Visual Outcomes and Patient Satisfaction after Bilateral Implantation of an Enhanced Monofocal Intraocular Lens: A Single Blind Prospective Randomized Study

doi:10.21203/rs.3.rs-2565134/v1

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Research Article

Visual Outcomes and Patient Satisfaction after Bilateral Implantation of an Enhanced Monofocal Intraocular Lens: A Single Blind Prospective Randomized Study

https://doi.org/10.21203/rs.3.rs-2565134/v1

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published 26 Feb, 2024

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Purpose: To evaluate and compare the visual outcomes of an enhanced monofocal IOL with two different monofocal IOLs.

Setting: Eye Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy.

Design: Prospective, single-centre, single-blind, randomized controlled clinical study.

Methods: The study included patients undergoing phacoemulsification and IOL implantation. Patients were consecutively randomized by block randomization and assigned in a 1:1:1 allocation ratio to three study arms to bilaterally receive Tecnis® Eyhance (model ICB00) or Tecnis®1-piece (model ZCB00) or Alcon®1-piece (model Clareon, CNA0T0) respectively. Monocular and binocular (both corrected and uncorrected) visual acuities for far, intermediate and near were registered and compared among groups. To track changes in patient quality of life, the Catquest-9SF questionnaire was administered to each patient before and after cataract extraction.

Results: A total of 90 patients (30 for each group) were enrolled. At 3 months follow-up, statistically significant differences for intermediate and near distance visual acuities were found between the three groups. Non-statistically significant differences were observed for distance visual acuities and the changes in Catquest-9SF scores.

Conclusion: Tecnis® Eyhance ICB00 IOL provided better results in intermediate visual outcomes without negative effects on patients’ quality of life.

Cataract surgery

enhanced monofocal IOL

intermediate vision

spectacle independence

Cataract extraction surgery is turning into a refractive surgery and will do so even more in the near future. Patients have become more demanding in terms of visual quality and post-operative functional vision, wishing for total, or nearly total, independence from glasses.

Monofocal intraocular lenses (IOLs) are still the most implanted lenses in the current scenario due, among other things, to the lower rate of optical side effects such as photic phenomena (glare, halos) compared to multifocal IOLs, which result from the refractive or diffractive morphology of the optics. Monofocal IOLs have a single point of focus for far vision and thus do not provide the intermediate vision required for the majority of our daily activities, such as working on a computer or tablet; playing music or sports; looking at the dashboard of a car and walking on uneven surfaces [1–7].

In recent years, the number of IOLs that provide both good distance and good intermediate vision has increased. One of the reasons for this is that the average age of the surgery is decreasing while the needs of cataract patients are increasing. Patients over the age of sixty engage in an increasing number of activities, often indoors, in dimly lit environments, and at intermediate distances [7].

Introduced in 2019, the Tecnis Eyhance ICB00 (Johnson & Johnson Vision, Irvine, CA, USA) was the first of a new generation of monofocal IOLs that allow patients to have a high-quality vision in both intermediate and far distances when compared to standard aspherical monofocal IOLs. The ICB00 features refractive technology with a design that is free of rings. Its power, designed to keep the benefits of a monofocal IOL, gradually increases from the periphery to the centre, creating a unique high-order asphere in the anterior surface [7–10].

The aim of the present study was to compare the visual outcomes of a new-generation monofocal IOL with those of two commonly implanted monofocal IOLs in patients undergoing bilateral cataract extraction.

Patients and Study Design

A prospective, single-centre, single-blind, randomized controlled clinical trial comparing the bilateral implants of two different monofocal IOLs and one enhanced monofocal IOL was conducted. Patients scheduled for consecutive bilateral cataract extraction at the Trieste University Eye Clinic's Cataract Surgery service were enrolled between November 2019 and May 2022. The enrolled patients were divided into three groups of 30 patients each, each of whom was a candidate for bilateral implantation of one of the three lenses under investigation: Tecnis® ZCB00 (Johnson & Johnson Vision), Tecnis® Eyhance-ICB00 (Johnson & Johnson Vision), or Clareon IOL CNA0T0 (Alcon). The second eye was implanted one month after the first.

Exclusion criteria included anterior segment pathology that could have a significant impact on outcomes (e.g. chronic uveitis, iritis, corneal dystrophy, keratoconus), axial length ≤ 21 mm or ≥ 26 mm, corneal astigmatism higher than 0.75 D, diabetic retinopathy, uncontrolled glaucoma and or IOP > 24 mmHg, all kind of infections (acute ocular disease, external/internal infection, systemic infection), traumatic cataract, pseudoexfoliation syndrome, pupillary abnormalities including aniridia and/or pupillary diameter in mesopic conditions in distance vision ≤ 2.5 mm and ≥ 6 mm, microphthalmia, amblyopia, degenerative visual disorders (e.g. macular degeneration, optic nerve atrophy or retinal disorders), previous intraocular and corneal surgery, systemic or ocular pharmacotherapy which could impact the visual acuity and/or cause floppy iris syndrome and/or insufficient dilation according to the investigator's opinion, strabismus, nystagmus, pregnancy or lactation period for female patients.

Following the Helsinki Declaration, each patient provided written informed consent before participating in the study. The Hospital Ethics Committee approved the study. Ethics Committee RCTICB00 approved this study; protocol 202/2019.

Patients were consecutively randomized by block randomization and assigned in a 1:1:1 allocation ratio to three study arms using Sealed Envelope Ltd. 2017 [Available from: https://www.sealedenvelope.com/simple-randomiser/v1/lists]. An automatically generated unique randomisation code was assigned to the randomized patient followed by the abbreviation LE or RE to distinguish between left and right eyes.

Assessments

All patients underwent a comprehensive pre-operative ophthalmological examination before surgery, which included a complete medical history recording, including demographic data and systemic diseases, the measurement of monocular and binocular uncorrected distance visual acuity (UDVA) (at 4 m) and corrected distance visual acuity (CDVA), anterior segment slit lamp examination, Goldmann applanation tonometry, fundus oculi examination after dilatation with Tropicamide 1% eye drops, macular optical coherence tomography (Spectralis HRA + OCT; Heidelberg Engineering, Heidelberg, Germany), bilateral optical biometry (IOLMaster®700; Carl Zeiss Meditec AG, Jena, Germany, OPD), corneal topography and pupillometry (Scheimpflug camera - Sirius; C.S.O.) and quality of life assessment using Catquest- 9SF questionnaire. Data acquired with IOLMaster®700 were used for the calculation of the IOLs’ dioptric power. The IOL powers were calculated using the Barrett Universal II formula. The dioptric power with the expected refractive target closest to emmetropia was chosen.

Postoperatively, patients were evaluated 12 weeks after the second eye surgery, and each patient underwent biomicroscopy of the anterior segment to assess the overall state of the operated eye, and subsequently monocular and binocular visual outcomes with uncorrected and best-corrected visual acuity for far distance (UDVA, CDVA), uncorrected visual acuity for intermediate distance (UIVA) and near distance (UNVA), distance corrected intermediate visual acuity (DCIVA), distance corrected near visual acuity (CNVA) and mean near vision correction (NVC) spherical equivalent.

Corrected visual acuity was obtained using the "Maximum plus" (or minimum minus) technique, a subjective refraction technique that produces the best vision with the minimum minus or maximum plus correction.

Early Treatment Diabetic Retinopathy Study (ETDRS) acuity charts were used to measure pre- and postoperative visual acuities. Distance Visual Acuity (DVA) was obtained with a 4 m ETDRS board illumination cabinet at high contrast (96%) with an 85 cd/m2 lamp filter tube (Precision Vision), intermediate visual acuity (IVA) was obtained with a 70 cm ETDRS printed chart (Precision Vision), and near visual acuity (NVA) was obtained with a 40 cm ETDRS printed chart (Precision Vision). Binocular corrected distance defocus curves were obtained. To produce defocus, a progression of IOLs in -0.50 D increments was consecutively added (range + 2.00 to -4.00 D), after which visual acuity was tested with 100% contrast ETDRS distance acuity charts at a test distance of 4 m. The self-administered validated Catquest-9SF questionnaire was used to assess patients' satisfaction with visual outcomes for daily-life activities at 12 weeks.

Intraocular Lenses

ICB00 is a 1-piece acrylic aspheric refractive foldable posterior chamber IOL designed for placement in the capsular bag. This IOL is made of the same hydrophobic Sensar acrylic material and has the same overall geometry/dimensions (13 mm overall length and 6.0 mm optic diameter) as the standard 1-piece monofocal IOL. It has the same features as the ZCB00 IOL, except for the modified aspheric anterior surface of the optic. Both the enhanced and standard monofocal IOLs are based on refractive technology without diffractive rings or zones and have the same IOL constant. The enhanced monofocal IOL has a refractive optical design with a higher order aspheric anterior surface that creates a continuous power profile (the power increases continuously from the periphery to the centre of the lens), which is intended to extend the depth of focus, thus improving vision for intermediate tasks compared with a standard monofocal IOL [7–10]. Moreover, ICB00 IOL compensates for corneal spherical aberration similarly to the standard 1-piece monofocal ZCB00 IOL, adding a spherical aberration of 0.27 µm. The standard IOL ZCB00 is a 1-piece UV-light filtering acrylic monofocal IOL with a modified prolate (aspheric) design on the anterior optic surface to reduce the overall spherical aberration to near zero once it is implanted. The CNA0T0 monofocal IOL is a one-piece aspheric, hydrophobic, monofocal non-toric IOL made of UV- and blue-light filtering acrylate/methacrylate copolymer. It has the same mechanical design as the AcrySof model SN60WF with a reported 0.20 µm of negative spherical aberration [11]. CNA0T0 IOL features include Stableforce® modified-L haptics (Alcon Vision), a full 6.0-mm optic diameter, a proprietary square-edged design, and a 13.0-mm overall length.

Surgery

Patients considered eligible during the pre-operative visit were scheduled for surgery and were operated on by an expert surgeon (DT). Standard phacoemulsification through a 2.4 mm clear corneal incision followed by IOL insertion in the capsular bag is the routine approach for cataract extraction using topical anaesthesia at our department (unless complicated cases). Anterior capsulotomies were to be performed as a continuous, curvilinear capsulorhexis of 5.0 to 5.5 mm diameter performed by manual rhexis.

Outcome measures

The primary goal of the study was to evaluate and compare the clinical outcomes of three parallel groups of patients following bilateral implantation of the ICB00 IOL, ZCB00 IOL, or CNA0T0 IOL. Considering the modified optical profile of the ICB00, the primary outcome was the evaluation of intermediate-distance visual performance. The primary endpoint was to compare groups in terms of binocular DCIVA at 12 weeks after the second eye implant. Secondary endpoints included: UIVA, UDVA, CDVA, UNVA, CNVA, binocular defocus curves and the results of the Catquest-9SF questionnaire.

Statistical Analysis

To compare the groups in terms of clinical and demographical variables, one-way ANOVA with partial eta squared (η_p²) as an effect size indicator was applied. The between-group differences in terms of postoperative data were evaluated with ANCOVA, including age-controlled covariate. In this case, all between-group comparisons performed with controlled covariates were carried out individually for each dependent variable. The Catquest-9SF data were fit to the Rasch model using WINSTEPS version 4.2 using the Andrich version of Rasch model estimates based on joint maximum likelihood estimation. A Rasch analysis compares the amount of difficulty required to complete a task mentioned in the items to the level of ability of the participant to perform that activity. Both the difficulty of the object and the ability of the individual are sorted on the same linear scale. If the data fit the Rasch model's assumptions, the ordinal raw score is transformed into a valid Rasch scale. This scale is linear and has a logit unit, which is the natural logarithm of the odds ratio. Because the Catquest-9SF should be valid for measuring both before and postoperative patient data, Rasch analysis was done on preoperative and postoperative data stacked as a single dataset. The Bonferroni correction was applied to establish a statistical significance threshold resulting from multiple testing other controlled covariates. After determining the distributional parameters significantly differentiating the groups, correlations between these parameters were calculated separately.

Clinical and demographical data of the three groups are reported in Table 1. After the ANOVA analysis, only age was significantly different between all three groups. The main difference in the age criterion was observed between the ICB00 and CNA0T0 (P = 0.001) groups.

Table 1

Population data analysis for PCB00, ICB00, CNA0T0
	PCB00	ICB00	CNA0T0	ANOVA
	PCB00	ICB00	CNA0T0	p-value	\({\eta }_{p}^{2}\)
Age ± SD	76.97 ± 6.1	75.73 ± 10.26	83.83 ± 7.28	0.001*	0.192
Mean IOL powers ± SD	22.32 ± 1.94	22.16 ± 1.79	21.91 ± 1.96	0.496	0.007
Mean pre-operative VA ± SD	0.31 ± 0.11	0.32 ± 0.12	0.33 ± 0.12	0.611	0.005
Mean WTW ± SD	11.9 ± 0.34	11.09 ± 0.35	11.98 ± 0.35	0.369	0.008
Mean ACD ± SD	3.03 ± 0.48	3.15 ± 0.39	2.94 ± 0.45	0.051	0.031
Mean AL ± SD	23.3 ± 0.88	23.15 ± 0.61	23.41 ± 0.81	0.184	0.018
Mean scotopic pupil diameter ± SD	4.31 ± 0.72	4.25 ± 0.71	4.1 ± 0.64	0.284	0.014
Mean mesopic pupil diameter ± SD	3.57 ± 0.58	3.61 ± 0.61	3.51 ± 0.58	0.607	0.005
Mean photopic pupil diameter ± SD	2.82 ± 0.45	2.88 ± 0.5	2.8 ± 0.48	0.589	0.006
*Post hoc PCB00 vs ICB00: p = 1; PCB00 vs CNA0T0: p = 0.163; ICB00 vs CNA0T0: p = 0.00
ACD = anterior chamber depth; AL = axial length; ANOVA = analysis of variance; IOL = intraocular lens; \({\eta }_{p}^{2}\) = partial etha squared; SD = standard deviation; SE = spherical equivalent; VA = visual acuity; WTW = white to white

Monocular and binocular visual acuities mean values and comparisons among groups are reported in Table 2.

Table 2

Post operative visual acuities and refraction analysis for PCB00, ICB00, CNA0T0
	PCB00	ICB00	CNA0T0	ANCOVA with Age as a Covariate
	PCB00	ICB00	CNA0T0	p-value	\({\eta }_{p}^{2}\)	Bonferroni Post-hoc analysis
Monocular:
Mean SE ± SD	-0.18 ± 0.41	0.03 ± 0.31	-0.03 ± 0.33	0.004	0.059
Mean UDVA ± SD	0.03 ± 0.08	0.003 ± 0.09	0.003 ± 0.07	0.141	0.022
Mean CDVA ± SD	-0.03 ± 0.04	-0.03 ± 0.05	-0.01 ± 0.04	0.198	0.018
Mean UIVA ± SD	0.32 ± 0.1	0.2 ± 0.13	0.34 ± 0.1	< 0.001	0.224	PCB00vsICB00: p < 0.001; PCB00vsCNA0T0: p = 1; ICB00vsCNA0T0: p < 0.001
Mean DCIVA ± SD	0.29 ± 0.11	0.17 ± 0.13	0.31 ± 0.11	< 0.001	0.187	PCB00vsICB00: p < 0.001; PCB00vsCNA0T0: p = 0.921; ICB00vsCNA0T0: p < 0.001
Mean UNVA ± SD	0.38 ± 0.11	0.25 ± 0.13	0.36 ± 0.12	< 0.001	0.178	PCB00vsICB00: p < 0.001; PCB00vsCNA0T0: p = 0.885; ICB00vsCNA0T0: p < 0.001
Mean CNVA ± SD	0.05 ± 0.07	0.02 ± 0.06	0.04 ± 0.06	0.076	0.028
Mean NVC SE (diopter) ± SD	2.07 ± 0.52	1.4 ± 0.6	2.22 ± 0.68	< 0.001	0.261	PCB00vsICB00: p < 0.001; PCB00vsCNA0T0: p = 0.569; ICB00vsCNA0T0: p < 0.001
Binocular:
Mean UDVA ± SD	− 0.05 ± 0.06	-0.03 ± 0.07	-0.03 ± 0.06	0.259	0.031
Mean CDVA ± SD	-0.08 ± 0.04	-0.07 ± 0.05	-0.07 ± 0.04	0.812	0.004
Mean UIVA ± SD	0.32 ± 0.11	0.17 ± 0.12	0.31 ± 0.09	< 0.001	0.285	PCB00vsICB00: p < 0.001; PCB00vsCNA0T0: p = 0.969; ICB00vsCNA0T0: p < 0.001
Mean DCIVA ± SD	0.29 ± 0.01	0.13 ± 0.11	0.29 ± 0.09	< 0.001	0.327	PCB00vsICB00: p < 0.001; PCB00vsCNA0T0: p = 1; ICB00vsCNA0T0: p < 0.001
Mean UNVA ± SD	0.36 ± 0.11	0.23 ± 0.11	0.33 ± 0.12	< 0.001	0.211	PCB00vsICB00: p < 0.001; PCB00vsCNA0T0: p = 0.899; ICB00vsCNA0T0: p < 0.001
Mean CNVA ± SD	0.36 ± 0.11	0.23 ± 0.11	0.33 ± 0.12	< 0.001	0.212	PCB00vsICB00: p < 0.001; PCB00vsCNA0T0: p = 0.999; ICB00vsCNA0T0: p < 0.001

ANCOVA = analysis of covariance; CDVA = corrected distance visual acuity; DCIVA = distance-corrected intermediate visual acuity; CNVA = corrected near visual acuity; NVC = near vision correction; \({\eta }_{p}^{2}\) = partial etha squared; SD = standard deviation; SE = spherical equivalent; UDVA = uncorrected distance visual acuity; UIVA = uncorrected intermediate visual acuity; UNVA = uncorrected near visual acuity

We observed a statistically significant difference for monocular and binocular intermediate and near vision, both corrected and uncorrected. Moreover, we found a statistically significant lower value of the spherical equivalent near addition (Mean NVC SE) for the ICB00 group. After the ANCOVA analysis with age covariate, only the mean values of postoperative results for the ICB00 group were significantly different (p < 0.001) compared to the other two groups. There were not statistically significant differences among the three IOL groups between Catquest-9SF pre and postoperative results. Binocular defocus curves are shown in Fig. 1.

The type of IOL to be implanted should be chosen carefully to provide patients with the desired refractive outcome and visual quality. The patient's characteristics, visual expectations, and preferences influence the final decision [12]. As the ESCRS Functional Vision Working Group has recently noted, intermediate distance vision is essential for the majority of common and practical daily tasks, such as using a computer or seeing the dashboard of a car. This raised awareness has led to the development of an increasing number of novel IOL designs including multifocal, EDOF and next generation monofocal IOLs, that can restore vision at various distances [13, 5].

Multifocal IOLs proved good visual acuity at all distances but can create dysphotopic phenomena, such as glare and halos, which are often reported even after uneventful surgery in healthy eyes [12]. In a Cochrane review of multifocal versus monofocal IOLs after cataract extraction, multifocal IOLs were effective at improving near vision compared to monofocal IOLs. The review concluded that improvement outweighed the adverse effects of multifocal IOLs. However, those side effects, like glare and haloes, varied between individuals, and that desire to avoid wearing spectacles might represent the deciding factor [14]. Dysphotopsia perception is necessarily subjective, making it difficult to fully predict how upsetting the photic phenomena will be for any given patient. Since neuronal processing of light distribution has an impact on the neural adaptation process, which affects how dysphotopsia is perceived, some patients benefit from this mechanism by building up a tolerance [15, 16]. However, the photic phenomena continue to be a burden for some patients. The risk of unpleasant associated photopic phenomena, the need for precise patient selection, and cost concerns continue to be barriers to the widespread adoption of multifocal IOLs.

Since 2019, a new class of monofocal IOLs has been introduced to meet patients' demand for improved intermediate-distance vision while minimizing risks and costs. We compared visual outcomes and patient satisfaction following the bilateral implantation of one of two high-quality aspheric monofocal IOLs (ZCB00 or CNA0T0) versus the bilateral implantation of the first of the new generation monofocal IOLs (ICB00). In our study, the refractive outcomes for distance were excellent for all IOL groups as previously observed by other studies [7, 10, 17–24]. We found a postoperative subjective SE close to 0 and similar between groups, with slightly higher variability in the ZCB00 group, although the mean values were not significantly different. Since different pupil sizes alone could result in different depths of focus, without considering the type of the implanted IOL, pupil size measurements before VA testing were taken. In mesopic conditions, in which VA tests were done, pupil size was not significantly different between the three groups. The enhanced monofocal IOL outperformed the conventional monofocal IOLs in terms of intermediate and near-distance visual acuity (both monocular and binocular, corrected and uncorrected). Similarly, Auffarth GU et al. comparing the enhanced monofocal IOL and the standard monofocal IOL reported similar visual outcomes to the results of this study, with significant improvements in intermediate vision achieved by the enhanced monofocal IOL. Auffarth GU et al. demonstrated the enhanced monofocal IOL to provide significant improvement in intermediate vision (monocular and binocular DCIVA and UIVA) by at least 1-line vs the standard monofocal IOL [25]. The standard arm length (60 to 70 cm) is the preferred screen-viewing distance for laptops and tablet devices, so we chose 70 cm as the intermediate distance. Moreover, this distance has already been used in other publications, which aids in comparison with studies performed with other IOLs [23, 26]. Corbelli et al. compared the ICB00 with the same brand EDOF ZXR00. The authors found that at the − 1.0 D defocus level, simulating vision at a distance of 1 meter, the visual acuity achieved by the ICB00 was not statistically significantly inferior to the ZXR00. This result highlights the non-inferiority of the enhanced monofocal ICB00 in intermediate-distance performance compared with the classic ZXR00 [21].

Yangzes et al. reported that monocular UNVA was better (p < 0.01) for the ICB00 group (0.43 +/- 13 logMAR) than for the ZCB00 group (0.61 +/- 16 logMAR) [7]. In our study monocular UNVA (0.25 ± 0.13 logMAR) and binocular UNVA in the ICB00 group (0.23 +/- 11 logMAR) were statistically significantly better than the other two groups (p < 0.001). Interestingly Lee et al. comparing the ICB00 and ZXR00 IOLs found binocular UNVA was comparable, though spectacle independence was higher in the ZXR00 group, at the expense of increased glare and halos [22]. Moreover, in our sample, the mean near vision correction (diopters) in the ICB00 group was significantly lower than in the other two groups. Defocus curves are widely used to objectively measure the performance of an IOL at various distances [7, 26]. In our work, the ICB00 group showed a significantly better visual acuity across defocus levels of -1.50 to -4.00 D as observed by other authors, with good intermediate distance vision [7, 10].

To assess patient-reported outcomes we employed the Catquest-9SF [28–31]. Despite the higher visual acuity in the ICB00 group for both intermediate and near vision, we found no statistically significant differences in Catquest-9SF scores between groups based on Rasch analysis. We hypothesized that this could be explained by the fact that the questionnaire specifies performing the tasks with correction, thereby reducing differences in those cases where glasses for intermediate and/or near vision were worn. A new questionnaire designed specifically for new-generation IOLs and an extended range of vision IOLs should be advocated.

It's remarkable to underline that our study was a prospective study. Moreover, to our knowledge, there is no other scientific work in literature that compares the ICB00 IOL performance to two groups of standard monofocal IOLs (the ZCB00 and the CNA0T0). In our study, we observed a statistically significant difference in the age of the three groups, with older patients in the CNA0T0 group. This difference should be kept into consideration when analysing the results and might represent a limitation of the current study. Another limitation might be the lack of objective contrast sensitivity and visual quality tests. However, a recent meta-analysis on enhanced monofocal IOLs has reported no increased risk of contrast sensitivity loss or increased incidence of photic phenomena [32].

Moreover, an aspheric IOL with negative SA could presumably decrease the depth of focus. For that reason, it would be interesting to compare the visual performance of the ICB00 IOL also with an SA-free monofocal IOL, where one could expect a wider depth of focus and, theoretically, a better intermediate visual acuity (VA) than a conventional monofocal IOL [33].

In conclusion, in comparison to standard monofocal IOLs, the TECNIS Eyhance IOLs significantly enhanced unaided intermediate vision while maintaining comparable distance performance. Furthermore, in this preliminary study, we only included patients who did not have ocular comorbidities. Future studies would be useful to assess whether the performance of the ICB00 IOL is comparable to that of a monofocal IOL in patients with ocular comorbidities.

Funding

The study has been supported by an unrestricted grant from Johnson & Johnson Vision.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University of Trieste RCTICB00; protocol 202/2019, January 2021.

Consent to participate and consent to publish

Informed consent was obtained from all individual participants included in the study. Only anonymized data were analyzed.

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No competing interests reported.

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published 26 Feb, 2024

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Editorial decision: Major revision
30 Oct, 2023
Reviews received at journal
28 Jun, 2023
Reviewers agreed at journal
13 Jun, 2023
Reviewers invited by journal
12 Apr, 2023
Editor assigned by journal
09 Feb, 2023
Submission checks completed at journal
09 Feb, 2023
First submitted to journal
08 Feb, 2023

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Visual Outcomes and Patient Satisfaction after Bilateral Implantation of an Enhanced Monofocal Intraocular Lens: A Single Blind Prospective Randomized Study

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Introduction

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Patients and Study Design

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Intraocular Lenses

Surgery

Outcome measures

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