Journal of Refractive Surgery

Original Article 

Comparison Between Bilateral Implantation of a Trifocal IOL and Mix-and-Match Implantation of a Bifocal IOL and an Extended Depth of Focus IOL

Ji Eun Song, MD; Ramin Khoramnia, MD; Hyeck-Soo Son, MD; Michael C. Knorz, MD; Chul Young Choi, MD, PhD

Abstract

PURPOSE:

To compare the clinical outcomes of mix-and-match implantation of a diffractive extended depth of focus intraocular lens (IOL) (TECNIS Symfony ZXR00; Johnson & Johnson Vision) and a diffractive bifocal IOL (TECNIS ZLB00 +3.25 diopters [D]; Johnson & Johnson Vision) and bilateral implantation of a diffractive trifocal IOL (AcrySof IQ PanOptix; Alcon Laboratories, Inc).

METHODS:

This prospective comparative study compares the clinical outcomes of patients with age-related cataract undergoing cataract surgery using the IOLs described. Patients were divided into the mix-and-match group and the trifocal group. Assessment included monocular and binocular uncorrected distance visual acuity (UDVA), intermediate visual acuity (UIVA at 60 cm), and near visual acuity (UNVA at 40 cm), uncorrected defocus curves, contrast sensitivity, and reading speed. Quality of vision was measured with the Visual Function Questionnaire (VFQ-25).

RESULTS:

A total of 50 patients (25 in each group) were enrolled. At 6 months postoperatively, outcomes of binocular UDVA, UIVA, and UNVA were similar in both groups. The binocular defocus curve only differed at vergences of −0.50 to −1.00 D (better for the mix-and-match group; P = .032 and .004, respectively) and at −4.00 D (better for the trifocal group; P = .001). Significantly higher reading speeds in the mix-and-match group were measured at 0.7 and 0.5 logMAR (P = .038 and .034, respectively). There were no significant differences between groups for contrast sensitivity and the results of the questionnaire.

CONCLUSIONS:

The mix-and-match implantation seemed to be a good option for patients with high demands for distance and intermediate visual acuity, whereas the trifocal IOL appeared to be more suitable for patients with enhanced near vision demands.

[J Refract Surg. 2020;36(8):528–535.]

Abstract

PURPOSE:

To compare the clinical outcomes of mix-and-match implantation of a diffractive extended depth of focus intraocular lens (IOL) (TECNIS Symfony ZXR00; Johnson & Johnson Vision) and a diffractive bifocal IOL (TECNIS ZLB00 +3.25 diopters [D]; Johnson & Johnson Vision) and bilateral implantation of a diffractive trifocal IOL (AcrySof IQ PanOptix; Alcon Laboratories, Inc).

METHODS:

This prospective comparative study compares the clinical outcomes of patients with age-related cataract undergoing cataract surgery using the IOLs described. Patients were divided into the mix-and-match group and the trifocal group. Assessment included monocular and binocular uncorrected distance visual acuity (UDVA), intermediate visual acuity (UIVA at 60 cm), and near visual acuity (UNVA at 40 cm), uncorrected defocus curves, contrast sensitivity, and reading speed. Quality of vision was measured with the Visual Function Questionnaire (VFQ-25).

RESULTS:

A total of 50 patients (25 in each group) were enrolled. At 6 months postoperatively, outcomes of binocular UDVA, UIVA, and UNVA were similar in both groups. The binocular defocus curve only differed at vergences of −0.50 to −1.00 D (better for the mix-and-match group; P = .032 and .004, respectively) and at −4.00 D (better for the trifocal group; P = .001). Significantly higher reading speeds in the mix-and-match group were measured at 0.7 and 0.5 logMAR (P = .038 and .034, respectively). There were no significant differences between groups for contrast sensitivity and the results of the questionnaire.

CONCLUSIONS:

The mix-and-match implantation seemed to be a good option for patients with high demands for distance and intermediate visual acuity, whereas the trifocal IOL appeared to be more suitable for patients with enhanced near vision demands.

[J Refract Surg. 2020;36(8):528–535.]

With the development of new intraocular lenses (IOLs) and cataract surgery techniques, it is possible to improve visual quality and spectacle independence after cataract surgery. The clinical use of multifocal IOLs was first reported in the late 1980s. Hoffer developed the first concept of a true multifocal IOL in 1983 and the first bifocal IOL implantation was performed by Pearce in 1986.1 Multifocal IOLs used either the diffractive or refractive principle to generate a distance and a near focus. The disadvantages of these IOLs are a reduced contrast sensitivity and unwanted photic phenomena such as glare and halos. In addition, these IOLs are not able to achieve satisfactory visual results in the intermediate range.2 Particularly in recent years, the importance of improving visual quality at intermediate distances has increased as patient priorities have shifted to tasks at medium distances, such as using a laptop, tablet, or smartphone.3

Trifocal IOLs were developed to extend the patient's independence from glasses at intermediate distance while also maintaining satisfactory visual acuity at far and near distances.4 However, the presence of the third focus may lead to a loss of light energy in the eye and reduces the optical quality at far and near distances.5 IOLs with extended depth of focus (EDOF) technology aim to improve intermediate vision without compromising quantitative and qualitative vision by offering a continuous range of vision from distance through intermediate. Some of these IOLs also correct chromatic aberration, aiming at a better contrast sensitivity and a decreased rate and intensity of glare and halo.6–8 However, near vision is inferior to multifocal or trifocal IOLs.9

One way to overcome these limitations and to achieve visual advantages for near and/or intermediate vision is a specific selection of the add-power of multifocal IOLs.10 Another possibility is the combination of multifocal IOLs with different designs for a blended approach,11–13 the so-called mix-and-match method, introduced by Jacobi et al.14 In such a case, careful selection of the different IOLs according to their peaks in the through-focus curves may further reinforce the visual outcomes.15–18

The purpose of this study was to compare visual outcomes, contrast sensitivity, reading speed, and patient satisfaction between a group of patients with blended implantation of an EDOF IOL in one eye and a bifocal IOL in the other eye and a group of patients with bilateral implantation of a trifocal IOL.

Patients and Methods

In this prospective study, patients with age-related cataract had bilateral cataract extraction with phacoemulsification and IOL implantation of three different IOL models: TECNIS Symfony ZXR00, TECNIS bifocal ZLB00 +3.25 diopters (D) (Johnson & Johnson Vision), and trifocal AcrySof IQ PanOptix IOL (Alcon Laboratories, Inc). Patients were randomized into two groups. This study comprised 50 eyes of 25 patients with mix-and-match implantation of the TECNIS Symfony ZXR00 IOL in their dominant eye and the TECNIS bifocal ZLB00 +3.25 D IOL in their nondominant eye (mix-and-match group) and 50 eyes of 25 patients with bilateral implantation of the AcrySof IQ PanOptix IOL (trifocal group). The preoperative patient characteristics are shown in Table 1.

Preoperative Characteristics of Patientsa

Table 1:

Preoperative Characteristics of Patients

Inclusion criteria were adults 21 years or older at the time of preoperative examination, willingness to undergo surgery on their second eye within 7 days after their first eye, a postoperative visual potential of 20/25 or better, and a preexisting corneal astigmatism of less than 1.00 D. The following exclusion criteria were applied: pregnant and lactating women; patients with a history of retinal disease, ocular trauma, or ocular surgery and with evidence of keratoconus or significant irregular astigmatism; patients who had worn rigid contact lenses within the past 6 months, gas-permeable lenses within the past month, or longer wearing times or daily soft contact lenses within 7 days of scheduled surgery; patients with other diseases affecting capsule stability such as pseudoexfoliation syndrome, glaucoma, traumatic cataract, or Marfan syndrome; and patients who were not able to read and understand the informed consent.

The study followed the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board of Kangbuk Samsung Hospital (IRB File No. 2018-07-025-005). Prior to enrollment, all participants signed a consent form.

All patients received a comprehensive ophthalmological preoperative examination, including slit-lamp examination, mesopic (3 cd/m2) pupillometry, refractive status, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, uncorrected intermediate visual acuity (UIVA), and uncorrected near visual acuity (UNVA), topography (Galilei G6; Ziemer Ophthalmic Systems AG), corneal aberration (KR-1W Wavefront Analyzer; Topcon Europe Medical BV), optical biometry and keratometry (IOLMaster 500; Carl Zeiss Meditec), and funduscopy. Cataract surgery was performed using topical anesthesia by one surgeon (CYC) using a 2.2-mm corneal incision, manual capsulorhexis, and phacoemulsification. All IOLs were implanted in the bag. Postoperative refraction was targeted at the nearest minus value from emmetropia using the Haigis formula in IOL power calculation.

Follow-up examinations were performed 1 week, 1 month, and 6 months after implantation of the second IOL. Main outcome measures included visual performance, monocular and binocular defocus curves, contrast sensitivity, reading speed, and a patient questionnaire. UDVA, UIVA at 60 cm, and UNVA at 40 cm were measured using the Early Treatment Diabetic Retinopathy Study charts (ETDRS; Vector Vision). Uncorrected monocular and binocular defocus curves were obtained for distance vision with ETDRS charts, at intervals of 0.50 spherical diopters from −4.00 to +1.00 D. Contrast sensitivity was measured at 3, 6, 12, and 18 cycles per degree under photopic (85 cd/m2) and mesopic (3 cd/m2) conditions with and without glare with the CSV-1000 (Vector Vision). Patient satisfaction (quality of vision [QoV], vision-related quality of life [QoL]), and spectacle independence were assessed with the 25-item National Eye Institute Visual Functional Questionnaire (VFQ-25). Binocular reading speed at 40 cm was measured 6 months postoperatively as described by Kim et al15 and using the application of Song et al.16 Letter sizes from 0.0 to 1.0 logMAR were displayed in steps of 0.1 logMAR. Patients were asked to read sentences of different sizes one after the other. Reading speed (words per minute) was automatically calculated by the system.

Data analysis was conducted using SPSS software (version 24.0; SPSS, Inc). Intragroup and intergroup comparisons of monocular and binocular visual outcomes were performed with the Wilcoxon signed-rank test and chisquare test. The Mann-Whitney U test was used to compare quantitative variables (eg, refraction) and reading speed. Spearman's rank correlation and Pearson's correlation were used to investigate correlations of photopsia. The t test for independent samples was used to compare overall satisfaction and spectacle independence. For the adjustment of P values, the Bonferroni correction was used. Data were expressed as mean and standard deviation. The analysis of monofocal parameters in the trifocal group included all 50 eyes.

Results

The mean monocular and binocular UDVA, UIVA, and UNVA are shown in Table 2. Postoperative monocular UIVA and UNVA, binocular CDVA, and binocular visual acuity at all distances did not differ statistically significantly between the groups (P > .05). Eyes receiving the TECNIS Symfony ZXR00 IOL achieved a significantly better monocular UDVA compared to eyes receiving the AcrySof IQ PanOptix IOL (P = .05). One hundred percent of patients of both groups achieved a binocular UDVA of 0.1 logMAR and better. A binocular UIVA of 0.1 logMAR or better was achieved by 96% of patients in the mix-and-match group and 100% of patients in the trifocal group. In both groups, 100% of patients achieved a binocular UNVA 0.2 logMAR or better. The refractive distribution in eyes with TECNIS Symfony ZXR00 IOL was significantly skewed toward myopic values compared to eyes with the AcrySof IQ PanOptix IOL (P < .05). Nevertheless, the trifocal group had better visual acuity at defocus curve from −1.50 to −4.00 D (Figure 1).

Monocular and Binocular Visual Outcomes 6 Months Postoperativelya

Table 2:

Monocular and Binocular Visual Outcomes 6 Months Postoperatively

(A) Mean monocular defocus curve of eyes implanted with the TECNIS Symfony ZXR00 (Johnson & Johnson Vision), TECNIS bifocal ZLB00 +3.25 diopters (D) (Johnson & Johnson Vision), and AcrySof IQ PanOptix trifocal (Alcon Laboratories, Inc) intraocular lenses. (B) Mean binocular defocus curves of the mix-and-match group and the trifocal group. *P < .05. EDOF = extended depth of focus; D = diopters

Figure 1.

(A) Mean monocular defocus curve of eyes implanted with the TECNIS Symfony ZXR00 (Johnson & Johnson Vision), TECNIS bifocal ZLB00 +3.25 diopters (D) (Johnson & Johnson Vision), and AcrySof IQ PanOptix trifocal (Alcon Laboratories, Inc) intraocular lenses. (B) Mean binocular defocus curves of the mix-and-match group and the trifocal group. *P < .05. EDOF = extended depth of focus; D = diopters

Mean monocular and binocular defocus curves of both groups are shown in Figure 1. At a vergence of 0.00 D (distance vision), all eyes of both groups achieved similar binocular visual acuity results (P = .152). The binocular defocus curve of the mix-and-match group showed statistically significant better visual acuity values at vergences of −0.50 and −1.00 D (corresponding to visual distances of 2 and 1 m) than in the trifocal group (P = .032 and .004, respectively). At a vergence of −2.00 D (50 cm), all eyes of both groups had an equivalent level of binocular visual acuity (between 0.02 and 0.03 logMAR). For near vision, the results are reversed. The eyes in the trifocal group achieved significantly better visual acuity at a vergence of −4.00 D (25 cm) compared to the eyes in the mix-and-match group (P = .001). Overall, patients in the mix-and-match group demonstrated better visual acuity over a vergence range of +1.00 to −1.50 D (distance and intermediate vision), whereas patients in the trifocal group had better visual acuity at near distance (vergence of −2.50 D or greater).

Figure 2 shows the results of binocular contrast sensitivity measurement of both groups obtained under photopic conditions and under mesopic conditions with and without glare. No significant differences were found for any spatial frequency between groups under different light conditions.

Mean binocular contrast sensitivity function in the mix-and-match group and the trifocal group under (A) photopic and (B) mesopic conditions with and without glare.

Figure 2.

Mean binocular contrast sensitivity function in the mix-and-match group and the trifocal group under (A) photopic and (B) mesopic conditions with and without glare.

The postoperative results of the VFQ-25 are shown in Figure 3. In general, the survey results of both groups were comparable, with slight advantages for the mix-and-match group in almost all categories except general health, but there was no statistically significant difference. Comparing the preoperative values, both groups showed improvements in all categories. The results of the questionnaire evaluating the spectacle use in daily life are shown in Figure 4.

Results of the Visual Function Questionnaire for the mixand-match group and the trifocal group.

Figure 3.

Results of the Visual Function Questionnaire for the mixand-match group and the trifocal group.

Results of the questionnaire for spectacle use in daily life for the (A) mix-and-match group and (B) trifocal group.

Figure 4.

Results of the questionnaire for spectacle use in daily life for the (A) mix-and-match group and (B) trifocal group.

With regard to the perception of photic phenomena (Figure 5A), slight differences were found between the groups. No glare or halos were reported in the mixand-match group in 84% and 88% of patients, respectively, and in the trifocal group in 92% and 100% of patients, respectively. The proportion of patients who were not affected by starbursts was slightly higher in the mix-and-match group than in the trifocal group (60% vs 54%). The overall satisfaction rate of patients in both groups was high for distance, intermediate, and near vision (Figure 5B). In the mix-and-match group, all patients were fully satisfied with distance vision. For intermediate vision, the overall satisfaction rate was 100% in both groups. The satisfaction rate at distance and near vision was higher in the mixand-match group (100% and 84%, respectively) than in the trifocal group (88% and 75%, respectively).

Results of the questionnaire regarding the (A) perception of photic phenomena and (B) overall satisfaction rates of patients in both groups.

Figure 5.

Results of the questionnaire regarding the (A) perception of photic phenomena and (B) overall satisfaction rates of patients in both groups.

As shown in Figure 6, the binocular measurements of patients with mix-and-match implantation demonstrated better reading speed at any type of letter size except 0.2 logMAR. At 0.7 and 0.5 logMAR, the mix- and-match group achieved statistically significantly higher reading speeds (P = .038 and .034, respectively). At 0.2 logMAR, reading speed was higher in the trifocal group, but differences were not statistically significant.

Results of postoperative reading speed at 6-month follow-up (words per minute). *P < .05.

Figure 6.

Results of postoperative reading speed at 6-month follow-up (words per minute). *P < .05.

Discussion

In this study, we implanted the TECNIS Symfony ZXR00 IOL in the patient's dominant eye and the TECNIS bifocal +3.25 D IOL in the non-dominant eye (mix-and-match group). Although there is no established method to determine the dominant eye in patients with bilateral cataract,19 the importance of eye dominance in monovision was shown in previous studies.20 Because the success of monovision depends on the suppression of intraocular blur, the approach is based on the assumption that blur suppression is easier in the non-dominant eye.21 That may explain why patients' acceptance rate leads to better results after correction of the dominant eye for distance vision and the non-dominant eye for near vision.22 In the current study, this approach proved to be successful, as the visual results of the mix-and-match group show.

Successful visual restoration after cataract surgery over all distances was achieved in both groups, which confirms previous studies with the same or similar IOL models.7,10–12,23,24 Full spectacle independence at intermediate distance was achieved in both groups. At distance, the rate of spectacle independence in the trifocal group was slightly lower (92%) compared to 100% in the mix-and-match group, which is similar compared to rates of previous studies with the same IOL model3,25 or other models of trifocal IOLs.26 A high degree of spectacle independence was also achieved at near. The percentage of patients who never or only occasionally (up to 25% of the time) needed glasses was 100% (mixand-match) and 96% (trifocal group), respectively.

In this study, the uncorrected defocus curve was measured. Although the corrected defocus curve represents the different characteristics of the lenses, it has the limitation that it does not represent patients' real life. The defocus curve is an objective indicator of the expected range of vision due to the depth of field of the eye and can help ophthalmologists to demonstrate expected visual performance of IOLs for their patients. The binocular defocus curve of the mix-and-match group in this study demonstrated a slightly wider and higher plateau between the two peaks of visual acuity at intermediate and distance (between +1.00 and −1.50 D of defocus), reaching statistical significance at defocus levels of −0.50 and −1.00 D (P = .032 and .004, respectively), whereas the defocus curve of the trifocal group showed slightly better visual acuity for near vision (between −2.50 and −4.00 D of defocus) with significantly better visual acuity at −4.00 D (P = .001). The superior visual acuity of the mix-and-match group at −0.50 and −1.00 D may be explained by this group's refractive distribution, which was significantly skewed toward myopia. The comparison with the defocus curves of de Medeiros et al12 shows similar results for the range of defocus between 0.00 and −1.50 D. In contrast to our results in the range between −3.00 and −4.00 D, patients with blended implantation in the study of de Medeiros et al12 achieved better visual acuity than patients after bilateral implantation of a trifocal IOL. This may be because de Medeiros et al chose a matched IOL with +4.00 D add power for blended implantation.

In our study, contrast sensitivity of both groups was within the normal range. In addition, the assessment of contrast sensitivity showed no statistically significant differences between both groups under different light conditions at any spatial frequency. This is confirmed by studies of Plaza-Puche et al27 and Mojzis et al.28 They found that contrast sensitivity with trifocal IOLs compared to bifocal IOLs is not negatively influenced despite the additional focus of trifocal IOLs in the intermediate range.

Because reading is one of the important factors in everyday life, reading speed measurement is more valuable and better at predicting visual performance in daily life in near vision function than visual acuity itself.29,30 The Korean writing system 'Hangul' is fundamentally based on an alphabetic principle. Reading speed measurement showed a pattern similar to the difference between the two groups shown in the defocus curve. It was originally thought to be more affected by contrast sensitivity, but in our study there was no statistically significant difference in contrast sensitivity between the two groups. LogMAR letters are printed in square-like blocks composed of initial consonants, medial vowels, and final consonants, whereas English is a linear spatial arrangement with each alphabet. So, reading Korean might be more sensitive to blurring.

In our study, we evaluated the patients' experiences with glare and halo to better understand their satisfaction in daily life. Based on the results of our questionnaire, patients in the trifocal group perceived more starburst than patients in the mix-and-match group. Also, whereas the trifocal lenses should, in theory, cause more positive dysphotopsia, our results showed that the trifocal group experienced less glare or halos, a finding that may be explained by the residual myopia observed in patients with EDOF lenses. Nevertheless, patient satisfaction for distance and intermediate vision did not differ much between the groups. When assessing patient satisfaction, it should also be noted that the occurrence of halos in the trifocal group is associated with the presence of two out-of-focus images, as experimental studies show.31 The results of other studies also indicate that patient satisfaction remains high despite the increased occurrence of optical phenomena.26,32 In an earlier study,33 binocular implantation of the TECNIS Symfony ZXR00 IOL resulted in a higher incidence of starburst than mix-and-match implantation of the TECNIS Symfony ZXR00 IOL and the TECNIS bifocal +3.25 D IOL. This indicates that the mix-and-match approach may decrease starburst compared to an EDOF-only group or a binocular trifocal IOL group.

Both groups in our study demonstrated good uncorrected and corrected visual acuities from far to near distances. Spectacle independence was high at all distances, and a small proportion of patients reported minimal to mild visual symptoms only. As shown by the defocus curve, patients in the mix-and-match group had advantages at intermediate distance compared to patients in the trifocal group, whereas patients in the trifocal group achieved better results at near. The results in patients treated with a mix-and-match approach can be further optimized by carefully selecting the different IOLs according to their peaks in the through-focus MTF curves. The mix-and-match implantation of an EDOF IOL and a multifocal IOL might be a good option in patients with high demands for distance and intermediate vision, whereas the tri-focal IOL appears to be more suitable for patients with higher near vision demands.

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Preoperative Characteristics of Patientsa

Characteristic Mix-and-Match Trifocal P
Age (years) 65.20 ± 5.38 67.08 ± 6.89 .13
Gender (no.) .19
  Male 18 12
  Female 32 38
SE (D) 0.18 ± 2.70 −0.66 ± 3.65 .29
Pupil size (mm) 4.04 ± 0.53 3.70 ± 0.53 .07
UDVA (logMAR) 0.30 ± 0.38 0.33 ± 0.30 .72
CDVA (logMAR) 0.09 ± 0.19 0.13 ± 0.13 .16
UIVA (logMAR) 0.47 ± 0.32 0.45 ± 0.24 .72
UNVA (logMAR) 0.56 ± 0.25 0.48 ± 0.24 .10

Monocular and Binocular Visual Outcomes 6 Months Postoperativelya

Parameter Mix-and-Match   P

 
EDOF Bifocal Trifocal EDOF vs Trifocal Bifocal vs Trifocal Mix-and-Match vs Binocular Trifocal
Monocular (logMAR)
  UDVA −0.01 ± 0.06 0.00 ± 0.08 0.03 ± 0.08 .05 .11
  UIVA 0.03 ± 0.07 0.08 ± 0.11 0.05 ± 0.05 .18 .12
  UNVA 0.12 ± 0.12 0.06 ± 0.08 0.08 ± 0.09 .07 .60
  CDVA −0.07 ± 0.08 −0.06 ± 0.06 −0.04 ± 0.50 .07 .16
Binocular (logMAR)
  UDVA −0.05 ± 0.07 −0.02 ± 0.06
.15
  UIVA 0.02 ± 0.05 0.01 ± 0.03
.50
  UNVA 0.05 ± 0.07 0.04 ± 0.06
.42
  CDVA −0.11 ± 0.06 −0.08 ± 0.04
.07
Refraction (D)
  Sphere −0.67 ± 0.47 −0.04 ± 0.44 −0.25 ± 0.30 < .05 .45
  Cylinder −0.48 ± 0.41 −0.49 ± 0.36 −0.55 ± 0.42 .54 .57
  SE −0.75 ± 0.60 −0.29 ± 0.45 −0.25 ± 0.30 < .05 .75
Authors

From the Department of Ophthalmology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (JES, CYC); The David J. Apple International Laboratory for Ocular Pathology and International Vision Correction Research Centre, Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany (RK, H-SS); and FreeVis LASIK Zentrum, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany (MCK).

Supported by Medical Research Funds from Kangbuk Samsung Hospital.

Dr. Khoramnia has received grants from AcuFocus, Inc, Alcon Laboratories, Inc, Hoya, Johnson & Johnson, Kowa, Oculentis, PhysIOL, Rayner, Santen, and SIFI, and has received financial support from Alcon Laboratories, Inc, Hoya, Johnson & Johnson, Oculentis, Ophtec, Rayner, and Santen. The remaining authors have no financial or proprietary interest in the materials presented herein.

AUTHOR CONTRIBUTIONS

Study concept and design (JES, CYC); data collection (JES, CYC); analysis and interpretation of data (JES, RK, H-SS, MCK, CYC); writing the manuscript (JES, CYC); critical revision of the manuscript (RK, H-SS, MCK, CYC); statistical expertise (RK); administrative, technical, or material support (CYC); supervision (CYC)

Correspondence: Chul Young Choi, MD, PhD, Department of Ophthalmology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Republic of Korea. Email: sashimi0@naver.com

Received: April 03, 2020
Accepted: June 12, 2020

10.3928/1081597X-20200616-01

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