Wavefront aberrations and the depth of focus of the human eye

The depth of focus (DOF) can be defined as the variation in image distance of a lens or an optical system which can be tolerated without incurring an objectionable lack of sharpness of focus. The DOF of the human eye serves a mechanism of blur tolerance. As long as the target image remains within the depth of focus in the image space, the eye will still perceive the image as being clear. A large DOF is especially important for presbyopic patients with partial or complete loss of accommodation (presbyopia), since this helps them to obtain an acceptable retinal image when viewing a target moving through a range of near to intermediate distances. The aim of this research was to investigate the DOF of the human eye and its association with the natural wavefront aberrations, and how higher order aberrations (HOAs) can be used to expand the DOF, in particular by inducing spherical aberrations ( 0 4 Z and 0 6 Z ). The depth of focus of the human eye can be measured using a variety of subjective and objective methods. Subjective measurements based on a Badal optical system have been widely adopted, through which the retinal image size can be kept constant. In such measurements, the subject.s tested eye is normally cyclopleged. Objective methods without the need of cycloplegia are also used, where the eye.s accommodative response is continuously monitored. Generally, the DOF measured by subjective methods are slightly larger than those measured objectively. In recent years, methods have also been developed to estimate DOF from retinal image quality metrics (IQMs) derived from the ocular wavefront aberrations. In such methods, the DOF is defined as the range of defocus error that degrades the retinal image quality calculated from the IQMs to a certain level of the possible maximum value. In this study, the effect of different amounts of HOAs on the DOF was theoretically evaluated by modelling and comparing the DOF of subjects from four different clinical groups, including young emmetropes (20 subjects), young myopes (19 subjects), presbyopes (32 subjects) and keratoconics (35 subjects). A novel IQM-based through-focus algorithm was developed to theoretically predict the DOF of subjects with their natural HOAs. Additional primary spherical aberration ( 0 4 Z ) was also induced in the wavefronts of myopes and presbyopes to simulate the effect of myopic refractive correction (e.g. LASIK) and presbyopic correction (e.g. progressive power IOL) on the subject.s DOF. Larger amounts of HOAs were found to lead to greater values of predicted DOF. The introduction of primary spherical aberration was found to provide moderate increase of DOF while slightly deteriorating the image quality at the same time. The predicted DOF was also affected by the IQMs and the threshold level adopted. We then investigated the influence of the chosen threshold level of the IQMs on the predicted DOF, and how it relates to the subjectively measured DOF. The subjective DOF was measured in a group of 17 normal subjects, and we used through-focus visual Strehl ratio based on optical transfer function (VSOTF) derived from their wavefront aberrations as the IQM to estimate the DOF. The results allowed comparison of the subjective DOF with the estimated DOF and determination of a threshold level for DOF estimation. Significant correlation was found between the subject.s estimated threshold level for the estimated DOF and HOA RMS (Pearson.s r=0.88, p<0.001). The linear correlation can be used to estimate the threshold level for each individual subject, subsequently leading to a method for estimating individual.s DOF from a single measurement of their wavefront aberrations. A subsequent study was conducted to investigate the DOF of keratoconic subjects. Significant increases of the level of HOAs, including spherical aberration, coma and trefoil, can be observed in keratoconic eyes. This population of subjects provides an opportunity to study the influence of these HOAs on DOF. It was also expected that the asymmetric aberrations (coma and trefoil) in the keratoconic eye could interact with defocus to cause regional blur of the target. A dual-Badal-channel optical system with a star-pattern target was used to measure the subjective DOF in 10 keratoconic eyes and compared to those from a group of 10 normal subjects. The DOF measured in keratoconic eyes was significantly larger than that in normal eyes. However there was not a strong correlation between the large amount of HOA RMS and DOF in keratoconic eyes. Among all HOA terms, spherical aberration was found to be the only HOA that helped to significantly increase the DOF in the studied keratoconic subjects. Through the first three studies, a comprehensive understanding of DOF and its association to the HOAs in the human eye had been achieved. An adaptive optics system was then designed and constructed. The system was capable of measuring and altering the wavefront aberrations in the subject.s eye and measuring the resulting DOF under the influence of different combination of HOAs. Using the AO system, we investigated the concept of extending the DOF through optimized combinations of 0 4 Z and 0 6 Z . Systematic introduction of a targeted amount of both 0 4 Z and 0 6 Z was found to significantly improve the DOF of healthy subjects. The use of wavefront combinations of 0 4 Z and 0 6 Z with opposite signs can further expand the DOF, rather than using 0 4 Z or 0 6 Z alone. The optimal wavefront combinations to expand the DOF were estimated using the ratio of increase in DOF and loss of retinal image quality defined by VSOTF. In the experiment, the optimal combinations of 0 4 Z and 0 6 Z were found to provide a better balance of DOF expansion and relatively smaller decreases in VA. Therefore, the optimal combinations of 0 4 Z and 0 6 Z provides a more efficient method to expand the DOF rather than 0 4 Z or 0 6 Z alone. This PhD research has shown that there is a positive correlation between the DOF and the eye.s wavefront aberrations. More aberrated eyes generally have a larger DOF. The association of DOF and the natural HOAs in normal subjects can be quantified, which allows the estimation of DOF directly from the ocular wavefront aberration. Among the Zernike HOA terms, spherical aberrations ( 0 4 Z and 0 6 Z ) were found to improve the DOF. Certain combinations of 0 4 Z and 0 6 Z provide a more effective method to expand DOF than using 0 4 Z or 0 6 Z alone, and this could be useful in the optimal design of presbyopic optical corrections such as multifocal contact lenses, intraocular lenses and laser corneal surgeries.

Ocular surface changes with short-term contact lens wear

Contact lenses are a common method for the correction of refractive errors of the eye. While there have been significant advancements in contact lens designs and materials over the past few decades, the lenses still represent a foreign object in the ocular environment and may lead to physiological as well as mechanical effects on the eye. When contact lenses are placed in the eye, the ocular anatomical structures behind and in front of the lenses are directly affected. This thesis presents a series of experiments that investigate the mechanical and physiological effects of the short-term use of contact lenses on anterior and posterior corneal topography, corneal thickness, the eyelids, tarsal conjunctiva and tear film surface quality. The experimental paradigm used in these studies was a repeated measures, cross-over study design where subjects wore various types of contact lenses on different days and the lenses were varied in one or more key parameters (e.g. material or design). Both, old and newer lens materials were investigated, soft and rigid lenses were used, high and low oxygen permeability materials were tested, toric and spherical lens designs were examined, high and low powers and small and large diameter lenses were used in the studies. To establish the natural variability in the ocular measurements used in the studies, each experiment also contained at least one “baseline” day where an identical measurement protocol was followed, with no contact lenses worn. In this way, changes associated with contact lens wear were considered in relation to those changes that occurred naturally during the 8 hour period of the experiment. In the first study, the regional distribution and magnitude of change in corneal thickness and topography was investigated in the anterior and posterior cornea after short-term use of soft contact lenses in 12 young adults using the Pentacam. Four different types of contact lenses (Silicone hydrogel/ Spherical/–3D, Silicone Hydrogel/Spherical/–7D, Silicone Hydrogel/Toric/–3D and HEMA/Toric/–3D) of different materials, designs and powers were worn for 8 hours each, on 4 different days. The natural diurnal changes in corneal thickness and curvature were measured on two separate days before any contact lens wear. Significant diurnal changes in corneal thickness and curvature within the duration of the study were observed and these were taken into consideration for calculating the contact lens induced corneal changes. Corneal thickness changed significantly with lens wear and the greatest corneal swelling was seen with the hydrogel (HEMA) toric lens with a noticeable regional swelling of the cornea beneath the stabilization zones, the thickest regions of the lenses. The anterior corneal surface generally showed a slight flattening with lens wear. All contact lenses resulted in central posterior corneal steepening, which correlated with the relative degree of corneal swelling. The corneal swelling induced by the silicone hydrogel contact lenses was typically less than the natural diurnal thinning of the cornea over this same period (i.e. net thinning). This highlights why it is important to consider the natural diurnal variations in corneal thickness observed from morning to afternoon to accurately interpret contact lens induced corneal swelling. In the second experiment, the relative influence of lenses of different rigidity (polymethyl methacrylate – PMMA, rigid gas permeable – RGP and silicone hydrogel – SiHy) and diameters (9.5, 10.5 and 14.0) on corneal thickness, topography, refractive power and wavefront error were investigated. Four different types of contact lenses (PMMA/9.5, RGP/9.5, RGP/10.5, SiHy/14.0), were worn by 14 young healthy adults for a period of 8 hours on 4 different days. There was a clear association between fluorescein fitting pattern characteristics (i.e. regions of minimum clearance in the fluorescein pattern) and the resulting corneal shape changes. PMMA lenses resulted in significant corneal swelling (more in the centre than periphery) along with anterior corneal steepening and posterior flattening. RGP lenses, on the other hand, caused less corneal swelling (more in the periphery than centre) along with opposite effects on corneal curvature, anterior corneal flattening and posterior steepening. RGP lenses also resulted in a clinically and statistically significant decrease in corneal refractive power (ranging from 0.99 to 0.01 D), large enough to affect vision and require adjustment in the lens power. Wavefront analysis also showed a significant increase in higher order aberrations after PMMA lens wear, which may partly explain previous reports of "spectacle blur" following PMMA lens wear. We further explored corneal curvature, thickness and refractive changes with back surface toric and spherical RGP lenses in a group of 6 subjects with toric corneas. The lenses were worn for 8 hours and measurements were taken before and after lens wear, as in previous experiments. Both lens types caused anterior corneal flattening and a decrease in corneal refractive power but the changes were greater with the spherical lens. The spherical lens also caused a significant decrease in WTR astigmatism (WRT astigmatism defined as major axis within 30 degrees of horizontal). Both the lenses caused slight posterior corneal steepening and corneal swelling, with a greater effect in the periphery compared to the central cornea. Eyelid position, lid-wiper and tarsal conjunctival staining were also measured in Experiment 2 after short-term use of the rigid and SiHy contact lenses. Digital photos of the external eyes were captured for lid position analysis. The lid-wiper region of the marginal conjunctiva was stained using fluorescein and lissamine green dyes and digital photos were graded by an independent masked observer. A grading scale was developed in order to describe the tarsal conjunctival staining. A significant decrease in the palpebral aperture height (blepharoptosis) was found after wearing of PMMA/9.5 and RGP/10.5 lenses. All three rigid contact lenses caused a significant increase in lid-wiper and tarsal staining after 8 hours of lens wear. There was also a significant diurnal increase in tarsal staining, even without contact lens wear. These findings highlight the need for better contact lens edge design to minimise the interactions between the lid and contact lens edge during blinking and more lubricious contact lens surfaces to reduce ocular surface micro-trauma due to friction and for. Tear film surface quality (TFSQ) was measured using a high-speed videokeratoscopy technique in Experiment 2. TFSQ was worse with all the lenses compared to baseline (PMMA/9.5, RGP/9.5, RGP/10.5, and SiHy/14) in the afternoon (after 8 hours) during normal and suppressed blinking conditions. The reduction in TFSQ was similar with all the contact lenses used, irrespective of their material and diameter. An unusual pattern of change in TFSQ in suppressed blinking conditions was also found. The TFSQ with contact lens was found to decrease until a certain time after which it improved to a value even better than the bare eye. This is likely to be due to the tear film drying completely over the surface of the contact lenses. The findings of this study also show that there is still a scope for improvement in contact lens materials in terms of better wettability and hydrophilicity in order to improve TFSQ and patient comfort. These experiments showed that a variety of changes can occur in the anterior eye as a result of the short-term use of a range of commonly used contact lens types. The greatest corneal changes occurred with lenses manufactured from older HEMA and PMMA lens materials, whereas modern SiHy and rigid gas permeable materials caused more subtle changes in corneal shape and thickness. All lenses caused signs of micro-trauma to the eyelid wiper and palpebral conjunctiva, although rigid lenses appeared to cause more significant changes. Tear film surface quality was also significantly reduced with all types of contact lenses. These short-term changes in the anterior eye are potential markers for further long term changes and the relative differences between lens types that we have identified provide an indication of areas of contact lens design and manufacture that warrant further development.

Corneal changes following short-term rigid contact lens wear

Purpose: The aim of this cross-over study was to investigate the changes in corneal thickness, anterior and posterior corneal topography, corneal refractive power and ocular wavefront aberrations, following the short term use of rigid contact lenses. Method: Fourteen participants wore 4 different types of contact lenses (RGP lenses of 9.5 mm and 10.5 mm diameter, and for comparison a PMMA lens of 9.5 mm diameter and a soft silicone hydrogel lens) on 4 different days for a period of 8 h on each day. Measures were collected before and after contact lens wear and additionally on a baseline day. Results: Anterior corneal curvature generally showed a flattening with both of the RGP lenses and a steepening with the PMMA lens. A significant negative correlation was found between the change in corneal swelling and central and peripheral posterior corneal curvature (all p ≤ 0.001). RGP contact lenses caused a significant decrease in corneal refractive power (hyperopic shift) of approximately 0.5 D. The PMMA contact lenses caused the greatest corneal swelling in both the central (27.92 ± 15.49 μm, p < 0.001) and peripheral (17.78 ± 12.11 μm, p = 0.001) corneal regions, a significant flattening of the posterior cornea and an increase in ocular aberrations (all p ≤ 0.05). Conclusion: The corneal swelling associated with RGP lenses was relatively minor, but there was slight central corneal flattening and a clinically significant hyperopic change in corneal refractive power after the first day of lens wear. The PMMA contact lenses resulted in significant corneal swelling and reduced optical performance of the cornea.

Effect of age on components of peripheral ocular aberrations

Purpose: To investigate the effect of age on the contributions of the anterior cornea and internal components to ocular aberrations in the peripheral visual field. Methods: Ocular aberrations were measured in 10 young emmetropes and 7 older emmetropes using a modified commercial Hartmann-Shack aberrometer across 42° x 32° of central visual field. Anterior corneal aberrations were estimated from anterior corneal topography using theoretical ray-tracing. Internal aberrations were calculated by subtracting anterior corneal aberrations from ocular aberrations. Results: Anterior corneal aberrations of young subjects were reasonably compensated by the internal aberrations, except for astigmatism for which the internal contribution was small out to the 21° field limit. The internal coma and spherical aberration of the older subjects were considerably smaller in magnitude than those of the young subjects such that the compensation for anterior corneal aberrations was poorer. This can be explained by age-related changes in the lens shape and refractive index distribution. Conclusion: oss of balance between anterior cornea and internal components of higher order aberrations with increasing age, found previously for on-axis vision, applies also to the peripheral visual field.

Corneal changes following short-term miniscleral contact lens wear

Purpose To examine the influence of short-term miniscleral contact lens wear on corneal shape, thickness and anterior surface aberrations. Methods Scheimpflug imaging was captured before, immediately following and 3 hours after a short period (3 hours) of miniscleral contact lens wear for 10 young (mean 27 ± 5 years), healthy participants. Natural diurnal variations were considered by measuring baseline diurnal changes obtained on a separate control day without contact lens wear. Results Small but significant anterior corneal flattening was observed immediately following lens removal (overall mean 0.02 ± 0.03 mm, p < 0.001) which returned to baseline levels three hours after lens removal. During the three hour recovery period significant corneal thinning (-13.4 ± 10.5 μm) and posterior surface flattening (0.03 ± 0.02 mm) were also observed (both p < 0.01). The magnitude of posterior corneal flattening during recovery correlated with the amount of corneal thinning (r = 0.69, p = 0.03). Central corneal clearance (maximum tear reservoir depth) was not associated with corneal swelling following lens removal (r = -0.24, p > 0.05). An increase in lower-order corneal astigmatism Z(2,2) was also observed following lens wear (mean -0.144 ± 0.075 μm, p = 0.02). Conclusions Flattening of the anterior corneal surface was observed immediately following lens wear, while ‘rebound’ thinning and flattening of the posterior surface was evident following the recovery period. Modern miniscleral contact lenses that vault the cornea may slightly influence corneal shape and power but do not induce clinically significant corneal oedema during short-term wear.

Miniscleral lens wear influences corneal curvature and optics

Purpose Transient changes in corneal topography associated with soft and conventional or reverse geometry rigid contact lens wear have been well documented; however, only a few studies have examined the influence of scleral contact lens wear upon the cornea. Therefore, in this study, we examined the influence of modern miniscleral contact lenses, which land entirely on the sclera and overlying tissues, upon anterior corneal curvature and optics. Methods Anterior corneal topography and elevation data were acquired using Scheimpflug imaging (Pentacam HR, Oculus) immediately prior to and following 8 hours of miniscleral contact lens wear in 15 young healthy adults (mean age 22 ± 3 years, 8 East Asian, 7 Caucasian) with normal corneae. Corneal diurnal variations were accounted for using data collected on a dedicated measurement day without contact lens wear. Corneal clearance was quantified using an optical coherence tomographer (RS-3000, Nidek) following lens insertion and after 8 hours of lens wear. Results Although corneal clearance was maintained throughout the 8 hour lens wear period, significant corneal flattening (up to 0.08 ± 0.04 mm) was observed, primarily in the superior mid-peripheral cornea, which resulted in a slight increase in against-the-rule corneal astigmatism (mean +0.02/-0.15 x 94 for an 8 mm diameter). Higher order aberration terms of horizontal coma, vertical coma and spherical aberration all underwent significant changes for an 8 mm corneal diameter (p ≤ 0.01), which typically resulted in a decrease in RMS error values (mean change in total higher order RMS -0.035 ± 0.046 µm for an 8 mm diameter). There was no association between the magnitude of change in central or mid-peripheral corneal clearance during lens wear and the observed changes in corneal curvature (p > 0.05). However, Asian participants displayed a significantly greater reduction in corneal clearance (p = 0.04) and greater superior-nasal corneal flattening compared to Caucasians (p = 0.048). Conclusions Miniscleral contact lenses that vault the cornea induce significant changes in anterior corneal surface topography and higher order aberrations following 8 hours of lens wear. The region of greatest corneal flattening was observed in the superior-nasal mid-periphery, more so in Asian participants. Practitioners should be aware that corneal measurements obtained following miniscleral lens removal may mask underlying corneal steepening.

Active Phase Conjugating Lens With Sub-Wavelength Resolution Capability

Experimental results are presented for the focusing capability of an active phase conjugating lens for a single and a dipole source pair and these are compared with predictions. In addition for a single source we illustrate the ability of the lens to project a null at the lens focus instead of a peak. A scheme is also presented such that when a source or pair of sources is imaged through an identical pair of passive scatterers located symmetrically about the lens that imaging with sub-wavelength resolution is possible. The rationale for the operation of the lens and aberrations observed due to its finite array size is discussed and is supported throughout by means of numerical simulation.

Effect of position of near addition in an asymmetric refractive multifocal intraocular lens on quality of vision

Purpose
To evaluate the impact of the position of an asymmetric multifocal near segment on visual quality.

Setting
Cathedral Eye Clinic, Belfast, United Kingdom.

Design
Retrospective comparative case series.

Methods
Data from consecutive patients who had bilateral implantation of the Lentis Mplus LS-312 multifocal intraocular lens were divided into 2 groups. One group received inferonasal near-segment placement and the other, superotemporal near-segment placement. A +3.00 diopter (D) reading addition (add) was used in all eyes. The main outcome measures included uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), contrast sensitivity, and quality of vision. Follow-up was 3 months.

Results
Patients ranged in age from 43 to 76 years. The inferonasal group comprised 80 eyes (40 patients) and the superotemporal group, 76 eyes (38 patients). The mean 3-month spherical equivalent was −0.11 D ± 0.49 (SD) in the inferonasal group and −0.18 ± 0.46 D in the superotemporal group. The mean postoperative UDVA was 0.14 ± 0.10 logMAR and 0.18 ± 0.15 logMAR, respectively. The mean monocular UNVA was 0.21 ± 0.14 logRAD and 0.24 ± 0.13 logRAD, respectively. No significant differences were observed in the higher-order aberrations, total Strehl ratio (point-spread function), or modulation transfer function between the groups. Dysphotopic symptoms measured with a validated quality-of-vision questionnaire were not significantly different between groups.

Conclusion
Positioning of the near add did not significantly affect objective or subjective visual function parameters.

Two-wavelength whole-field interferometry setup for thermal lens study

In this paper we present a new approach for thermal lens analysis using a two-wavelength DSPI (Digital Speckle Pattern Interferometry) setup for wavefront sensing. The employed geometry enables the sensor to detect wavefronts with small phase differences and inherent aberrations found in induced lenses. The wavefronts was reconstructed by four-stepping fringe evaluation and branch-cut unwrapping from fringes formed onto a diffusive glass. Real-time single-exposure contour interferograms could be obtained in order to get discernible and low-spacial frequency contour fringes and obtain low-noise measurements. In our experiments we studied the thermal lens effect in a 4% Er-doped CaO-Al2O3 glass sample. The diode lasers were tuned to have a contour interval of around 120 μm. The incident pump power was longitudinally and collinearly oriented with the probe beams. Each interferogram described a spherical-like wavefront. Using the ABCD matrix formalism we obtained the induced lens dioptric power from the thermal effect for different values of absorbed pump power. © 2012 Copyright SPIE.

Developing Psychosis and Its Risk States Through the Lens of Schizotypy

Starting from the early descriptions of Kraepelin and Bleuler, the construct of schizotypy was developed from observations of aberrations in nonpsychotic family members of schizophrenia patients. In contemporary diagnostic manuals, the positive symptoms of schizotypal personality disorder were included in the ultra high-risk (UHR) criteria 20 years ago, and nowadays are broadly employed in clinical early detection of psychosis. The schizotypy construct, now dissociated from strict familial risk, also informed research on the liability to develop any psychotic disorder, and in particular schizophrenia-spectrum disorders, even outside clinical settings. Against the historical background of schizotypy it is surprising that evidence from longitudinal studies linking schizotypy, UHR, and conversion to psychosis has only recently emerged; and it still remains unclear how schizotypy may be positioned in high-risk research. Following a comprehensive literature search, we review 18 prospective studies on 15 samples examining the evidence for a link between trait schizotypy and conversion to psychosis in 4 different types of samples: general population, clinical risk samples according to UHR and/or basic symptom criteria, genetic (familial) risk, and clinical samples at-risk for a nonpsychotic schizophrenia-spectrum diagnosis. These prospective studies underline the value of schizotypy in high-risk research, but also point to the lack of evidence needed to better define the position of the construct of schizotypy within a developmental psychopathology perspective of emerging psychosis and schizophrenia-spectrum disorders

Clinical and quality of life data correlation with a single-optic accommodating intraocular lens

Purpose: To examine a single-optic accommodating intraocular lens (IOL) visual performance by correlating IOL implanted eyes’ defocus curve with the intraocular aberrometric profile and the impact on the quality of life (QOL). Methods: Prospective consecutive case series study including a total of 25 eyes of 14 patients with ages ranging between 52 and 79 years old. All cases underwent cataract surgery with implantation of the single-optic accommodating IOL Crystalens HD (Bausch & Lomb). Distance and near visual acuity outcomes, intraocular aberrations, the defocus curve and QOL (NEI VFQ-25) were evaluated 3 months after surgery. Results: A significant improvement in distance visual acuity was found postoperatively (p = 0.02). Mean postoperative LogMAR uncorrected near visual acuity was 0.44 ± 0.23 (20/30). 60% of eyes had a postoperative addition between 0 and 1.5 diopters (D). The defocus curve showed an area of maximum visual acuity for the levels of defocus corresponding to distance and intermediate vision (−1 to +0.5 D). Postoperative intermediate visual acuity correlated significantly some QOL indices (r ≥ 0.51, p ≤ 0.03; difficulty in going down steps or seeing how people react to things that patient says) as well as with J0 component of manifest cylinder. Postoperative distance-corrected near visual acuity correlated significantly with age (r = 0.65, p < 0.01). Conclusions: This accommodating IOL seems to be able to restore the distance visual function as well as to provide an improvement in intermediate and near vision with a significant impact on patient's QOL, although limited by age and astigmatism. Future studies with larger sample sizes should confirm all these trends.

Visual and optical performance and quality of life after implantation of posterior chamber phakic intraocular lens

Purpose To evaluate visual, optical, and quality of life (QoL) outcomes and intercorrelations after bilateral implantation of posterior chamber phakic intraocular lenses. Methods Twenty eyes with high to moderate myopia of 10 patients that underwent PRL implantation (Phakic Refractive Lens, Carl Zeiss Meditec AG) were examined. Refraction, visual acuity, photopic and low mesopic contrast sensitivity (CS) with and without glare, ocular aberrations, as well as QoL outcomes (National Eye Institute Refractive Error Quality of Life Instrument-42, NEI RQL-42) were evaluated at 12 months postoperatively. Results Significant improvement in uncorrected (UDVA) and best-corrected distance (CDVA) visual acuities were found postoperatively (p < 0.01), with significant reduction in spherical equivalent (p < 0.01). Low mesopic CS without glare was significantly better than measurements with glare for 1.5, 3, and 6 cycles/degree (p < 0.01). No significant correlations between higher order root mean square (RMS) with CDVA (r = −0.26, p = 0.27) and CS (r ≤ 0.45, p ≥ 0.05) were found. Postoperative binocular photopic CS for 12 cycles/degree and 18 cycles/degree correlated significantly with several RQL-42 scales. Glare index correlated significantly with CS measures and scotopic pupil size (r = −0.551, p = 0.04), but not with higher order RMS (r = −0.02, p = 0.94). Postoperative higher order RMS, postoperative primary coma and postoperative spherical aberration was significant higher for 5-mm pupil diameter (p < 0.01) compared with controls. Conclusions Correction of moderate to high myopia by means of PRL implantation had a positive impact on CS and QoL. The aberrometric increase induced by the surgery does not seem to limit CS and QoL. However, perception of glare is still a relevant disturbance in some cases possibly related to the limitation of the optical zone of the PRL.

The posterior chamber phakic refractive lens (PRL): a review

Implantation of phakic intraocular lenses (pIOLs) is a reversible refractive procedure, preserving the patient’s accommodative function with minimal induction of higher order aberrations compared with corneal photoablative procedures. Despite this, as an intraocular procedure, it has potential risks such as cataracts, chronic uveitis, pupil ovalization, corneal endothelial cell loss, pigmentary dispersion syndrome, pupillary block glaucoma, astigmatism, or endophthalmitis. Currently, only two models of posterior chamber pIOLs are commercially available, the implantable collammer lens (STAAR Surgical Co.) and the phakic refractive lens (PRL; Zeiss Meditec). The number of published reports on the latter is very low, and some concerns still remain about its long-term safety. The present article reviews the published literature on the outcomes after PRL implantation in order to provide a general overview and evaluate its real potential as a surgical refractive option.

New-Generation Hybrid Contact Lens for the Management of Extreme Irregularity in a Thin Cornea After Unsuccessful Excimer Laser Refractive Surgery

Purpose: To report a very successful outcome obtained with the fitting of a new-generation hybrid contact lens of reverse geometry in a thin cornea with extreme irregularity due to the presence of a central island after unsuccessful myopic excimer laser refractive surgery. Methods: A 32-year-old man attended to our clinic complaining of very poor vision in his right eye after bilateral laser in situ keratomileusis (treatment or surgery) for myopia correction and some additional retreatments afterward. After a comprehensive ocular evaluation, contact lens fitting with a reverse geometry hybrid contact lens (SynergEyes PS, SynergEyes, Carlsbad, CA) was proposed as a solution for this case. Visual, refractive, and ocular aberrometric outcomes with the contact lens were evaluated. Results: Distance visual acuity improved from a prefitting uncorrected value of 20/200 to a postfitting corrected value of 20/16. Prefitting manifest refraction was +6.00 sphere and −3.00 cylinder at 70°, with a corrected distance visual acuity of 20/40. Higher order root mean square for a 5-mm pupil changed from a prefitting value of 1.45 to 0.34 µm with the contact lens. The contact lens wearing was reported as comfortable, and the patient was very satisfied with this solution. Conclusions: The SynergEyes PS contact lens seems to be an excellent option for the visual rehabilitation of corneas with extreme irregularity after myopic excimer laser surgery, minimizing the level of higher order aberrations and providing an excellent visual outcome.

Fixed Mydriatic Pupil Associated with an Intraocular Pressure Rise as a Complication of the Implant of a Phakic Refractive Lens (PRL)

We describe a case report of a patient that was implanted with a posterior chamber phakic intraocular lens (Phakic Refractive Lens, PRL) for the correction of moderate myopia and who developed postoperatively a fixed mydriasis compatible with an Urrets-Zavalia Syndrome (UZS). Specifically, a sudden acute increase of IOP in the left eye was observed in the immediate postoperative period. After IOP stabilization, the refractive result was good, but a fixed and mydriatic pupil appeared. This condition led the patient to experience visual discomfort, halos, and glare associated with high levels of higher-order aberrations in spite of the good visual result. A tinted-contact lens was fitted in order to minimize those symptoms. The UZS should be considered as a possible complication after implantation of posterior chamber phakic intraocular lenses.