Journal of Refractive Surgery

Original Article 

Impact of a Chromatic Aberration-Correcting Intraocular Lens on Automated Refraction

Jorge S. Haddad, MD; Larissa Gouvea, MD; Joseana L. Ferreira, MD; Renato Ambrósio Jr, MD, PhD; George O. Waring, MD; Karolinne M. Rocha, MD, PhD

Abstract

PURPOSE:

To compare ray-tracing aberrometry, Hartmann-Shack wavefront analysis, automated refraction, and manifest refraction in patients with echelette diffractive intraocular lenses (IOLs) and patients with monofocal IOLs with negative spherical aberration.

METHODS:

Pseudophakic patients implanted with an echelette diffractive IOL (Tecnis ZXR00; Johnson & Johnson Vision) and a control group consisting of patients implanted with a negative spherical aberration monofocal IOL (Tecnis ZCBOO, Johnson & Johnson Vision) were included in this study. Ray-tracing aberrometry (iTrace; Tracey Technologies Corp.), Hartmann-Shack wavefront analysis (LADARWave; Alcon Laboratories, Inc.), automated refraction (Topcon KR-8800; Topcon Medical Systems, Inc.), and manifest refraction spherical equivalent were performed 1 to 3 months postoperatively.

RESULTS:

Thirty-two eyes implanted with a ZXR00 IOL and 30 eyes implanted with a ZCBOO IOL were enrolled in this study. The ZXR00 IOL group yielded more myopic results with automated refactions (−0.62 ± 0.41 diopters [D]), Hartmann-Shack wavefront analysis (−0.85 ± 0.40 D), and ray-tracing aberrometry (−0.45 ± 0.64 D), compared to manifest refraction (−0.12 ± 0.44 D) (P < .001). Hartmann-Shack wavefront analysis showed a statistically significant myopic shift (−0.39 ± 0.47 D) in the ZCBOO group compared to ray-tracing aberrometry, automated refraction, and manifest refraction spherical equivalent (−0.14 ± 0.56, −0.14 ± 0.50, and −0.06 ± 0.44 D, respectively; P < .001).

CONCLUSIONS:

Manifest refraction techniques unique to echelette technology should be used to avoid over-minus end points. Autorefractors and aberrometers commonly use near-infrared light; thus, myopic results are expected with echelette achromatic technology.

[J Refract Surg. 2020;36(5):334–339.]

Abstract

PURPOSE:

To compare ray-tracing aberrometry, Hartmann-Shack wavefront analysis, automated refraction, and manifest refraction in patients with echelette diffractive intraocular lenses (IOLs) and patients with monofocal IOLs with negative spherical aberration.

METHODS:

Pseudophakic patients implanted with an echelette diffractive IOL (Tecnis ZXR00; Johnson & Johnson Vision) and a control group consisting of patients implanted with a negative spherical aberration monofocal IOL (Tecnis ZCBOO, Johnson & Johnson Vision) were included in this study. Ray-tracing aberrometry (iTrace; Tracey Technologies Corp.), Hartmann-Shack wavefront analysis (LADARWave; Alcon Laboratories, Inc.), automated refraction (Topcon KR-8800; Topcon Medical Systems, Inc.), and manifest refraction spherical equivalent were performed 1 to 3 months postoperatively.

RESULTS:

Thirty-two eyes implanted with a ZXR00 IOL and 30 eyes implanted with a ZCBOO IOL were enrolled in this study. The ZXR00 IOL group yielded more myopic results with automated refactions (−0.62 ± 0.41 diopters [D]), Hartmann-Shack wavefront analysis (−0.85 ± 0.40 D), and ray-tracing aberrometry (−0.45 ± 0.64 D), compared to manifest refraction (−0.12 ± 0.44 D) (P < .001). Hartmann-Shack wavefront analysis showed a statistically significant myopic shift (−0.39 ± 0.47 D) in the ZCBOO group compared to ray-tracing aberrometry, automated refraction, and manifest refraction spherical equivalent (−0.14 ± 0.56, −0.14 ± 0.50, and −0.06 ± 0.44 D, respectively; P < .001).

CONCLUSIONS:

Manifest refraction techniques unique to echelette technology should be used to avoid over-minus end points. Autorefractors and aberrometers commonly use near-infrared light; thus, myopic results are expected with echelette achromatic technology.

[J Refract Surg. 2020;36(5):334–339.]

Presbyopia-correcting intraocular lenses (IOLs), including accommodative and pseudoaccommodative diffractive bifocals and trifocals, as well as extended depth of focus (EDOF) IOLs, aim to reduce spectacle dependency at all distances.1–3 One type of EDOF IOL is the Tecnis ZXR00 lens (Johnson & Johnson Vision), which is a hybrid IOL with an echelette design and achromatic diffractive surface.4 Its modified design allows for increased depth of focus from distance to intermediate vision by elongating the focus range of the eye to provide a wider spectrum of vision.2,4

In pseudophakic eyes, the quality of vision is determined primarily by higher order aberrations (HOAs) of the optical system and chromatic dispersion of IOLs.5 The materials, additions, Abbe number, and the relationship between refractive index and wavelength play a critical role in IOL performance in polychromatic light.6 IOLs with higher Abbe numbers and lower chromatic dispersion have been shown to have better optical performance.6 Furthermore, IOLs with an Abbe number of 47, which is comparable to a crystalline lens, produce longitudinal chromatic aberration similar to phakic eyes.7 More recently, optical bench studies have shown that IOLs that correct spherical aberration and longitudinal chromatic aberration have the highest modulation transfer function and contrast sensitivity compared to spherical IOLs or IOLs that only correct spherical aberration.8–10

Subjective manifest refraction is ideal to evaluate the refractive status of eyes. Automated refraction is a reliable method that can be used as a starting point for manifest refraction; it is influenced by previous corneal procedures and refractive-diffractive multifocal IOLs.11,12 Wavefront devices are commonly used to measure monochromatic aberrations in healthy eyes, which can be divided into lower order aberrations and HOAs.13 The most commonly used technologies in clinical practice include the Hartmann-Shack sensor,14 Tscherning aberrometry,13 ray-tracing aberrometry,15 dynamic skiascopy,16 and double-pass wavefront.17 Wavefront analysis results must be interpreted with caution for eyes with diffractive IOLs because multifocal centroids are generated and may lead to ambiguities in the position of the images produced. Nonetheless, in vivo evaluation of multifocal IOLs with wavefront sensors produces valuable results regarding the optical quality of pseudophakic eyes.18

The purpose of this study was to compare automated refraction methods (ray-tracing aberrometry, Hartmann-Shack wavefront analysis, and automated refraction) to subjective manifest refraction, and to measure the composite refraction, defocus, astigmatism, coma, spherical aberration, and total HOAs in patients implanted with an aspheric monofocal IOL with negative spherical aberration (Tecnis ZCBOO; Johnson & Johnson Vision) and in patients with an EDOF IOL with echelette achromatic technology (ZXR00).

Patients and Methods

Patients

This prospective study enrolled patients who had undergone cataract surgery with implantation of a monofocal IOL (ZCBOO) or a posterior achromatic diffractive surface IOL with an echelette design (ZXR00) between October 2017 and October 2019. Exclusion criteria included ocular diseases that could have a negative influence on postoperative visual outcomes, including a history of ocular trauma, corneal scarring and opacity, infectious keratitis, previous ocular surgery, glaucoma, and diabetic retinopathy. The study protocol was approved by the Institutional Review Board of the Medical University of South Carolina and adhered to the tenets of the 1975 Declaration of Helsinki, as revised in 1983.

IOLs

The Tecnis ZCBOO and ZXR00 IOLs share the same platform; both are single-piece aspheric hydrophobic acrylic IOLs, with an optical zone diameter of 6 mm and an overall diameter of 13 mm, and have a posterior surface with a spherical aberration of −0.27 µm for a 6-mm pupil size. The available power spectrum ranges from +5.00 to +34.00 diopters (D) in 0.50-D increments and incorporates an ultraviolet light-absorbing filter. The Tecnis ZXR00 is an EDOF IOL with an anterior aspheric surface that combines an echelette design and a posterior achromatic diffractive surface to correct both spherical aberration and longitudinal chromatic aberration and to produce an elongated focus.4,19

Surgical Technique

All surgeries were performed by the same experienced surgeon (KMR) under topical anesthesia. Phacoemulsification was performed with the Centurion Vision System (Alcon Laboratories, Inc.) through a 2.2-mm self-sealing clear corneal incision at 135 degrees. The IOL was implanted into the capsular bag through the main incision using the Unfolder Platinum 1 series screw-style injector (Johnson & Johnson Vision). IOL power calculations were performed using the Barrett Universal II formula and an A-constant of 119.3. We aimed to achieve emmetropia in all patients, and the power closest to plano or the first minus was chosen.

Postoperative Assessment

From 1 to 3 months postoperatively, uncorrected and corrected distance visual acuity were assessed, and ray-tracing aberrometry (iTrace; Tracey Technologies Corp.), Hartmann-Shack wavefront analysis (LADAR-Wave; Alcon Laboratories, Inc.), automated refraction (Topcon KR-8800; Topcon Medical Systems, Inc.), and manifest refraction were performed. Defocus, astigmatism, coma, spherical aberration, and total HOAs using ray-tracing aberrometry and Hartmann-Shack wavefront analysis were analyzed.

Ray-tracing Aberrometer

The iTrace is a ray-tracing aberrometer that uses 256 parallel beams with a wavelength of 785 nm projected onto the eye through the pupil within 1/8th of a second. The location of each spot on the retina is measured by a position-sensitive detector placed in the device. The amount of displacement of the laser beam reflected from the retina is analyzed and the wavefront of the eye is reconstructed using Zernike polynomials. The velocity of the beam enables the measurement of highly aberrated optical systems, generating refractive information of the eye over a range of ±15.00 D. Furthermore, the equipment combines Placido reflection rings to provide corneal topographic maps, as well as total, corneal, and internal aberration data.20–22 Ray-tracing measurements were performed under mesopic conditions with natural pupil sizes and scaled down to 3.5 mm for comparison and further analysis.

Hartmann-Shack Wavefront Analysis

The Hartmann-Shack aberrometer projects an infrared light beam of 820 nm through the pupil that forms a small spot on the retina. The device measures the displacement of each spot from its ideal location and uses this information to compute the slope of the entire wavefront at each lenslet location. For a 6-mm diameter pupil, approximately 170 wavefront samples are generated. Zernike polynomials are used to reconstruct the wavefront aberrations up to the eighth order. The device can measure wavefronts between ±15.00 D and up to 8.00 D of astigmatism.23 All wavefront measurements were performed under mesopic conditions without cycloplegia and scaled down to 3.5 mm for comparison and further analysis.

Automated Refraction

The automated refraction device is based on the Scheiner double-pinhole principle; two infrared light sources of 830 to 850 nm are directed onto the pupil plane to stimulate the Scheiner pinhole aperture and to reflect the two images onto a photodetector. A rotary prism measuring system is used to determine the corneal refractive status and refractive error. It has an auto-fogging mechanism to relax accommodation, and an automated tracking and shot function that captures each eye three times to obtain the mean power. The device measures spherical and cylindrical refractive power, astigmatic axis, and corneal curvature.24,25

Manifest Refraction

The subjective manifest refraction spherical equivalent (MRSE) was measured based on the corrected distance visual acuity. Cylindrical power and axis were confirmed by cross-cylinder examination in increments of 0.25 D.

Statistical Analysis

Refractive evaluations were compared according to different methods (manifest refraction, automated refraction, ray-tracing aberrometry, and Hartmann-Shack wavefront analysis) for each IOL using a linear mixed-model regression analysis. The random intercept was considered to represent the repetition of conditional eye evaluation (linear mixed-model regression with random intercept by sample unit [patients' eye]).26

Optical aberration results are presented as means and standard deviations, in addition to the estimated average deviations. Aberrometers (Hartmann-Shack and ray-tracing) were compared using a paired Student's t test. P values less than .05 were considered statistically significant for two-tailed tests. Analyses were performed with R version 3.6.1 software (R Core Team, 2019).27

Results

In this study, a total of 62 eyes were included (ZXR00 group = 32; ZCBOO group = 30). The mean ages ± standard deviations were 63 ± 10.16 and 67 ± 10.09 years in the ZXR00 and ZCBOO groups, respectively (P = .97).

The mean MRSE values are shown in Table 1 and Figure 1 shows the range of data.

Mean Average Spherical Equivalent Refraction for Both Intraocular Lensesa

Table 1:

Mean Average Spherical Equivalent Refraction for Both Intraocular Lenses

Representative results showing the average refraction values obtained in each intraocular lens (Tecnis ZCBOO and Tecnis ZXR00; Johnson & Johnson Vision). SE = spherical equivalent

Figure 1.

Representative results showing the average refraction values obtained in each intraocular lens (Tecnis ZCBOO and Tecnis ZXR00; Johnson & Johnson Vision). SE = spherical equivalent

In the ZXR00 group, the ray-tracing aberrometry (−0.45 ± 0.64 D), automated refraction, and Hartmann-Shack wavefront analysis results were found to be significantly more myopic compared to the MRSE (P < .001). In the ZCBOO group, there was no statistical difference between the ray-tracing aberrometry, automated refraction, and MRSE results (P > .796). Hartmann-Shack wavefront analysis yielded significantly more negative results compared to the other ZCBOO measures (P < .001; Table 1).

Statistically significant differences were seen between ray-tracing aberrometry and Hartmann-Shack wavefront analysis in terms of defocus (P < .001) and coma (P = .048) in the ZXR00 group. The spherical aberration results were significantly more myopic when using ray-tracing aberrometry compared to Hartmann-Shack wavefront analysis (P < .001). No statistically significantly differences were observed between ray-tracing aberrometry and Hartmann-Shack wavefront analysis in terms of total astigmatism (P = .850) and total HOAs (P = .307; Table 2).

Tecnis ZXR00 Average Optical Aberrations Correlation (n = 32)

Table 2:

Tecnis ZXR00 Average Optical Aberrations Correlation (n = 32)

In the ZCBOO group, ray-tracing aberrometry displayed a defocus of 0.05 ± 0.219 µm compared to 0.34 ± 0.711 µm with Hartmann-Shack wavefront analysis (P = .40). A statistically significant difference was observed between ray-tracing aberrometry and Hartmann-Shack wavefront analysis with regard to total astigmatism (P = .034). No statistically significant differences were found in terms of coma (P = .278), spherical aberration (P = .090), or total HOAs (P = .167; Table 3).

Tecnis ZCBOO Average Optical Aberrations Correlation (n = 30)

Table 3:

Tecnis ZCBOO Average Optical Aberrations Correlation (n = 30)

Discussion

The poor accuracy of automated methods for determining the precise objective refraction of multifocal IOLs has been widely reported, whereas no study has been performed with EDOF IOLs.18,22,28 This study aimed to determine whether automated refraction methods such as automated refraction, ray-tracing aberrometry, and Hartmann-Shack wavefront analysis are reliable methods to estimate postoperative refraction in diffractive EDOF lenses with achromatic technology.

The main concern regarding automated refractions in multifocal IOLs is their different focal points.18 Different from regular zeroth-and-first-diffractive-order bifocal IOLs, the ZXR00 is a hybrid low addition first-and-second-diffractive-order IOL with no purely refractive focus. It is an IOL with longitudinal chromatic aberration compensation for both distance and near vision to allow the lens to focus on different wavelengths in the same focal plane.4,10,29 For pupils within the central region, the echelettes in this zone produce an EDOF with balanced light dispersal between the distant and intermediate foci.10 Similar to diffractive bifocal IOLs, we found more myopic results for ZXR00 with all automated refraction methods, especially automated refraction and Hartmann-Shack wavefront analysis.11,12 One possible explanation is that these devices use infrared light, which has been shown to produce two asymmetric foci both close up and at a distance for a 3.5-mm pupil, as was used in this study. In addition, similar to Jun et al,22 we found that ray-tracing aberrometry was highly accurate for monofocal IOL postoperative refraction. In contrast, we found a slight myopic shift with Hartmann-Shack wavefront analysis, which differs from previous studies17,22 that report excellent results with monofocal IOLs.

Bench studies demonstrated that monofocal IOLs have a single focal point for distance in blue, green, and red light. At 550 nm, green is at the center of the curve.10 In hybrid bifocal IOLs, it is possible to see two focal points (one for distance and one for near), which corresponds to 0 and first diffractive orders. In this lens, the green remains at the center of the measurements. In contrast, the ZXR00 IOL produces two asymmetric peaks that overlap between the two focal points (for distance and near). Furthermore, this IOL corrects chromatic aberrations and inverts the light spectrum distribution we usually see with bifocal IOLs, which may explain why we observed the myopic results with near-infrared devices.

Ray-tracing aberrometry uses sequential shooting, which leads to less interference between abnormal value points. More precise results are expected because abnormal values are rejected and are not included in calculating the total HOAs. This explains why the measurement objective refraction with ray-tracing aberrometry was closer to the results of subjective manifest refraction compared to automated refraction and Hartmann-Shack wavefront analysis. Jun et al22 used ray-tracing aberrometry to evaluate internal spherical aberration in monofocal and multifocal IOLs, with accurate results. In our study, we observed less defocus and spherical aberration and more coma with ray-tracing aberrometry in the ZXR00 and monofocal groups. This may be explained by the optical alignment of the visual axis with ray-tracing aberrometry compared to pupil alignment with Hartmann-Shack wavefront analysis.30 Also, although the ZXR00 IOL has one elongated focus when measured in polychromatic light,4 two different focal points have been described for a 3.5-mm pupil size when measured in green light (543-nm wavelength); the lowest peak corresponds to the distant focus, and the highest peak corresponds to the intermediate focus.10,29 Therefore, distorted wavefront and spot-doubling phenomena would be expected when using Hartmann-Shack wavefront technology depending on the vertical decentration.28

Previous studies31,32 have reported residual refractive error as the most common cause of patient dissatisfaction after presbyopia-correcting IOL implantation. Surgical enhancement with phototherapeutic keratectomy or laser in situ keratomileusis might be necessary in these cases.33,34 Our findings show that, similarly to diffractive bifocal IOLs, we may see inaccurate results with automated refraction methods in EDOF lenses with an echelette design and achromatic diffractive technology. Therefore, to prevent unwanted hyperopic outcomes after enhancement, neither Hartmann-Shack wavefront analysis nor automated refraction should be used to plan refractive surgery in patients with an EDOF IOL. Automated refraction may only be used as a starting point for subjective manifest refraction in these patients. In addition, due to the elongated defocus curve of this IOL, a push-plus technique must be used to avoid over-minus endpoints. Furthermore, several Hartmann-Shack wavefront devices are commercially available; devices with higher resolution and different infrared light wavelengths may produce more accurate results.18

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Mean Average Spherical Equivalent Refraction for Both Intraocular Lensesa

ParameterZXR00ZCBOO
No.3230
Manifest refraction−0.12 ± 0.44−0.06 ± 0.44
Ray-tracing−0.45 ± 0.64b−0.14 ± 0.56
Automated refraction−0.62 ± 0.41b−0.14 ± 0.50
Hartmann-Shack−0.85 ± 0.40b−0.39 ± 0.47b
Pb< .001< .001

Tecnis ZXR00 Average Optical Aberrations Correlation (n = 32)

Optical AberrationsHartmann-ShackRay-tracingMD (95% CI)Bias (95% PI)P
Defocus0.392 ± 0.1830.133 ± 0.1810.259 (0.209 to 0.309)0.259 (−0.018 to 0.536)< .001
Astigmatism0.186 ± 0.1370.181 ± 0.1000.005 (−0.044 to 0.053)0.005 (−0.265 to 0.275).850
HOAs0.134 ± 0.0620.155 ± 0.101−0.022 (−0.064 to 0.021)−0.022 (−0.258 to 0.215).307
Coma0.055 ± 0.0340.078 ± 0.060−0.022 (−0.045 to 0.000)−0.022 (−0.146 to 0.101).048
Spherical aberration0.018 ± 0.014−0.015 ± 0.0330.033 (0.019 to 0.047)0.033 (−0.043 to 0.109)< .001

Tecnis ZCBOO Average Optical Aberrations Correlation (n = 30)

Optical AberrationsHartmann-ShackRay-tracingMD (95% CI)Bias (95% PI)P
Defocus0.34 ± 0.7110.05 ± 0.2190.291 (0.014 to 0.567)0.291 (−1.19 to 1.772).040
Astigmatism0.175 ± 0.1370.231 ± 0.142−0.057 (−0.109 to −0.005)−0.057 (−0.336 to 0.223).034
HOAs0.138 ± 0.0560.147 ± 0.065−0.010 (−0.024 to 0.004)−0.01 (−0.085 to 0.066).167
Coma0.071 ± 0.0570.08 ± 0.053−0.009 (−0.026 to 0.008)−0.009 (−0.1 to 0.082).278
Spherical aberration0.021 ± 0.0360.006 ± 0.0230.015 (−0.002 to 0.032)0.015 (−0.078 to 0.108).090
Authors

From Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina (JSH, LG, JLF, KMR); the Department of Ophthalmology, the Federal University of São Paulo, São Paulo, Brazil (JSH, LG, RA); the Department of Ophthalmology, the Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil (JSH, LG, RA); and Waring Vision Institute, Mount Pleasant, South Carolina (GOW).

Drs. Ambrósio and Waring are consultants for Oculus Optikgeräte. The remaining authors have no financial or proprietary interest in the materials presented herein.

AUTHOR CONTRIBUTIONS

Study concept and design (JSH, LG, RA, GOW, KMR); data collection (JSH, LG, JLF); analysis and interpretation of data (JSH, LG, RA, GOW, KMR); writing the manuscript (JSH, LG, JLF); critical revision of the manuscript (JSH, RA, GOW, KMR); statistical expertise (LG, JLF); administrative, technical, or material support (JSH); supervision (RA, GOW, KMR)

Correspondence: Jorge S. Haddad, MD, 167 Ashley Avenue, Charleston, SC 29425. Email: jshaddad2@hotmail.com

Received: February 04, 2020
Accepted: April 02, 2020

10.3928/1081597X-20200403-01

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