Eyeworld

12 | EYEWORLD | JUNE/JULY 2020 EYEWORLD JOURNAL CLUB ASCRS NEWS by Matthew Floyd, MD, Jeremy Jones, MD, Rebecca Neustein, MD, Kenneth Price, MD, Gina Shetty, MD value hyperopic uncorrected visual acuity, an era of handheld technology places a premium on intermediate and near visual acuity for daily functioning. Identifying which refractive goal— emmetropia or mild myopia—can preserve the greatest depth of focus at intermediate and near focal points, without sacrificing sharpness of distance vision, remains a critical challenge in surgical planning for patients receiving bilateral monofocal IOLs. Study review The study by Vinciguerra et al. is a retrospec- tive study of 60 patients who were recruited postoperatively after phacoemulsification with monofocal IOL implantation in both eyes. This study was conducted at a single center with all surgeries being performed by a single surgeon. Once recruited, the 60 patients were divided into two groups. Group 1 included 30 patients who received bilateral monofocal IOLs with a near emmetropic target (0 to –0.30 D), and Group 2 included 30 patients who received bi- lateral monofocal IOLs with a mild myopic tar- get (–0.40 to –0.75 D). Exclusion criteria were previous ocular surgery (aside from cataract surgery), ocular pathology, corneal abnormal- ities, and endothelial cell count less than 2,000 cells/mm. Patients were examined 1 month after cataract surgery in the second eye. Both groups underwent near (40 cm), intermediate (66 cm; 80 cm), and distance (4 m) visual acuity testing using a Snellen chart with 100% contrast. This was performed under monocular and binocular conditions with and without correction. Defo- cus curve testing was performed from –4.0 D to +1.5 D in 0.5 D increments using a distance target under photopic lighting conditions. Patients in both groups completed a subjective questionnaire assessing visual satisfaction at near, intermediate, and distance targets. Spec- tacle independence and hours of spectacle use were also assessed. The mean age of the emmetropic group was 71.7±8.7, and the mean age of the mildly I n the modern era of cataract surgery, surgical approaches and options for IOLs have grown exponentially. Mirroring this growth, patient expectations for postoper- ative vision and spectacle independence are higher than ever before. Innovative IOL designs aim to accommodate these expec- tations with options ranging from traditional monofocal IOLs to premium lenses, including bifocal, trifocal, multifocal, and extended depth of focus IOLs. These premium lenses have been reported to deliver better uncorrected near vision and have allowed for a higher proportion of patients to achieve spectacle independence compared to monofocal IOLs. However, they carry a greater risk of unwanted visual phenom- ena in contrast to typical monofocal lenses. 1 Despite the increasing prevalence and versatility of premium IOLs, monofocal lenses remain the most common IOLs utilized in cataract surgery around the world. A drawback of bilateral monofocal IOLs is the requirement for spectacle correction to optimize vision at near or distance. This can be attributed to the loss of depth of focus (DOF) that occurs with intraocular lens implantation. Patients who want to minimize the use of glass- es postoperatively may consider "mini-monovi- sion," where the surgeon targets the dominant eye for emmetropia and the non-dominant eye for mild myopia. 2 Patients with mini-mono- vision acquire an increased DOF at the cost of losing a degree of stereopsis. As a result, a portion of patients cannot overcome this discrepancy between postoperative focal points and require refractive correction via spectacles, contact lenses, or LASIK/PRK. 3 As such, the majority of patients aim for equal refractive outcomes in both eyes. Cataract surgeons employing monofocal IOLs typically aim for emmetropia or mild my- opia. The choice between these two refractive targets is often guided by the surgeon's assump- tion, within the context of the patient's refrac- tive history, of what will provide the most func- tional postoperative vision. While some patients Review of "Comparison of visual bilateral emmetropic vs. a bilateral monofocal intraocular lens" Shouldn't plano be our target for monofocal IOL patients who want to see in the distance without eyeglasses? I asked the Emory residents to review this June JCRS study that reaches a different conclusion. —David F. Chang, MD EyeWorld Journal Club Editor Jeremy Jones, MD Director, Residency Program in Ophthalmology Emory Eye Center Atlanta, Georgia

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