Objective Optical Quality With Multifocal Intraocular Lenses Should Stop to Be Used or Cautiously Interpreted : The Asia-Pacific Journal of Ophthalmology

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Objective Optical Quality With Multifocal Intraocular Lenses Should Stop to Be Used or Cautiously Interpreted

Fernández, Joaquıín MD, PhD*; Rocha-de-Lossada, Carlos MD, PhD*,‡; Rodríguez-Vallejo, Manuel OD, PhD*

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Asia-Pacific Journal of Ophthalmology: November/December 2022 - Volume 11 - Issue 6 - p 569
doi: 10.1097/APO.0000000000000502
  • Open

We read with interest the manuscript “Comparison Between an Intraocular Lens with Extended Depth of Focus (Tecnis Symfony ZXR00) and a New Monofocal Intraocular Lens with Enhanced Intermediate Vision (Tecnis Eyhance ICB00).” Authors conducted a very well-written and comprehensive manuscript. However, we would like to discuss a particular point on which we partly disagree and one confounding result.

The HD Analyzer was used for assessing clinical optical quality with both intraocular lenses (IOLs).1 One of our studies was cited to argue that this instrument was useful for characterizing the optical quality of the IOLs.2 Moreover, we would like to clarify that our study was conducted with phakic healthy subjects, and we pointed out that the device had limitations on the measurement of multifocal IOLs, particularly due to infrared wavelength (780 nm) and the first pass nonlimited exclusively by the diffraction of the aperture.2

Although the limitation on estimating visual performance with diffractive IOLs through objective clinical measurements is well known for a long time, not only for double-pass systems3 but also for aberrometers,4 there is still an overuse of these systems in clinical studies for multifocal IOL comparison. Its use can lead to an overestimation of the visual performance, as it was recently reported with pyramidal aberrometry, on which results showed a higher optical quality with a trifocal IOL than with a monofocal IOL.5

Another particular point that deserves a clarification by authors is related to the measurement of defocus curves. These were measured accounting for the manifest error, but visual acuity at 0 D location with both lenses is higher than 0.1 logMAR (below 0.1 logMAR in the figure), whereas mean corrected distance visual acuity was close to 0 logMAR. These results suggest an error in the figure or a mistake in the methods description, and it might be explained by defocus curves measured without manifest refraction.

In conclusion, unless future clinical studies evidence that visual performance can be estimated with an objective clinical system, there are enough theoretical reasons and some clinical evidence to argue that none of the current objective clinical systems commercially available can be used to estimate visual performance with multifocal IOLs. We encourage clinical researchers to avoid the comparison of diffractive IOLs (as Symfony) with these objective systems, especially considering that results can be differently biased depending on the IOL technology. For refractive IOLs (as Eyhance), we suggest conducting a previous validation of the objective clinical system through an agreement study with a subjective measurement of visual performance as we conducted in healthy phakic eyes.2

Joaquıín Fernández, MD,PhD*

Carlos Rocha-de-Lossada, MD, PhD*‡

Manuel Rodríguez-Vallejo, OD, PhD*


1. Jeon YJ, Yoon Y, Kim T, et al. Comparison between an intraocular lens with extended depth of focus (Tecnis Symfony ZXR00) and a new monofocal intraocular lens with enhanced intermediate vision (Tecnis Eyhance ICB00). Asia Pac J Ophthalmol. 2021;10:542–547.
2. Fernández J, Rodríguez-Vallejo M, Martínez J, et al. Agreement between subjective and predicted high and low contrast visual acuities with a double-pass system. Graefes Archive Clin Exp Ophthalmol. 2021;259:1651–1657.
3. Gatinel D. Double pass-technique limitations for evaluation of optical performance after diffractive IOL implantation. J Cataract Refract Surg. 2011;37:621–622.
4. Charman WN, Montés-Micó R, Radhakrishnan H. Problems in the measurement of wavefront aberration for eyes implanted with diffractive bifocal and multifocal intraocular lenses. J Refract Surg. 2008;24:280–286.
5. Alio JL, D’Oria F, Toto F, et al. Retinal image quality with multifocal, EDoF, and accommodative intraocular lenses as studied by pyramidal aberrometry. Eye Vis. 2021;8:1–11.
Copyright © 2022 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.