Journal of Refractive Surgery

Original Article Supplemental Data

Visual Outcomes and Patient Satisfaction After Bilateral Sequential Implantation of a Capsular Bag IOL and a Supplementary Sulcus-Fixated Trifocal IOL

Guenal Kahraman, MD; Nikolaus Dragostinoff, PhD; Wolfgang Brezna, PhD; Clemens Bernhart, MD; Michael Amon, MD

Abstract

PURPOSE:

To assess visual and refractive outcomes and patient satisfaction after bilateral sequential implantation of a primary capsular bag intraocular lens (IOL) and a supplementary sulcus-fixated trifocal IOL.

METHODS:

All patients had bilateral implantation of a mono-focal IOL in the capsular bag followed by a supplementary trifocal IOL (Sulcoflex 703F, Rayner Intraocular Lenses Limited) in the sulcus. Patients were evaluated for monocular uncorrected and corrected distance visual acuity, binocular uncorrected and corrected distance, intermediate and near visual acuity, photopic and mesopic contrast sensitivity, defocus curves, visual symptoms, spectacle independence, and patient satisfaction at 1 and 6 months postoperatively.

RESULTS:

Forty eyes of 20 patients were evaluated. Six months after surgery, mean binocular uncorrected visual acuity was −0.07 ± 0.06 logMAR for distance vision (range: −0.2 to 0.0 logMAR), −0.03 ± 0.17 logMAR for intermediate vision (range: −0.1 to 0.6 logMAR), and 0.09 ± 0.08 logMAR for near vision (range: −0.1 to 0.2 logMAR). All patients reported full spectacle independence after 6 months and no adverse events were reported for any of the patients.

CONCLUSIONS:

Sequential implantation of a monofocal IOL in the capsular bag and a supplementary trifocal IOL in the sulcus provides a safe and effective choice for patients who desire spectacle independence after cataract surgery.

[J Refract Surg. 2021;37(2):105–111.]

Abstract

PURPOSE:

To assess visual and refractive outcomes and patient satisfaction after bilateral sequential implantation of a primary capsular bag intraocular lens (IOL) and a supplementary sulcus-fixated trifocal IOL.

METHODS:

All patients had bilateral implantation of a mono-focal IOL in the capsular bag followed by a supplementary trifocal IOL (Sulcoflex 703F, Rayner Intraocular Lenses Limited) in the sulcus. Patients were evaluated for monocular uncorrected and corrected distance visual acuity, binocular uncorrected and corrected distance, intermediate and near visual acuity, photopic and mesopic contrast sensitivity, defocus curves, visual symptoms, spectacle independence, and patient satisfaction at 1 and 6 months postoperatively.

RESULTS:

Forty eyes of 20 patients were evaluated. Six months after surgery, mean binocular uncorrected visual acuity was −0.07 ± 0.06 logMAR for distance vision (range: −0.2 to 0.0 logMAR), −0.03 ± 0.17 logMAR for intermediate vision (range: −0.1 to 0.6 logMAR), and 0.09 ± 0.08 logMAR for near vision (range: −0.1 to 0.2 logMAR). All patients reported full spectacle independence after 6 months and no adverse events were reported for any of the patients.

CONCLUSIONS:

Sequential implantation of a monofocal IOL in the capsular bag and a supplementary trifocal IOL in the sulcus provides a safe and effective choice for patients who desire spectacle independence after cataract surgery.

[J Refract Surg. 2021;37(2):105–111.]

In recent years, visual expectations of patients with cataract have changed significantly. While becoming more active in later periods of life, an increasing number of patients seek spectacle independence at a wide range of distances, which can be provided by implantation of a multifocal intraocular lens (IOL) in the capsular bag during cataract surgery. However, a multifocal lens generates more than one image on the retina: the sharp in-focus image is overlaid by at least one blurred defocused image, thereby reducing the overall contrast. Although this phenomenon is well tolerated by many, some patients are unable to adjust to the multiple images and the reduced contrast on the retina.1 It has been shown in several studies that IOL exchange needs to be performed markedly more often in patients with multifocal IOLs compared to patients with monofocal implants.2–5 In many cases, explantation of multifocal IOLs is related to visual disturbances such as glare or halos. For these reasons, patients need to be carefully advised before the decision to use a multifocal IOL is made, and many surgeons still hesitate to recommend multifocal IOLs, especially because explantation of a capsular bag IOL is a laborious procedure that is often stressful to the eye and associated with a high risk of complications.6–9 These problems can be overcome by implantation of a primary monofocal IOL in the capsular bag and a supplementary multifocal IOL in the sulcus. In the event of patient dissatisfaction or occurrence of ocular pathologies that require removal of multifocality, the supplementary sulcus-fixated IOL can be removed.

The aim of this prospective study was to assess visual outcomes (visual acuity and contrast sensitivity), refractive error, and patient satisfaction after bilateral implantation of a monofocal capsular bag IOL followed by a supplementary trifocal IOL in the ciliary sulcus.

Patients and Methods

Patients

This prospective nonrandomized study included patients with bilateral cataract and a desire for postoperative spectacle independence. The study was performed at the Department of Ophthalmology, Academic Teaching Hospital of St. John, Vienna, Austria. Approval was obtained from the local ethics committee, and all procedures were performed in accordance with the tenets of the Declaration of Helsinki. Written informed consent was obtained from all study participants.

Only patients without preexisting ocular pathology other than cataract were included in the study. Additional inclusion criteria were less than 1.00 diopter (D) of corneal astigmatism, clear ocular media, and regular corneal topography. Patients with acute or chronic diseases that would distort the results, with previous cataract surgery, capsular or zonular anomalies, or insufficient pupil dilation, or who were unlikely to adapt to multifocality were excluded from the study.

Preoperative Assessment

Before surgery, all patients had a complete eye examination including monocular and binocular corrected distance visual acuity (CDVA), autorefraction, subjective refraction, funduscopy, and slit-lamp examination. The primary lens power was calculated with the SRK/T formula using optical biometry (IOL-Master 500; Carl Zeiss Meditec AG).

Supplementary Trifocal Lens

The Sulcoflex Trifocal IOL (model 703F; Rayner Intraocular Lenses Limited) is a single-piece hydrophilic acrylic IOL designed for implantation in the ciliary sulcus (Figure A, available in the online version of this article). The overall length is 14 mm and the optic diameter is 6.5 mm, with convex anterior and concave posterior surfaces designed to minimize the risk of physical contact with the anterior convex surface of the capsular bag IOL. Haptics feature 10° posterior angulation and edges are rounded to reduce ciliary irritation. All implanted supplementary IOLs had a base power of 0.00 D, a near addition of +3.50 D, and an intermediate addition of +1.75 D.

Sulcoflex Trifocal IOL, model 703F (Rayner Intraocular Lenses Limited).

Figure A.

Sulcoflex Trifocal IOL, model 703F (Rayner Intraocular Lenses Limited).

Surgical Technique

All implantations were performed by the same surgeon (MA). Both eyes were operated on at the same time. Before surgery, pupils were dilated with tropicamide, phenylephrine hydrochloride 2.5%, cyclopentolate 1.0%, and diclofenac sodium 0.1%. The phacoemulsification was performed through a 2.7-mm self-sealing clear corneal incision under topical anesthesia. After implanting the primary IOL in the capsular bag, the ciliary sulcus was filled with an ophthalmic viscosurgical device (Ophteis 1.0%; Rayner Intraocular Lenses Limited) and the supplementary Sulcoflex Trifocal IOL was implanted using the Accuject 1.8 injector (Medicel AG) into the ciliary sulcus. The ophthalmic viscosurgical device was then irrigated and intracameral cefuroxime applied.

Postoperative Assessment

Postoperative evaluations were performed after 1 and 6 months. Outcome measures were subjective refraction, monocular and binocular uncorrected distance visual acuity (UDVA) and CDVA,10 binocular uncorrected (UIVA) and corrected (CIVA) intermediate visual acuity, binocular uncorrected (UNVA) and corrected (CNVA) near visual acuity, photopic and mesopic contrast sensitivity, defocus curves, visual symptoms, spectacle independence, and satisfaction with the visual results. UDVA and CDVA were measured using Early Treatment of Diabetic Retinopathy Study (ETDRS) charts at 4 m distance, UIVA and CIVA at 70 cm, and UNVA and CNVA at 40 cm. Defocus curves were recorded using ETDRS charts at 4 m distance and ancillary lenses ranging from −4.00 to +2.00 D in steps of 0.50 D. Contrast sensitivity was determined with F.A.C.T. charts under standardized photopic (85 cd/m2) and mesopic (6 cd/m2) conditions using the Optec 6500 tester (Stereo Optical Co, Inc).

For assessment of visual symptoms, spectacle independence, and patient satisfaction, a questionnaire with standardized answers (ranging from 0 to 10 for photic phenomena and satisfaction, and from 0% to 100% in steps of 25% for requiring spectacles at distance, intermediate, and near) was used. All postoperative or intra-operative complications were documented.

Statistical Analysis

Data are provided as mean ± standard deviation. Statistical analysis was performed using Origin-Pro 2018G (OriginLab Corporation). Normality and variance homogeneity of the data was tested via the Kolmogorov-Smirnov test and the Levene test (both with a significance level of .05), respectively, and the comparison test method was chosen accordingly: two-way repeated measures analysis of variance (ANOVA) was used to compare the defocus curves and contrast sensitivities after 1 and 6 months, the Wilcoxon signed-rank test for comparison of subjective rating of pseudophakic photic phenomena after 1 and 6 months, and the paired t test for comparison of patient satisfaction after 1 and 6 months. Differences were considered significant when the corresponding P value was less than .05 (5% level).

Results

The study comprised 40 eyes of 20 patients. The mean age of the cohort was 69.85 years (range: 56 to 80 years). The mean preoperative binocular CDVA was 0.20 ± 0.06 logMAR (range: 0.1 to 0.3 logMAR) and the mean preoperative monocular CDVA was 0.28 ± 0.13 logMAR (range: 0.1 to 0.7 logMAR). Table A (available in the online version of this article) shows the patients' demographics and the type and dioptric power of the primary capsular bag IOL. As the supplementary IOL, the Sulcoflex Trifocal (model 703F) was bilaterally implanted in all cases. No intraoperative or postoperative complications occurred. No signs of pigment dispersion, iris bulging, foreign body giant cell formation, or interlenticular opacification were observed during the follow-up. We did not observe any IOL rotation or tilt. Centration stability of Sulcoflex IOLs has been investigated previously11 and was not measured here. However, no signs of relevant decentration were found during slit-lamp examinations. Follow-up examinations were performed 1 and 6 months after surgery.

Patient Demographics, Primary Lens, and Dioptric Power

Table A:

Patient Demographics, Primary Lens, and Dioptric Power

Visual Acuity and Refraction

One month postoperatively, mean binocular CDVA was −0.08 ± 0.07 logMAR (range: −0.2 to 0.0 logMAR) and mean binocular UDVA was −0.07 ± 0.07 logMAR (range: −0.2 to 0.0 logMAR). Detailed results are shown in Table B (available in the online version of this article). Residual subjective refraction was 0.00 D in 33 eyes, −0.25 D in 4 eyes of 3 patients, and −0.50 D in 3 eyes of 2 patients. Mean binocular UIVA (0.00 ± 0.17 logMAR, range: −0.2 to 0.6 logMAR) and UNVA (0.12 ± 0.09 logMAR, range: −0.1 to 0.2 logMAR) indicate good performance of the trifocal implant in the intermediate and near range.

Postoperative Visual Acuity

Table B:

Postoperative Visual Acuity

After 6 months, mean binocular UDVA was −0.07 ± 0.06 logMAR (range: −0.2 to 0.0 logMAR). Residual subjective refraction was 0.00 D in 40 eyes, −0.25 D in 2 eyes of 2 patients, and −0.50 D in 3 eyes of 3 patients. Mean binocular UIVA was −0.03 ± 0.17 logMAR (range: −0.1 to 0.6 logMAR) and mean binocular UNVA was 0.09 ± 0.08 logMAR (range: −0.1 to 0.2 logMAR). Comparison of monocular UDVA versus monocular CDVA (cumulative and difference in Snellen lines) and refractive outcomes after 6 months are shown in Figure 1.

Comparison of (A) monocular uncorrected distance visual acuity (UDVA) versus corrected distance visual acuity (CDVA) and (B–D) refractive outcomes after 6 months postoperatively. D = diopters

Figure 1.

Comparison of (A) monocular uncorrected distance visual acuity (UDVA) versus corrected distance visual acuity (CDVA) and (B–D) refractive outcomes after 6 months postoperatively. D = diopters

Defocus Curves

Averaged binocular visual acuity defocus curves (logMAR) for defocus values ranging from −4.00 to +2.00 D measured 1 and 6 months postoperatively are shown in Figure 2. The Sulcoflex Trifocal IOL provides good levels of functional visual acuity over a wide range of defocus values (−3.00 to +0.50 D). No significant difference was found between the defocus curves recorded 1 and 6 months postoperatively (P = .96, two-way repeated measures ANOVA).

Averaged binocular visual acuity defocus curves for defocus values measured at 1 and 6 months postoperatively. D = diopters

Figure 2.

Averaged binocular visual acuity defocus curves for defocus values measured at 1 and 6 months postoperatively. D = diopters

Contrast Sensitivity

Figure 3 shows the mean photopic and mean mesopic contrast sensitivities (in log CS) for different spatial frequencies ranging from 1.5 to 18 cycles per degree measured 1 and 6 months after surgery. For photopic conditions, no significant differences were found between the contrast data acquired after 1 and 6 months (P = .14, two-way repeated measures ANOVA). Contrast sensitivities under mesopic conditions were significantly better after 6 months (P = .022).

Mean (A) photopic and (B) mesopic contrast sensitivity for different spatial frequencies measured at 1 and 6 months postoperatively. cpd = cycles per degree

Figure 3.

Mean (A) photopic and (B) mesopic contrast sensitivity for different spatial frequencies measured at 1 and 6 months postoperatively. cpd = cycles per degree

Patient-Reported Outcome Measures

Pseudophakic photic phenomena (halos, glare, and starburst) and patient satisfaction were rated subjectively by the study participants on an 11-point numerical rating scale at 1 and 6 months after surgery. For pseudophakic photic phenomena, a rating of 0 refers to the lowest (no incidence) and a rating of 10 to the most disturbing (highest subjective incidence) of these phenomena. Concerning patient satisfaction, a value of 0 relates to the lowest and a value of 10 to the highest level of satisfaction. Detailed results are shown in Tables 12. Halos were rated with 3.85 ± 2.87 (range: 0 to 10) after 1 month and with 1.90 ± 1.89 (range: 0 to 8) after 6 months. This reduction in the subjective incidence of halos was significant (P = .003, Wilcoxon signed-rank test). For glare and starburst, subjective ratings were also lower after 6 months but not statistically significant (P = .08 for glare and P = .14 for starburst).

Pseudophakic Photic Phenomena

Table 1:

Pseudophakic Photic Phenomena

Postoperative Patient Satisfaction

Table 2:

Postoperative Patient Satisfaction

Mean overall postoperative patient satisfaction was 8.75 ± 1.29 (range: 5 to 10) after 1 month and increased to 9.21 ± 0.79 (range: 8 to 10) after 6 months (P = .06, not statistically significant, paired t test). Dependence on spectacles was also rated by the study participants after 1 and 6 months, starting from 0% (no spectacles required) to 100% (spectacles required) in steps of 25%. After 1 month, one patient required spectacles for distance vision in some situations (25%). However, at the 6-month follow-up all patients reported full spectacle independence for distance, intermediate, and near vision, high levels of satisfaction, and good functional vision over a wide range of distances.

Discussion

The piggyback technique, in which at least two IOLs are implanted in the posterior chamber of the same eye, was first described by Gayton and Sanders in 1993 for the treatment of high hyperopic errors.12 Because implantation of a second IOL in the posterior chamber is usually less traumatic and associated with a lower risk of complications compared to IOL exchange, the piggyback technique was developed further as a secondary procedure to correct postoperative refractive errors.6,13–17 Safety and predictability of the supplementary IOL implantation were reported in a previous study.7 Another advantage of this method is its predictability: power calculation for the supplementary IOL depends only on the patient's current refraction.6

The first piggybacked multifocal IOLs were described by Mejía in 199918 and by Donoso and Rodríguez in 2001,19 who reported on a case series of 5 patients and concluded that piggyback implantation with a multifocal IOL was safe and efficient, with good refractive results. However, several late complications were observed with piggybacking, most importantly interlenticular opacification, which is particularly seen when both IOLs are implanted in the capsular bag.14 With the advent of new lens designs enabling implantation of supplementary IOLs in the sulcus, the incidence of interlenticular opacification was reduced. A further advantage of this approach is reversibility: a supplementary IOL can easily be explanted from the sulcus if necessary, for example if the patients are not satisfied with the multifocal solution or want to change their refraction again.6 Several more recent studies support the finding that adding multifocality via implantation of a multifocal sulcus-fixated lens is a safe option and provides visual outcomes similar to those of a multifocal capsular bag implant.8,20

The diffractive trifocal profile of the Sulcoflex Trifocal supplementary IOL is a construct of two profiles (binary and triangular) with 16 diffractive rings in a 4.5-mm central zone providing a near addition of +3.50 D, an intermediate addition of +1.75 D, and an outer monofocal distance zone at greater than 4.5 mm. A capsular bag–fixated IOL with the same diffractive design (RayOne Trifocal) has been investigated in several studies, and good visual outcomes and high patient satisfaction were reported.21,22 The Sulcoflex Trifocal supplementary lens can be employed to add trifocality in patients who had previously undergone cataract surgery, or in new patients via implantation of a primary monofocal capsular bag IOL followed by the supplementary sulcus-fixated IOL in the same procedure.

In our prospective study, 20 patients had bilateral sequential implantation of a monofocal IOL in the capsular bag and a trifocal supplementary IOL in the sulcus. Follow-up visits were scheduled 1 and 6 months after surgery. At these times, visual and refractive outcomes were evaluated, as well as subjective patient satisfaction and incidence of pseudophakic photic phenomena. In our cohort, after 6 months the mean binocular UDVA was −0.07 logMAR, the mean UIVA was −0.03 logMAR, and the mean UNVA was 0.09 logMAR, indicating high visual acuities at the measured distances and associated with complete spectacle independence of the study participants. Also, overall patient satisfaction was high (9.21 on a scale from 0 to 10, with 0 corresponding to the lowest and 10 to the highest level of satisfaction) after 6 months. At this time, the incidence of halos had a mean rating of 1.90, glare 0.45, and starburst 1.35, indicating that photic phenomena occur in some situations but are not disturbing to the patients. A limitation of this study was the lack of a control group with a capsular bag trifocal IOL bilaterally implanted to assess the differences in terms of intermediate visual quality, contrast sensitivity, and visual symptoms between the groups.

A critical issue when choosing IOLs based on diffractive optics is centration stability. Centration of the supplementary lenses has been investigated in a previous study and was found to be significantly better than centration of capsular bag–fixated IOLs.11 A possible explanation for this difference is the effect of capsular contraction on the position of the capsular bag–fixated lens. Centration stability was not methodologically tested in this study but was found to be adequate in the study sample. Figure B (available in the online version of this article) shows, as an example, a slit-lamp image taken at 6 months of follow-up showing good centration of both lenses (patient 9, right eye).

Slit-lamp photograph of the right eye of patient 9 at 6 months postoperatively showing good centration of both lenses.

Figure B.

Slit-lamp photograph of the right eye of patient 9 at 6 months postoperatively showing good centration of both lenses.

Considering the discussed advantages of sulcus-fixated trifocal IOLs (centration stability and easier exchange), the question arises whether these lenses can be used as primary (stand-alone) IOLs. However, it must be noted that several limitations and risks are associated with implanting a sulcus-fixated lens as the primary lens instead of a capsular bag implant, making this method not suitable in most cases. First, although approximation formulas are available and data concerning the geometry of the ciliary sulcus and the positioning of sulcus-fixated lenses can be obtained using ultrasound biomicroscopy,23 preoperative calculation of the dioptric power of sulcus-fixated IOLs is hampered by a lack of clinical data, particularly concerning the estimated positions of the principal planes. Further, the Sulcoflex Trifocal lens with its concave posterior shape and dioptric power range (−3.00 to +3.00 D) was designed to be implanted as a piggyback IOL rather than as a stand-alone lens. Moreover, implantation of a stand-alone sulcus-fixated IOL can affect vitreous volume and may increase the risk of capsular fibrosis (posterior capsule opacification) and macular edema. Therefore, a stand-alone lens is usually implanted in the sulcus only in cases where a lens cannot be securely placed within the capsular bag (eg, due to capsular rupture). In these cases, IOLs with large haptic diameters and posterior angulation (three-piece IOLs) should be used rather than single-piece acrylic lenses that are designed to be implanted in the capsular bag.23

Generally, explantation rates of multifocal IOLs are higher compared to monofocal IOLs, and in almost all cases the multifocal implant is replaced by a mono-focal one. Therefore, compared to implantation of a multifocal IOL in the capsular bag, this method is also a more flexible option in case of patient dissatisfaction with multifocality. If the patient develops an eye pathology in the future, where the reduced contrast of a multifocal lens affects vision, such as diabetic macular edema, age-related macular degeneration, or glaucoma, the sulcus-fixated trifocal implant can be relatively easily removed with less trauma, thereby restoring monofocal vision.

Overall, implantation of a monofocal capsular bag IOL followed by a trifocal sulcus-fixated IOL seems to be a safe method to provide good functional vision for distance, intermediate, and near, as well as high patient satisfaction.

References

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Pseudophakic Photic Phenomena

Parameter1 Month6 MonthsPa
Halos (0 to 10)
  Mean ± SD3.85 ± 2.871.90 ± 1.89.003
  Range0, 100, 8
Glare (0 to 10)
  Mean ± SD1.55 ± 2.670.45 ± 0.89.08
  Range0, 80, 3
Starburst (0 to 10)
  Mean ± SD2.30 ± 2.721.35 ± 2.01.14
  Range0, 80, 8

Postoperative Patient Satisfaction

Parameter1 Month6 MonthsPa
Overall (0 to 10)
  Mean ± SD8.75 ± 1.299.21 ± 0.79.06
  Range5, 108, 10
Distance (0 to 10)
  Mean ± SD8.70 ± 1.429.00 ± 1.05.18
  Range5, 107, 10
Intermediate (0 to 10)
  Mean ± SD8.85 ± 1.469.00 ± 1.29.53
  Range5, 105, 10
Near (0 to 10)
  Mean ± SD8.50 ± 1.479.05 ± 1.03.48
  Range5, 107, 10

Patient Demographics, Primary Lens, and Dioptric Power

PatientPrimary LensPrimary IOL Power (D) (Left/Right)
1Acrysof SA60AT14.00 / 14.00
2Acrysof SA60AT17.50 / 17.50
3RayOne RAO100C21.50 / 22.00
4AMO Z900223.50 / 22.50
5Acrysof SA60AT20.50 / 20.00
6Acrysof SA60AT22.50 / 23.00
7Acrysof SA60AT22.50 / 22.50
8RayOne RAO100C10.50 / 14.50
9AMO Z900222.00 / 22.00
10RayOne RAO100C21.00 / 20.00
11RayOne RAO100C20.00 / 20.00
12RayOne RAO100C14.00 / 14.50
13RayOne RAO100C21.00 / 21.00
14RayOne RAO100C17.50 / 18.00
15Acrysof SA60AT21.00 / 20.50
16RayOne RAO100C21.00 / 21.50
17RayOne RAO100C23.00 / 23.00
18RayOne RAO100C10.00 / 10.50
19RayOne RAO100C24.50 / 24.00
20RayOne RAO100C15.50 / 15.50

Postoperative Visual Acuity

Parameter1 Month6 Months


LeftRightBothLeftRightBoth
UDVA (logMAR)
  Mean ± SD0.03 ± 0.070.02 ± 0.06−0.07 ± 0.070.02 ± 0.050.01 ± 0.05−0.07 ± 0.06
  Range−0.1, 0.2−0.1, 0.1−0.2, 0.0−0.1, 0.1−0.1, 0.1−0.2, 0.0
CDVA (logMAR)
  Mean ± SD0.01 ± 0.060.00 ± 0.05−0.08 ± 0.070.01 ± 0.040.01 ± 0.04−0.07 ± 0.06
  Range−0.1, 0.1−0.1, 0.1−0.2, 0.0−0.1, 0.1−0.1, 0.1−0.2, 0.0
UIVA (logMAR)
  Mean ± SD0.00 ± 0.17−0.03 ± 0.17
  Range−0.2, 0.6−0.1, 0.6
CIVA (logMAR)
  Mean ± SD−0.04 ± 0.08−0.07 ± 0.07
  Range−0.2, 0.1−0.1, 0.1
UNVA (logMAR)
  Mean ± SD0.12 ± 0.090.09 ± 0.08
  Range−0.1, 0.2−0.1, 0.2
CNVA (logMAR)
  Mean ± SD0.12 ± 0.090.09 ± 0.08
  Range−0.1, 0.2−0.1, 0.2
Authors

From Sigmund Freud University, Faculty of Medicine, Vienna, Austria (GK, CB, MA); and the Austrian Center for Medical Innovation and Technology, Wiener Neustadt, Austria (ND, WB).

Supported by the Austrian Center for Medical Innovation and Technology (ACMIT), which is funded within the scope of the Competence Centers for Excellent Technologies (COMET) program and by the federal government of Austria and the governments of Lower Austria and Tyrol. The competence center program COMET is managed by the Austrian Funding Agency FFG.

Dr. Amon is a paid consultant for Rayner Intraocular Lenses Limited. The remaining authors have no financial or proprietary interest in the materials presented herein.

AUTHOR CONTRIBUTIONS

Study concept and design (GK, MA); data collection (GK, CB); analysis and interpretation of data (GK, ND, WB, CB); writing the manuscript (GK, ND, WB, CB); critical revision of the manuscript (GK, ND, WB, MA); statistical expertise (ND, WB); supervision (MA)

Correspondence: Guenal Kahraman, MD, Department of Ophthalmology, Academic Teaching Hospital of St. John, Johannes-von-Gott Platz 1, 1020 Vienna, Austria. Email: kahraman@gmx.at

Received: July 16, 2020
Accepted: November 23, 2020

10.3928/1081597X-20201215-01

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