Intraocular lens (IOL) tilt and decentration are important risk factors for the deterioration of visual quality after cataract surgery. Previous studies have found that IOL tilt larger than 7 degrees or decentration greater than 0.4 mm impact the postoperative visual quality of patients by inducing larger higher-order aberrations (HOAs), especially for multifocal IOL and toric IOLs.1–4 Thus, tilt ≥7 degrees and decentration ≥0.4 mm were defined as clinically significant IOL tilt and decentration.5 Therefore, it is important to evaluate the risk factors of clinically significant IOL tilt and decentration and build a model to predict the risk for clinically significant IOL tilt and decentration for personalized choice of IOL.

Several studies have found that the magnitude and the direction of tilt and decentration of postoperative IOLs were strongly correlated with the position of preoperative crystalline lenses.6 Therefore, the tilt and decentration of crystalline lenses can be used to predict postoperative IOL position.7 Moreover, axial length (AL) was also confirmed to be negatively related to IOL tilt and positively related to IOL decentration after cataract surgery.8 However, in high myopia, clinically significant tilt and decentration of the IOL were both found larger in patients with AL more than 30 mm.5 AL ≥30.3 mm could effectively predict IOL decentration ≥0.6 mm.5 But for patients with normal AL, the relative factors of clinically significant IOL tilt and decentration were still uncertain.

The second-generation swept-source anterior segment optical coherence tomography Casia2 is an effective and reliable device to measure the tilt and decentration of crystalline lenses and IOLs using the corneal topographic axis as a reference.9 In this study, we sought to explore the risk factors of clinically significant IOL misalignment using Casia2 and to develop a model to predict the occurrence of clinically significant IOL misalignment.

METHODS Study Population

This prospective study was conducted at Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China. It was approved by the Zhongshan Ophthalmic Center Institutional Review Board (No. 2019 KYPJ033) and was conducted following the Declaration of Helsinki. All the patients received detailed conversations and signed informed consents. Using single population proportion formula, the sample sizes were calculated based on the prevalence of 8.9% and 10.72% for clinically significant IOL tilt and decentration.6,8 Taking a 20% nonresponse rate and a 5% error margin into consideration, 157 and 184 sample sizes were acceptable for the studies of clinically significant IOL tilt and decentration, respectively. Two hundred and seven patients with age-related cataract who underwent phacoemulsification combined with IOL implantation from October 2019 to July 2021 were included in this study. Patients with the following conditions were excluded: (1) age less than 45 years, (2) AL ≥26 mm, (3) previous intraocular surgeries, and (4) previous other ocular diseases or ocular trauma.

Study Procedures

All the patients received comprehensive ophthalmic examinations before surgery. General information such as age, sex, and general diseases was obtained via inquiry. The IOLMaster 700 (Carl Zeiss Meditec AG) was used to obtain AL, lens thickness (LT), and anterior chamber depth (ACD). Casia2 (Tomey Corp.) was conducted to measure the tilt and decentration of crystalline lenses before surgery using Lens Scan mode after mydriasis. A Haag-Streit BQ-900 slitlamp with an EyeCap imaging system (Haag-Streit International) was used to obtain images of the anterior segment of the eyes before surgery. The opacity of the lens was graded according to Lens Opacities Classification System III by 2 ophthalmologists (X.Y.-C. and X.X.-G.).

After comprehensive assessments, all the patients received standard phacoemulsification and an in-the-bag folded single-piece IOL implantation surgery by experienced cataract surgeons. Of these 207 patients, 168 (81.16%) had a single-piece hydrophobic acrylic IOL (SN60WF, MX60, or ZCB00), and 39 (18.84%) had a single-piece hydrophilic acrylic IOL (Rayner 920H, 970C, or ASPIRA-aA). Three months after surgery, IOL tilt and decentration were accessed by Casia2 using IOL Scan mode, and the wavefront aberrations were obtained by OPD SCAN-III (Nidek Technologies) after sufficient mydriasis (pupil size ≥6 mm). The extent of capsulorhexis–IOL overlap was evaluated using posterior capsular retro illumination images and separated into complete overlapping and partial overlapping.

Statistical Analysis

Statistical analysis was performed using StataSE15 (v. 15.0, Statacorp LLC). All continuous variables were expressed as mean ± SDs. Categorical variables were counted as values and percentages. The Shapiro-Francia W test was used to confirm the normal distribution. Differences in the tilt and decentration of crystalline lenses and IOLs were analyzed using the rank-sum test. The effects of IOL tilt and decentration on corrected distance visual acuity (CDVA) and wavefront aberrations were tested by the rank-sum test or t test. Univariate and multivariate logistic regression analyses were used to explore the risk factors of clinically significant IOL tilt and decentration. Comparison of tilt of crystalline lens and IOL among different AL groups were accessed by the Kruskal-Wallis test. A P value of less than 0.05 was considered statistically significant. Nomogram models were constructed according to the results of the multivariate analysis to predict the risks of clinically significant IOL tilt and decentration. To assess the model performance, a receiver operating characteristic was constructed and used to find the best cutoff point. The discriminatory capacity of the model was assessed using the area under the curve (AUC). The nomograms were subjected to internal validation with the Hosmer-Lemeshow test and the Stukel test.

RESULTS Participant Characteristics

A total of 207 patients with age-related cataract (207 eyes) who finished preoperative and postoperative examinations (3 months after surgery) were recruited in this study. The mean age of patients was 67.23 ± 8.05 years, and 93 participants (44.93%) were male. The mean anterior chamber depth was 3.11 ± 0.39 mm, and the mean AL was 23.47 ± 0.89 mm. Table 1 shows the characteristics of the involved patients.

Table 1. - Characteristics of enrolled participants Characteristic Value Patients, n 207 Age (y), mean (SD) 67.23 (8.05) M, n (%) 93 (44.93) Diabetes, n (%) 38 (18.36) Hypertension, n (%) 65 (31.40) Right eye, n (%) 103 (49.76) Nuclear opacity grading score (LOCS III), mean (SD) 3.69 (1.30) Cortical opacity grading score (LOCS III), mean (SD) 3.02 (1.36) ACD (mm), mean (SD) 3.11 (0.39) LT (mm), mean (SD) 4.48 (0.44) AL (mm), mean (SD) 23.47 (0.89) Single-piece IOL type  Hydrophilic IOL, n (%) 39 (18.84)  Hydrophobic IOL, n (%) 168 (81.16)

ACD = anterior chamber depth; AL = axial length; LT = lens thickness

Distribution of Tilt and Decentration Before and 3 Months After Surgery

As shown in Table S1 (https://links.lww.com/JRS/A769), the mean tilt of crystalline lenses was 4.98 ± 1.42 degrees, and the mean decentration was 0.19 ± 0.12 mm before surgery. At 3 months after surgery, the mean tilt of IOLs was 5.14 ± 1.51 degrees, and the mean decentration was 0.20 ± 0.11 mm. No significant difference existed in tilt and decentration between preoperative crystalline lenses and postoperative IOLs (P = .263 and P = .692, respectively). Figure 1 also displayed that the magnitudes and the directions of tilt and decentration of preoperative crystalline lenses and postoperative IOLs were almost consistent before and after surgery. Natural crystalline lenses and IOLs both tilted toward the inferotemporal direction and most decentered toward the temporal direction in both eyes. In addition, among the 207 patients, 24 eyes (11.59%) had clinically significant IOL tilt, and 16 eyes (7.73%) had clinically significant IOL decentration at 3 months after cataract surgery (Table S1, https://links.lww.com/JRS/A769).

Figure 1.:

The distributions of the tilt and decentration of preoperative crystalline lenses and postoperative IOLs in both eyes. A: Polar graphics showing the orientations and values of crystalline lens and IOL tilt in both eyes. B: Polar graphics showing the orientations and values of crystalline lens and IOL decentration in both eyes. Blue points: crystalline lens; red points: IOL.

Risk Factors for Clinically Significant IOL Tilt and Decentration

Table 2 compared the characteristics of patients with and without clinically significant IOL tilt or decentration. Patients with clinically significant IOL tilt and decentration both had larger crystalline lens tilt (P < .001) and decentration (P = .042) before surgery. Moreover, patients with clinically significant IOL decentration tend to have longer AL (P = .040). To access the relationships between AL and tilt of both IOLs and crystalline lenses, we divided patients into 3 groups according to AL: AL less than 22 mm, AL over 22 mm and less than 24 mm, and AL over 24 mm. We found that IOL and crystalline lens tilt tended to be larger in patients with shorter AL (Table S2, https://links.lww.com/JRS/A769).

Table 2. - Characteristics of participants with clinically significant IOL tilt and decentration Factors IOL tilt <7 degrees IOL tilt ≥7 degrees P value IOL decentration <0.4 mm IOL decentration ≥0.4 mm P value Number, n (%) 183 (88.41) 24 (11.59) 191 (92.27) 16 (7.73) Age (y), mean (SD) 67.11 (7.92) 68.17 (9.08) .546 67.00 (8.10) 70.00 (7.03) .152 LT (mm), mean (SD) 4.47 (0.44) 4.59 (0.44) .217 4.49 (0.45) 4.43 (0.34) .581 AL (mm), mean (SD) 23.47 (0.91) 23.45 (0.71) .902 23.43 (0.88) 23.91 (0.93) .040 IOL tilt (degree), median (IQR) 4.80 (4.00, 5.50) 7.80 (7.50, 8.38) <.001* — — — IOL decentration (mm), median (IQR) — — — 0.18 (0.11, 0.24) 0.44 (0.43, 0.52) <.001* CL tilt (degree), median (IQR) 4.80 (4.00, 5.60) 6.80 (5.35, 7.60) <.001* 5.00 (4.20, 5.90) 4.60 (3.53, 6.08) .479* CL tilt <7 degrees, n (%) 177 (96.72) 13 (54.17) 177 (92.37) 13 (81.25) CL tilt ≥7 degrees, n (%) 6 (3.28) 11 (45.83) 14 (7.33) 3 (18.75) <.001 .132 CL decentration (mm), median (IQR) 0.17 (0.10, 0.25) 0.23 (0.14, 0.39) .013* 0.17 (0.10, 0.26) 0.22 (0.15, 0.50) .042* CL decentration <0.4 mm, n (%) 175 (95.63) 18 (75.00) 181 (94.76) 12 (75.00) CL decentration ≥0.4 mm, n (%) 8 (4.73) 6 (25.00) 10 (5.24) 4 (25.00) <.001 .015

AL = axial length; CL = crystalline lens; IQR = interquartile range; LT = lens thickness

**Wilcoxon rank-sum test

The risk factors of clinically significant IOL tilt and decentration were assessed via univariate and multivariate logistic regression analyses (Table 3). For clinically significant IOL tilt, preoperative crystalline lens tilt was the risk factor for it (multivariate regression: odds ratio [OR], 3.519, P < .001). Age, LT, and the overlap of capsulorhexis-IOL were not significantly associated with clinically significant IOL tilt. For clinically significant IOL decentration, larger IOL decentration was associated with larger preoperative crystalline lens decentration (multivariate regression: OR, 410.22, P = .001) and longer AL (multivariate regression: OR, 2.155, P = .019).

Table 3. - Associations of clinically significant IOL tilt and decentration Factors Univariate analysis Multivariate analysis (stepwise) β (95% CI) OR P value β (95% CI) OR P value IOL tilt ≥7 degrees  Age (y) 0.017 (−0.037, 0.070) 1.017 .544 — — —  AL (mm) −0.030 (−0.511, 0.450) 0.970 .901 — — —  LT (mm) 0.614 (−0.361, 1.588) 1.848 .217 — — —  CL tilt (degree) 1.146 (0.697, 1.597) 3.148 <.001 1.258 (0.773, 1.743) 3.519 <.001  CL decentration (mm) 4.729 (1.635, 7.823) 113.21 .003 — — —  Capsulorhexis overlapping IOL edges 0.451 (−0.420, 1.321) 1.569 .311 — — — IOL decentration ≥0.4 mm  Age (y) 0.048 (−0.018, 0.115) 1.049 .153 — — —  AL (mm) 0.604 (−0.020, 1.187) 1.829 .043 0.768 (0.129, 1.407) 2.155 .019  LT (mm) −0.332 (−1.507, 0.842) 0.717 .579 — — —  CL tilt (degree) −0.013 (−0.373, 0.347) 0.987 .942 — — —  CL decentration (mm) 5.318 (1.791, 8.845) 204.03 .003 6.017 (2.326, 9.707) 410.22 .001  Capsulorhexis overlapping IOL edges 0.775 (−0.298, 1.849) 2.171 .157 — — —

AL = axial length; β = coefficient; CL = crystalline lens; LT = lens thickness; OR = odds ratio

Prediction of Clinically Significant IOL Tilt and Decentration After Surgery

We further established prediction models for clinically significant IOL tilt and decentration according to the results of the multivariate logistic regression analysis. The predictive model for clinically significant IOL tilt included preoperative crystalline lens tilt as independent predictive variables. A receiver operating characteristic analysis was performed to define the optimal cutoff value of preoperative crystalline lens tilt on clinically significant IOL tilt. We found that the AUC was 0.833 with the best cutoff value of 6.5 for crystalline lens tilt (sensitivity 62.5%; specificity 93.48%, Figure 2, A). Based on the results of the logistic regression analysis, the predicted probability was calculated by the following formula:Predictive score = 1/(1 + exp [9.24 − 1.26 × crystalline lens tilt])

Figure 2.:

A: The ROC curve using crystalline lens tilt to predict clinically significant IOL tilt (AUC = 0.833). B: The ROC curve using CL-D and AL to predict clinically significant IOL decentration (AL: AUC = 0.666; CL-D: AUC = 0.653; AL + CL-D: AUC = 0.757). C: The calibration curve for the predictive model of clinically significant IOL tilt. D: The calibration curve for the predictive model of clinically significant IOL decentration. AL = axial length; AUC = area under the curve; CL-D = crystalline lens decentration; ROC = receiver operating characteristics

Moreover, the predictive model for clinically significant IOL decentration included AL and preoperative crystalline lens decentration as independent predictive variables. The AUC for the model was 0.757 with the best cutoff value of 0.08 score (sensitivity 81.25%; specificity 73.82%, Figure 2, B). The cutoff values of preoperative crystalline lens decentration and AL were 0.20 mm and 23.74 mm, respectively. The predicted probability was calculated by the following formula:Predictive score = 1/(1 + exp [22.05 − 6.02 × crystalline lens decentration −0.77 × AL])

Furthermore, the predictive models for clinically significant IOL tilt and decentration performed well in calibration (Hosmer-Lemeshow test: P = .771 and P = .583, respectively, Figure 2, C and D; Stukel test: P = .601 and P = .749, respectively).

Effect of IOL Tilt and Decentration on Postoperative Vision and Wavefront Aberrations

Finally, we also investigated the effects of IOL tilt and decentration on the patients' postoperative vision and wavefront aberrations. We found significant difference between patients with and without clinically significant IOL tilt in median (interquartile range) of postoperative CDVA (0.1 [0 to 0.37] vs 0 [0 to 0.1], P = .013); however, there was no difference between patients with and without clinically significant IOL decentration groups.

Furthermore, a total of 101 patients fulfilled the OPD SCAN III examination. Logarithmic total and ocular aberrations with a pupil diameter of 6 mm were included in the analysis. Compared with those without clinically significant IOL decentration, patients with clinically significant IOL decentration had larger total ocular aberrations (1.15 ± 0.76 vs 0.57 ± 0.53, P = .006), HOAs (0.41 ± 0.94 vs −0.14 ± 0.56, P = .014), coma (−0.18 ± 1.02 vs −0.83 ± 0.74, P = .026), trefoil (−0.29 ± 1.15 vs −0.91 ± 0.67, P = .020), and astigmatism (−1.04 ± 1.07 vs −1.80 ± 0.65, P = .004) (Figure 3, A, left). However, the intraocular total aberrations, HOAs, coma, trefoil, and astigmatism showed no difference between 2 groups (Figure 3, B, left). In addition, there were no significant differences between patients with and without clinically significant IOL tilt in terms of ocular and intraocular total, HOAs, coma, trefoil, and astigmatism aberrations (all P > .05, Figure 3, A and B right).

Figure 3.:

The effects of IOL decentration and tilt on the patients' postoperative ocular and intraocular aberrations. A: Ocular aberrations (*P < .05, **P < .01). B: Intraocular aberrations.

DISCUSSION

The predictions of clinically significant IOL tilt and decentration after cataract surgery are helpful for the personalized choice of IOL. In this prospective study, we found that 11.59% and 7.73% of patients had clinically significant IOL tilt and decentration after cataract surgery. Moreover, we demonstrated that preoperative crystalline lens tilt was the risk factor for clinically significant IOL tilt, and preoperative crystalline lens decentration and AL were the associated factors of clinically significant IOL decentration. Our risk models showed good calibrations and discriminations for the prediction of clinically significant IOL tilt and decentration. Finally, we also confirmed that clinically significant IOL tilt had an effect on postoperative visual quality, and clinically significant IOL decentration increased ocular aberrations.

The correlations between the tilt and decentration of crystalline lenses and IOLs have been reported in previous studies.6,10,11 Hirnschall et al. reported a strong correlation between crystalline lens and IOL tilt direction, whereas a weak correlation for the magnitude.10 However, Wang et al. found that IOL tilt exceeded crystalline lens tilt by 1.2 ± 1.1 degrees, and the magnitude and the direction of crystalline lens and IOL tilt were significantly correlated (magnitude: R = 0.707, direction: R = 0.765, all P < .01).11 Our previous study also confirmed that preoperative crystalline lens tilt was the strongest determinant of IOL tilt, and AL and preoperative crystalline lens decentration were the 2 most important factors in determining IOL decentration.6 In this study, we got similar results with the previous studies. We found that preoperative crystalline lens tilt and decentration were the strongest determinants for clinically significant IOL tilt and decentration, respectively. This is mainly determined by the position and compliance of the original lens capsule.

Moreover, AL is another critical factor that affects the tilt and decentration of crystalline lenses and IOLs. In patients with age-related cataract, Chen et al.'s study has reported that shorter AL contributed to larger crystalline lens tilt.12 Wang et al.'s study has elaborated that AL ≥30 mm was a risk factor for clinically significant IOL decentration in patients with high myopia.5 Our previous studies also showed that short AL was associated with a greater IOL tilt, whereas longer AL was highly associated with IOL decentration.6,8 Moreover, Zhu et al.'s study showed humans with long AL have larger lens equatorial diameters than those in common people, indicating that IOL would be easier to shift in the long AL eyes with a larger lens capsular bag.13 Our results also showed that AL was a risk factor for clinically significant IOL decentration, which was consistent with previous studies. Although the relationship of AL and clinically significant IOL tilt was not significant in logistic regression analysis in this study, there still existed a decreased tendency in the tilt of crystalline lenses and IOLs with the increase of AL (Table S2, https://links.lww.com/JRS/A769). These were also consistent with the previous studies.

Taken together, we used crystalline lens tilt, decentration, and AL to establish the predictive models for clinically significant IOL tilt and decentration. We found that when patients with preoperative crystalline lens tilt ≥6.5 degrees (AUC = 0.833), postoperative IOL tilt would be at risk of being larger than 7 degrees. In addition, when preoperative crystalline lens decentration ≥0.2 mm and AL ≥23.74 mm, postoperative IOL decentration ≥0.4 mm might occur. These results were consistent with a previous study.14 Zhang et al. found that preoperative lens tilt and decentration can be used to predict clinically significant IOL tilt (AUC = 0.78) and decentration (AUC = 0.82) for patients with a history of pars plana vitrectomy, respectively.14 Our results for clinically significant IOL tilt were similar to Zhang et al.'s study. But for clinically significant IOL decentration, AL and crystalline lens decentration both needed to be included in the predictive model. We thought that the possible reason was that the conditions of the enrolled patients were different in 2 studies.

In this study, we also found that IOL tilt over 7 degrees decreased the postoperative visual quality of patients, whereas IOL decentration over 0.4 mm increased ocular aberrations. These results were comparable with previous studies.1,15–17 Holladay et al. found that IOL tilt of more than 7 degrees or decentration of more than 0.4 mm would deteriorate aspheric IOL visual function via increasing HOAs.1 Zhang et al. found that IOL tilt and decentration was negatively correlated with CDVA.17 Furthermore, Lawu et al. reported that astigmatism, coma, and HOAs generated by IOL misalignment was increased by additional spherical aberration correction amount.16 Thus, even for aspheric IOL, the prediction of IOL tilt and decentration was still critical.

This study has some limitations. First, the type of IOL included in this study was 1-piece IOL with C-loop, and the stability of other designs of IOL still needs further research. Second, the follow-up period of our study was 3 months, and the risk factors of the long-term stability of IOL remain unclear. Thus, a long-term study with different designs of IOL will be promising. Finally, the definitions of tilt ≥7 degrees and decentration ≥0.4 mm as clinically significant IOL tilt and decentration are just references for clinical practice. This means that patients with tilt greater than 7 degrees or decentration ≥0.4 mm are more likely to affect their postoperative visual quality, but they cannot be used as definitive (yes/no) criteria.

In conclusion, we found that 11.59% and 7.73% of patients had clinically significant IOL tilt or decentration after cataract surgery for 3 months. Preoperative crystalline lens tilt was the determinant for the incident of clinically significant IOL tilt. Larger crystalline lens decentration and longer AL were the risk factors for clinically significant IOL decentration. Crystalline lens tilt ≥6.5 degrees could effectively predict IOL tilt ≥7 degrees. The model combined AL and crystalline lens decentration could also help to predict IOL decentration ≥0.4 mm. Therefore, our findings suggested that our models may be useful risk prediction tools for postoperative IOL tilt and decentration. It is necessary to measure crystalline lens tilt and decentration before cataract surgery for patients applying multifocal and toric IOLs.WHAT WAS KNOWN Approximately 10% of patients with age-related cataract have clinically significant IOL tilt or decentration. Preoperative crystalline lens tilt and decentration are the risk factors for IOL tilt and decentration.

WHAT THIS PAPER ADDS Preoperative crystalline lens tilt ≥6.5 degrees can effectively predict IOL tilt ≥7 degrees. Preoperative crystalline lens decentration ≥0.2 mm and AL ≥23.74 mm can be used to predict IOL decentration ≥0.4 mm. Clinically significant IOL tilt has an effect on patient's postoperative visual quality. REFERENCES 1. Holladay JT, Piers PA, Koranyi G, van der Mooren M, Norrby NE. A new intraocular lens design to reduce spherical aberration of pseudophakic eyes. J Refract Surg 2002;18:683–691 2. Montes-Mico R, Lopez-Gil N, Perez-Vives C, Bonaque S, Ferrer-Blasco T. In vitro optical performance of nonrotational symmetric and refractive-diffractive aspheric multifocal intraocular lenses: impact of tilt and decentration. J Cataract Refract Surg 2012;38:1657–1663 3. Zhu X, He W, Zhang K, Lu Y. Factors influencing 1-year rotational stability of AcrySof Toric intraocular lenses. Br J Ophthalmol 2016;100:263–268 4. Zhu X, He W, Zhang Y, Chen M, Du Y, Lu Y. Inferior decentration of multifocal intraocular lenses in myopic eyes. Am J Ophthalmol 2018;188:1–8 5. Wang L, Jin G, Zhang J, Chen X, Tan X, Wang W, Ruan X, Gu X, He M, Liu Z, Luo L, Liu Y. Clinically significant intraocular lens decentration and tilt in highly myopic eyes: a swept-source optical coherence tomography study. Am J Ophthalmol 2022;235:46–55 6. Gu X, Chen X, Yang G, Wang W, Xiao W, Jin G, Wang L, Dai Y, Ruan X, Liu Z, Luo L, Liu Y. Determinants of intraocular lens tilt and decentration after cataract surgery. Ann Transl Med 2020;8:921 7. Hirnschall N, Buehren T, Bajramovic F, Trost M, Teuber T, Findl O. Prediction of postoperative intraocular lens tilt using swept-source optical coherence tomography. J Cataract Refract Surg 2017;43:732–736 8. Chen X, Gu X, Wang W, Xiao W, Jin G, Wang L, Dai Y, Zhang E, Ruan X, Liu Z, Luo L, Liu Y. Characteristics and factors associated with intraocular lens tilt and decentration after cataract surgery. J Cataract Refract Surg 2020;46:1126–1131 9. Kimura S, Morizane Y, Shiode Y, Hirano M, Doi S, Toshima S, Fujiwara A, Shiraga F. Assessment of tilt and decentration of crystalline lens and intraocular lens relative to the corneal topographic axis using anterior segment optical coherence tomography. PLoS One 2017;12:e0184066 10. Hirnschall N, Buehren T, Bajramovic F, Trost M, Teuber T, Findl O. Prediction of postoperative intraocular lens tilt using swept-source optical coherence tomography. J Cataract Refract Surg 2017;43:732–736 11. Wang L, Guimaraes de Souza R, Weikert MP, Koch DD. Evaluation of crystalline lens and intraocular lens tilt using a swept-source optical coherence tomography biometer. J Cataract Refract Surg 2019;45:35–40 12. Chen X, Gu X, Wang W, Jin G, Wang L, Zhang E, Xu J, Liu Z, Luo L, Liu Y. Distributions of crystalline lens tilt and decentration and associated factors in age-related cataract. J Cataract Refract Surg 2021;47:1296–1301 13. Zhu X, Du Y, Li D, Xu J, Wu Q, He W, Zhang K, Zhu J, Guo L, Qi M, Liu A, Qi J, Wang G, Meng J, Yang Z, Zhang K, Lu Y. Aberrant TGF-beta1 signaling activation by MAF underlies pathological lens growth in high myopia. Nat Commun 2021;12:2102 14. Zhang J, Han X, Zhang M, Liu Z, Chen X, Qiu X, Lin H, Li J, Liu B, Zhang C, Wei Y, Jin G, Tan X, Luo L. Predicting the risk of clinically significant intraocular lens tilt and decentration in vitrectomized eyes. J Cataract Refract Surg 2022;48:1318–1324 15. McKelvie J, McArdle B, McGhee C. The influence of tilt, decentration, and pupil size on the higher-order aberration profile of aspheric intraocular lenses. Ophthalmology 2011;118:1724–1731 16. Lawu T, Mukai K, Matsushima H, Senoo T. Effects of decentration and tilt on the optical performance of 6 aspheric intraocular lens designs in a model eye. J Cataract Refract Surg 2019;45:662–668 17. Zhang F, Zhang J, Li W, Zhou L, Feng D, Zhang H, Fang W, Sun R, Liu Z. Correlative comparison of three ocular axes to tilt and decentration of intraocular lens and their effects on visual acuity. Ophthalmic Res 2020;63:165–173