Screening cataract patients in a public hospital for a multifocal intraocular lens implantation

doi:10.21203/rs.3.rs-3400407/v1

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Research Article

Screening cataract patients in a public hospital for a multifocal intraocular lens implantation

https://doi.org/10.21203/rs.3.rs-3400407/v1

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Journal Publication

published 20 Mar, 2024

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Purpose

To identify the rate and characteristics of cataract surgery candidates suitable for multifocal intraocular lens (MIOL) implantation among patients undergoing preoperative evaluation in a public hospital.

Materials and Methods

Screening was performed based on patient’s medical record, comprehensive ophthalmic examination, optical biometry (Zeiss, IOL Master 700) and Optical Coherence Tomography (Heidelberg, OCT Spectralis) in accordance with the relative indications and contraindications as mentioned in pertinent literature.

Results

The study evaluated 1200 consecutive patients. Four hundred and thirty -two patients (36%) were not eligible for bilateral surgery and were excluded from the study. Of 768 patients included in the present study 346 (45.1%) were considered suitable candidates. Four hundred twenty-two patients (54.9%) had reasons of exclusion in one or both eyes. Among them 121 (28.7%) were excluded because of retinal disease, 120 (28.4%) due to regular astigmatism (> 1.0 D of corneal astigmatism), 32 (7.5%) due to pseudoexfoliation or zonular instability, 30 (7.1%) because of glaucoma or ocular hypertension while in 90 (21.3%) patients there were multiple reasons of exclusion. Suitable candidates were significantly younger (70 and 75 years respectively (p < 0.001). After being informed about potential risks and benefits of MOIL implantation 212 of 346 (83.8%) eligible patients would consent for it.

Conclusion

Close to half of cataract patients in a public hospital are eligible for MOIL implantation and the majority would procced with the operation. The most prevalent contraindication is macular disease.

multifocal IOL

cataract surgery

presbyopia

Cataract surgery is currently the most common surgical procedure. During the past decades the surgical techniques have evolved and in current years cataract surgery is performed as an outpatient procedure with an almost immediate visual rehabilitation. Cataract surgery undisputable improves dramatically visual functioning which in term is translated in gains in real life activities in emotional and social wellbeing and in great improvement of quality of life [1].

The standard of care in cataract surgery is phacoemulsification with implantation of a monofocal intraocular lens (IOL) which allows the patients to see clearly in a predetermined distance [2]. Nevertheless, recent advances in IOLs design and biometry have further increased patients and doctors’ expectations form cataract surgery. It is considered not only as an operation that restores vision but as a refractive procedure that minimizes if not eliminates the use of glasses [3–5].

To decrease spectacle dependence after cataract surgery multifocal intraocular lenses (MIOLs) have been increasingly advocated during preoperative patient counseling. However, in contrast to monofocal lenses which may be implanted in every patient, not all cataract patients are suitable candidates or would consent for the implantation of MIOLs. The extended range of vision that MIOLs offer comes along with the expense of the reduction of contrast sensitivity [6]. Therefore, a healthy fundus and the absence of optic nerve or macular disease that compromise further the contrast sensitivity are necessary prerequisites for the choice of a MIOL to be offered to a patient. Furthermore, accurate centration in the bag is necessary during the implantation of these IOLs otherwise the quality of vision is greatly reduced. Patients with a compromised zonular apparatus are not good candidates for multifocal IOL implantation. These along with many other contraindications for the implantation of multifocal IOLs have been previously well summarized in a consensus paper [7].

Another disadvantage of MIOLs is that MIOLs in comparison to monofocal IOLs, are associated with the increased risk for the perception of photic phenomena, such as halos, starburst, and glare that may affect daily activities of patients such as night driving, and even dictate the exchange of the MIOL with a monofocal one [8,9]. It is not very well studied how many of cataract patients would consent for the implantation of a multifocal IOL if they were informed about the potential risks. According to a recent study performed in English public hospitals fear of complications was a significant reason that prevent patients from consenting for premium IOLs [10].

This study was conducted to assess the feasibility and acceptability of introduction of multifocal IOLs in a public hospital practice in which the cost of the IOLs is covered by the insurance. Therefore, the purpose of the present study was to identify suitable candidates for MIOL implantation among the patients undergoing preoperative evaluation for cataract surgery and to investigate how many among them would proceed to the procedure if this choice was offered to them.

This prospective study comprised consecutive patients scheduled for cataract surgery at Ophthalmiatrion Eye Hospital Athens, Greece which is a public hospital from October 2021 to March 2022. The center’s institutional review board approved the study. The study adhered to the tenets of the Declaration of Helsinki.

A complete ophthalmic examination was performed on all patients including medical and ocular history, uncorrected and best corrected visual acuity, tonometry slit lamp and fundus examination after pupil dilation.

Best corrected Visual acuity (BCVA) was obtained by letter charts and expressed as decimal notations. The decimal notations were converted mathematically to logMAR for the purposes of the present study. Lens status was assessed for nuclear, cortical, and posterior subcapsular cataract following the Lens Opacities Classification System (LOCS III).

Additional tests performed were Optical Coherence Tomography of macula and optic nerve (Heidelberg, OCT Spectralis) and optical biometry (Zeiss, IOL Master 700). Corneal topography (Oculus Pentacam ®) was performed in selected patents. Data were collected from the patient chart during the preoperative patient evaluation.

Patients were included in the present study if they were eligible for bilateral cataract surgery. The criteria to define the suitable and unsuitable candidates for the implantation of MIOL have been previously published in a consensus paper and are summarized in Table 1 [7].

Table 1

Contraindications for the implantation of a multifocal IOL
Central nervous system issues: Dementia
Corneal astigmatism > 1.0 D
Corneal dystrophies- ocular surface disease
Prior refractive surgery -irregular astigmatism
Pupil issues (small pupil, iris colovoma etc)
Zonular issues (pseudoexfoliation, trauma, etc )
Impaired fundus visualization
Retinal disease (Retinal dystrophies, epiretinal membrane, ARMD, Diabetic retinopathy etc.)
Optic neuropathy- glaucoma
Strabismus / amblyopia
Combined

The presence of vitreoretinal interface abnormalities was based on OCT findings according to previously described definitions [11] Age-related macular degeneration (ARMD) was defined following Beckman Initiative for Macular Research Classification Committee [12].

Eligible patients were informed about the advantages and disadvantages of the implantation of a multifocal IOL and were asked if they were consent for the multifocal MIOL if the cost was not an issue.

In order to compare characteristics of suitable and unsuitable candidates fot MIOL implantation chi-square test was applied to qualitative and t-test to quantitative variables.

One thousand two hundred patients (1200) were evaluated for cataract surgery in the examined period.

Four hundred and thirty-two patients (36%) had undergone cataract surgery in the past with a monofocal IOL in one eye or were not eligible for bilateral surgery and were excluded from the study.

Seven hundred sixty-eight patients with a mean age 73.4 ± 8 (range 42–93) years included in the present study. Three hundred forty-six (45.1%) were considered suitable candidates for bilateral implantation of multifocal IOL. The demographic and clinical characteristics of suitable and unsuitable candidates for the implantation of the MIOL are depicted in Table 2. The patients that were proper candidates for the implantation of the MIOL were significantly younger than the unsuitable candidates (70.6 years versus 75.4 years p < 0.001). Three hundred forty patients were over 75 years old. Only 92 (27.1%) patients were considered candidates for the implantation of multifocal IOL. On the contrary 254 of 428 patients (59.3%) aged less than 76 years were considered good candidates for the implantation of MIOL.

Table 2

Demographic data of suitable and unsuitable candidates for multifocal IOL implantation
	Suitable Candidates (346)	Unsuitable Candidates (422)	P
Age Years Mean± SD	70.6 ± 7.1	75.4 ± 8.1	< 0.001
Gender Male/ Female	140/206	162/280	0.27
Corrected Visual Acuity LogMAR±Coefficient of variance	0.62 ± 0.35	0.61 ± 0.42	0.8
Axial Length mm Mean± SD	23.74 ± 1.10	23.65 ± 1.21	0.46

Four hundred twenty-two patients (54.9%) had reasons of exclusion in one or both eyes. Among them 121 (28.7%) were excluded because of retinal disease, 120 (28.4%) due to regular astigmatism (> 1.0 D of corneal astigmatism), and 32 (7.5%) due to pseudoexfoliation (PEX) or zonular instability, 30 (7.1%) because of glaucoma or ocular hypertension while in 90 (21.3%) patients there were more than one reasons of exclusion. Reasons of exclusion are presented in Table 3. The magnitude of astigmatism in the most astigmatic eye is depicted in Table 4.

Table 3

Contraindications for the implantation of a multifocal IOL
Central nervous system issues: Dementia	2
Corneal astigmatism > 1D	120
Corneal dystrophies- ocular surface disease	5
Prior refractive surgery /Irregular astigmatism	5
Pupil issues (small pupil without apparent pseudoexfoliation, iris colovoma etc)	3
Zonular issues (pseudoexfoliation, trauma, etc)	33
Impaired fundus visualization	7
Retinal disease (Retinal dystrophies, epiretinal membrane, ARMD, Diabetic retinopathy, retinal vessel occlusion, etc.)	121
Optic neuropathy- glaucoma -ocular hypertension	32
Strabismus / amblyopia	2
Combined	90
Other (uncertain biomery etc.)	2

Table 4

Magnitude of astigmatism in the most astigmatic eye
Diopters	Patients (768)
0–1	562 (73.2%)
1.1-2	159 (20.7%)
2.1-3	40 (5.2%)
> 3	3 (0.4%)
Irregular Astigmatism	4 (0.5%)

The most common cause of exclusion due to retinal disease was age related macular degeneration in 66 (55%) patients, epiretinal membrane in 25 (20.8%) patients and diabetic retinopathy in 19 patients (15.8%).

Three hundred twenty-one patients (76.1%) met exclusion criteria in both eyes and one hundred and one patients (23.9%) met exclusion criteria in one eye.

After being informed about potential risks and benefits of MIOLs and especially about the risks unique to MIOLs, 263 of 346 patients (76%) would consent for MIOL. implantation.

The present study indicated that 45.1% of patients presented for bilateral cataract surgery in a public hospital were considered as proper candidates for a MIOL implantation. Furthermore, if we add the patients who were excluded because of the presence of regular astigmatism more than half of cataract patients (60.7%) may be benefited from a toric or a non toric MIOL. This compares with a previous study by Desphande et al who reported the feasibility of implantation of a multifocal IOL in 54.4% of their patients [13]. Their patient population, however, was significantly younger (mean age 59.4 years) than the patient population in the present study. This fact may explain why in their study an increased number of suitable candidates among patients without astigmatism was observed.

A significant burden for the implantation of MIOL is indisputably ocular comorbidities. According to results of the present study excluding patients with regular astigmatim and dementia thirty-nine percent of patients had an eye disease along with cataract in either or both eyes. The 39% prevalence of comorbidities in our patient population is within the range of 26–49% previously reported [14,15]. The present study, however, differs from previous studies as the exclusion criteria were applied in either one of the eyes.

The most prevalent contraindication for the implantation of a MIOL according to the present study was retinal pathology, which was the sole contraindication in 121 of 768 patients (15.8%). This compares well with a more than 20% of patients having macular disease or diabetic retinopathy reported recently in Swedish cataract registry [15]. Similarly, to the present study Desphande et al [13] reported that retinal pathology was the most common reason for non-feasibility of MIOL implantation in their patient population. More than half of the patients had ARMD and 20% an epiretinal membrane that most of the times was detected only by the OCT examination of the fundus. This fact underlies the importance of macular examination with an OCT before the implantation of a premium IOL. A recent study has shown that in 13% of cataract cases scheduled for a premium IOL implantation macular pathology was not detected by biomicroscopic examination [16].

All patients with retinal pathology were considered unsuitable candidates for the purpose of the current study. This is because MIOLs apart from reducing contrast sensitivity make problematic the visualization of the fundus for retinal surgery [7]. There is no unanimity among the experts however, regarding this subject. Although most experts would not implant a multifocal IOL in a patient with wet ARMD or diabetic retinopathy with macular edema a significant minority would not object to the implantation of a multifocal IOL in a patient with a non-proliferative diabetic retinopathy without macular edema or resolved central serous chorioretinopathy [17]. Furthermore, a recent review failed to find convincing evidence that patients with retinal disease should be advised against multifocal IOL [18]..

Two hundred and six patients in our sample (26.8%) had more than 1 diopter of astigmatism. Previous studies reported that the percentage of eyes that had astigmatism of 1 diopter or higher ranged between 23 and 47%. [19]. For the one hundred and twenty of 768 patients (15.6%) astigmatism was the sole contraindication for the implantation of a multifocal IOL. The presence of astigmatism, however, is not considered an absolute contraindication for the implantation of a multifocal IOL as there are various methods for the correction of astigmatism during or after cataract surgery. Among them implantation of toric multifocal IOLs resulted in excellent visual outcomes [20].

Seven-point five percent of patients were considered bad candidates due to PEX. The prevalence of PEX varies in different parts of the world. Previous studies in Greece reported a prevalence of 11.3%. [21].Pseudoexfoliation is associated with loose zonules, and it is the most common risk factor for spontaneous IOL dislocation, accounting for more than 50% of cases [22].The detrimental effect of PEX to the zonules is a continuously evolving process that may affect IOL centration long after cataract surgery. The quality of vision in cases of MIOLs is greatly affected by even small amounts of decentration (> 0.25mm) so the contraindication of MIOLs implantation in PEX eyes seems reasonable [23,24].

Seven-point one percent (7.1%) of patients were considered unsuitable candidates because of glaucoma or ocular hypertension. This fact likewise underlies the importance of optic nerve examination with biomicroscopy or OCT as a significant percentage of patients in the present study were unaware of glaucoma and had normal IOP at the time of preoperative examination. The percentage of undiagnosed glaucoma is high and in Greek population may well reach 50% [25].Similarly to what happens with retinal disease most experts would agree that moderate or advanced glaucoma is an absolute contraindication for the implantation of MIOL. There is uncertainty however, regarding the implantation of MIOLs in patients with early glaucoma or ocular hypertension [26,27].Although these patients may not exhibit any significant visual disability [28] there is always the concern of progression of disease and treatment effects to ocular surface and quality of vision.

In this study, we excluded a priori all patients who had a monofocal IOL implanted in one eye at the time they presented for evaluation for possible MIOL implantation in the second eye as well as patients not eligible for bilateral cataract surgery. Applying these rigid exclusion criteria resulted in 432 out of 1200 tested patients (36%) not being given the option of benefiting from a MIOL implantation. For years, literature has been advocating bilateral MIOL implantation [7] and there is extensive literature on symmetrical or mix and match techniques for bilateral MIOL implantation.

“Hybrid” monovision, though, ie implantation of a monofocal IOL in the dominant eye and a multifocal in the other eye has not been tested in a large scale study; however there are studies [29] addressing this clinical scenario reported encouraging results.

A significant result of the present study is that the only characteristic that differentiated suitable from unsuitable candidates was age. This finding was not unexpected as comorbidities increase with age. This pairs with an earlier finding that younger patients have higher gain and higher self-assessed visual function than older patients after cataract surgery probably from the same reason [30].

The present study indicated that three quarters of the Greek cataract patients who were qualified for the MIOL implantation would prefer a MIOL to a monofocal IOL if the procedure was carried out in a public hospital and the cost was covered by the insurance. Results of the present study contrast those of a recent survey conducted in public sector in Great Britain. According to this survey 85.8% of cataract patients did not mind wearing glasses after cataract surgery, most patients (75.3%) were not familiar with premium IOLs, and 58.9% of patients were not willing to consider them because of associated risks [10].There are several reasons for this contrast: Our patient population was familiar with premium IOLs as toric IOLs have been used for several years in our institution with excellent results. Furthermore, our patients devoted increase time to near activities as almost all used either smart phone or tablet. This necessity of MIOLs becomes apparent by a very recent study conducted in Switzerland which found that most patients who achieve perfect bilateral emmetropia after implantation of monofocal aspheric lenses have bought varifocal spectacles within 6 months of surgery [31].This preference of the patients should be taken in account by policy makers. Although several previous studies have shown that implantation of a multifocal IOL is more cost effective than the implantation of monofocal IOL paired with the use of glasses [32,33], the National Health systems do not cover or partly cover the extra cost of multifocal IOLs. This is one of the major restrains for the widespread use of MIOLs.

Recently, extended depth of focus (EDOF) lenses came into practice. Instead of diverging the light to more than one focus as do MIOLs these IOLs split the light in an elongated area of focus [34].They provide good far and intermediate vision with a supposedly reduced risk of photic phenomena compared to MIOLs. It is not clear to us if results of the present study apply to EDOF lenses as it was based on exclusion criteria summarized in the consensus paper that referred only to MIOLs. A very recent metanalysis failed to detect significant differences in the contrast sensitivity between multifocal and EDOF IOLs [34] Although reports in the literature [35] indicated favorable results with EDOF IOLs in cases were MIOLs may be contraindicated more data are necessary.

There are various limitations in the present study. First it was conducted in a predominantly urban population with specific demographic and socioeconomic characteristics that may prevent generalizations. Second, strict exclusion criteria were applied during screening that as we have already mentioned are not universally accepted. Furthermore, advances in the optical design of MIOLs may ameliorate some of these contraindications especially in early stages of ocular diseases. Finally, in the setting of a busy public hospital. personality traits that could made some patients unsuitable candidates for MIOLs may not have been adequately assessed.

In conclusion the present study illustrates the relative frequency of contraindications of MIOL implantation in the Greek population and provides an insight into

the percentage of well-informed eligible candidates that would consent to it.

Financial Support: None

No conflicting relationship exists for any author.

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

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

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ioannis Halkiadakis, Thomas Ntravalias and Elpida Kollia and Eleni Patsea. The first draft of the manuscript was written by Ioannis Halkiadakis and Stelios Kandarakis and Klio Chatzistefanou , and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

This is an observational study. The Ophthalmiatrion Eye hospital Ethics Committee has confirmed that no ethical approval is required.

Informed consent was obtained from all individual participants included in the study

Lamoureux EL, Fenwick E, Pesudovs K, Tan D. The impact of cataract surgery on quality of life. Curr Opin Ophthalmol. 2011 ;22:19-27.
Wang SY, Stem MS, Oren G, Shtein R, Lichter PR. Patient-centered and visualquality outcomes of premium cataract surgery: a systematic review. Eur J Ophthalmol. 2017 ;27:387-401.
Kohnen T. Keeping patient outcome surveys in pace with presbyopia correction technology. J Cataract Refract Surg. 2022; 48:133-134.
Panagiotopoulou EK, Ntonti P, Vlachou E, Georgantzoglou K, Labiris G.Patients' Expectations in Lens Extraction Surgery: a Systematic Review. Acta Medica (Hradec Kralove). 2018; 61:115-124
Logothetis HD, Feder RS. Which intraocular lens would ophthalmologists choose for themselves? Eye (Lond). 2019 ;33:1635-1641.
Schallhorn JM, Pantanelli SM, Lin CC, Al-Mohtaseb ZN, Steigleman WA 3rd, Santhiago MR, Olsen TW, Kim SJ, Waite AM, Rose-Nussbaumer JR. Multifocal and Accommodating Intraocular Lenses for the Treatment of Presbyopia: A Report by the American Academy of Ophthalmology. Ophthalmology. 2021; 128:1469-1482
Braga-Mele R, Chang D, Dewey S, Foster G, Henderson BA, Hill W, Hoffman R,Little B, Mamalis N, Oetting T, Serafano D, Talley-Rostov A, Vasavada A,Yoo S;ASCRS Cataract Clinical Committee. Multifocal intraocular lenses: relative indications and contraindications for implantation. J Cataract Refract Surg.2014; 40:313-22.
de Silva SR, Evans JR, Kirthi V, Ziaei M, Leyland M. Multifocal versus monofocal intraocular lenses after cataract extraction. Cochrane Database SystRev. 2016 12;12(12): CD003169.
Kamiya K, Hayashi K, Shimizu K, Negishi K, Sato M, Bissen-Miyajima H; SurveyWorking Group of the Japanese Society of Cataract and Refractive Surgery. Multifocal intraocular lens explantation: a case series of 50 eyes. Am J Ophthalmol. 2014 ;158:215-220.
Jameel A, Dong L, Lam CFJ, Mahmood H, Naderi K, Low S, Azan E, Verma S,Robbie S, Bhogal M, O'Brart D. Attitudes and understanding of premium intraocular lenses in cataract surgery: a public health sector patient survey. Eye (Lond). 2023 Jun 24. doi: 10.1038/s41433-023-02633
Meuer SM, Myers CE, Klein BE, Swift MK, Huang Y, Gangaputra S, Pak JW, Danis RP, Klein R. The epidemiology of vitreoretinal interface abnormalities as detected by spectral-domain optical coherence tomography: the beaver dam eye study. Ophthalmology. 2015 ;122:787-95.
Ferris FL 3rd, Wilkinson CP, Bird A, Chakravarthy U, Chew E, Csaky K, SaddaSR; Beckman Initiative for Macular Research Classification Committee. Clinical classification of age-related macular degeneration. Ophthalmology. 2013;120:844-51.
Deshpande R, Mangiraj V, Deshpande M, Dole K, Bharucha K, Sanghavi N. A clinical study to assess feasibility, acceptance, and outcome of multifocal intraocular lens in patients with bilateral immature cataract at a tertiary eye care institute. Indian J Ophthalmol. 2020 ;68:2421-2426.
Pham TQ, Wang JJ, Rochtchina E, et al. Systemic and ocular comorbiditity of cataract surgical patients in a western Sydney public hospital. Clin Experiment Ophthalmol 2004;32:383–7.
Bro T, Behndig A, Viberg A, Zetterberg M, Kugelberg M, Nilsson I, Thorburn W, Stenevi U, Lundström M. Two point four million cataract surgeries: 30 years with the Swedish National Cataract Register, 1992-2021. J Cataract Refract Surg. 2023; 49:879-884.
Klein BR, Brown EN, Casden RS. Preoperative macular spectral-domain optical coherence tomography in patients considering advanced-technology intraocular lenses for cataract surgery. J Cataract Refract Surg. 2016; 42:537-41.
Lee JH, Kong M, Sohn JH, Cho BJ, Choi KY, Lee SM. Analysis of Korean Retinal Specialists' Opinions on Implanting Diffractive Multifocal Intraocular Lenses in Eyes with Underlying Retinal Diseases. J Clin Med. 2022;11:1836.
Grzybowski A, Kanclerz P, Tuuminen R. Multifocal intraocular lenses and retinal diseases. Graefes Arch Clin Exp Ophthalmol. 2020 ;258:805-8.
Anderson DF, Dhariwal M, Bouchet C, Keith MS. Global prevalence and economic and humanistic burden of astigmatism in cataract patients: a systematic literature review. Clin Ophthalmol. 2018 ; 12:439-452
Shen J, Ma D, Cai L, Zhang L, Guo H, Yang J. Comparison of visual outcomes inadult patients with different types of developmental cataracts after toric multifocal intraocular lenses implantation. Graefes Arch Clin Exp Ophthalmol. 2023 Jun 29. doi: 10.1007/s00417-023-06148-4. Epub ahead of print
Anastasopoulos E, Topouzis F, Wilson MR, Harris A, Pappas T, Yu F, KoskosasA, Founti P, Coleman AL. Characteristics of pseudoexfoliation in the Thessaloniki Eye Study. J Glaucoma. 2011 ;20:160-6.
Gimbel HV, Condon GP, Kohnen T, Olson RJ, Halkiadakis I. Late in-the-bag intraocular lens dislocation: incidence, prevention, and management. J Cataract Refract Surg. 2005;31:2193-204.
Ashena Z, Maqsood S, Ahmed SN, Nanavaty MA. Effect of Intraocular Lens Tilt and Decentration on Visual Acuity, Dysphotopsia and Wavefront Aberrations. Vision (Basel). 2020 ;4(3):41.
Xu J., Zheng T., Lu Y. Effect of decentration on the optical quality of monofocal, extended depth of focus, and bifocal intraocular lenses. J. Refract. Surg.2019; 35:484–492.
Topouzis F, Coleman AL, Harris A, Koskosas A, Founti P, Gong G, Yu F,Anastasopoulos E, Pappas T, Wilson MR. Factors associated with undiagnosed open-angle glaucoma: the Thessaloniki Eye Study. Am J Ophthalmol. 2008 ;145:327-335.
Ichhpujani P, Bhartiya S, Sharma A. Premium IOLs in Glaucoma. J Curr Glaucoma Pract. 2013;7:54-7.
Alio JL, Plaza-Puche AB, Férnandez-Buenaga R, Pikkel J, Maldonado M.Multifocal intraocular lenses: An overview. Surv Ophthalmol. 2017 ;62:611-634.
Daga FB, Gracitelli CPB, Diniz-Filho A, Medeiros FA. Is vision-related quality of life impaired in patients with preperimetric glaucoma? Br J Ophthalmol. 2019 ;103:955-959.
Iida Y, Shimizu K, Ito M. Pseudophakic monovision using monofocal and multifocal intraocular lenses: hybrid monovision. J Cataract Refract Surg. 2011; 37:2001–2005.
Grimfors M, Mollazadegan K, Lundström M, Kugelberg M. Ocular comorbidity and self-assessed visual function after cataract surgery. J Cataract Refract Surg. 2014 ;40:1163-9.
Tinner C, Eppenberger L, Golla K, Mohanna S, Schmid MK, Thiel M. Use of Spectacles after Cataract Surgery. Klin Monbl Augenheilkd. 2023;240:408-414.
Lafuma A, Berdeaux G. Modelling lifetime cost consequences of ReSTOR in cataract surgery in four European countries. BMC Ophthalmol. 2008;8:12.
De Vries NE, Laurendeau C, Lafuma A, Berdeaux G, Nuijts RMMA. Lifetime costs and effectiveness of ReSTOR compared with a monofocal IOL and Array-SA40 in the Netherlands. Eye. 2010;24: 663–72.
Karam M, Alkhowaiter N, Alkhabbaz A, Aldubaikhi A, Alsaif A, Shareef E, Alazaz R, Alotaibi A, Koaik M, Jabbour S. Extended Depth of Focus Versus Trifocal for Intraocular Lens Implantation: An Updated Systematic Review and Meta-Analysis. Am J Ophthalmol. 2023 ;251:52-70.
Jeon S, Choi A, Kwon H. Clinical outcomes after implantation of extendeddepth-of-focus AcrySof® Vivity® intraocular lens in eyes with low-grade epiretinal membrane. Graefes Arch Clin Exp Ophthalmol. 2022;260:3883-3888.

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Screening cataract patients in a public hospital for a multifocal intraocular lens implantation

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