Strehl ratio., Conclusion: The correction of presbyopia by micromonovision and aspheric aberration ablation with an excimer laser led to minimal changes in stereopsis, contrast sensitivity, and optical quality., (Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe and to experimentally assess a new intraocular lens (IOL) design using new diffractive technology., Setting: AMO Groningen b.v., Groningen, Netherlands., Design: Experimental study., Materials and Methods: The basic principles of the new diffractive technology are described. The new IOL comprises two diffractive technologies; one is designed to extend the range of vision by elongating the focus, and the other increases the retinal image contrast by correcting chromatic aberration. To assess the potential visual performance, simulations were carried out in clinically verified eye models to predict the clinical defocus curves (visual acuity). The optical performance of the new lens design was evaluated by optical measurements in a model eye. The model eye had a cornea having the spherical aberration and chromatic aberration of an average cataract patient. The measurements were performed in white light and monochromatic light., Results: The simulations suggested an increase in visual acuity of 0.27 logMAR as compared to an aspherical monofocal IOL in the range from -1 to -3 diopter defocus. The white light modulation transfer function in the far focus was identical to that of a monofocal IOL. The new lens demonstrated negative chromatic aberration, therefore showing the capability to actively reduce ocular chromatic aberration. The experiments also show retinal image characteristics of an extended light source that suggest that dysphotopsias (halos) of the new IOL are comparable to those associated with monofocal IOLs., Conclusions: The application of new IOL diffractive technology enabled optical characteristics that suggested that an extended range of vision can be obtained without compromising distance vision., Financial Disclosure: All authors are employees of Abbott Medical Optics, Inc., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the visual impact of adding different spherical aberration values to an Implantable Collamer Lens phakic intraocular lens (pIOL) to increase the depth of focus using an adaptive optics visual simulator., Setting: University of Valencia, Valencia, Spain., Design: Experimental study., Methods: Wavefront aberrations in -3.00 D and -6.00 diopter (D) pIOLs were measured in vitro. Afterward, different simulated pIOL experimental prototypes were created along with variances in the spherical aberration. An adaptive optics visual simulator was used to simulate vision after the implantation of the different pIOL prototypes from their wavefront aberrations. The corrected distance visual acuity (CDVA) and depth of focus were measured in 3.0 and 4.5 mm pupils., Results: In a 3.0 mm pupil, the CDVA achieved with -3.00 and -6.00 D pIOLs and all pIOL prototypes evaluated was above 20/20 except for a -6.00 D pIOL + spherical aberration 4 at 50% CDVA contrast, which decreased to 20/25. However, in a 4.5 mm pupil, the CDVA obtained with the pIOL prototypes decreased significantly and was more pronounced when the spherical aberration induced was negative. The depth of focus increment was larger with the highest spherical aberration added and with a small pupil. Nevertheless, it was independent of the sign of the added spherical aberration., Conclusions: The outcomes show that residual negative spherical aberration after pIOL implantation will disrupt the CDVA. However, some residual positive spherical aberration after pIOL implantation increased the depth of focus with excellent CDVA, providing a possible pIOL design for young presbyopic patients., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the extent to which stereoscopic depth perception influences the performance of tasks executed under an operating microscope., Setting: Laboratory of Experimental Ophthalmology, University Medical Center Groningen, the Netherlands., Design: Experimental study., Methods: Medical students were assigned (on the basis of their stereoacuity) to a stereo-sufficient group (depth perception ≤240 seconds of arc [arcsec]) or stereo-deficient group (≥480 arcsec). They performed a bead-stringing task (a mockup surgical test) under an operating microscope or a task on a cataract surgery simulator. The stereo-sufficient subjects also performed the bead-stringing task under artificial stereo-deficient conditions (binocular and monocular viewing)., Results: The study comprised 77 medical students. The stereo-sufficient subjects performed both tasks faster than the stereo-deficient subjects and artificially stereo-deficient subjects (P ≤ .024). In addition, a within-group analysis established that the stereo-sufficient subjects were faster at the bead-stringing task with stereoscopic viewing than under artificial stereo-deficient conditions with binocular viewing (P ≤ .011)., Conclusions: Having stereovision resulted in better initial performance on certain tasks involving the use of an operating microscope or cataract surgery simulator. However, this study did not show that stereo deficiency necessarily results in an inability to perform such tasks properly. Hence, it was not evident that for admission to an ophthalmology residency program, stereovision should be judged more stringently than other traits., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the relationship between ocular deviation and stereopsis and fusion in patients who had pseudophakic monovision surgery., Setting: Department of Ophthalmology, Kitasato University Hospital, Kanagawa, Japan., Design: Retrospective comparative case series., Methods: Patients had surgical monovision correction with monofocal intraocular lens placement followed by routine postoperative examinations. The alternate prism cover test was used to measure motor alignment. Sensory tests for binocularity included sensory fusion determinations using the Worth 4-dot test, near stereopsis test, and fusion amplitude measured with a prism bar. Patients with monovision were categorized as having small-angle exophoria (≤10.0 prism diopters [Δ]) or moderate-angle exophoria (>10.0 Δ)., Results: This study comprised 60 patients with a mean age of 70.2 years ± 7.7 (SD). The difference in the mean stereopsis values between patients with small-angle exophoria and patients with moderate-angle exophoria was statistically significant (P<.001). In the moderate-angle exophoria group, 10 patients (62.5%) developed intermittent exotropia after surgery; however, no serious ocular deviation problems were observed. The fusion amplitudes in patients with pseudophakic monovision were approximately similar to normal values. Patients with moderate-angle exophoria were more likely to fail the Worth 4-dot test than those with small-angle exophoria., Conclusions: In patients with pseudophakic monovision having a near exophoria angle of more than 10.0 Δ, the possibility of changes in ocular deviation and stereopsis after surgery is a concern. Moreover, the application of monovision in patients with a previous moderate-angle exophoria should be carefully considered., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare laser in situ keratomileusis (LASIK) outcomes between 2 wavefront-guided excimer laser systems in the treatment of myopia., Setting: University eye clinic, Palo Alto, California, USA., Design: Prospective comparative case series., Methods: One eye of patients was treated with the Allegretto Wave Eye-Q system (small-spot scanning laser) and the fellow eye with the Visx Star Customvue S4 IR system (variable-spot scanning laser). Evaluations included measurement of uncorrected visual acuity, corrected visual acuity, and wavefront aberrometry., Results: One hundred eyes (50 patients) were treated. The mean preoperative spherical equivalent (SE) refraction was -3.89 diopters (D) ± 1.67 (SD) and -4.18 ± 1.73 D in the small-spot scanning laser group and variable-spot scanning laser group, respectively. There were no significant differences in preoperative higher-order aberrations (HOAs) between the groups. Twelve months postoperatively, all eyes in the small-spot scanning laser group and 92% in the variable-spot scanning laser group were within ±0.50 D of the intended correction (P = .04). At that time, the small-spot scanning laser group had significantly less spherical aberration (0.12 versus 0.15) (P = .04) and significantly less mean total higher-order root mean square (0.33 μm versus 0.40 μm) (P = .01). Subjectively, patients reported that the clarity of night and day vision was significantly better in the eye treated with the small-spot scanning laser., Conclusions: The predictability and self-reported clarity of vision of wavefront-guided LASIK were better with the small-spot scanning laser. Eyes treated with the small-spot scanning laser had significantly fewer HOAs., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate refractive and visual parameters related to distance, intermediate, and near vision after cataract surgery and the optical quality of a new diffractive trifocal intraocular lens (IOL)., Setting: Vissum Instituto Oftalmologico de Alicante, Alicante, Spain., Design: Case series., Methods: Patients had bilateral refractive lens exchange and multifocal diffractive IOL (AT Lisa tri 839 MP) implantation. A complete ophthalmology examination was performed preoperatively and postoperatively. The follow-up was 6 months. The main outcome measures were uncorrected distance (UDVA) and corrected distance (CDVA), intermediate, and near visual acuities; keratometry; manifest refraction; and aberrations (total, corneal, internal)., Results: The study comprised 60 eyes of 30 patients (mean age 57.9 years ± 7.8 [SD]; range 42 to 76 years). There was significant improvement in UDVA, uncorrected intermediate visual acuity, uncorrected near visual acuity, CDVA, and distance-corrected intermediate and near visual acuity. The postoperative refractive status was within the range of +1.00 to -1.00 diopter. Total internal aberrations decreased significantly (P<.001)., Conclusions: The trifocal IOL improved near, intermediate, and distance vision in presbyopic patients. The use of 3 foci provided significant intermediate visual results without sacrificing near or distance vision., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare visual acuity, intraocular lens (IOL) movement, and depth of focus with the Crystalens HD single-optic accommodating IOL and the Tecnis ZCB00 aspheric monofocal IOL., Setting: St. Thomas' Hospital, London, United Kingdom., Design: Prospective randomized controlled trial., Methods: Patients with bilateral symptomatic cataract had bilateral sequential cataract surgery within 6 weeks with randomized implantation of the accommodating or monofocal IOL in both eyes. Exclusion criteria included other ocular conditions and corneal astigmatism greater than 2.00 diopters. The primary outcome was uniocular distance-corrected near visual acuity (DCNVA). Secondary measures were IOL movement, depth of focus, intermediate and distance vision, objective refraction, and pupil size at distance and near fixation. Results from 3 months postoperatively are presented., Results: Three months postoperatively, 64 patients (32 in each group) were available for study. The distance vision was not statistically significantly different between the accommodating IOL and monofocal IOL (mean 0.05 logMAR versus 0.06 logMAR). The mean DCNVA (0.48 logMAR ± 0.15 [SD] versus 0.61 ± 0.13 logMAR) and intermediate visual acuity (0.08 ± 0.1 logMAR versus 0.20 ± 0.09 logMAR) were significantly better with the accommodating IOL (P<.001). Neither IOL had clinically significant movement, and near vision did not directly correlate with movement of the accommodating IOL. The accommodating IOL provided greater depth of focus., Conclusions: Near and intermediate acuities were better with the accommodating IOL. This effect was not directly linked to IOL movement but was at least partly due to depth of focus.

Unlabelled: The aim of this systematic review was to synthesize and appraise the evidence of benefits of second-eye cataract extraction for visual function, patient-reported quality of life, falls, and driving ability among the elderly. We conducted a comprehensive search in MEDLINE using "surgery," "cataract extraction," "second eye," and "bilateral." Ten studies met the inclusion and quality criteria. We found "moderate" evidence supporting improvement in stereopsis, stereoacuity, and anisometropia over and above the benefits of first-eye surgery. We also found "moderate" evidence supporting improvement in visual acuity, contrast sensitivity, and self-reported visual functioning. Studies included in the review do not provide definitive evidence of second-eye surgery benefits on health-related quality of life, visual fields, falls prevention, and driving performance. However, the heterogeneity of outcome measures and the limited number of studies likely contributed to our findings. The findings have implications for clinicians and policymakers in the health-care industry and emphasize the need for additional trials examining this important and widely performed clinical procedure., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare binocular visual function in patients with unilateral cataract after monocular implantation of a multifocal intraocular lens (IOL) and after monocular implantation of a monofocal IOL., Setting: Hayashi Eye Hospital, Fukuoka, Japan., Design: Nonrandomized comparative study., Methods: Patients with unilateral cataract scheduled for implantation of a diffractive multifocal IOL and age-matched patients scheduled for implantation of a monofocal IOL were recruited. Three months postoperatively, binocular visual acuity from far to near distances, binocular photopic or mesopic high- to low-contrast visual acuity with and without glare, and stereoacuity were examined., Results: The mean binocular uncorrected near visual acuity or corrected near visual acuity at 0.3 m and uncorrected or corrected intermediate visual acuity at 0.5 m were significantly better in the multifocal group than in the monofocal group (P≤.0196), although there was no significant difference in uncorrected or corrected visual acuity at other distances. Binocular photopic contrast visual acuity and glare visual acuity at low contrasts and mesopic glare visual acuity were significantly worse in the multifocal group than in the monofocal group (P≤.0147). Near stereoacuity was similar between groups. Spectacle independence was significantly better in the multifocal group than in the monofocal group (P≤.0006)., Conclusion: Monocular implantation of a diffractive multifocal IOL in patients with unilateral cataract provided better binocular near and intermediate visual acuity and spectacle independence than monocular implantation of a monofocal IOL, although distance contrast sensitivity was worse with the multifocal IOL., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the validity and effectiveness of 2 methods for expanding depth of focus to correct for presbyopia; that is, induction of spherical aberration and small-pupil apertures., Setting: University of California, Berkeley, California, USA., Design: Comparative case series., Methods: A random 4-alternative forced-choice acuity task was performed on 13 subjects. Visual performance and depth of focus were compared using adaptive optics-corrected distance visual acuity (CDVA) values and mean visual acuity over a 3.0 diopter (D) range of defocus using the following 3 adaptive optics-corrected profiles: 2.0 mm pupil, 5.0 mm pupil, and 5.0 mm pupil with -0.274 μm of spherical aberration., Results: The 5.0 mm pupil profile had a CDVA of -0.218 logMAR and a mean visual acuity through focus of 0.156 logMAR. The 2.0 mm pupil profile had a worse CDVA (0.012 logMAR) but an improved mean visual acuity (0.061 logMAR). The 5.0 mm pupil profile with -0.274 μm of spherical aberration measured a CDVA of -0.082 logMAR and a mean visual acuity of 0.103 logMAR., Conclusions: The spherical aberration and small-pupil profiles improved the mean visual acuity across a 3.0 D range of defocus but resulted in decreased CDVA at the plane of best focus in comparison to an adaptive optics-corrected 5.0 mm pupil. Small-pupil profiles are a better choice than spherical aberration profiles for presbyopic corrections due to expected accuracy, predictability, and patient satisfaction., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Published by Elsevier Inc.)

Purpose: To establish the safety of nondominant-hand simulated intraocular surgery., Setting: Horizon Suite Simulation Centre, South Devon Foundation NHS Trust, Devon, United Kingdom., Design: Cohort study., Methods: Physicians with no previous ophthalmic surgical experience completed an introductory program on the EyeSi ophthalmic surgical simulator to eliminate the learning curve. They then completed the validated level-4 forceps module 4 times with their dominant hand and then 4 times with their nondominant hand. Simulator total score, odometer movement, corneal injury, lens injury, and total time were recorded. Acuity (Snellen near) and stereoacuity (Frisby) were also recorded., Results: All 30 physicians showed good acuity (6/6 and N6 or better) and stereopsis (mean 35 seconds of arc). The total score was lower (mean 60.8 versus 65.6; P=.019), operating times were longer (mean 71.6 versus 70.0; P=.026), and lens injury was greater (mean 0.93 versus 0.79, P=.021) when operating with the nondominant hand than with operating with the dominant hand. Those with higher scores with the dominant hand had higher scores with their nondominant hand., Conclusions: Simulated nondominant-hand ophthalmic surgery resulted in less efficient, less safe, and slower surgery. This observation was more marked in those with less skill with their dominant hand. This has practical implications for trainee and trainer if 1 surgeon is left handed and 1 right handed. It also suggests that a higher degree of competence with the dominant hand is required before performing nondominant-hand surgery., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To measure the impact of corneal aberrations on the through-focus image quality of presbyopia-correcting intraocular lenses (IOLs) using an adaptive optics IOL metrology system., Setting: Flaum Eye Institute, University of Rochester, Rochester, New York, USA., Design: Experimental study., Methods: An adaptive optics IOL metrology system comprising a model eye, wavefront sensor, deformable mirror, and an image-capturing device acquired through-focus images of a letter chart with 3.0 mm and 5.0 mm pupil diameters. The system was used to induce corneal astigmatism and higher-order aberrations (HOAs) in previously measured pseudophakic presbyopic eyes. A single-optic accommodating IOL (Crystalens HD (HD500), an apodized (Restor +3.0 diopter [D] SN6AD1) and full-aperture (Tecnis ZM900) diffractive multifocal IOL, and a monofocal IOL (Acrysof SN60AT) were evaluated. Image quality was quantified using the correlation-coefficient image-quality metric., Results: The single-optic accommodating IOL and monofocal IOL performed similarly; however, with a 3.0 mm pupil, the former had better intermediate (1.50 D) image quality. The multifocal IOLs had bimodal through-focus image quality trends. Corneal astigmatism reduced through-focus image quality and depth of focus with all IOLs; however, the multifocal IOLs had the most severe decline in depth of focus. Ocular spherical aberration had the strongest impact on image quality when typical pseudophakic corneal HOAs were present., Conclusions: The uncorrected corneal astigmatism and HOAs in pseudophakic eyes significantly affected through-focus performance of presbyopia-correcting IOLs. Although multifocal IOLs significantly increased depth of focus, this benefit diminished when more than 0.75 D astigmatism remained uncorrected. Residual ocular spherical aberration had a significant effect on image quality in the presence of other corneal HOAs., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate change in reading performance parameters after monocular Kamra corneal inlay implantation for the surgical correction of presbyopia., Setting: University surgical outpatient center., Design: Prospective interventional case series., Methods: A corneal inlay was implanted in the nondominant eye. Naturally emmetropic and presbyopic patients between 45 years and 60 years old with an uncorrected distance visual acuity of at least 20/20 in both eyes without additional ocular pathology were eligible for inclusion. Bilateral uncorrected reading acuity, reading distance, mean and maximum reading speed, and the smallest log-scaled print size (lower case letter of a Radner reading chart) were evaluated using the Salzburg Reading Desk. The minimum postoperative follow-up was 24 months., Results: Twenty-four patients were enrolled. The mean reading distance was 46.7 cm ± 6.3 (SD) preoperatively and 39.5 ± 6.4 cm 24 months postoperatively (P<.001). The mean reading acuity at best distance improved (0.33 ± 0.13 logRAD versus 0.23 ± 0.11 logRAD) (P=.004). The mean reading speed increased from 141 ± 20 words per minute (wpm) to 146 ± 20 wpm, respectively (P=.261), and the mean maximum reading speed from 171 ± 28 wpm to 180 ± 22 wpm, respectively (P=.110). The smallest print size improved from 1.50 ± 0.42 mm to 1.01 ± 0.22 mm, respectively (P<.001)., Conclusion: Improving the depth of focus by monocular implantation of a small-aperture optic caused statistically significant changes in all tested reading performance parameters except reading speed metrics in emmetropic presbyopic patients., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the efficiency of ray-tracing intraocular lens (IOL) power calculation with anterior segment optical coherence tomography (AS-OCT) in normal eyes with cataract., Setting: Miyata Eye Hospital, Miyakonojo, Miyazaki, Japan., Design: Case series., Methods: The study comprised consecutive patients who had cataract surgery and obtained a corrected visual acuity of 0.15 logMAR or better postoperatively. Preoperatively, Placido topography and AS-OCT measurements were taken during a routine examination. The predicted postoperative refractions were obtained using 3 methods: the SRK/T formula with autokeratometry, ray-tracing calculation with Placido topography data, and ray-tracing calculations with AS-OCT measurement of both corneal surfaces. The refractive errors from the manifest refraction spherical equivalent were compared 1 month postoperatively, and the effects of corneal eccentricity and posterior corneal curvature were evaluated., Results: Seventy patients (102 eyes) were enrolled. There was no significant difference in refractive errors (P=.89). The refractive error with the SRK/T formula was correlated significantly with corneal eccentricity (P=.0017); the ray-tracing calculations were unaffected. There was a weak correlation with the posterior corneal curvature in the ray-tracing calculations performed with Placido topography (P<.0002)., Conclusion: The accuracy of the ray-tracing IOL power calculations using AS-OCT data was comparable to that of the conventional formula and minimized the effect of corneal eccentricity and posterior corneal curvature., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the long-term clinical outcomes and acceptability of pseudophakic monovision., Setting: Department of Ophthalmology, Kitasato University Hospital, Kanagawa, Japan., Design: Case series., Methods: Patients who had surgery using the monovision method with monofocal intraocular lenses had routine postoperative examinations. Assessed were visual acuity, near stereopsis, ocular deviation, patient satisfaction, and the rate of spectacle dependence preoperatively and 1, 3, and 6 months and 1, 2, 3, 4, and 5 years postoperatively., Results: The study enrolled 54 patients with a mean age of 74.7 years ± 7.9 (SD). The mean difference in the spherical equivalent refractive error between eyes of each patient was 2.13 diopters. The binocular uncorrected distance visual acuity was at least 0.10 logMAR in 98% of patients, with 76% achieving Jaeger 2 or better binocular uncorrected near visual acuity. Near stereopsis in patients who shifted from exophoria to intermittent exotropia decreased, although no serious problems were observed. The rate of spectacle dependence was 88% preoperatively, 41% at 1 year, and 22% at 5 years. Patient satisfaction improved gradually during the follow-up., Conclusion: Pseudophakic monovision was an effective approach for correcting presbyopia throughout the 5-year observation period; however, a longer follow-up, including further studies is necessary to allow selection of appropriate patients., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine whether extreme pseudophakic monovision can reduce or eliminate diplopia in patients with cataract and longstanding acquired strabismus., Setting: Department of Ophthalmology, University of Cincinnati, and the Cincinnati Eye Institute, Cincinnati, Ohio, USA., Design: Case series., Methods: Intentional extreme monovision was created in patients with stable diplopia having cataract surgery. Intraocular lens selection was targeted for emmetropia in 1 eye and at least 3.0 diopters of myopia in the fellow eye., Results: Twelve patients with stable diplopia attained excellent uncorrected distance and near vision with a marked reduction in or elimination of double vision., Conclusion: Patients with stable acquired strabismus with diplopia may be candidates for extreme pseudophakic monovision, which may be a new strategy to eliminate double vision., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze visual quality differences between intraocular lenses (IOLs) and assess the impact of IOL decentration and tilt on visual quality., Setting: University of Valencia, Valencia, Spain., Design: Cohort study., Methods: The crx1 adaptive optics visual simulator was used to simulate the wavefront aberration pattern of 2 commercially available aspheric aberration-correcting IOLs (Acrysof IQ SN60WF and Tecnis ZA9003) and 2 spherical IOLs (Akreos Adapt and Triplato) in 5 situations: centered, decentered 0.2 mm and 0.4 mm, and tilted 2 degrees and 4 degrees. Monocular distance visual acuity at 100%, 50%, and 10% contrast and the depth of focus were measured., Results: Ten eyes of 10 patients were evaluated. When the IOLs were centered, there were no differences in visual acuity between the 4 IOLs at any contrast. The aberration-correcting IOLs were more sensitive to tilt and decentration than the spherical IOLs; Tecnis ZA9003 IOL was the most sensitive to decentration and the Acrysof IQ SN60WF IOL was the most sensitive to tilt. Higher residual spherical aberration slightly improved depth of focus and the tolerance to defocus., Conclusions: The results in this study suggest that the aspheric aberration-correcting and spherical IOLs provided comparable visual quality when centered in eyes in which the corneal higher-order aberrations are those of the average of the human cornea. Tilt and decentration of the IOLs had an impact on visual quality, with aberration-correcting IOLs having a greater effect than the spherical IOLs., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effects of different contact lens-based artificial pupil designs on visual performance., Setting: University of Valencia, Burjassot, Spain, and University of Manchester, Manchester, United Kingdom., Design: Comparative case series., Methods: Presbyopic patients were evaluated using 4 artificial pupil designs in the nondominant eye. Binocular uncorrected distance visual acuity (UDVA), binocular corrected distance visual acuity (CDVA), binocular uncorrected near visual acuity (UNVA), binocular distance-corrected near visual acuity (DCNVA), defocus curve, binocular distance, and near contrast sensitivity under photopic and mesopic conditions, and stereoacuity were measured after contact lens fitting., Results: The mean UDVA and CDVA ranged from 0.04 ± 0.05 (SD) to -0.01 ± 0.04 logMAR and from -0.02 ± 0.05 to -0.05 ± 0.03 logMAR, respectively. The UNVA and DCNVA ranged from 0.37 ± 0.11 to 0.42 ± 0.20 logMAR and from 0.35 ± 0.17 to 0.38 ± 0.12 logMAR, respectively. The difference in binocular distance contrast sensitivity was statistically significant between the pinhole systems and the control group (distance-corrected patients without pinhole lens) for 6 cycles per degree (cpd), 12 cpd, and 18 cpd; for near vision, differences were also significant for 3 cpd at the 2 luminance levels (P<.05). Stereoacuity values for near vision were not significantly different between the 4 pinhole systems (P>.05)., Conclusions: Soft contact lens apertures provide good visual acuity at distance, functional intermediate vision, and poor near visual acuity and stereoacuity. An improvement in visual performance with decreasing pupil diameter was not found., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate visual performance and aberrations with aspheric and spherically neutral microincision intraocular lenses (IOLs) and assess the influence of asphericity on visual performance, wavefront aberration, and depth of focus., Setting: St. Thomas' Hospital, London, United Kingdom., Design: Clinical trial and cohort study., Methods: In the first study, patients with bilateral cataract were randomized to receive an aspheric Acri.Smart 36A IOL or a spherically neutral Akreos MI60 IOL in the first eye. The other IOL was implanted in the second eye within 3 weeks. Assessments at 3 months were 100% and 9% corrected distance visual acuity (CDVA) and distance-corrected near visual acuity (DCNVA). Aberrations and depth of focus were computed using iTrace software. In the second study, data from the other published study was combined to assess the visual performance, aberration, and depth of focus in groups of spherical, spherically neutral, and negatively aspheric (asphericity -0.17 μm) IOLs., Results: In part 1, there was no difference in 100% or 9% CDVA, DCNVA, or depth of focus between the 2 microincision IOLs. Total spherical aberration was lower with the aspheric IOL. In part 2, the CDVA and DCNVA were not different between the spherical (n = 44), spherically neutral (n = 32), or aspheric (n = 76) IOLs. Total spherical (P<.01) and vertical coma aberrations decreased with increasing IOL asphericity (P<.01). Depth of focus (4.0 mm pupil) also decreased with increasing asphericity and was significant between the spherical IOL and aspheric IOLs. The DCNVA did not differ between groups., Conclusion: Asphericity of IOLs did not affect distance visual acuity. The difference in depth of focus was significant only between negatively aspheric and spherical IOLs. Asphericity differences up to 20 μm did not influence depth of focus., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the impact of wavefront ocular aberrations on objective vision quality and depth of focus in pseudophakic patients., Setting: University Hospital Bretonneau of Tours, Francois Rabelais Medicine Faculty of Tours, France., Design: Cohort study., Methods: Consecutive eyes having implantation of an aspheric monofocal intraocular lens (IOL) (Acri.Smart) were studied. Aberrometry measurements were performed under mesopic conditions with a 6.0 mm pupil using a Wavescan aberrometer. Objective evaluation of optical vision quality was performed using the Optical Quality Analysis System II. The 3 measurements were the modulation transfer function values (MTF cutoff); objective depth of focus, which was computed as the focus range at which Strehl ratio did not fall below 50% of the maximum; and the objective scatter index., Results: Fifty-four eyes (30 patients) were enrolled. Six months postoperatively, MTF cutoff values were increased with decreasing total ocular spherical aberration, ocular trefoil, and 2nd-order astigmatism (P<.05). Objective depth of focus was positively correlated with 2nd-order astigmatism (r(2) = 0.171, P<.001) and total spherical aberration (r(2) = 0.091, P=.028). Objective scatter was more beneficial for depth of focus, with a significantly positive correlation with this parameter (r(2) = 0.28, P=.002), than compromising of optical quality (no significant correlation with MTF measurements in same multiple regression analysis)., Conclusion: Three ocular aberrations (2nd-order astigmatism, trefoil, spherical aberration) seemed to interact with objective contrast sensitivity and depth of focus, whereas residual spherical aberration exerted opposite effects on image quality in individual patients., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the effect of primary spherical aberration and vertical coma on depth of focus measured with 2 methods., Setting: Laboratoire Aimé Cotton, Centre National de la Recherche Scientifique, and Université Paris-Sud, Orsay, France., Design: Evaluation of technology., Methods: The subjective depth of focus, defined as the interval of vision for which the target was still perceived acceptable, was evaluated using 2 methods. In the first method, the subject changed the defocus term by reshaping the mirror, which also corrected the subject's aberrations and induced a certain value of coma or primary spherical aberration. In the second procedure, the subject changed the displayed images, which were calculated for various defocuses and with the desired aberration using a numerical eye model. Depth of focus was measured using a 0.18 diopter (D) step in 4 nonpresbyopic subjects corrected for the entire eye aberrations with a 6.0 mm and 3.0 mm pupil and with the addition of 0.3 μm and 0.6 μm of positive primary spherical aberration or vertical coma., Results: There was good concordance between the depth of focus measured with both methods (differences within 1/3 D, r(2) = 0.88). Image-quality metrics failed to predict the subjective depth of focus (r(2) < 0.41)., Conclusion: These data confirm that defocus in the retinal image can be generated by optical or computational methods and that both can be used to assess the effect of higher-order aberrations on depth of focus., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the optimum position to center a small-aperture corneal inlay and the effect of residual defocus in the surgical eye to maximize depth of focus., Setting: Laboratorio de Óptica, Universidad de Murcia, Murcia, Spain., Design: Cohort study., Methods: Personalized eye models were built using actual data (corneal topography, eye length, ocular aberrations, and eye alignment). A small aperture 1.6 mm in diameter was placed at the corneal plane in each model. The monochromatic and polychromatic Strehl ratios were calculated as a function of the pinhole position. Different residual defocus values were also incorporated into the models, and the through-focus Strehl ratios were calculated., Results: Sixteen eye models were built. For most subjects, the optimum location of the aperture for distance vision was close to the corneal reflex position. For a given optimized centration of the aperture, the best compromise of depth of focus was obtained when the eyes had some residual myopic defocus (range -0.75 to -1.00 diopter [D]). Strehl ratio values were over 0.1 for far distance, which led to visual acuities better than 20/20. The depth of focus was 2.50 D with a mean near visual acuity of Jaeger 1 or better., Conclusions: In eyes with little astigmatism and aberrations, the optimum centration of the small aperture was near the corneal reflex position. To improve optical outcomes with the inlay, some small residual myopia and correction of corneal astigmatism might be required., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effect of stereoacuity on various intraocular surgical skills in inexperienced medical students using a virtual reality intraocular surgical simulator., Setting: Department of Clinical Sciences, Malmö: Ophthalmology, Skåne University Hospital, Malmö, Sweden., Design: Comparative case series., Methods: Ninth-semester medical students performed 1 iteration on each of the following 3 cataract training modules: navigation, forceps, and capsulorhexis. Before the simulator training, the trainees received standardized instructions and were allowed to perform 1 training round on the cataract navigation training module. After completion of the training, the level of stereoacuity was measured using TNO charts. Surgical performance for each task was measured, and performance parameter scores were recorded., Results: The study included 70 students. The simulator performance score correlated with the level of stereoacuity for the navigation training module (Spearman r = 0.377, P=.001) and forceps training module (Spearman r = 0.306, P=.01), showing a gradual increase in surgical performance with increasing stereoacuity. No such relationship was found for the capsulorhexis module (Spearman r = 0.18, P=.136)., Conclusions: A gradual detrimental effect on initial intraocular surgical skill with decreasing stereoacuity was shown. This calls for studies of the impact of deficient stereopsis on long-term training effects., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the visual function after bilateral cataract surgery performed with a new technique (hybrid monovision) that uses a monofocal intraocular lens (IOL) and a diffractive multifocal IOL., Setting: Department of Ophthalmology, Kitasato University Hospital, Kanagawa, Japan., Design: Case series., Methods: Hybrid monovision was achieved by implanting a monofocal IOL (AQ310Ai) in the dominant eye and a diffractive multifocal IOL (Tecnis ZM900) in the nondominant contralateral eye. The target refraction was emmetropia in both eyes. Visual acuity at various distances, contrast sensitivity, near stereopsis, reading ability, and the degree of patient satisfaction were measured., Results: The study enrolled 32 patients with a mean age of 61.2 years ± 14.7 (SD). At all distances, the mean binocular visual acuity was better than 0.1 logMAR. Binocular contrast sensitivity was better than monocular vision in the eye with the diffractive multifocal IOL. Near stereopsis within normal range was maintained in 62.5% of patients. Of the patients, 18.8% reported spectacle dependence. With binocular vision, no patients reported waxy vision (ie, as though they were looking through water)., Conclusion: Hybrid monovision may be an effective approach for managing loss of accommodation after cataract surgery and may be the method of choice in cases of waxy vision caused by bilateral multifocal IOL implantation., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze the astigmatic changes after cataract surgery with the implantation of a new toric multifocal intraocular lens (IOL) using the Alpins vector method., Setting: Vissum-Instituto de Oftalmológico de Alicante, Alicante, Spain., Design: Prospective case series., Methods: After cataract surgery with implantation of an AT Lisa 909M toric multifocal IOL, the visual, refractive, corneal topographic, internal astigmatism, defocus curves, and contrast sensitivity outcomes were evaluated over 6 months. Refractive astigmatic changes (target astigmatism [TIA]; surgically induced astigmatism [SIA]; difference vector; magnitude of error; flattening effect; torque) were analyzed using the Alpins vectorial method., Results: The study enrolled 23 eyes (12 patients). Postoperatively, there was a significant reduction in refractive cylinder (P < .01) with an associated visual improvement for near (P = .03) and distance (P=.01). The magnitude of SIA vector was significantly larger than the TIA 3 months postoperatively (P = .03). The mean magnitude of the difference vector was 0.67 diopter (D) ± 0.51 (SD) at 6 months. The mean magnitude of error remained positive and close to zero over the entire follow-up (P ≥ .19). The mean magnitude of torque vector was 0.49 ± 0.54 D at 6 months. Significant positive correlation was found between the magnitude of torque and the difference vector (r ≥ 0.70, P<.01)., Conclusion: The new toric IOL restored distance and near visual function with excellent predictability in eyes with moderate to high corneal astigmatism having cataract surgery., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the level of residual spherical aberration that gives the best objective and subjective quality of image after cataract surgery with intraocular lens (IOL) implantation., Setting: Department of Ophthalmology, CHU Bretonneau, Tours, France., Design: Cohort study., Methods: Six months after microincision (1.8 mm) cataract surgery with aspheric IOL implantation, total aberrations were computed using a Wavescan aberrometer. The modulation transfer function (MTF), Strehl ratio, and objective index of scattering were measured using the Objective Quality Analysis System. Objective depth of focus was computed as the focus range at which the Strehl ratio did not fall below 50% of maximum. Subjective depth of focus was calculated as the difference between the vergence of the punctum remotum and that of the punctum proximum., Results: Thirty patients (54 eyes) were evaluated. The MTF cutoff values were higher with decreasing total ocular spherical aberration (r = 0.56; P < .05). Objective and subjective depth of focus were positively correlated with total spherical aberration (r = 0.26 and r = 0.46, respectively; P < .05)., Conclusions: A final spherical aberration of zero obtained by compensation of IOL asphericity gave the greatest improvement in objective quality of vision and better MTF contrast. However, a final target ocular spherical aberration between 0.07 μm and 0.10 μm should be considered to be the best compromise between subjective depth of focus and objective contrast sensitivity., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze the symptoms, etiology, and treatment of patient dissatisfaction after multifocal intraocular lens (IOL) implantation., Setting: Department of Ophthalmology, Maastricht University Medical Center, The Netherlands., Design: Case series., Methods: 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., Results: 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%)., Conclusion: The cause of dissatisfaction after implantation of a multifocal IOL can be identified and effective treatment measures taken in most cases., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the change in reading-performance parameters after implantation of the Kamra small-aperture intracorneal inlay over a 2-year follow-up., Setting: University Eye Clinic, Paracelsus Medical University, Salzburg, Austria., Design: Cohort study., Methods: This study comprised naturally emmetropic presbyopic patients. Bilateral reading acuity, reading distance, reading speed, and the smallest log-scaled sentence were evaluated in a standardized testing procedure using the Salzburg Reading Desk. The minimum postoperative follow-up was 24 months., Results: The study enrolled 32 patients. The reading desk results showed a significant improvement in each parameter tested. After a mean follow-up of 24.2 months ± 0.8 (SD), the mean reading distance changed from the preoperative value of 48.1 ± 5.5 cm to 38.9 ± 6.3 cm (P < .0001), the mean reading acuity at best distance improved from 0.3 ± 0.14 logRAD to 0.24 ± 0.11 logRAD (P < .000001), and the mean reading speed increased from 142 ± 13 words per minute (wpm) to 149 ± 17 wpm (P=.029). One patient lost 1 line, and 1 patient had no change. The improvement was up to 6 log-scaled lines (mean improvement 2.7 ± 1.6 lines) in the other 30 patients., Conclusions: After implantation of the small-aperture intracorneal inlay, there was an improvement in all tested reading performance parameters in emmetropic presbyopic patients; the improvement was the result of an increased depth of field. These 2-year results indicate that the inlay is an effective treatment for presbyopia., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To study the impact on the subjective depth of field of 4th-order spherical aberration and its combination with 6th-order spherical aberration and analyze the accuracy of image-quality metrics in predicting the impact., Setting: Laboratoire Aimé Cotton, Centre National de la Recherche Scientifique, Université Paris-Sud, Orsay, France., Design: Case series., Methods: Subjective depth of field was defined as the range of defocus at which the target (3 high-contrast letters at 20/50) was perceived acceptable. Depth of field was measured using 0.18 diopter (D) steps in young subjects with the addition of the following spherical aberration values: ±0.3 μm and ±0.6 μm 4th-order spherical aberration with 3.0 mm and 6.0 mm pupils and ±0.3 μm 4th-order spherical aberration with ±0.1 μm 6th-order spherical aberration for 6.0 mm pupils., Results: The addition of ±0.3 and ±0.6 μm 4th-order spherical aberration increased depth of field by 30% and 45%, respectively. The combination of 4th-order spherical aberration and 6th-order spherical aberration of opposite signs increased depth of field more than 4th-order spherical aberration alone (ie, 63%), while the combination of 4th-order spherical aberration and 6th-order spherical aberration of the same signs did not (ie, 24%). Whereas the midpoint of the depth of field could be predicted by image-quality metrics, none was found a good predictor of objectionable depth of field., Conclusion: Subjective depth of field increased when 4th-order spherical aberration and 6th-order spherical aberration of opposite signs were added but could not be predicted with image-quality metrics., (Copyright © 2010 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the refractive, visual acuity, and binocular results of laser-assisted subepithelial keratectomy (LASEK) in children with bilateral hyperopia or hyperopic anisometropic amblyopia., Setting: Nonhospital surgical facility and hospital clinic, Calgary, Alberta, Canada., Methods: This retrospective review comprised children with bilateral hyperopia or hyperopic anisometropic amblyopia who had LASEK. Refractive status, visual acuity, and binocular vision were assessed and recorded 2 months and 1 year postoperatively., Results: The mean spherical equivalent (SE) in all 72 hyperopic eyes (47 patients) was +3.42 diopters (D) (range 0.00 to +12.50 D) preoperatively and +0.59 D (range -1.25 to +2.00 D) 1 year postoperatively. After LASIK, 41.7% of eyes had improved corrected distance visual acuity (CDVA). No patient had reduced CDVA or loss of fusional ability; there was a 25.0% improvement in stereopsis at 1 year. The mean anisometropic difference in the hyperopic anisometropic amblyopia subgroup (18 eyes, 10 patients) was 4.39 D (range +1.75 to +7.75 D) preoperatively and +0.51 D (range 0 to +0.875 D) at 1 year. One year postoperatively, 83% of anisometropic eyes were within +/-1.00 D of the fellow eye and 94.0% were within +/-3.00 D. Postoperatively, 64.7% of eyes had improved CDVA with no reduced CDVA or loss of fusional ability; there was a 22% improvement in stereopsis at 1 year., Conclusion: Laser-assisted subepithelial keratectomy improved visual acuity in pediatric hyperopia with or without associated hyperopic anisometropic amblyopia., (Copyright 2010 ASCRS and ESCRS. All rights reserved.)

Purpose: To compare the optical performance of aspheric Tecnis ZA9003 and spherical Sensar AR40e intraocular lenses (IOLs)., Setting: Laboratory of Experimental Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands., Methods: An aspheric IOL was implanted in 1 eye and a spherical IOL in the other eye of patients with bilateral age-related cataract. Contrast sensitivity was measured using 2 computerized tests (vertical sine-modulated gratings and circular sine-modulated patterns) with cycloplegia and a 5.0 mm artificial pupil under photopic conditions at optimum refractive correction and at several defocus levels. The depth of focus and the myopic shift (shift of optimum focus toward more myopic values at lower spatial frequencies) were determined. Higher-order aberrations were assessed using a Hartmann-Shack wavefront analyzer; straylight was measured with a straylight meter., Results: In the 60 eyes evaluated, there were no statistically significant differences in contrast sensitivity measured at optimum focus, depth of focus, or straylight between the 2 IOLs. The mean spherical aberration was significantly lower with the aspheric IOL (-0.036 microm) than with the spherical IOL (0.064 microm) (P<.001) and the mean myopic shift, statistically significantly smaller (0.05 diopter [D] and -0.47 D, respectively) (P<.001)., Conclusions: Eyes with the aspheric IOL had lower spherical aberration than eyes with the spherical IOL and, related to that, a smaller myopic shift. No significant differences were found between the 2 IOLs in contrast sensitivity measured at optimum focus, depth of focus, or straylight., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright 2010 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the visual, motor, and sensory outcomes of photorefractive keratectomy (PRK) in the treatment of purely refractive accommodative esotropia in young adult patients., Setting: Policlinico Umberto I, Department of Ophthalmology, Rome, Italy., Methods: This prospective study comprised patients with hyperopia and purely accommodative hyperopic esotropia. A complete ophthalmologic examination was performed preoperatively and 1, 3, and 12 months postoperatively. The examination included uncorrected (UDVA) and corrected (CDVA) distance visual acuities and orthoptic and sensory tests. All patients also had keratometry, pachymetry, and corneal topography assessment before and after treatment. Treatment was performed using a Technolas 217 excimer laser., Results: Thirty eyes of 15 patients (mean age 30.8 years) were treated. Preoperatively, the CDVA was 20/30 or better in all eyes and the mean cycloplegic spherical equivalent (SE) was +3.50 diopters (D). One year postoperatively, the UDVA was 20/30 or better in all eyes and the mean SE was -0.01 D. The mean esotropic deviation for distance vision without correction preoperatively was 8.7 prism diopters. At 1 year of follow-up, 12 patients achieved orthophoria and 3 patients had a reduction in the angle of deviation. There were no intraoperative or postoperative complications. Stereopsis was unaffected by treatment in all patients., Conclusions: Photorefractive keratectomy was effective in the treatment of purely accommodative esotropia in young adult patients at a follow-up of 1 year. There were no cases of visual acuity loss or complications from the laser treatment.

Purpose: To evaluate the impact of higher-order aberrations on depth of focus using an adaptive optics visual simulator., Setting: Refractive Surgery Department, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA., Methods: An adaptive optics simulator was used to optically introduce individual aberrations in eyes of subjects with a 6.0 mm pupil under cycloplegia (coma and trefoil, magnitudes +/-0.3 microm; spherical aberration, magnitudes +/-0.3, +/-0.6, +/-0.9 microm). A through-focus response curve was assessed by recording the percentage of Sloan letters at a fixed size identified at various target distances. The subject's ocular depth of focus and center of focus were computed as the half-maximum width and the midpoint of the through-focus response curve., Results: The dominant eyes of 10 subjects were evaluated. The simulation of positive or negative spherical aberration had the effect of enhancing depth of focus and resulted in linearly shifting of the center of focus by 2.6 diopters (D)/microm of error. This increase in depth of focus reached a maximum of approximately 2.0 D with 0.6 microm of spherical aberration and became smaller when the aberration was increased to 0.9 microm. Trefoil and coma appeared to neither shift the center of focus nor significantly modify the depth of focus., Conclusion: The introduction of both positive and negative spherical aberration using adaptive optics technology significantly shifted and expanded the subject's overall depth of focus; simulating coma or trefoil did not produce such effects.

Purpose: To evaluate visual and stereoscopic performance after pediatric cataract extraction with intraocular lens (IOL) implantation performed by the same surgeon over 24 years and to review the complications., Setting: The Alberta Children's Hospital, Calgary, Alberta, Canada., Methods: This retrospective review comprised children aged 1 month to 18 years who had small-incision cataract extraction with foldable posterior chamber IOL implantation from 1995 to 2008., Results: The postoperative follow-up was 6 months to 12 years. Posterior capsule opacification (PCO) requiring secondary surgical membranectomy developed in 22.7% of the children. Younger children developed PCO more often than older children. The PCO rate was 70.8% in children younger than 1 year and decreased steadily to 6.1% in children older than 7 years. The mean onset of PCO was 6.1 months postoperatively. Other complications were vitreous tags (12.0%), IOL dislocation (4.7%), and loose corneal sclera sutures (2.7%). Of the eyes in which vision could be recorded, 89.5% had improved corrected visual acuity, with no eye losing acuity. Stereopsis was present in 35% of testable children preoperatively and 91% postoperatively., Conclusions: Cataract surgery in children younger than 2 years should be considered a 2-stage procedure in view of the higher incidence of PCO. Secondary glaucoma decreased significantly when surgery was performed after 30 days of age and the eye was left pseudophakic after surgery. Further improvements in IOL design, surgical instrumentation, and implantation techniques will continue to improve the ability to visually rehabilitate children.

Purpose: To evaluate the visual outcomes and patient satisfaction with modified pseudophakic monovision., Setting: Tertiary teaching hospital., Methods: This prospective study comprised patients with emmetropia after first-eye cataract surgery who were offered monovision for the second-eye surgery with a moderate myopic target refraction (-1.00 to -1.50 diopters [D]). Visual acuity, contrast sensitivity, stereopsis, patient satisfaction, and degree of spectacle independence were measured preoperatively and 3 to 4 months postoperatively., Results: The study evaluated 52 eyes of 26 patients with a mean anisometropia between the near eye and the distance eye of 1.16 D. Uncorrected distance visual acuity was at least 20/30 in 96% of patients, with 92% achieving N8 (J4) or better uncorrected near acuity. Good stereopsis and contrast sensitivity were maintained. Patients were generally satisfied with the surgery. One fourth of patients were completely independent of spectacles; 1 patient was totally dependent on spectacles. No patient required intraocular lens (IOL) exchange or other refractive corrective procedures., Conclusion: Monovision with modest refractive targets achieved good visual function and patient satisfaction without the inherent risk for troublesome visual symptoms associated with multifocal IOLs.