Tolerance to lens tilt and decentration of two multifocal intraocular lenses: using the quick contrast sensitivity function method

This retrospective study was approved by the institutional review board of the Eye & Ear, Nose, and Throat (ENT) Hospital of Fudan University, Shanghai, China, and was registered at www.clicicaltrials.gov (accession number NCT02182921). All procedures adhered to the tenets of the Declaration of Helsinki. All participants provided written informed consent before cataract surgery for the use of their clinical data.

Subjects

Patients underwent uneventful cataract surgery with a trifocal IOL (Zeiss AT LISA tri 839MP, Carl Zeiss, Germany) or an EDOF IOL (Tecnis Symfony ZXR00, Johnson & Johnsons, USA) implantation and were continuously recruited from the Eye & ENT Hospital of Fudan University between September 1, 2021, and February 1, 2022. Eyes with corneal pathologies including glaucoma, uveitis, zonular weakness, strabismus, retinal pathologies, had intraoperative or postoperative complications, previous trauma or surgeries, and incomplete clinical data were excluded. One eye was randomly selected if both eyes met the criteria. Finally, a total of 136 eyes from 136 patients were included, with 72 eyes implanted with the 839MP IOL and 64 eyes implanted with the ZXR00 IOL. Eyes with axial length > 24.5 mm were defined as myopic eyes, and eyes with axial length ≤ 24.5 mm were defined as non-myopic eyes.

Preoperative examinations

All patients received complete ophthalmic examinations before the operation, including visual acuity assessment, slit lamp examination, fundoscopy, B-scan ultrasonography, corneal topography (Pentacam HR, Oculus Optikgeräte, Wetzlar, Germany), and axial length (AL) measurements (IOLMaster 700, Carl Zeiss AG, Oberkochen, Germany).

Surgical procedure

All the surgeries were performed by a single, experienced surgeon (XZ) using the standard procedure. A 2.6 mm clear corneal incision was made temporally before a 5.5 mm continuous curvilinear capsulorhexis, hydrodissection, and phacoemulsification. The IOL was implanted in the capsular bag and adjusted to the center. A capsular tension ring was inserted in eyes with AL > 28.0 mm to keep the actual effective lens position. After thorough removal of the viscoelastic, the incision was hydrated. All patients were prescribed with routine postoperative medications, including 0.5% levofloxacin (Cravit, Santen, Japan), 1% prednisolone acetate (Pred Forte, Allergan, Ireland), and pranoprofen (Pranopulin, Santen, Japan) eye drops.

Postoperative examinations

One month after surgery, all patients underwent ophthalmic examinations, including visual acuity assessment, CSF measurement, and IOL tilt and decentration evaluation.

Uncorrected distance, intermediate and near visual acuity [UDVA, UIVA, UNVA, logarithm of the minimal angle of resolution (logMAR)] and corrected distance visual acuity (CDVA, logMAR) were recorded monocularly at 4 m, 60 cm and 40 cm, respectively, using an Early Treatment Diabetic Retinopathy Study (ETDRS) chart (Wehen Vision Technology Co., Ltd, Guangzhou, China) at high contrast (96%) under photopic conditions (85 cd/m2).

CSF was measured using the qCSF procedure on the Manifold Contrast Vision Meter (Adaptive Sensory Technology, San Diego, CA, USA), a novel computerized method for assessing contrast sensitivity. The platform consisted of a 46″ light emitting diode (LED) screen of 1920 × 1080 pixels, calibrated to 90 cd/m2 background luminance. At a viewing distance of 3 m, under mesopic conditions (3 cd/m2), the screen displays three bandpass-filtered Sloan numeric optotypes at a time. Patients wearing best-correcting spectacles were asked to patch the non-test eye. Patients’ responses (correct, incorrect, or number not seen) were recorded by a trained operator using a mobile phone for each number [16]. During 25 triplets, the qCSF distributes testing across a wide range of contrast (0.002% to 100%) and spatial frequencies [from 1 to 27 cycle per degree (cpd)] using a Bayesian optimal strategy to best predict the CSF shape [17]. Test results, including the area under the log CSF (AULCSF), CSF acuity (spatial frequency where threshold contrast is 100%), and CS at 1, 1.5, 3, 6, 12, 18 cpd, were recorded and used for analysis.

IOL tilt and decentration were evaluated using an optical aberrometer (OPD-Scan III, NIDEK, Japan). The tilt of the IOL was obtained directly from the aberrometer in the wavefront mode under a 4.0 mm pupil diameter, following pupil dilation with a mixture of 0.5% phenylephrine and 0.5% tropicamide (1% Mydrin-P, Santen, Japan). The overall decentration was the distance between the center of the multifocal IOL (also the center of diffractive rings) and the visual axis in the retrobulbar illumination analysis mode, which was then decomposed into horizontal and vertical decentrations. Positive values indicated the nasal and superior decentration, while negative values indicated the opposite decentration. More detailed description about the measurement of IOL tilt and decentration can be found in our previous report [18].

Statistical analysis

Quantitative data were expressed as mean ± standard deviations (SD) and compared using the Student’s t-test. Categorical data were displayed as proportions and compared using the χ2 test. Correlations between CSF parameters and IOL tilt, IOL decentration or age were assessed using the Pearson’s correlation analysis. Backward stepwise multiple linear regression analyses were performed for predictors of CS at 1, 6 and 18 cpd. A P value < 0.05 was considered statistically significant. All analyses were performed using SPSS (version 20.0, IBM Corp., New York, US).

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