Implantable collamer lenses (ICLs) are preferred for correcting diverse refractive errors, effectively preserving accommodative function, and minimizing corneal complications.1,2 However, despite their significant efficacy in mitigating moderate to high myopia, a notable number of patients experience nocturnal visual disturbances following the procedure. These disturbances, including glares and halos, have the potential to reduce postoperative satisfaction.3

As a relevant concept, mainly in ophthalmology, glare disability is identified as the decreased visibility of objects due to reduced contrast in retinal images, often attributed to the dispersion of intraocular scattered light (straylight).4–7 The current clinical landscape lacks a standardized procedure for glare diagnosis. Subjective methods, such as psychometric questionnaires, present an extensive scale to evaluate glare symptoms. These are complemented by objective techniques that integrate contrast sensitivity tests and glare sources to emulate real-world scenarios.8,9

Theoretically, a potential correlation exists between the occurrence of glare and variation in mesopic pupil size, particularly during pupil dilation, especially during nocturnal periods.10 Although traditional guidance suggests considering preoperative pupil size in refractive surgery, existing data, including studies on ICLs V4c (with the largest optical zone of 5.8 mm) and corneal refractive surgeries with ablation zones of <6.0 mm, reveal conflicting evidence on mesopic pupil dimensions as a sole determinant for glare disability.11–14 This ambiguity leads to the hypothesis that other factors, such as refractive status in mesopic conditions, may play a significant role in post-ICL glare disability.

Hence, this study aimed to broaden the analysis of the connection between ICL implantation and postoperative glare by integrating pupil-centered ocular metrics. This approach enhances the distinction between populations experiencing glare and those without the condition, using a combination of subjective and objective evaluations.

METHODS Patients

In this prospective study, we collected and reviewed the preoperative ocular parameters and postoperative glare status of patients who underwent ICL V4c implantation at the Second Affiliated Hospital of Nanchang University between January 2022 and September 2022, at 6 months postoperatively. This study was approved by the Ethics Committee of the Second Affiliated Hospital of Nanchang University and was conducted in accordance with the tenets of the Declaration of Helsinki. Ethics approval was obtained from the Ethics Committee of the Second Affiliated Hospital of Nanchang University ([2021] No. (113)) and registered at ClinicalTrials.gov (NCT05658718).

We included patients with the following characteristics: (1) age ≥18 years; (2) myopia with spherical error of −0.50 to −18.0 diopters (D), cylinder of ≤6.0 D, and stable refractive power (≤0.50 D change per year); (3) corrected distance visual acuity (CDVA) of ≥20/25 before ICL implantation, minimum anterior chamber depth of ≥2.8 mm, and endothelial cell density of ≥2000 cells/mm2; and (4) at the 6-month follow-up, within 5.0 degrees tilt and 0.5 mm decentration of ICL based on a Scheimpflug image.15

The exclusion criteria comprised (1) history of ocular trauma or surgery; (2) suspected keratoconus, severe dry eye disease, and previous or active ocular diseases (corneal inflammation or edema, glaucoma, cataract, amblyopia, etc); and (3) systemic diseases, such as central neurological diseases, hyperthyroidism, autoimmune diseases, and mental disorders, such as severe anxiety and depression.

Preoperative Examination

Before surgery, the patients underwent a complete ophthalmologic examination, including uncorrected distance visual acuity (UDVA), CDVA, objective refraction (Auto Refractometer, ARK-510A, Nidek Co., Ltd.), manifest and cycloplegic refraction, slitlamp microscopy, fundoscopic examination, endothelial cell density measured through an automated specular microscopy (CEM530, Nidek Co., Ltd.), and intraocular pressure measured with a computerized tonometer (CT-80A, Topcon Corp.).

Measurements of the anterior segment, including the horizontal corneal diameter, central keratometry, and central corneal thickness, were performed using a corneal topographer (Pentacam HR, Oculus Optikgeräte GmbH), and the anterior chamber depth and sulcus-to-sulcus distance were measured using an ultrasound biomicroscope (MD-300L, Tianjin Suowei Electronic Technology Co., Ltd.). Pupil size and pupillary refractive parameters were measured under mesopic illuminance (3.5 lux), photopic illuminance (125.6 lux), and central conditions (125.6 lux, with a pupil diameter of 2.3 mm) using an OPDScan III (Nidek Co., Ltd.) in a dark room (2 lux). The specific protocol for accuracy and repeatability was as follows: (1) expose the participants to normal room lighting (56 lux) for 1 min, followed by 2 min of dark adaptation (2 lux); (2) the measurement was taken 3 times, and the intermediate value of pupil size differences was <0.50 mm; and (3) the displayed corneal topography confirmation area was required to be ≥21 rings.

Surgical Technique

Under ocular surface anesthesia, the ICL was inserted through a 3.0 mm clear corneal incision using the manufacturer's injector cartridge (STAAR Surgical Co.). The anterior chamber was filled with a standard amount of viscoelastic surgical agent (Amvisc, Bausch & Lomb, Inc.), and the ICL was adjusted into the posterior chamber. After ensuring the proper placement of the ICL in the posterior chamber, the viscoelastic agent was thoroughly flushed. Antibiotics, corticosteroids, and nonsteroidal anti-inflammatory eyedrops were routinely administered to prevent postoperative inflammation. All surgical procedures were performed by the same experienced surgeon (Y.Y.).

Postoperative Examination and Glare Reference Standard

Glare disability was defined as both a glare symptom score of >6 determined by a questionnaire and a glare sensitivity at a contrast level of >1:2.7 (the inspection threshold was derived from the Quality Assurance Commission of the German Ophthalmological Society [DOG]) determined by a Binoptometer 4P (Oculus Optikgeräte GmbH).16 Conversely, the nonglare group was defined as both a glare symptom score of ≤6 and a glare sensitivity at a contrast level of ≤1:2.7.

A binoptometer 4P was used to measure the glare sensitivity across 4 distinct contrast levels (1:23, 1:5, 1:2.7, and 1:2), with 1:23 being the easiest to discern, simulating the glare conditions typically encountered on a nighttime roadway. The optotype characters were displayed on a test field with a luminance of 0.1 cd/m2.17

The patients who underwent ICL surgery were asked to evaluate their current glare symptoms according to frequency (never [0 score], occasionally [1 score], fairly frequently [2 score], and very frequently [3 score]); severity (none at all [0 score], mild [1 score], moderate [2 score], and severe [3 score]); and bothersome effect (none at all [0 score], somewhat bothered [1 score], fairly bothered [2 score], and very bothered [3 score]) based on the Quality-of-Vision (QoV) questionnaire.11,18,19 Higher scores indicated more severe glare symptoms. The total score for glare symptoms was calculated by summing the scores of the included items. The glare symptom scores did not follow a normal distribution; therefore, we dichotomized the overall glare symptom score using a median score of 6 as the cutoff value. Scores of 6 and below were categorized as “without glare disability symptoms,” while scores above 6 were classified as “with glare disability symptoms.”

Statistical Analysis

Statistical analyses were performed using SPSS (v. 25.0, IBM Corp.). To compare the sociodemographic data between patients with and without glare, the Kolmogorov-Smirnov test was used for continuous variables and the mean ± SD was used for categorical variables. Data are presented as frequencies and percentages. For comparative analyses of glare and nonglare variables, both the chi-square test and independent sample t tests were applied. Univariate regression was used to explore risk factors associated with glare. Subsequently, stepwise regression was used for the multivariate model construction. In the model, odds ratios and their corresponding CIs were used for characterization, and the associated P-values reflected the results of hypothesis testing. Pearson correlation was used for variable interrelations and the identification of independent risk factors for glare. Statistical significance was set at P < .05.

RESULTS

The characteristics of the study participants are summarized in Table 1. Of the 187 eyes analyzed, 99 (53%) evidenced glare disabilities. In the total sample, the implanted ICL V4c sizes were 12.1 mm in 49 eyes, 12.6 mm in 81 eyes, and 13.2 mm in 57 eyes. Specifically, in the glare disability group, the sizes were 12.1 mm in 22 eyes, 12.6 mm in 43 eyes, 12.6 mm in 43 eyes, and 13.2 mm in 34 eyes. In the nonglare group, the sizes were 12.1 mm in 27 eyes, 12.6 mm in 38 eyes, and 13.2 mm in 23 eyes. Regarding pupil size, the mean photopic and mesopic measurements were 4.89 ± 0.92 and 6.70 ± 0.87 mm, respectively. Spherical and cylindrical powers were also assessed under various lighting conditions; for mesopic, photopic, and central pupils (2.3 mm diameter), the mean spheres were −9.42 ± 2.87 D, −9.51 ± 2.67 D, and −8.83 ± 2.54 D, respectively, while the mean cylinders were −1.64 ± 1.29 D, −1.38 ± 1.1 D, and −1.22 ± 0.98 D, respectively.

Table 1. - Demographic and clinicopathological characteristics Characteristic Sex (M/F) 30/65 Age (y) 26.04 ± 6.29 Glare disability (yes/no) 99/88 WTW (mm) 11.63 ± 0.38 K flat (D) 43.11 ± 1.43 K steep (D) 44.62 ± 1.61 ACD (mm) 3.37 ± 0.26 ICL sphere (D) −9.98 ± 3.42 ICL cylinder (D) 0.58 ± 1.06 Photopic pupil size (mm) 4.89 ± 0.92 Mesopic pupil size (mm) 6.70 ± 0.87 Central sphere (D) −8.83 ± 2.54 Central cylinder (D) −1.22 ± 0.98 Pupillary offset (mm) 0.15 ± 0.31 Sphere on photopic pupil (D) −9.51 ± 2.67 Cylinder on photopic pupil (D) −1.38 ± 1.11 HOAs on photopic pupil (μm) 0.38 ± 0.75 Sphere on mesopic pupil (D) −9.42 ± 2.87 Cylinder on mesopic pupil (D) −1.64 ± 1.29 HOAs on mesopic pupil (μm) 0.65 ± 0.85

ACD = anterior chamber depth; K = keratometric value

Data were presented as means ± SDs or numbers

Visual and Refractive Outcomes

Six months postsurgery, 95% of the eyes treated with ICL implantation achieved a UDVA of 20/20 or better, whereas 100% of the eyes achieved a UDVA equal to or better than the CDVA and an unchanged or better postoperative CDVA (Figure 1, A–C). The scatterplot presented in Figure 1, D illustrates good refractive predictability between the attempted and achieved standard error (SE) corrections. The surgical predictability (achieved SE of attempted correction) was 94% within ±1.0 D (Figure 1, E). Regarding astigmatism correction, 99% of the treated eyes had postoperative astigmatism less than or equal to 1 diopter (Figure 1, F).

Figure 1.:

Graphs for reporting average refractive surgery outcomes 6 months after implantable collamer lens. (A) UDVA; (B) efficacy; (C) change in CDVA; (D) attempted vs SEQ; (E) SEQ refractive accuracy; and (F) refractive astigmatism. SEQ = spherical equivalent

Univariable and Multivariate Analyses of Glare After ICL Implantation Surgery

Based on univariate analysis, Table 2 listed the preoperative variables, including corneal white-to-white (P = .037), flat K (P = .004), photopic pupil size (P = .022), mesopic pupil size (P = .004), central cylinder (P = .043), cylinder on photopic pupil (P = .005), sphere on mesopic pupil (P = .014), and cylinder on mesopic pupil (P = .010), which were statistically associated with postoperative glare (P < .05).

Table 2. - Univariate analysis of glare disability after ICL implantation Factors Glare disability 95% CI P value Yes No Sex (M/F) 31/68 27/61 — .926 Age (y) 26.74 ± 6.66 25.24 ± 5.83 −0.317 to 3.314 .101 WTW (mm) 11.68 ± 0.37 11.57 ± 0.37 0.007 to 0.223 .037* K flat (D) 42.83 ± 1.29 43.44 ± 1.53 −1.018 to −0.203 .004* K steep (D) 44.45 ± 1.60 44.81 ± 1.60 −0.827 to 0.096 .120 Anterior chamber depth (mm) 3.34 ± 0.30 3.29 ± 0.33 −0.040 to 0.142 .268 ICL size (mm) 12.71 ± 0.42 12.63 ± 0.43 −0.045 to 0.200 .215 ICL sphere (D) −10.06 ± 4.21 −9.89 ± 2.27 −1.168 to 0.819 .730 ICL cylinder (D) 0.68 ± 1.25 0.40 ± 0.82 −0.029 to 0.576 .076 Photopic pupil size (mm) 5.02 ± 0.92 4.71 ± 0.70 0.044 to 0.570 .022* Mesopic pupil size (mm) 6.87 ± 0.84 6.50 ± 0.88 0.117 to 0.615 .004* Central sphere (D) −9.12 ± 2.65 −8.50 ± 2.38 −1.354 to 0.106 .093 Central cylinder (D) −1.36 ± 1.13 −1.07 ± 0.76 −0.561 to −0.010 .043* Pupillary offset (mm) 0.17 ± 0.41 0.13 ± 0.13 −0.054 to 0.126 .432 Sphere on photopic pupil (D) −9.87 ± 2.78 −9.11 ± 2.49 −1.525 to 0.005 .051 Cylinder on photopic pupil (D) −1.59 ± 1.32 −1.14 ± 0.75 −0.750 to −0.137 .005* HOAs on photopic pupil (μm) 0.29 ± 0.29 0.30 ± 1.08 −0.232 to 0.212 .928 Sphere on mesopic pupil (D) −9.91 ± 2.92 −8.88 ± 2.74 −1.849 to −0.210 .014* Cylinder on mesopic pupil (D) −1.86 ± 1.46 −1.38 ± 1.01 −0.835 to −0.117 .010* HOAs on mesopic pupil (μm) 0.67 ± 0.69 0.58 ± 1.10 −0.168 to 0.355 .481

K = keratometric value

The chi-square test and independent sample t test were performed for glare and nonglare variables

*Statistically significant

Through multivariate analysis, the variables that retained significance included mesopic pupil size (β = 0.561, P = .005), sphere (β = −0.124, P = .039), and cylinder (β = −0.412, P = .009) under mesopic pupil conditions (Table 3). In addition, the cylinder under photopic pupil conditions (β = −0.430, P = .007) remained significant. However, corneal white-to-white, photopic pupil size, central cylinder, and cylinder under mesopic pupil conditions were no longer significantly associated with postoperative glare. Pearson correlation analysis was used to investigate potential interactions between pupil size and refractive parameters; all correlation coefficients were <0.1 (Table 4).

Table 3. - Multivariate analysis of glare disability after ICL surgery Factors β Z value P value Mesopic pupil size (mm) 0.561 2.799 .005* Cylinder on photopic pupil (D) −0.430 −2.691 .007* Cylinder on mesopic pupil (D) −0.412 −2.611 .009* Sphere on mesopic pupil (D) −0.124 −2.066 .039*

β = standardized regression coefficients

The model used a multiple stepwise regression method

*Statistically significant

Table 4. - Pearson correlation analysis of risk factors Factors Photopic pupil Mesopic pupil Sphere on photopic pupil Cylinder on photopic pupil Sphere on mesopic pupil Cylinder on mesopic pupil Central sphere Central cylinder Photopic pupil (mm) 1 Mesopic pupil (mm) 0.711* 1 Sphere on photopic pupil (D) 0.033 0.054 1 Cylinder on photopic pupil (D) −0.078 −0.093 −0.119 1 Sphere on mesopic pupil (D) −0.036 −0.050 0.945* −0.114 1 Cylinder on mesopic pupil (D) −0.017 −0.064 0.005 0.757 −0.091 1 Central sphere (D) 0.095 0.148 0.968* −0.124 0.884* 0.005 1 Central cylinder (D) 0.070 −0.006 −0.134 0.762* −0.153 0.681* −0.136 1

Pearson correlation analysis was used to investigate the relationships between the risk factors. The values in the table are correlation coefficients (r).

*Significantly correlated at the 0.05 level (2-sided)

DISCUSSION

To further elucidate the postoperative glare, we examined the relationship between biometric and ICL-related parameters. The findings of this study highlight that glare manifestation after ICL implantation is closely correlated with various preoperative pupillary attributes. Notably, the evaluation of sphere and cylinder values under mesopic conditions has emerged as an essential factor. Moreover, the nuanced relationship between the mesopic pupil characteristics and cylindrical assessments conducted under photopic pupil conditions enhances the prospect of a refined strategy in preoperative assessments, potentially nurturing superior results in future surgical endeavors.

Glare disability reduces visual contrast, impairs vision owing to stray light, and offers no visual benefit.20 It typically occurs due to exposure to sunlight, nighttime headlights, and streetlights in everyday scenarios. To preliminarily assess these symptoms, patient-reported outcome questionnaires are used and are essential for evaluating refractive error domains, including those after refractive surgery.8,9,12 One such questionnaire, the QoV, includes 30 items for 10 visual symptoms (eg, glare, halos, and starbursts) and strongly correlates with visual acuity and contrast sensitivity after refractive surgery.21 Clinical glare tests aim to emulate these regular conditions, using contrast sensitivity or visual acuity evaluations under glare exposure. For instance, the Binoptometer 4P quantifies glare sensitivity across various contrast levels.16,17,22 However, after over 2 decades of research, the test outcomes remain inconsistent without a standardized protocol.6 In our efforts to streamline clinical research, we defined the notion of “glare disability” based on psychophysical tests (Binoptometer 4P) and subjective surveys (glare symptoms questionnaire). This approach aimed to define this elusive concept with greater precision.

The impact of mesopic pupil size on glare after refractive surgery remains contentious, whereas the singular role of pupil size has been debated with conflicting reports.11–14 In our study, a larger preoperative mesopic pupil was identified as a potential risk factor for postoperative glare disability after ICL implantation. This can be explained using geometric optics: one from the central light rays through the optical zone and the other from the peripheral ICL, resulting in an out-of-focus image of the retina-caused glare. Studies have reported that glare occurs when the pupil diameter is larger than the optical zone of the lens.23 However, other studies have suggested that a larger mesopic pupil does not always result in glare.11 Clinical observations also indicate that glare symptoms do not always manifest when the pupil size exceeds the optical zone of the ICL.24

A key finding of our study was that a high degree of sphericity under mesopic conditions was associated with postoperative disabling glare. Glare disability occurs when stray light from the ocular media causes illumination from peripheral glare sources to reach the central retinal area. This phenomenon results in “equivalent veiling luminance,” which diminishes the contrast of the target to be discerned. The veiling luminance caused by straylight varies with the brightness of the glare sources and their angular distances from the visual axis, as described by the Holladay-Stiles equation.6 In the mesopic state, we hypothesized that a pronounced mesopic sphere directs stray light originating from the cornea and lens at wider angles. Simultaneously, a sizably mesopic pupil covers a broad, uncorrected area outside the optical zone of the ICL. This leads to substantial veiling illuminance superimposed on the retinal image, reducing retinal contrast, and affecting target clarity in the retina (Figure 2).

Figure 2.:

Diagram simulating straylight from the glare source to reach the central retinal area in different pupil states after intraocular implantable collamer lens implantation. (A) Mild mesopic sphere on photopic pupil; (B) moderate glare on mesopic pupil; (C) severe glare on mesopic pupil with higher spherical power; and (D) night vision in a patient with glare disability.

Preoperative factors were significantly correlated with postoperative glare, as identified by multivariate analysis, including cylinders on the photopic and mesopic pupils. However, the cylinder on the central pupil (2.3 mm diameter) did not show any significant difference. Few studies have discussed the impact of preoperative astigmatism on post-ICL surgery glare particularly because astigmatism values from objective refraction are typically addressed during ICL procedures. Notably, autorefractometers such as Nidek's ARK-530A/ARK-510A have a limited ability to analyze pupil diameters of ≤4 mm. This means they fail to cover both the photopic (averaging 4.89 ± 0.92 mm) and mesopic (averaging 6.70 ± 0.87 mm) pupil zones.

In mesopic conditions, the eye exhibits greater overall astigmatism (mean preoperative diopter in Table 1: 1.64 ± 1.29 D for mesopic pupils, −1.38 ± 1.11 D for photopic pupils, and −1.22 ± 0.98 D for central pupils), which may not be entirely corrected because addressing astigmatism in the central pupil area is often a therapeutic goal. Kobashi et al. found that eyes with larger pupils often exhibited reduced optical quality when astigmatic.25 Our study also highlights that astigmatism under photopic pupil conditions is a risk factor for postoperative glare, potentially explaining daytime glare complaints in some patients.

In this study, the univariate analysis revealed that a large corneal white-to-white ratio and large photopic pupil size were associated with postoperative glare; a significant difference was no longer observed in the multivariate analysis. Lim et al. found that corneal white-to-white was not a risk factor for ICL-postoperative glare, which is consistent with our results.5 For the ICL V4c, the largest optical zone of 5.8 mm was sufficient to cover the photopic pupil zone, which may explain why the photopic pupil size was not relevant to glare.

The strengths of our study include its prospective design, relatively comprehensive evaluation of pupils under different lighting conditions and their refractive statuses, relatively long follow-up period (6 months postoperatively), and standardized protocols for glare disability identification. However, our study has some limitations. First, it consisted of participants of Asian descent, mainly aged between 20 and 30 years, with high myopia. This could introduce selection bias due to the loss of follow-up and residual bias due to unmeasured confounding factors. Future studies should include a more diverse range of age groups to provide clearer insights into glare after ICL surgery. In addition, multicenter studies involving broader populations could help develop predictive models for glare disability. Second, we studied the conventional V4c model (VICMO) with an optic diameter of 4.9 to 5.8 mm and focused exclusively on the dioptric power (sphere) of the EVO ICL because it is collinear with the optic diameter that varies with dioptric power. Notably, the larger optic diameter (5.0 to 6.1 mm) of the V5 model (VICM5) may improve night vision performance; however, further research is needed to understand its influencing factors. Furthermore, the differences in night vision disturbances in patients after refractive surgery may require specific precautionary guidelines. We anticipate a move toward a risk-adjusted approach by applying these guidelines to high-level research.

In summary, our findings underscore the significant correlation between mesopic pupil size, associated refractive parameters (spheres and cylinders), and the incidence of glare disability after ICL surgery. This enhanced our understanding of pupillary metrics. Moreover, this study refined the conceptual framework surrounding “glare disability” by merging subjective experiences with objective visual evaluations, potentially paving the way for a more accurate delineation.WHAT WAS KNOWN Although existing research has identified various risk factors for night vision disturbances after ICL surgery, the specific role of the mesopic pupil size remains unclear. Current clinical practice lacks a uniform protocol for glare diagnosis, even when using subjective assessments such as psychometric scales, and objective measures such as contrast sensitivity tests, which aim to emulate real-world conditions.

WHAT THIS PAPER ADDS The correlation between mesopic pupil dimensions, associated refractive metrics (spheres and cylinders), and glare disability after ICL surgery has the potential to advance our understanding of pupillary metrics. The conceptual framework of “glare disability,” which integrates the patient-reported outcome questionnaire and contrast sensitivity evaluation, may facilitate the definition of this elusive concept with greater precision. REFERENCES 1. Montés-Micó R, Pastor-Pascual F, Artiaga-Elordi E, Ruiz-Mesa R, Tañá-Rivero P. In vivo optical quality of posterior-chamber phakic implantable collamer lenses with a central port. Eye Vis (Lond) 2021;8:30 2. Chen D, Zhao X, Chou Y, Luo Y. Comparison of visual outcomes and optical quality of femtosecond laser-assisted SMILE and Visian implantable collamer lens (ICL V4c) implantation for moderate to high myopia: a meta-analysis. J Refract Surg 2022;38:332–338 3. Mohr N, Dirisamer M, Siedlecki J, Mayer WJ, Schworm B, Harrant L, Priglinger SG, Luft N. Determinants of subjective quality of vision after phakic intraocular lens implantation. J Refract Surg 2022;38:280–287 4. Piñero DP, Ortiz D, Alio JL. Ocular scattering. Optom Vis Sci 2010;87:E682–E696 5. Lim DH, Lyu IJ, Choi SH, Chung ES, Chung TY. Risk factors associated with night vision disturbances after phakic intraocular lens implantation. Am J Ophthalmol 2014;157:135–141.e1 6. Mainster MA, Turner PL. Glare's causes, consequences, and clinical challenges after a century of ophthalmic study. Am J Ophthalmol 2012;153:587–593 7. Fan-Paul NI, Li J, Miller JS, Florakis GJ. Night vision disturbances after corneal refractive surgery. Surv Ophthalmol 2002;47:533–546 8. Martínez-Plaza E, López-Miguel A, López-de la Rosa A, McAlinden C, Fernández I, Maldonado MJ. Effect of the EVO+ Visian phakic implantable collamer lens on visual performance and quality of vision and life. Am J Ophthalmol 2021;226:117–125 9. Martínez-Plaza E, López-Miguel A, López-de la Rosa A, McAlinden C, Fernández I, Maldonado MJ. EVO+ implantable collamer lens KS-aquaPORT location, stability, and impact on quality of vision and life. J Refract Surg 2022;38:177–183 10. Siedlecki J, Schmelter V, Schworm B, Mayer WJ, Priglinger SG, Dirisamer M, Luft N. Corneal wavefront aberrations and subjective quality of vision after small incision lenticule extraction. Acta Ophthalmol 2020;98:e907–e913 11. Du H, Zhang B, Wang Z, Xiong L. Quality of vision after myopic refractive surgeries: SMILE, FS-LASIK, and ICL. BMC Ophthalmol 2023;23:291 12. Martínez-Plaza E, López-Miguel A, Fernández I, Blázquez-Arauzo F, Maldonado MJ. Effect of central hole location in phakic intraocular lenses on visual function under progressive headlight glare sources. J Cataract Refract Surg 2019;45:1591–1596 13. Schallhorn S, Brown M, Venter J, Hettinger K, Hannan S. The role of the mesopic pupil on patient-reported outcomes in young patients with myopia 1 month after wavefront-guided LASIK. J Refract Surg 2014;30:159–165 14. Myung D, Schallhorn S, Manche EE. Pupil size and LASIK: a review. J Refract Surg 2013;29:734–741 15. Wang Y, Yang R, Huang Y, Zhang C, Liu H, Jia Z, Zhao S. ICL postimplantation decentration and tilt in myopic patients with primary iridociliary cysts. J Ophthalmol 2023;2023:3475468 16. Wilhelm H, Peters T, Durst W, Roelcke S, Quast R, Hütten M, Wilhelm B. Assessment of mesopic and contrast vision for driving licences: which cut-off values, which methods are appropriate? [in German]. Klin Monbl Augenheilkd 2013;230:1106–1113 17. Bai Z, Nie D, Zhang J, Hu H, Sun L, Zeng K, Wang J, Liu X. Visual function assessment of posterior-chamber phakic implantable collamer lenses with a central port. Ann Transl Med 2022;10:194 18. McAlinden C, Pesudovs K, Moore JE. The development of an instrument to measure quality of vision: the Quality of Vision (QoV) questionnaire. Invest Ophthalmol Vis Sci 2010;51:5537–5545 19. Adrian J, Hue D, Porte S, Le Brun J. Validation of the driver ecological glare test. J Safety Res 2020;72:139–143 20. Vos JJ. Reflections on glare. Light Res Technol 2003;35:163–176 21. Kandel H, Khadka J, Lundström M, Goggin M, Pesudovs K. Questionnaires for measuring refractive surgery outcomes. J Refract Surg 2017;33:416–424 22. Aslam TM, Haider D, Murray IJ. Principles of disability glare measurement: an ophthalmological perspective. Acta Ophthalmol Scand 2007;85:354–360 23. Dick HB, Aliyeva S, Tehrani M. Change in pupil size after implantation of an iris-fixated toric phakic intraocular lens. J Cataract Refract Surg 2005;31:302–307 24. Anderson HA, Ravikumar A, Benoit JS, Marsack JD. Impact of pupil diameter on objective refraction determination and predicted visual acuity. Transl Vis Sci Technol 2019;8:32 25. Kobashi H, Kamiya K, Yanome K, Igarashi A, Shimizu K. Effect of pupil size on optical quality parameters in astigmatic eyes using a double-pass instrument. Biomed Res Int 2013;2013:124327