Lens-based surgical correction of presbyopia. Where are we in 2020? | Archivos de la Sociedad Española de Oftalmología (English Edition)

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However, despite continued technical advances, the correction of the ensuing loss of accommodation remains a challenge. The ideal scenario would be to be able to replace a dysfunctional lens with a clear intraocular lens (IOL) that allows functional vision at all distances, without the need for spectacles or contact lenses. Although filling the crystalline sac with a transparent and viscoelastic substance would achieve this objective, experiments in this line of research have been carried out for years without success and no results have been published to date. Other lines of research such as trying to "soften" the rigid presbyopic lens with pharmacological substances, or restoring its flexibility by using specific patterns of intralenticular incisions that will not damage the capsule using various femtosecond laser models<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> have also been unsuccessful so far.Accordingly, from the optical point of view, the current therapeutic approach to presbyopia after lens surgery will depend mainly on the type of lens used and the definitive post-surgery graduation achieved. Four types of strategies have been described based on the types of implants used as lens substitutes: pseudophakic monovision (MNV) with monofocal IOLs, accommodative IOLs, multifocal IOLs and finally the so-called extended depth of focus (EDOF) lenses. The most commonly used lens models analyzed in this review article are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, classified by the physical principle of weight in their optical functioning.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Monovision or pseudophakic combined visionMNV or combined vision through the use of monofocal lenses consists in having one eye focused for far vision, aiming at the final emmetropia, and the other for intermediate/near vision, leaving for this "reader" eye between 1 (mini-monovision) and 2.5 diopters (D) of myopia, according to the therapeutic algorithm used. It is a well-proven technique, both in the follow-up time and in the high number of operated patients, with reported satisfaction indexes above 80%–90%, and important referred independence of optical correction.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Physiologically, MNV is based on the phenomenon of ocular suppression by which we only consciously perceive the sharp object corresponding to the image of the eye focused at the distance where we are looking, while the vision of the out-of-focus images of the opposite eye is suppressed. The MNV technique can achieve good functional results and with fewer undesirable dysphotopsic symptoms than multifocal IOL implantation. There is some reduction in some visual functions, such as stereopsis and contrast sensitivity, but satisfaction rates are high, especially in older patients, with high rates of independence from glasses albeit lower than with modern trifocal diffractive lenses. Thus, corrective eyewear must often be used for activities that require significant visual accuracy.It is imperative to carry out a detailed preoperative study to rule out patients not suitable for this technique (especially those with low stereopsis or moderate to severe amblyopia) and to decide on the most appropriate MR strategy. Three different types of MNV have been described: conventional when the reading eye is focused for near and the dominant eye for distance, crossed MNV when the dominant eye is focused for near (both strategies appear to be equally effective and safe)<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and hybrid MNV when one eye (usually the dominant eye) is implanted with a monofocal IOL focused for emmetropia and the contralateral with a multifocal IOL or EDOF. It should also be noted that when many of the so-called EDOF IOLs are implanted, the aim is to leave a minimal residual myopic defect of about 0.5 D, in a mini-monovision strategy, to enhance the improvement in near-intermediate vision of these implants.Therefore, pseudophakic MNV is a simple, accessible, predictable, safe and effective method for the correction of presbyopia after lens surgery.Accommodative lensesThese IOLs were designed to improve near vision by simulating physiological accommodation. They are defined by a dynamic increase in the diopter power of the lens, associated with the effort to refocus from far distance to an intermediate or near vergence. They use the contraction of the ciliary muscle, the elasticity of the lens capsule and the changes in vitreous pressure to cause a change in the position or shape of the implant optics that are ultimately responsible for the change in the optical power of the eye. The amount of accommodation achieved will depend on different factors such as the position of the optics in the capsular sac, the depth of the posterior chamber and the optical power of the IOL. Hinges between the haptics and the lens optics would allow the lens to move forward when focusing on close objects, and backward when looking at a distance.Most accommodative lenses are single-lens models such as the Eyeonics Crystalens (Eyeonics, Inc., Aliso Viejo, CA, USA) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), the Tetraflex KH-3500 (Lenstec Inc., St. Petersburg, FL, USA) or the ICU lens (Human Optics AG, Erlangen, Germany); the Syncrony IOL models (Visiogen Inc, Irvine, CA, USA) and Lumina IOL (AkkoLens International, Breda, The Netherlands) operate with dual-optic systems (a very high positive-power moving anterior lens and a negative-power fixed posterior lens that adjusts emetropia to the patient) designed to enhance this accommodative effect, and appear to have improved the near visual outcomes of single-lens systems<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a>; however, they require more complex surgical manipulation due to their large size.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>An intermediate model, classified between accommodative and extended focus EDOF IOLs, is the Withcherle continuous focus IOL (WIOL-CF, Medicem, Czech Republic), a hydrogel lens designed to emulate the crystalline lens with a similar shape without haptics, and a refractive optic with a negative spherical aberration (SA). After promising initial results<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> some cases were reported with dislocations of the IOL to the vitreous cavity and, as far as we know, the distribution of the lens was suspended a few months ago.Accommodative lenses are designed to obtain excellent far and intermediate vision and functional near vision only. Initial visual results reported with these accommodative models were good,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> without presenting as many dysphotopic phenomena or loss of contrast sensitivity as multifocal IOLs.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> However, it is very complex to accurately measure their actual accommodative power since pseudo-accommodation mechanisms, such as pupil miosis or changes in spherical aberrations, can also contribute to the improvement of the depth of focus inherent to these lenses. Some ultrasound studies have shown that the actual anterior displacement of the optics is insufficient to provide significant accommodative amplitude to the eye, so their mechanism of action is often considered pseudo-accommodative as well. On the other hand, these models present a very high incidence of associated posterior capsular fibrosis that causes, in addition to the induced visual loss, a progressive reduction of their accommodation capacity. Therefore, their effect on near vision is highly variable, with some studies equating their optical results with those of monofocal lenses,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> leading to clearly inferior results to those of multifocal IOLs.<a class="elsevierStyleCrossRefs" href="#bib0025">5,12,13</a> For all these reasons, these lenses have been practically abandoned in clinical practice. Some new models such as NuLens (NuLens Ltd., Herzliya Pituah, Israel), with new designs and innovative mechanisms of action, have offered promising preliminary results and could extend the use of this type of implant in the future.<a class="elsevierStyleCrossRefs" href="#bib0040">8,14</a>Multifocal lensesMultifocal lenses produce 2 or more coexisting retinal images corresponding to various distances, where only one of the images is clearly perceived. This concept is known as simultaneous vision.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Having 2 or more fixed focal points instead of one makes these lenses pseudo-accommodative but not accommodative. In simultaneous vision, the brain must minimize the blurred and unfocused component and enhance focus to obtain clear perception. The greater the intensity of the negative effects of out-of-focus images, the lower the quality of the image perceived by the patient. In exchange for achieving greater clarity over a wider range of distances, simultaneous vision always entails a certain loss of contrast compared to vision with a monofocal lens.Multifocal IOLs have been developed based on the concepts of refraction, diffraction or a combination of both. Differences between multifocal IOL designs are best evaluated in ray tracing studies. The type of optics used will later have a fundamental influence on the clinical results of the lens. A detailed description of all existing models and their clinical results is beyond the scope of this review. A systematic review of published medical literature confirms that bilateral implantation of multifocal IOLs obtains good results in near and far visual acuity and allows for improved independence from spectacles compared to monofocal IOLs.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> However, these IOLs also have certain drawbacks, since halos and glare, and worse contrast sensitivity, especially in low-light conditions, are more frequent than with monofocal implants. A review by the Cataract Clinical Committee of the American Society of Cataract and Refractive Surgery (ASCRS) detailed several clinical features that can help surgeons identify suitable candidates for multifocal IOLs.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> In addition, an important part of the decisions we make must also rest on the patient's motivation to correct their dependence on spectacles.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Comparing the performance of different types of multifocal IOLs is complex for several reasons: First, there is no consensus on which questionnaire or clinical test should be used to quantify the incidence and severity of undesirable photic phenomena nor on whether visual acuity should be measured monocularly or binocularly. In addition, we do not have a standardized test for measuring near visual acuity, and contrast sensitivity tests are not, at present, completely standardized either. Finally, multifocal IOLs have been associated with higher levels of higher order aberrations than monofocal IOLs, and neither the measurement systems nor the exact role of these aberrations are fully clarified.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Without a consensus on these issues, a direct comparison between models is difficult. In recent years, the introduction of blur curves has made it possible to obtain a more realistic and objective measurement of patient vision at all functional distances. Although it is a tedious test to perform, it has also allowed us to better objectify the performance of each of the multifocal IOL models and thus to conduct better comparison.<a class="elsevierStyleCrossRefs" href="#bib0095">19–22</a>Multi-focal refractive lensesClassic bifocal refractive lenses with rotational distributionRefraction is based on a change in the direction of the light beam due to a change in the optical density of the transmitter material. Refractive multifocal IOLs incorporate 2 integrated powers in 2 different refractive zones, generally circular and concentric. The power of addition for near vision varies between models from +2.5 to +3.75 D. The most used models are the ReZoom (Johnson & Johnson, USA) and M-flex MIOL (LIO Rayner, West Sussex, UK).<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> Refractive multifocal IOLs show good results in distance vision and less light scattering than diffractive IOLs.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> However, they frequently cause dysphotopic phenomena, particularly in mesopic and scotopic conditions<a class="elsevierStyleCrossRef" href="#bib0075">15</a> which constitute one of the most frequent causes of dissatisfaction after a multifocal implant. They also present worse results than diffractive IOLs in general in terms of contrast sensitivity, lower tolerance to IOL misalignments and worse near vision.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Therefore, their clinical use has decreased significantly in recent years.Asymmetrically distributed bifocal refractive lensesIn order to minimize the dysphotopic phenomena of conventional refractive IOLs with rotational symmetry, these models composed of 2 asymmetrically arranged refractive segments were first marketed: a large aspherical surface designed for distant vision, and a conical sector with an addition embedded in the rear surface of the optics, designed for near vision. The most widely used model is the Lentis Mplus lens (Oculentis GmbH, Berlin, Germany) which is available with different additions for near vision in order to customize the visual needs of each patient. Published results in far, intermediate and near visual acuity are very good, with high levels of contrast sensitivity and satisfaction, and a very low incidence of dysphotopic phenomena.<a class="elsevierStyleCrossRefs" href="#bib0135">27–29</a> Its design enables the minimization of dissipated light loss (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Recent studies suggest that visual outcomes after implantation of this rotational asymmetric IOL can be improved if its orientation coincides with a personalized meridian. Theoretically, placing the near segment in a super-temporal position in the dominant eye with an addition of +2 D, and in the non-dominant one of +3 D in the lower nasal sector, would allow the best visual results.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> This shows that it is an implant which, contrary to what its manufacturers claim, is not totally pupil-independent. In our experience, which agrees with that of other habitual users, there is a small percentage of patients with this IOL who do not achieve the expected results and are very dissatisfied, without a clear causative or predictive factor. In addition, there were cases of significant off-centering in some eyes implanted with the C-loop platform, which has practically been set aside. Multiple cases of opacification of some implants have also been reported recently.<a class="elsevierStyleCrossRefs" href="#bib0155">31,32</a>A new model with similar optical technology to the Lentis Mplus, the SBL-3 IOL (Lenstec Inc., St. Petersburg, FL, USA), has demonstrated very similar visual, refractive and functional results, although with minimal improvement in near vision compared to the Lentis Mplus.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Studies with longer follow-up and larger numbers of patients are needed to corroborate these results.Recently, these lenses have introduced low addition versions (Lentis MPlusX, Lentis Comfort, LS-313 and SBL-2) to improve intermediate vision for easier work with computers, tablets and all daily activities that require vision in the 50−80cm range. Manufacturers include these latest models in the EDOF lens group. The results published were very satisfactory, with good far and intermediate vision without correction and a low incidence of dysphotopic phenomena.<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a> However, foreseeably these lenses could present the same limitations related to their pupil dependence as the precursor models with higher near addition.Recently, a modification of the existing Oculentis Comfort EDOF lens design called Femtis Comfort FB-313MF15 has been introduced. The lens is fixed 360°° in the capsulorhexis of the anterior capsule with the edge of the optics. The aim of the design is to minimize the occurrence of capsular phimosis and negative dysphotopsia. A prospective study with 44 eyes of 25 patients showed that the surgical process of interlocking these lenses was safe and effective over time and eliminated negative dysphotopsia. In addition, the lens had low rates of unwanted visual phenomena and good refractive and visual results.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>A new IOL model designed to overcome the disadvantages of previous segmental refractive multifocal IOLs, particularly pupil dependence, is the Precizon Presbyopic IOL (Ophtec BV, Groningen, The Netherlands).<a class="elsevierStyleCrossRef" href="#bib0185">37</a> The Precizon IOL is an implant made of hydrophilic acrylic material, with a hydrophobic surface modification, a C-loop design with modified haptics and a 6mm optical zone. The optics of the IOL called "continuous transition focus" (CTF) are divided in 3 concentric sectors. The central sector is dedicated to far vision correction, and the 2 peripheral sectors present a bimodal distribution (50-50%) of the far and near vision correction, changing this distribution along 4 segments in each sector (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The segments are 0.75mm wide with a close addition of +2.75 D. This CTF design theoretically creates a continuous blur curve to facilitate a clear image on the retina at all distances. To our knowledge, only one recently published prospective study with this IOL lens has been published,<a class="elsevierStyleCrossRef" href="#bib0190">38</a> comprising 31 patients with bilateral implants and with a capsular tension ring (CTR), with excellent visual results at far, intermediate and near distances, and very few referred undesirable photic phenomena (10% halos and 7% glare).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Multifocal diffractive lensesThese lenses are based on the principle of diffraction whereby light slows down and changes direction when it passes through an edge on a transparent surface. These IOLs have microscopic steps (diffractive zones) distributed concentrically on the lens surface. When light passes through this surface, new wavefronts are generated, as many as there are steps. These wavefronts are in the same phase and can give rise to interference phenomena between them.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> The interference can give rise to a wave of greater or lesser amplitude, or in its neutralization. Interference generated by diffraction is grouped into diffractive orders, each with a specific location in space and intensity depending on the characteristics of the obstacle that has generated it, in this case the height and separation of the steps.At present, diffractive lenses include 2 subtypes: the purely diffractive ones and those that combine the properties of a central diffractive optical design and a peripheral refractive one. The refractive surface determines the far focus and the diffractive steps the near focus. The width of these steps determines the power of addition (the smaller the width, the greater the power) and their height determines the distribution of light between the far focus and the near focus (the greater the height, the greater the amount of light that is diffracted for the near focus). In addition, the diffractive lenses can also be apodized (progressive reduction of the height of the steps from the center to the periphery) so that the proportion of light directed to the 2 focuses is variable depending on lighting conditions.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> For a multifocal IOL, the difference between the powers of the 2 spotlights is called addition. It is usually specified under the conditions of the plane of the spectacles, with air being the surrounding medium. After implantation, the IOL is surrounded by aqueous humor, so that the difference between the refractive indices of the IOL and its surroundings decreases. This leads to a reduction in the refractive power of the lens in the plane of the IOL. For power differences (P), the approximate formula P (plane of IOL)=0.7* P (plane of spectacles) can be derived. This formula is valid for both toric IOL cylinders and spherical additions; e.g. an addition of 3.33 D multifocal IOL produces an effective addition of 2.33 D in the plane of the IOL, which corresponds to a distance of 1 / (2.33 D)=0.43m.Bifocal diffractive lensesThe first generation of multifocal, diffractive and refractive implants<a class="elsevierStyleCrossRef" href="#bib0200">40</a> were bifocal and most incorporated +4 D addition in the lens plane in order to minimize the risk of diplopia as a result of the simultaneous superimposition of sharp and unfocused images and to allow useful near vision. Although some amount of incident light is intrinsically lost in the higher orders of diffraction, numerous studies with these initial models reported good results in both near and far vision.<a class="elsevierStyleCrossRefs" href="#bib0195">39,41–43</a> However, they neglected intermediate vision, and in today's life, work and leisure activities are dominated by the use of computers and tablets, and many of those patients required optical aids for intermediate distance vision.Later, the introduction in bifocal diffractive IOLs of lower near additions, in the range of 2.5–3.0 D,<a class="elsevierStyleCrossRefs" href="#bib0220">44–46</a> and strategies to combine different additions in both eyes (known in the Anglo-Saxon literature as Mix and Match [MM]),<a class="elsevierStyleCrossRef" href="#bib0235">47</a> tried to increase visual acuity in the intermediate distance. However, this improvement in optical lens design was not sufficient to provide satisfactory intermediate vision for many of the patients implanted with these bifocals.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Alfonso et al.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> demonstrated that an addition of +3 D provided better intermediate visual acuity than the same IOL with the addition of +4 D. However, the defocusing curve obtained had a V pattern with 2 peaks corresponding to the vergence of near and far vision, and a marked central valley corresponding to the intermediate vergence. This prompted the manufacturers to develop a new concept, i.e., the trifocal multifocal IOL, in an effort to obtain good quality of vision at far, intermediate and near distances.Trifocal diffractive lensesIn trifocal lenses, as the diffracted light waves propagate towards the retina, the waves coming from various diffractive zones mix forming 3 regions of constructive interference that correspond to the 3 main focuses of the IOL,<a class="elsevierStyleCrossRef" href="#bib0240">48</a> and that allow minimizing the amount of incident light lost to bifocal models. Voskresenskaya et al. describe good initial results with a first prototype,<a class="elsevierStyleCrossRef" href="#bib0245">49</a> but the first commercialized trifocal diffractive IOL was the FineVision Micro F IOL (BVI-PhysIol, Liège, Belgium). Its first clinical results were published by Lesieur in 2012.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> Gatinel et al.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> describe the design of this lens which combines on its anterior optical surface 2 diffractive profiles (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>The second trifocal IOL to reach the market was the AT Lisa tri 839MP (Carl Zeiss, Germany)<a class="elsevierStyleCrossRef" href="#bib0255">51</a>; and the third important trifocal IOL to be marketed was the PanOptix IOL (Alcon, Fort Worth, TX, USA) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The technical characteristics of the 3 main trifocal diffractive IOLs are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In 2013, our most widespread strategy for correcting presbyopia after lens surgery was to implant bifocal diffractive IOLs with different additions, Restor +2.5 D in the dominant eye and Restor +3 D in the reading eye. A question inevitably arose with the appearance of these trifocal IOLs: if the added intermediate focus could produce better intermediate visual acuity, it could also lead to worse distance vision, decreased contrast sensitivity and a greater number of dysphotopic phenomena. In an attempt to clarify these controversies, our group published a prospective comparison between Mix and Match implantation of bifocal IOLs with different near addition and bilateral implant of trifocal IOLs.<a class="elsevierStyleCrossRef" href="#bib0260">52</a> The article reported that monocular and binocular vision at near and intermediate distances was better with trifocal than with bifocal implants. In addition, the study showed no significant difference in either distance vision or contrast sensitivity between the two groups. Bilateral trifocal implantation led to greater independence from glasses and higher levels of patient satisfaction. These results were later confirmed by other studies<a class="elsevierStyleCrossRefs" href="#bib0265">53,54</a> and meta-analyses that also compared the clinical performance between bifocal and trifocal diffractive IOLs.<a class="elsevierStyleCrossRefs" href="#bib0275">55,56</a>A retrospective analysis of more than 5000 bilaterally implanted patients with 2 trifocal models (AT Lisa tri and FineVision Micro F)<a class="elsevierStyleCrossRef" href="#bib0285">57</a> confirmed the capacity of the human brain to use the 3 available foci with few undesirable dysphotopic phenomena. Excellent refractive and visual results were obtained at near, far and intermediate distances, with high satisfaction rates and independence from spectacles. The results were very similar with both models. Although the referred night vision was not optimal, most patients did not identify it as crucial and gave much more emphasis to the independence of glasses obtained with the surgical procedure. Several studies<a class="elsevierStyleCrossRefs" href="#bib0290">58–63</a> published later on also reported very good refractive and visual results at different distances, corroborating them with defocusing curves; likewise, they showed a high degree of patient satisfaction, a high independence of eyeglasses and few undesirable dysphotopic phenomena. Furthermore, these published visual and functional results are similar among the different models of trifocal lenses evaluated. These would differ fundamentally by the material and design of the lens platform, the amount of light distributed to each of the 3 focuses and, to a lesser extent, the distance calculated by addition, for intermediate vision. A retrospective study with a very extensive sample<a class="elsevierStyleCrossRef" href="#bib0320">64</a> compared the incidence of YAG capsulotomies with 2 different trifocal lenses and found that eyes implanted with the FineVision Micro F IOL required significantly fewer Nd: YAG laser capsulotomies than those implanted with the Lisa tri 839MP, during the first 4 years after implantation (14% vs. 35%). The platform design of both lenses could justify this difference.Among all the trifocal models currently available, perhaps the PanOptix IOL could be the most suitable for patients who require closer intermediate vision (about 60cm), and any of the other models, for those patients who use more distant intermediate vision (about 80cm).<a class="elsevierStyleCrossRef" href="#bib0325">65</a> Finally, the decision between the different trifocal options available will depend mainly on surgeon preferences based on personal trust with each platform and on local availability conditions of each model.Recently, new trifocal diffractive models such as the Physiol Triumph lens (BVI-Physiol, S. A., Liège, Belgium) with a new trifocal diffractive profile providing a better distribution of light energy for the intermediate focus and an improvement of its longitudinal chromatic aberration (ACL), and the Tecnis Synergy IOL (Johnson & Johnson Vision Care Inc, USA) with a new diffractive achromatic surface, may prove to be very interesting options within this subgroup of diffractive multifocal lenses, but their clinical studies, still in initial stages, have not been published yet.In general, these trifocal lenses provide a wider range of vision compared to other types of IOLs, but they also cause undesirable visual effects that may occasionally be unacceptable to certain patients and are not recommended for certain very visually demanding activities. In addition, trifocal IOLs, like many other multifocal lenses, are contraindicated in certain clinical or anatomical circumstances.Extended depth of focus (EDOF) lensesDuring the past five years numerous models of lenses catalogued as EDOF have reached the market. The basic principle of the EDOF IOLs would be to create a single, elongated focal point, which would improve depth of focus and thus provide better performance in intermediate vision than single-focus IOLs. This extended focal point is intended to eliminate the image overlap caused by traditional refractive and diffractive multifocal IOLs, and thus the halo effect of the out-of-focus image. Theoretically, EDOF technology seeks to combine some advantages of multifocal lenses with others of monofocal lenses. However, the term EDOF is somewhat confusing and to some extent controversial. It has been used for many types of lenses that are completely different in their optical properties and therefore in their performance. For this reason, it would seem reasonable to try to limit the EDOF qualifier to those lenses that endeavour to extend distance to intermediate vision through continuous and preferably single focus. And if this is not possible, the manufacturers should at least try to define as precisely as possible the physical properties that would explain the optical performance of the lens and that would justify its inclusion in this IOL subgroup. A frequently very complicated task in a market with so much competition in the field of industrial design and property rights.Eyes implanted with EDOF lenses should experience less photic phenomena and less loss of contrast sensitivity than those with traditional multifocal IOLs while providing improved depth of focus with vision quality similar to that of monofocal lenses. To achieve this, IOL manufacturers have developed different and sometimes combined optical strategies in search of the magic formula. The objective is to generate a series of controlled aberrations in the optics, to extend the distance of vision without excessive degradation of sharpness, in order to strike the right balance between increasing the depth of focus and decreasing the quality of vision. The bibliographic references published on this type of lenses have multiplied during the last years. And as discussed above there is no clear scientific consensus on how to objectively and reproducibly measure the loss of visual quality, the dysphotopic phenomena generated and the optical performance of the lenses at intermediate or close distances. This is why some of these publications may be controversial and confusing. In addition, it should be noted that, by definition, EDOF lenses were created to improve intermediate vision while maintaining good distance vision, so these lenses could not provide absolute independence from spectacles. The main EDOF lenses available are discussed below, globally describing the main clinical and comparative results they provide.So far, four optical technologies have been used by IOL manufacturers to extend the depth of focus of EDOF lenses: diffractive optical lenses, pinhole effect lenses, lenses with zone refractive optics, and lenses with modified AE. Some models combine 2 of these strategies and many also recommend their users to leave a minimum residual myopia of approximately -0.5 D to achieve some mini-monovision and enhance the lens effect. Some emerging new models such as the Vivity lens (Alcon Laboratories, Inc., Fort Worth, TX, USA) use modifications to the central part of the anterior surface of the optics called transition elements to extend the focal range. These variants may represent very interesting options in the near future, but their precise optical properties have not been evaluated and clinical results are pending publication.Low addition diffractive EDOF IOLsIn these lenses the near vision focal point of diffractive optics is directed to intermediate vision with a low power addition.The Symfony XZR00 IOL (Johnson & Johnson Vision Care Inc., USA) was the first EDOF-labeled lens launched in the market and received CE marking in Europe in 2014 and FDA approval in 2016. It shares the hydrophobic acrylic platform of the Tecnis monofocal lens, with an achromatic diffractive rear surface with +1.75 D addition that achieves extended range of vision from far to intermediate distance and seeks to compensate the ACL of the entire optical system for improved contrast sensitivity.<a class="elsevierStyleCrossRef" href="#bib0330">66</a> In a comparison with the monofocal lens,<a class="elsevierStyleCrossRefs" href="#bib0335">67,68</a> the Symfony IOL achieves significantly improved near and uncorrected visual acuity and greater independence from glasses; however, the EDOF IOL also had some decrease in contrast sensitivity and more frequent halos. An international multicenter study<a class="elsevierStyleCrossRef" href="#bib0345">69</a> reported excellent visual, refractive and optical correction independence results, with few undesired visual effects referred, improving performance with micro-monovision (-0.5 to -0.75 D) in the non-dominant eye. Later studies that compared the results between this lens and different diffractive trifocal IOLs<a class="elsevierStyleCrossRefs" href="#bib0350">70–76</a> showed that far and intermediate visual acuities were similar, but near vision was significantly better with trifocal IOLs. In most studies, contrast sensitivity testing under photopic and mesopic conditions was similar in both groups, or only minimally better with Symfony, while perception of adverse dysphotopic phenomena and patient satisfaction were comparable. And with respect to the postoperative independence of optical correction, both strategies achieved it almost absolutely for far and intermediate distances, but for near vision the group implanted with trifocal lenses obtained better results.Another popular EDOF lens based on a diffractive, low addition principle is the AT LARA 829MP (Carl Zeiss Meditec, Jena, Germany) which received the CE mark in 2017. In addition to the distant focal point, the IOL has 2 additional focal points of +1.9 and +0.95 D for intermediate distances. The lens has an aspherical neutral optical design and an optimized chromatic aberration to improve the quality of vision. It is a hydrophilic plate platform with a hydrophobic surface coating, with an optical diameter of 6mm and an overall length of 11mm. To date, there is limited published evidence. An initial study<a class="elsevierStyleCrossRef" href="#bib0385">77</a> with 11 bilaterally implanted patients found a good range of focus and optimal visual acuity for intermediate distances. A retrospective review published in 2019<a class="elsevierStyleCrossRef" href="#bib0390">78</a> evaluated 293 bilaterally implanted patients after 3 months of postoperative follow-up. Reasonable uncorrected near and far vision was achieved with optimal patient satisfaction (90% satisfied or very satisfied) and high rates of spectacle independence (83.6% for near). Some undesirable optical side effects were reported, especially during the early postoperative period, and 6.8% of patients eventually reported considerable difficulty or inability to drive at night. A later publication<a class="elsevierStyleCrossRef" href="#bib0395">79</a> analyzed the predictive factors associated with the postoperative satisfaction of the patients evaluated in the aforementioned study; the study concluded that early management of dry eye, avoiding mini-monovision, and warning patients of possible adverse visual effects helped improve patient satisfaction after the procedure with this implant.Another recently launched model within this category of EDOF IOL with diffractive optics, but with a smaller number of diffractive rings, is the Xact Mono-EDoF lens (Santen, Japan). To date, no published results have been found in the literature.Both the Symfony lens and the AT LARA showed in the laboratory a bifocal behavior in the modulation transfer function (MTF) curve, except with pupil sizes around 2mm, possibly due to the pinhole effect.<a class="elsevierStyleCrossRefs" href="#bib0400">80,81</a> Its diffractive nature would explain these findings. Therefore, and despite the improvements in its optical design, especially in the field of ACL, instead of generating a single extended focal point perfectly continuous, the diffractive polyfocal optics of these lenses generates several focal points, close but separate. This justifies that the visual results obtained in patients are approximately (or only minimally better) in the range of low addition bifocal diffractive IOLs, with their advantages and limitations previously mentioned in the comparative studies with diffractive trifocal models. Possibly, the functional differences between these 2 diffractive EDOF models would be related to the different EC approach. The Symfony lens, with a negative EC that seeks to compensate the average corneal EC of the human eye, should present a better optical performance, in mesopic and scopic conditions with larger pupil diameters, than the AT LARA lens that presents a profile without added EC.Pinhole stenopeic effect lensesAnother subtype of EDOF IOL are the so-called small opening IOLs. These lenses are designed with a central hole and a mask that blocks out unfocused peripheral light rays that can degrade image quality. Reducing the pupil aperture allows only the focused central light to reach the retina, which reduces the size of the circle of confusion and improves the resolution of the image, increasing the depth of focus. The IC-8 lens (AcuFocus Inc., Irvine, CA, USA) is a monobloc hydrophobic acrylic rear camera IOL that incorporates a 3.23mm diameter non-diffractive opaque mask with a central aperture of 1.36mm (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).<elsevierMultimedia ident="fig0030"></elsevierMultimedia>Another small opening lens on the market is the XtraFocus Pinhole Implant (Morcher, Stuttgart, Germany), intended for implantation in the ciliary sulcus as a piggyback lens. The device is made of a black hydrophobic acrylic material that blocks visible light but is transparent to infrared light above 750nm (to allow examination of the retina through the opaque material with optical coherence tomography). Its total diameter is 14mm with a central opening of 1.3mm.These IOLs are especially recommended for treating patients with highly irregular corneas from previous trauma, keratoconus, radial keratotomy or penetrating keratoplasties. Recently, a prospective study<a class="elsevierStyleCrossRef" href="#bib0410">82</a> reported excellent visual results in eyes with severe corneal irregularities.In this type of IOLs, perfect centering is particularly essential. Distance vision is degraded when lighting conditions decrease,<a class="elsevierStyleCrossRef" href="#bib0415">83</a> and in these circumstances patients may even experience undesirable visual disturbances (halos, glare) when their pupil size exceeds the opaque lens mask. The implanted eye can be left emmetropic or with a residual myopic blur of -0.75 to -0.5 D in one eye, especially with bilateral implants. A multicenter prospective trial<a class="elsevierStyleCrossRef" href="#bib0420">84</a> with 105 patients revealed excellent visual performance, safety, patient satisfaction and tolerance to residual astigmatism after unilateral implantation of IC-8 and an aspherical monofocal lens in the opposite eye. Another multicenter retrospective study<a class="elsevierStyleCrossRef" href="#bib0425">85</a> with 126 consecutive patients with monocular implants found that more than half of the patients implanted with the IC-8 IOL were completely independent of spectacles. Two other studies<a class="elsevierStyleCrossRefs" href="#bib0430">86,87</a> evaluated binocular and monocular implantation of this small aperture IOL in cataract patients and found that bilateral implantation of the IC-8 IOL produced a larger extended range of focus, with improved intermediate and near vision. However, it is contradictory that in one of these studies, monocular implantation of the IOL enabled a significantly higher overall satisfaction index and better halos perception scores,<a class="elsevierStyleCrossRef" href="#bib0430">86</a> while in the other study overall satisfaction and independence from glasses were better with bilateral implants.<a class="elsevierStyleCrossRef" href="#bib0435">87</a>Good results have also recently been reported in patients implanted after a previous corneal LASIK procedure.<a class="elsevierStyleCrossRef" href="#bib0440">88</a> A recent prospective randomized study with 38 patients compared bilateral implantation of Symfony versus IC-8 in the non-dominant eye and an aspherical monofocal lens in the opposite eye. In both groups, a mini-monovision effect was sought, leaving -0.75 D of residual myopia in the non-dominant eye. Both EDOF strategies provided very good far vision, but with superior results in the IC-8 group, and good and similar intermediate and near vision in low vision conditions in both groups. The referred subjective satisfaction was greater in the group of the IC-8 lens.<a class="elsevierStyleCrossRef" href="#bib0445">89</a>EDOF lenses with zonal refractive designsThe first LIO EDOF model to use this strategy, along with modifications to the EC, was the Mini WELL lens (Sifi, Catania, Italy). It is a hydrophilic biconvex lens with 3 differentiated optical zones; 2 sections within a central diameter of 3mm, where the human eye has an insignificant amount of AE, where a distribution of positive and negative AEs is introduced to achieve an increase in the depth of focus. The peripheral section between 3 and 6mm of the optics has an aspherical monofocal design to achieve optimal distance vision, even in low vision conditions<a class="elsevierStyleCrossRef" href="#bib0450">90</a> (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>). Several studies reported that the Mini WELL IOL<a class="elsevierStyleCrossRefs" href="#bib0455">91–93</a> provided good postoperative functional results at far and intermediate distances and improved visual acuity at reading distance, causing very few dysphotopsies. In another study, Savini et al.<a class="elsevierStyleCrossRef" href="#bib0470">94</a> obtained similar results with a diffractive bifocal lens with an addition of +2.5 D, in distant and near vision, but it was superior at intermediate distances. In a comparative study with an IOL with the same platform but with monofocal aspherical optics,<a class="elsevierStyleCrossRef" href="#bib0475">95</a> the Mini WELL lens showed better performance at intermediate and near distances, without worsening distant vision or contrast sensitivity, but with greater dysphotopia perception.<elsevierMultimedia ident="fig0035"></elsevierMultimedia>A laboratory study<a class="elsevierStyleCrossRef" href="#bib0480">96</a> compared image quality with 3 models of EDOF IOLs in monochromatic (green) and polychromatic conditions. Any lens will get a worse quality in polychromatic conditions due to the ACL, and the analysis showed that the Mini WELL IOL had a worse MTF in polychromatic light conditions in the far focus than the Symfony and AT LARA IOLs; furthermore, it had a greater drop in MTF compared to the evaluation with monochromatic light than the other 2 models. Both diffractive IOLs with an "achromatic" profile are more resistant to the negative effects of ACL. In contrast, the optical quality of the Mini WELL IOL is relatively less affected by defocus, showing a more horizontal defocusing curve than the 2 diffractive models, which both share a certain bicuspid shape. Finally, the refractive zonal design of the Mini WELL exhibited a high level of pupil dependence that should be taken into account in preoperative decision making. It has been demonstrated in vitro that ACL and EC have an important impact on visual quality, and undoubtedly this should have a certain impact on the visual quality of patients. The correction of both aberrations allows the MTF of multifocal lenses to be improved in the laboratory, together with the subsequent subjective visual experience.Another EDOF model available with a zonal refractive optics is the Suprahob Infocus IOL (Appasamy As., Chenai, India). This IOL is acrylic with yellow chromophore and has a central zone of 1.5mm for near vision (+3.50 D), a larger middle peripheral zone for intermediate vision and an external zone for distance vision. Published evidence is very limited with this IOL. A prospective study with 63 patients<a class="elsevierStyleCrossRef" href="#bib0485">97</a> compared the results of the Supraphob Infocus IOL with its monofocal counterpart. The EDOF model was better for intermediate and near distances without affecting distance vision or contrast sensitivity.Another model with similar optical performance is the LIO Lucidis IOL (Swiss Advanced Vision, SAV-IOL SA, Neuchatel, Switzerland). It is a bizonal, hydrophilic acrylic monobloc refractive/aspheric IOL with a total optical diameter of 6mm, with an aspherical central area of 1mm and an addition/EDOF power of +3.0 D. Optically, the Lucidis IOL uses both refraction and an aspherical element.Only one published retrospective study<a class="elsevierStyleCrossRef" href="#bib0490">98</a> has been found comprising 45 eyes with monocular or bilateral implants, with uncorrected far visual performance inferior to other EDOF models but with better results in intermediate and near vision, near normal contrast sensitivity and good satisfaction as well as independence from spectacles. The authors state that it could be a valid alternative for patients with age-related macular degeneration. As mentioned above, "traditional" segmental refractive lenses such as Lentis Mplus or Lenstec SB with their low power addition models could also be included in this sub-group of EDOF IOLs.IOL with modifications of the spherical lens aberrationThis is a very recent EDOF lens subtype, in which modifications in the asphericity of the optics would create an extension of the focal point without excessively degrading the image quality obtained. In contrast with refractive or diffractive zone optics, this technology does not split light and therefore could also be called enhanced single vision lenses for intermediate vision. This could mitigate some of the adverse visual phenomena of some of the EDOF models mentioned above. Other models, such as the Mini WELL or Lucidis IOLs, combine zone refractive technology with EC modifications of these different areas in their optics and therefore have not been included in this category of our classification.Conventional aspherical single-focus IOLs have a fixed negative EC in the range of -10 to -20μ m to compensate for the corneal average positive EC. These new EDOF IOLs increase the total negative IOL EC by creating a continuous progressive increase in the diopter power of the lens from the periphery to the center. This design causes the central and peripheral rays entering through the pupil not to converge identically, thus causing an extension of the focuses on the retina and providing depth of focus (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>). As negative EC increases, the focal area is extended but the resolution power and contrast sensitivity of the eye decreases. The value of induced EC is crucial to maximize its beneficial effect without introducing too many harmful effects (blurring/loss of contrast sensitivity). Ideally, these IOLs should be designed to induce a greater amount of negative EC in eyes with corneas with a greater amount of positive EC. Laboratory studies limit the amount of depth of focus this technology could induce to 1 D; therefore, in some of the current initial studies researchers point to a myopic result of -0.5−0.75 D in one of the eyes to obtain some mini-monovision effect binocularly.<elsevierMultimedia ident="fig0040"></elsevierMultimedia>The first EDOF IOL in this category to be marketed was the Tecnis Eyehance ICB00 lens (Johnson & Johson Vision Care, Inc., USA), which shares the same hydrophobic acrylic platform as its single-focus precursor Tecnis ZBC00, but a modified aspherical front surface and -0.27 m μAE. This improved aspherical lens creates a continuous power profile (progressively increasing from the periphery to the center of the lens), which is intended to extend the depth of focus, thus improving intermediate and near vision compared to a standard monofocal IOL. A recent prospective study with 40 patients99 compared the results of Tecnis Eyehance with those of the precursor monofocal model, with the EDOF lens achieving better uncorrected intermediate vision and greater independence from spectacles in intermediate vision without deterioration of distance vision or visual quality.<a class="elsevierStyleCrossRef" href="#bib0495">99</a>In July 2019, the authors’ group started a prospective study with another EDOF lens model in this category, the IsoPure lens (BVI-Physiol SA, Liège, Belgium), with very promising initial visual results. Based on the hydrophobic glistening-free platform of 4 closed haptics of its previous aspherical monofocal precursor, the IsoPure lens combines a continuous progressive aspherical profile over the entire optical zone, which is unique as it is combined on both the front and rear surfaces of the optics and adjusted for each dioptric power of the lens. To date, there are no published studies.These promising initial results with this group of EDOF lenses, which we could also call extended range monofocals, should be confirmed in future studies with a much larger number of patients and longer follow-up. It would be useful to include also patients with ocular comorbidities to assess their performance in these circumstances, and compare it with that of standard monofocal lenses. In addition, their visual outcomes should be evaluated under different conditions, such as environments with low ambient lighting, different pupil sizes, or lens offsets, factors that can undoubtedly modify the behavior of optics with high negative EC values. Finally, these lenses could become an interesting option for standard cataract surgery; especially for patients who wish to improve their independence from eyeglasses but do not wish to undergo the undesirable visual phenomena of zonal diffractive and refractive lenses as well as for those who suffer from certain comorbidities that are currently generalized contraindications for multifocal IOL implantation.Over the past few years, many EDOF IOLs have been developed that have allowed us to expand the portfolio of lenses available, in an effort to combine some of the advantages of multifocal and others of monofocal lenses. In 2017, a working group of the American Academy of Ophthalmology (AAO) published a consensus statement on EDOF IOLs.<a class="elsevierStyleCrossRef" href="#bib0500">100</a> It provides benchmarks for classifying an implant as an EDOF IOL and recommendations on how to evaluate lens performance under standard conditions (photopic, mesopic, and glare). It specified the minimum visual acuity levels of the implant in far and intermediate vision and the extension of focus in the blur curve, compared to a reference monofocal implant that should serve as control in validation studies. The AAO established these criteria to help researchers evaluate current and future EDOF IOLs objectively in a framework that would then facilitate comparison between all of them. So far, none of the existing EDOF lenses have met all of these clinical requirements in any of the published studies.ConclusionsThe options for surgical correction of presbyopia have multiplied over the past 2 decades. At present, achieving independence in optical correction after lens surgery has become an option. However, as surgeons, we still face the dilemma of offering our patients a better quality of life without depending on spectacles but with a somewhat worse visual quality using multifocal lenses, or the opposite with single vision lenses. EDOF lenses, in our opinion, especially those based on modified monofocal optical systems, will bring these two alternatives closer together. As discussed above, comparative studies between lenses have several drawbacks and limitations, and furthermore the lens with the best result in a certain parameter is definitely not going to be the best lens for all patients. Therefore, we must consider that the success in the correction of presbyopia with lens surgery must be based on 4 processes: first, to carry out an exhaustive preoperative clinical evaluation of the patient; second, to carry out a meticulous preoperative planning and a technically perfect surgical intervention; third, to know in depth the technical characteristics and previous results of the lenses available in our portfolio, especially considering their design, the blurring curves and the usual incidence of associated dysphotopic phenomena; and finally, to consider the personality, professional and leisure activities of our patients with their visual needs, and to try to evaluate their degree of motivation for eyeglass independence and their expectations, through a personal preoperative, honest and detailed discussion.Perhaps today, in 2020, we could consider trifocal diffractive lenses, with its pros and cons, to be the gold standard in the surgical lens correction of presbyopia. In the next few years we will witness the development of innovative and very interesting optical technologies, such as new polyfocal diffractive platforms, ingenious strategies for EDOF lenses such as axicons or spiral phase elements, or even new adjustable IOLs, or perhaps filling gels for the lens sac, with which we will expand and improve the alternatives that we offer to our patients as surgeons. Laboratory tests, particularly clinical studies with large series of patients, with standardized evaluations and long follow-up times, will determine the true performance of these new lenses.Conflict of interestThe authors have no commercial or financial interest in any of the products mentioned in this article.During the last 12 months, Rafael Bilbao-Calabuig has received fees as a medical consultant from Physiol SA, and for participating as a speaker in conferences/congresses of Physiol SA and Alcon.Felix Gonzalez-Lopez has received honorary awards for participating as a speaker at Johnson&Johnson Vision Care conferences/congresses.Fernando Llovet-Osuna has received fees as a medical consultant from Johnson&Johnson Vision Care, Rayner and Alcon, and for participating as a speaker at Johnson&Johnson Vision Care and Alcon conferences/congresses." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1456420" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1327702" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1456419" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1327701" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Monovision or pseudophakic combined vision" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Accommodative lenses" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Multifocal lenses" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0025" "titulo" => "Multi-focal refractive lenses" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Classic bifocal refractive lenses with rotational distribution" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Asymmetrically distributed bifocal refractive lenses" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Multifocal diffractive lenses" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Bifocal diffractive lenses" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Trifocal diffractive lenses" ] ] ] ] ] 8 => array:3 [ "identificador" => "sec0055" "titulo" => "Extended depth of focus (EDOF) lenses" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Low addition diffractive EDOF IOLs" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Pinhole stenopeic effect lenses" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "EDOF lenses with zonal refractive designs" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "IOL with modifications of the spherical lens aberration" ] ] ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-28" "fechaAceptado" => "2020-07-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1327702" "palabras" => array:8 [ 0 => "Lens surgery" 1 => "Phacoemulsification" 2 => "Intraocular lenses" 3 => "Multifocal lenses" 4 => "Accommodative lenses" 5 => "EDOF lenses" 6 => "Monovision" 7 => "Blended vision" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1327701" "palabras" => array:7 [ 0 => "Cirugía cristaliniana" 1 => "Facoemulsificación" 2 => "Lentes intraoculares multifocales" 3 => "Lentes acomodativas" 4 => "Lentes EDOF" 5 => "Monovisón" 6 => "Visión combinada" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionPresbyopia is the progressive and irreversible loss of accommodation due to aging. It is one of the main causes of loss of quality of life in people from 45 years of age, due to the, often novel, dependence on spectacles. The eagerness to correct it by ophthalmologists driven by the desire of millions of people who suffer from it, has become one of the main drivers for the development of intraocular lens (IOL) technology over the last twenty years. Material and methodsThis review briefly presents the different alternatives that have allowed us to improve the crystalline lens surgical approach of presbyopia; from monofocal lenses and monovision technique, accommodation, refractive, and diffractive multifocal lenses, and finally the most recent focus or extended depth or focus/ field lenses known as EDOFs. ResultsEach IOL has its advantages, limitations and disadvantages. Furthermore, there is no single lens that suits the needs of all patients. ConclusionsIt is necessary to know the variety of lenses available, and to have an in-depth understanding of their optical properties, as well as the impact that these will have later on their clinical performance and on the visual quality of the patients. This should help us to select the best alternative for each of them." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa presbicia es la pérdida progresiva e irreversible de la acomodación debido al envejecimiento. Es una de las principales causas de disminución de la calidad de vida en personas a partir de los 45 años derivada de la, muchas veces novedosa, dependencia de las gafas. El afán por corregirla por parte de los oftalmólogos, impulsados por el deseo de millones de personas que la padecen, se ha convertido en uno de los principales motores de desarrollo de la tecnología de las lentes intraoculares (LIO) durante los últimos veinte años. Material y métodosEsta revisión repasa las distintas alternativas que han permitido ir mejorando el enfoque quirúrgico cristaliniano de la presbicia; desde las lentes monofocales y la técnica de la monovisión, a las lentes acomodativas, pasando por las lentes multifocales refractivas y difractivas y terminando con las más recientes lentes de foco o campo extendido conocidas como EDOF. ResultadosCada una de estas LIOs tiene sus ventajas, limitaciones e inconvenientes; y además, no existe la lente que se adapte a las necesidades de todos los pacientes. ConclusionesEs necesario conocer la variedad de lentes disponibles, y comprender en profundidad tanto sus propiedades ópticas como el impacto que éstas van a tener luego en su rendimiento clínico y en la calidad visual de los pacientes. Esto nos debería ayudar a poder seleccionar la mejor alternativa para cada uno de ellos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Bilbao-Calabuig R, Gónzalez-López F, Llovet-Rausell A, Ortega-Usobiaga J, Tejerina Fernández V, Llovet-Osuna F. Corrección de la presbicia tras cirugía cristaliniana ¿Dónde nos encontramos en 2020? Arch Soc Esp Oftalmol. 2021;96:74–88." ] ] "multimedia" => array:10 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 672 "Ancho" => 1074 "Tamanyo" => 45558 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Eyeonics Crystalens accommodative IOL (Eyeonics, Inc., Aliso Viejo, CA, USA)." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 939 "Ancho" => 1207 "Tamanyo" => 74387 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Refractive zonal Lentis Mplus IOL (Oculentis GmbH, Berlin, Germany)." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1069 "Ancho" => 1500 "Tamanyo" => 129457 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Precizon Presbyopic zone refractive IOL (Ophtec BV, Groningen, The Netherlands)." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1758 "Ancho" => 1207 "Tamanyo" => 125251 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Micro F trifocal diffractive IOL (BVI-PhysIol, Liège, Belgium)." ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 573 "Ancho" => 1207 "Tamanyo" => 44097 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "PanOptix trifocal diffractive IOL (Alcon, Fort Worth, TX, USA)." ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1371 "Ancho" => 1207 "Tamanyo" => 61869 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "IC-8 Small Aperture IOL (AcuFocus Inc., Irvine, CA, USA)." ] ] 6 => array:8 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 854 "Ancho" => 1506 "Tamanyo" => 95613 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Mini WELL zonal refractive-aspheric IOL (Sifi, Catania, Italy)." ] ] 7 => array:8 [ "identificador" => "fig0040" "etiqueta" => "Fig. 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 2005 "Ancho" => 1508 "Tamanyo" => 135640 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Optical effect of spherical aberration (a) and power distribution (b) of the IsoPure IOL (BVI-Physiol SA, Liège, Belgium)." ] ] 8 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Monofocal IOL: pseudo-phakic monovision \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Accommodative IOL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single lens: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eyeonics Crystalens (Eyeonics, Inc., Aliso Viejo, CA, USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tetraflex KH-3500 (Lenstec Inc., St. Petersburg, FL, USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICU lens (Human Optics AG, Erlangen, Germany) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Double lens: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Syncrony IOL (Visiogen Inc., Irvine, CA, USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lumina IOL (AkkoLens International, Breda, Netherlands) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multifocal IOL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Refractive multifocal IOL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bifocal "classical" refractive IOL (rotational symmetry): \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ReZoom (Johnson & Johnson, USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M-flex MIOL (LIO Rayner, West Sussex, UK) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asymmetrically distributed refractive IOLs: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lentis Mplus, Lentis MPlusX, Lentis Comfort (Oculentis GmbH, Berlin, Germany) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SBL-3, LS-313 and SBL-2 (Lenstec Inc., St. Petersburg, FL, USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Precizon Presbyopic (Ophtec BV, Groningen, The Netherlands) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multifocal Diffractive IOL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bifocal diffractive IOL: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Restor (Alcon, Fort Worth, TX, USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(Johnson & Johnson, USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AT Lisa (Carl Zeiss, Germany) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trifocal diffractive IOL: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FineVision Micro F, POD-F, Triumph (BVI-PhysIol, Liège, Belgium) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AT Lisa tri 839MP (Carl Zeiss, Germany) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PanOptix IOL (Alcon, Fort Worth, TX, USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Synergy (Johnson & Johnson Vision Care Inc., USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extended Depth of Focus (EDOF) IOL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EDOF IOL with low addition diffractive optics: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symfony XZR00 (Johnson & Johnson Vision Care Inc., USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AT LARA 829MP (Carl Zeiss Meditec, Jena, Germany) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Xact Mono-EDoF (Santen, Japan) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EDOF LIO with pinhole effect: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IC-8 (AcuFocus Inc., Irvine, CA, USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">XtraFocus Pinhole (Morcher, Stuttgart, Germany) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EDOF IOL with zonal refractive designs: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mini WELL (Sifi, Catania, Italy) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suprahob Infocus (Appasamy As., Chennai, India) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lucidis IOL (Swiss Advanced Vision, SAV-IOL SA, Neuchâtel, Switzerland) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EDOF IOL with modified spherical aberration monofocal designs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tecnis Eyehance ICB00 (Johnson & Johson Vision Care, Inc., USA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IsoPure (BVI-Physiol SA, Liège, Belgium) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EDOF IOL with monofocal design and elements in transition: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vivity (Alcon Laboratories, Inc., Fort Worth, TX, EE.UU.) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2505353.png" ] ] ] ] "descripcion" => array:1 [ "en" => "IOL models described, classified by their main optical mechanisms of action." ] ] 9 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">FineVision Micro F Physiol (10−35 D) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AT Lisa tri Zeiss (0−32 D) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PanOptix Alcon (13−34 D) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intermediate addition (D) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Addition nearby \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Focus energy away \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.85% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intermediate focus energy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.14% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Focus energy near \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.71% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Loss of energy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asfericity (μm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Platform material \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hydrophilic (25%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hydrophilic (25%) hydrophobic surface \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hydrophobic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diameters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optics 6.15mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optics 6mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optics 6mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total 10.75mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dish 11mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total 13mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diffractive system \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Convoluted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EnLighten \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smooth Micro Phase \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2505354.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Technical characteristics of the 3 main trifocal IOLs." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:100 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Finite element modelling of radial lentotomy cuts to improve the accommodation performance of the human lens" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Graefes Arch Clin Exp Ophthalmol." 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Lens-based surgical correction of presbyopia. Where are we in 2020?

Corrección de la presbicia tras cirugía cristaliniana ¿Dónde nos encontramos en 2020?

R. Bilbao-Calabuiga,

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rbilbao@clinicabaviera.com

Corresponding author.

, F. Gónzalez-Lópeza, A. Llovet-Rausellb,d, J. Ortega-Usobiagac, V. Tejerina Fernándeza, F. Llovet-Osunaa,b

a Unidad de Cirugía Refractiva y Cataratas, Clínica Baviera-Aier Hospital Eye Group, Madrid, Spain

b Unidad de Cirugía Refractiva y Cataratas, Clínica Baviera-Aier Hospital Eye Group, Valencia, Spain

c Unidad de Cirugía Refractiva y Cataratas, Clínica Baviera-Aier Hospital Eye Group, Bilbao, Spain

d Servicio Oftalmología, Hospital Universitario La Fe, Valencia, Spain

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classified by the physical principle of weight in their optical functioning&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Monovision or pseudophakic combined vision</span><p id="par0015" class="elsevierStylePara elsevierViewall">MNV or combined vision through the use of monofocal lenses consists in having one eye focused for far vision&#44; aiming at the final emmetropia&#44; and the other for intermediate&#47;near vision&#44; leaving for this &#34;reader&#34; eye between 1 &#40;mini-monovision&#41; and 2&#46;5 diopters &#40;D&#41; of myopia&#44; according to the therapeutic algorithm used&#46; It is a well-proven technique&#44; both in the follow-up time and in the high number of operated patients&#44; with reported satisfaction indexes above 80&#37;&#8211;90&#37;&#44; and important referred independence of optical correction&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Physiologically&#44; MNV is based on the phenomenon of ocular suppression by which we only consciously perceive the sharp object corresponding to the image of the eye focused at the distance where we are looking&#44; while the vision of the out-of-focus images of the opposite eye is suppressed&#46; The MNV technique can achieve good functional results and with fewer undesirable dysphotopsic symptoms than multifocal IOL implantation&#46; There is some reduction in some visual functions&#44; such as stereopsis and contrast sensitivity&#44; but satisfaction rates are high&#44; especially in older patients&#44; with high rates of independence from glasses albeit lower than with modern trifocal diffractive lenses&#46; Thus&#44; corrective eyewear must often be used for activities that require significant visual accuracy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">It is imperative to carry out a detailed preoperative study to rule out patients not suitable for this technique &#40;especially those with low stereopsis or moderate to severe amblyopia&#41; and to decide on the most appropriate MR strategy&#46; Three different types of MNV have been described&#58; conventional when the reading eye is focused for near and the dominant eye for distance&#44; crossed MNV when the dominant eye is focused for near &#40;both strategies appear to be equally effective and safe&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and hybrid MNV when one eye &#40;usually the dominant eye&#41; is implanted with a monofocal IOL focused for emmetropia and the contralateral with a multifocal IOL or EDOF&#46; It should also be noted that when many of the so-called EDOF IOLs are implanted&#44; the aim is to leave a minimal residual myopic defect of about 0&#46;5 D&#44; in a mini-monovision strategy&#44; to enhance the improvement in near-intermediate vision of these implants&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Therefore&#44; pseudophakic MNV is a simple&#44; accessible&#44; predictable&#44; safe and effective method for the correction of presbyopia after lens surgery&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Accommodative lenses</span><p id="par0035" class="elsevierStylePara elsevierViewall">These IOLs were designed to improve near vision by simulating physiological accommodation&#46; They are defined by a dynamic increase in the diopter power of the lens&#44; associated with the effort to refocus from far distance to an intermediate or near vergence&#46; They use the contraction of the ciliary muscle&#44; the elasticity of the lens capsule and the changes in vitreous pressure to cause a change in the position or shape of the implant optics that are ultimately responsible for the change in the optical power of the eye&#46; The amount of accommodation achieved will depend on different factors such as the position of the optics in the capsular sac&#44; the depth of the posterior chamber and the optical power of the IOL&#46; Hinges between the haptics and the lens optics would allow the lens to move forward when focusing on close objects&#44; and backward when looking at a distance&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Most accommodative lenses are single-lens models such as the Eyeonics Crystalens &#40;Eyeonics&#44; Inc&#46;&#44; Aliso Viejo&#44; CA&#44; USA&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; the Tetraflex KH-3500 &#40;Lenstec Inc&#46;&#44; St&#46; Petersburg&#44; FL&#44; USA&#41; or the ICU lens &#40;Human Optics AG&#44; Erlangen&#44; Germany&#41;&#59; the Syncrony IOL models &#40;Visiogen Inc&#44; Irvine&#44; CA&#44; USA&#41; and Lumina IOL &#40;AkkoLens International&#44; Breda&#44; The Netherlands&#41; operate with dual-optic systems &#40;a very high positive-power moving anterior lens and a negative-power fixed posterior lens that adjusts emetropia to the patient&#41; designed to enhance this accommodative effect&#44; and appear to have improved the near visual outcomes of single-lens systems<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a>&#59; however&#44; they require more complex surgical manipulation due to their large size&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">An intermediate model&#44; classified between accommodative and extended focus EDOF IOLs&#44; is the Withcherle continuous focus IOL &#40;WIOL-CF&#44; Medicem&#44; Czech Republic&#41;&#44; a hydrogel lens designed to emulate the crystalline lens with a similar shape without haptics&#44; and a refractive optic with a negative spherical aberration &#40;SA&#41;&#46; After promising initial results<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> some cases were reported with dislocations of the IOL to the vitreous cavity and&#44; as far as we know&#44; the distribution of the lens was suspended a few months ago&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Accommodative lenses are designed to obtain excellent far and intermediate vision and functional near vision only&#46; Initial visual results reported with these accommodative models were good&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> without presenting as many dysphotopic phenomena or loss of contrast sensitivity as multifocal IOLs&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However&#44; it is very complex to accurately measure their actual accommodative power since pseudo-accommodation mechanisms&#44; such as pupil miosis or changes in spherical aberrations&#44; can also contribute to the improvement of the depth of focus inherent to these lenses&#46; Some ultrasound studies have shown that the actual anterior displacement of the optics is insufficient to provide significant accommodative amplitude to the eye&#44; so their mechanism of action is often considered pseudo-accommodative as well&#46; On the other hand&#44; these models present a very high incidence of associated posterior capsular fibrosis that causes&#44; in addition to the induced visual loss&#44; a progressive reduction of their accommodation capacity&#46; Therefore&#44; their effect on near vision is highly variable&#44; with some studies equating their optical results with those of monofocal lenses&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> leading to clearly inferior results to those of multifocal IOLs&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;12&#44;13</span></a> For all these reasons&#44; these lenses have been practically abandoned in clinical practice&#46; Some new models such as NuLens &#40;NuLens Ltd&#46;&#44; Herzliya Pituah&#44; Israel&#41;&#44; with new designs and innovative mechanisms of action&#44; have offered promising preliminary results and could extend the use of this type of implant in the future&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Multifocal lenses</span><p id="par0055" class="elsevierStylePara elsevierViewall">Multifocal lenses produce 2 or more coexisting retinal images corresponding to various distances&#44; where only one of the images is clearly perceived&#46; This concept is known as simultaneous vision&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Having 2 or more fixed focal points instead of one makes these lenses pseudo-accommodative but not accommodative&#46; In simultaneous vision&#44; the brain must minimize the blurred and unfocused component and enhance focus to obtain clear perception&#46; The greater the intensity of the negative effects of out-of-focus images&#44; the lower the quality of the image perceived by the patient&#46; In exchange for achieving greater clarity over a wider range of distances&#44; simultaneous vision always entails a certain loss of contrast compared to vision with a monofocal lens&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Multifocal IOLs have been developed based on the concepts of refraction&#44; diffraction or a combination of both&#46; Differences between multifocal IOL designs are best evaluated in ray tracing studies&#46; The type of optics used will later have a fundamental influence on the clinical results of the lens&#46; A detailed description of all existing models and their clinical results is beyond the scope of this review&#46; A systematic review of published medical literature confirms that bilateral implantation of multifocal IOLs obtains good results in near and far visual acuity and allows for improved independence from spectacles compared to monofocal IOLs&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> However&#44; these IOLs also have certain drawbacks&#44; since halos and glare&#44; and worse contrast sensitivity&#44; especially in low-light conditions&#44; are more frequent than with monofocal implants&#46; A review by the Cataract Clinical Committee of the American Society of Cataract and Refractive Surgery &#40;ASCRS&#41; detailed several clinical features that can help surgeons identify suitable candidates for multifocal IOLs&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In addition&#44; an important part of the decisions we make must also rest on the patient&#39;s motivation to correct their dependence on spectacles&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Comparing the performance of different types of multifocal IOLs is complex for several reasons&#58; First&#44; there is no consensus on which questionnaire or clinical test should be used to quantify the incidence and severity of undesirable photic phenomena nor on whether visual acuity should be measured monocularly or binocularly&#46; In addition&#44; we do not have a standardized test for measuring near visual acuity&#44; and contrast sensitivity tests are not&#44; at present&#44; completely standardized either&#46; Finally&#44; multifocal IOLs have been associated with higher levels of higher order aberrations than monofocal IOLs&#44; and neither the measurement systems nor the exact role of these aberrations are fully clarified&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Without a consensus on these issues&#44; a direct comparison between models is difficult&#46; In recent years&#44; the introduction of blur curves has made it possible to obtain a more realistic and objective measurement of patient vision at all functional distances&#46; Although it is a tedious test to perform&#44; it has also allowed us to better objectify the performance of each of the multifocal IOL models and thus to conduct better comparison&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;22</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Multi-focal refractive lenses</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Classic bifocal refractive lenses with rotational distribution</span><p id="par0070" class="elsevierStylePara elsevierViewall">Refraction is based on a change in the direction of the light beam due to a change in the optical density of the transmitter material&#46; Refractive multifocal IOLs incorporate 2 integrated powers in 2 different refractive zones&#44; generally circular and concentric&#46; The power of addition for near vision varies between models from &#43;2&#46;5 to &#43;3&#46;75 D&#46; The most used models are the ReZoom &#40;Johnson &#38; Johnson&#44; USA&#41; and M-flex MIOL &#40;LIO Rayner&#44; West Sussex&#44; UK&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> Refractive multifocal IOLs show good results in distance vision and less light scattering than diffractive IOLs&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> However&#44; they frequently cause dysphotopic phenomena&#44; particularly in mesopic and scotopic conditions<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which constitute one of the most frequent causes of dissatisfaction after a multifocal implant&#46; They also present worse results than diffractive IOLs in general in terms of contrast sensitivity&#44; lower tolerance to IOL misalignments and worse near vision&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Therefore&#44; their clinical use has decreased significantly in recent years&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Asymmetrically distributed bifocal refractive lenses</span><p id="par0075" class="elsevierStylePara elsevierViewall">In order to minimize the dysphotopic phenomena of conventional refractive IOLs with rotational symmetry&#44; these models composed of 2 asymmetrically arranged refractive segments were first marketed&#58; a large aspherical surface designed for distant vision&#44; and a conical sector with an addition embedded in the rear surface of the optics&#44; designed for near vision&#46; The most widely used model is the Lentis Mplus lens &#40;Oculentis GmbH&#44; Berlin&#44; Germany&#41; which is available with different additions for near vision in order to customize the visual needs of each patient&#46; Published results in far&#44; intermediate and near visual acuity are very good&#44; with high levels of contrast sensitivity and satisfaction&#44; and a very low incidence of dysphotopic phenomena&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;29</span></a> Its design enables the minimization of dissipated light loss &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Recent studies suggest that visual outcomes after implantation of this rotational asymmetric IOL can be improved if its orientation coincides with a personalized meridian&#46; Theoretically&#44; placing the near segment in a super-temporal position in the dominant eye with an addition of &#43;2 D&#44; and in the non-dominant one of &#43;3 D in the lower nasal sector&#44; would allow the best visual results&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> This shows that it is an implant which&#44; contrary to what its manufacturers claim&#44; is not totally pupil-independent&#46; In our experience&#44; which agrees with that of other habitual users&#44; there is a small percentage of patients with this IOL who do not achieve the expected results and are very dissatisfied&#44; without a clear causative or predictive factor&#46; In addition&#44; there were cases of significant off-centering in some eyes implanted with the C-loop platform&#44; which has practically been set aside&#46; Multiple cases of opacification of some implants have also been reported recently&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">A new model with similar optical technology to the Lentis Mplus&#44; the SBL-3 IOL &#40;Lenstec Inc&#46;&#44; St&#46; Petersburg&#44; FL&#44; USA&#41;&#44; has demonstrated very similar visual&#44; refractive and functional results&#44; although with minimal improvement in near vision compared to the Lentis Mplus&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Studies with longer follow-up and larger numbers of patients are needed to corroborate these results&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Recently&#44; these lenses have introduced low addition versions &#40;Lentis MPlusX&#44; Lentis Comfort&#44; LS-313 and SBL-2&#41; to improve intermediate vision for easier work with computers&#44; tablets and all daily activities that require vision in the 50&#8722;80<span class="elsevierStyleHsp" style=""></span>cm range&#46; Manufacturers include these latest models in the EDOF lens group&#46; The results published were very satisfactory&#44; with good far and intermediate vision without correction and a low incidence of dysphotopic phenomena&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> However&#44; foreseeably these lenses could present the same limitations related to their pupil dependence as the precursor models with higher near addition&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Recently&#44; a modification of the existing Oculentis Comfort EDOF lens design called Femtis Comfort FB-313<span class="elsevierStyleHsp" style=""></span>MF15 has been introduced&#46; The lens is fixed 360&#176;&#176; in the capsulorhexis of the anterior capsule with the edge of the optics&#46; The aim of the design is to minimize the occurrence of capsular phimosis and negative dysphotopsia&#46; A prospective study with 44 eyes of 25 patients showed that the surgical process of interlocking these lenses was safe and effective over time and eliminated negative dysphotopsia&#46; In addition&#44; the lens had low rates of unwanted visual phenomena and good refractive and visual results&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">A new IOL model designed to overcome the disadvantages of previous segmental refractive multifocal IOLs&#44; particularly pupil dependence&#44; is the Precizon Presbyopic IOL &#40;Ophtec BV&#44; Groningen&#44; The Netherlands&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The Precizon IOL is an implant made of hydrophilic acrylic material&#44; with a hydrophobic surface modification&#44; a C-loop design with modified haptics and a 6<span class="elsevierStyleHsp" style=""></span>mm optical zone&#46; The optics of the IOL called &#34;continuous transition focus&#34; &#40;CTF&#41; are divided in 3 concentric sectors&#46; The central sector is dedicated to far vision correction&#44; and the 2 peripheral sectors present a bimodal distribution &#40;50-50&#37;&#41; of the far and near vision correction&#44; changing this distribution along 4 segments in each sector &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The segments are 0&#46;75<span class="elsevierStyleHsp" style=""></span>mm wide with a close addition of &#43;2&#46;75 D&#46; This CTF design theoretically creates a continuous blur curve to facilitate a clear image on the retina at all distances&#46; To our knowledge&#44; only one recently published prospective study with this IOL lens has been published&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> comprising 31 patients with bilateral implants and with a capsular tension ring &#40;CTR&#41;&#44; with excellent visual results at far&#44; intermediate and near distances&#44; and very few referred undesirable photic phenomena &#40;10&#37; halos and 7&#37; glare&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Multifocal diffractive lenses</span><p id="par0105" class="elsevierStylePara elsevierViewall">These lenses are based on the principle of diffraction whereby light slows down and changes direction when it passes through an edge on a transparent surface&#46; These IOLs have microscopic steps &#40;diffractive zones&#41; distributed concentrically on the lens surface&#46; When light passes through this surface&#44; new wavefronts are generated&#44; as many as there are steps&#46; These wavefronts are in the same phase and can give rise to interference phenomena between them&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The interference can give rise to a wave of greater or lesser amplitude&#44; or in its neutralization&#46; Interference generated by diffraction is grouped into diffractive orders&#44; each with a specific location in space and intensity depending on the characteristics of the obstacle that has generated it&#44; in this case the height and separation of the steps&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">At present&#44; diffractive lenses include 2 subtypes&#58; the purely diffractive ones and those that combine the properties of a central diffractive optical design and a peripheral refractive one&#46; The refractive surface determines the far focus and the diffractive steps the near focus&#46; The width of these steps determines the power of addition &#40;the smaller the width&#44; the greater the power&#41; and their height determines the distribution of light between the far focus and the near focus &#40;the greater the height&#44; the greater the amount of light that is diffracted for the near focus&#41;&#46; In addition&#44; the diffractive lenses can also be apodized &#40;progressive reduction of the height of the steps from the center to the periphery&#41; so that the proportion of light directed to the 2 focuses is variable depending on lighting conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> For a multifocal IOL&#44; the difference between the powers of the 2 spotlights is called addition&#46; It is usually specified under the conditions of the plane of the spectacles&#44; with air being the surrounding medium&#46; After implantation&#44; the IOL is surrounded by aqueous humor&#44; so that the difference between the refractive indices of the IOL and its surroundings decreases&#46; This leads to a reduction in the refractive power of the lens in the plane of the IOL&#46; For power differences &#40;P&#41;&#44; the approximate formula P &#40;plane of IOL&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;7&#42; P &#40;plane of spectacles&#41; can be derived&#46; This formula is valid for both toric IOL cylinders and spherical additions&#59; e&#46;g&#46; an addition of 3&#46;33 D multifocal IOL produces an effective addition of 2&#46;33 D in the plane of the IOL&#44; which corresponds to a distance of 1 &#47; &#40;2&#46;33 D&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;43<span class="elsevierStyleHsp" style=""></span>m&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Bifocal diffractive lenses</span><p id="par0115" class="elsevierStylePara elsevierViewall">The first generation of multifocal&#44; diffractive and refractive implants<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> were bifocal and most incorporated &#43;4 D addition in the lens plane in order to minimize the risk of diplopia as a result of the simultaneous superimposition of sharp and unfocused images and to allow useful near vision&#46; Although some amount of incident light is intrinsically lost in the higher orders of diffraction&#44; numerous studies with these initial models reported good results in both near and far vision&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;41&#8211;43</span></a> However&#44; they neglected intermediate vision&#44; and in today&#39;s life&#44; work and leisure activities are dominated by the use of computers and tablets&#44; and many of those patients required optical aids for intermediate distance vision&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Later&#44; the introduction in bifocal diffractive IOLs of lower near additions&#44; in the range of 2&#46;5&#8211;3&#46;0 D&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#8211;46</span></a> and strategies to combine different additions in both eyes &#40;known in the Anglo-Saxon literature as Mix and Match &#91;MM&#93;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> tried to increase visual acuity in the intermediate distance&#46; However&#44; this improvement in optical lens design was not sufficient to provide satisfactory intermediate vision for many of the patients implanted with these bifocals&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Alfonso et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> demonstrated that an addition of &#43;3 D provided better intermediate visual acuity than the same IOL with the addition of &#43;4 D&#46; However&#44; the defocusing curve obtained had a V pattern with 2 peaks corresponding to the vergence of near and far vision&#44; and a marked central valley corresponding to the intermediate vergence&#46; This prompted the manufacturers to develop a new concept&#44; i&#46;e&#46;&#44; the trifocal multifocal IOL&#44; in an effort to obtain good quality of vision at far&#44; intermediate and near distances&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Trifocal diffractive lenses</span><p id="par0125" class="elsevierStylePara elsevierViewall">In trifocal lenses&#44; as the diffracted light waves propagate towards the retina&#44; the waves coming from various diffractive zones mix forming 3 regions of constructive interference that correspond to the 3 main focuses of the IOL&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> and that allow minimizing the amount of incident light lost to bifocal models&#46; Voskresenskaya et al&#46; describe good initial results with a first prototype&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> but the first commercialized trifocal diffractive IOL was the FineVision Micro F IOL &#40;BVI-PhysIol&#44; Li&#232;ge&#44; Belgium&#41;&#46; Its first clinical results were published by Lesieur in 2012&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> Gatinel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> describe the design of this lens which combines on its anterior optical surface 2 diffractive profiles &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The second trifocal IOL to reach the market was the AT Lisa tri 839<span class="elsevierStyleHsp" style=""></span>M<span class="elsevierStyleHsp" style=""></span>P &#40;Carl Zeiss&#44; Germany&#41;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>&#59; and the third important trifocal IOL to be marketed was the PanOptix IOL &#40;Alcon&#44; Fort Worth&#44; TX&#44; USA&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The technical characteristics of the 3 main trifocal diffractive IOLs are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">In 2013&#44; our most widespread strategy for correcting presbyopia after lens surgery was to implant bifocal diffractive IOLs with different additions&#44; Restor &#43;2&#46;5 D in the dominant eye and Restor &#43;3 D in the reading eye&#46; A question inevitably arose with the appearance of these trifocal IOLs&#58; if the added intermediate focus could produce better intermediate visual acuity&#44; it could also lead to worse distance vision&#44; decreased contrast sensitivity and a greater number of dysphotopic phenomena&#46; In an attempt to clarify these controversies&#44; our group published a prospective comparison between Mix and Match implantation of bifocal IOLs with different near addition and bilateral implant of trifocal IOLs&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> The article reported that monocular and binocular vision at near and intermediate distances was better with trifocal than with bifocal implants&#46; In addition&#44; the study showed no significant difference in either distance vision or contrast sensitivity between the two groups&#46; Bilateral trifocal implantation led to greater independence from glasses and higher levels of patient satisfaction&#46; These results were later confirmed by other studies<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53&#44;54</span></a> and meta-analyses that also compared the clinical performance between bifocal and trifocal diffractive IOLs&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55&#44;56</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">A retrospective analysis of more than 5000 bilaterally implanted patients with 2 trifocal models &#40;AT Lisa tri and FineVision Micro F&#41;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> confirmed the capacity of the human brain to use the 3 available foci with few undesirable dysphotopic phenomena&#46; Excellent refractive and visual results were obtained at near&#44; far and intermediate distances&#44; with high satisfaction rates and independence from spectacles&#46; The results were very similar with both models&#46; Although the referred night vision was not optimal&#44; most patients did not identify it as crucial and gave much more emphasis to the independence of glasses obtained with the surgical procedure&#46; Several studies<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">58&#8211;63</span></a> published later on also reported very good refractive and visual results at different distances&#44; corroborating them with defocusing curves&#59; likewise&#44; they showed a high degree of patient satisfaction&#44; a high independence of eyeglasses and few undesirable dysphotopic phenomena&#46; Furthermore&#44; these published visual and functional results are similar among the different models of trifocal lenses evaluated&#46; These would differ fundamentally by the material and design of the lens platform&#44; the amount of light distributed to each of the 3 focuses and&#44; to a lesser extent&#44; the distance calculated by addition&#44; for intermediate vision&#46; A retrospective study with a very extensive sample<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> compared the incidence of YAG capsulotomies with 2 different trifocal lenses and found that eyes implanted with the FineVision Micro F IOL required significantly fewer Nd&#58; YAG laser capsulotomies than those implanted with the Lisa tri 839<span class="elsevierStyleHsp" style=""></span>M<span class="elsevierStyleHsp" style=""></span>P&#44; during the first 4 years after implantation &#40;14&#37; vs&#46; 35&#37;&#41;&#46; The platform design of both lenses could justify this difference&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Among all the trifocal models currently available&#44; perhaps the PanOptix IOL could be the most suitable for patients who require closer intermediate vision &#40;about 60<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; and any of the other models&#44; for those patients who use more distant intermediate vision &#40;about 80<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> Finally&#44; the decision between the different trifocal options available will depend mainly on surgeon preferences based on personal trust with each platform and on local availability conditions of each model&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Recently&#44; new trifocal diffractive models such as the Physiol Triumph lens &#40;BVI-Physiol&#44; S&#46; A&#46;&#44; Li&#232;ge&#44; Belgium&#41; with a new trifocal diffractive profile providing a better distribution of light energy for the intermediate focus and an improvement of its longitudinal chromatic aberration &#40;ACL&#41;&#44; and the Tecnis Synergy IOL &#40;Johnson &#38; Johnson Vision Care Inc&#44; USA&#41; with a new diffractive achromatic surface&#44; may prove to be very interesting options within this subgroup of diffractive multifocal lenses&#44; but their clinical studies&#44; still in initial stages&#44; have not been published yet&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In general&#44; these trifocal lenses provide a wider range of vision compared to other types of IOLs&#44; but they also cause undesirable visual effects that may occasionally be unacceptable to certain patients and are not recommended for certain very visually demanding activities&#46; In addition&#44; trifocal IOLs&#44; like many other multifocal lenses&#44; are contraindicated in certain clinical or anatomical circumstances&#46;</p></span></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Extended depth of focus &#40;EDOF&#41; lenses</span><p id="par0160" class="elsevierStylePara elsevierViewall">During the past five years numerous models of lenses catalogued as EDOF have reached the market&#46; The basic principle of the EDOF IOLs would be to create a single&#44; elongated focal point&#44; which would improve depth of focus and thus provide better performance in intermediate vision than single-focus IOLs&#46; This extended focal point is intended to eliminate the image overlap caused by traditional refractive and diffractive multifocal IOLs&#44; and thus the halo effect of the out-of-focus image&#46; Theoretically&#44; EDOF technology seeks to combine some advantages of multifocal lenses with others of monofocal lenses&#46; However&#44; the term EDOF is somewhat confusing and to some extent controversial&#46; It has been used for many types of lenses that are completely different in their optical properties and therefore in their performance&#46; For this reason&#44; it would seem reasonable to try to limit the EDOF qualifier to those lenses that endeavour to extend distance to intermediate vision through continuous and preferably single focus&#46; And if this is not possible&#44; the manufacturers should at least try to define as precisely as possible the physical properties that would explain the optical performance of the lens and that would justify its inclusion in this IOL subgroup&#46; A frequently very complicated task in a market with so much competition in the field of industrial design and property rights&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Eyes implanted with EDOF lenses should experience less photic phenomena and less loss of contrast sensitivity than those with traditional multifocal IOLs while providing improved depth of focus with vision quality similar to that of monofocal lenses&#46; To achieve this&#44; IOL manufacturers have developed different and sometimes combined optical strategies in search of the magic formula&#46; The objective is to generate a series of controlled aberrations in the optics&#44; to extend the distance of vision without excessive degradation of sharpness&#44; in order to strike the right balance between increasing the depth of focus and decreasing the quality of vision&#46; The bibliographic references published on this type of lenses have multiplied during the last years&#46; And as discussed above there is no clear scientific consensus on how to objectively and reproducibly measure the loss of visual quality&#44; the dysphotopic phenomena generated and the optical performance of the lenses at intermediate or close distances&#46; This is why some of these publications may be controversial and confusing&#46; In addition&#44; it should be noted that&#44; by definition&#44; EDOF lenses were created to improve intermediate vision while maintaining good distance vision&#44; so these lenses could not provide absolute independence from spectacles&#46; The main EDOF lenses available are discussed below&#44; globally describing the main clinical and comparative results they provide&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">So far&#44; four optical technologies have been used by IOL manufacturers to extend the depth of focus of EDOF lenses&#58; diffractive optical lenses&#44; pinhole effect lenses&#44; lenses with zone refractive optics&#44; and lenses with modified AE&#46; Some models combine 2 of these strategies and many also recommend their users to leave a minimum residual myopia of approximately -0&#46;5 D to achieve some mini-monovision and enhance the lens effect&#46; Some emerging new models such as the Vivity lens &#40;Alcon Laboratories&#44; Inc&#46;&#44; Fort Worth&#44; TX&#44; USA&#41; use modifications to the central part of the anterior surface of the optics called transition elements to extend the focal range&#46; These variants may represent very interesting options in the near future&#44; but their precise optical properties have not been evaluated and clinical results are pending publication&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Low addition diffractive EDOF IOLs</span><p id="par0175" class="elsevierStylePara elsevierViewall">In these lenses the near vision focal point of diffractive optics is directed to intermediate vision with a low power addition&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The Symfony XZR00 IOL &#40;Johnson &#38; Johnson Vision Care Inc&#46;&#44; USA&#41; was the first EDOF-labeled lens launched in the market and received CE marking in Europe in 2014 and FDA approval in 2016&#46; It shares the hydrophobic acrylic platform of the Tecnis monofocal lens&#44; with an achromatic diffractive rear surface with &#43;1&#46;75 D addition that achieves extended range of vision from far to intermediate distance and seeks to compensate the ACL of the entire optical system for improved contrast sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> In a comparison with the monofocal lens&#44;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">67&#44;68</span></a> the Symfony IOL achieves significantly improved near and uncorrected visual acuity and greater independence from glasses&#59; however&#44; the EDOF IOL also had some decrease in contrast sensitivity and more frequent halos&#46; An international multicenter study<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> reported excellent visual&#44; refractive and optical correction independence results&#44; with few undesired visual effects referred&#44; improving performance with micro-monovision &#40;-0&#46;5 to -0&#46;75 D&#41; in the non-dominant eye&#46; Later studies that compared the results between this lens and different diffractive trifocal IOLs<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#8211;76</span></a> showed that far and intermediate visual acuities were similar&#44; but near vision was significantly better with trifocal IOLs&#46; In most studies&#44; contrast sensitivity testing under photopic and mesopic conditions was similar in both groups&#44; or only minimally better with Symfony&#44; while perception of adverse dysphotopic phenomena and patient satisfaction were comparable&#46; And with respect to the postoperative independence of optical correction&#44; both strategies achieved it almost absolutely for far and intermediate distances&#44; but for near vision the group implanted with trifocal lenses obtained better results&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Another popular EDOF lens based on a diffractive&#44; low addition principle is the AT LARA 829<span class="elsevierStyleHsp" style=""></span>M<span class="elsevierStyleHsp" style=""></span>P &#40;Carl Zeiss Meditec&#44; Jena&#44; Germany&#41; which received the CE mark in 2017&#46; In addition to the distant focal point&#44; the IOL has 2 additional focal points of &#43;1&#46;9 and &#43;0&#46;95 D for intermediate distances&#46; The lens has an aspherical neutral optical design and an optimized chromatic aberration to improve the quality of vision&#46; It is a hydrophilic plate platform with a hydrophobic surface coating&#44; with an optical diameter of 6<span class="elsevierStyleHsp" style=""></span>mm and an overall length of 11<span class="elsevierStyleHsp" style=""></span>mm&#46; To date&#44; there is limited published evidence&#46; An initial study<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> with 11 bilaterally implanted patients found a good range of focus and optimal visual acuity for intermediate distances&#46; A retrospective review published in 2019<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> evaluated 293 bilaterally implanted patients after 3 months of postoperative follow-up&#46; Reasonable uncorrected near and far vision was achieved with optimal patient satisfaction &#40;90&#37; satisfied or very satisfied&#41; and high rates of spectacle independence &#40;83&#46;6&#37; for near&#41;&#46; Some undesirable optical side effects were reported&#44; especially during the early postoperative period&#44; and 6&#46;8&#37; of patients eventually reported considerable difficulty or inability to drive at night&#46; A later publication<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> analyzed the predictive factors associated with the postoperative satisfaction of the patients evaluated in the aforementioned study&#59; the study concluded that early management of dry eye&#44; avoiding mini-monovision&#44; and warning patients of possible adverse visual effects helped improve patient satisfaction after the procedure with this implant&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Another recently launched model within this category of EDOF IOL with diffractive optics&#44; but with a smaller number of diffractive rings&#44; is the Xact Mono-EDoF lens &#40;Santen&#44; Japan&#41;&#46; To date&#44; no published results have been found in the literature&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Both the Symfony lens and the AT LARA showed in the laboratory a bifocal behavior in the <span class="elsevierStyleItalic">modulation</span> transfer function &#40;MTF&#41; curve&#44; except with pupil sizes around 2<span class="elsevierStyleHsp" style=""></span>mm&#44; possibly due to the pinhole effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">80&#44;81</span></a> Its diffractive nature would explain these findings&#46; Therefore&#44; and despite the improvements in its optical design&#44; especially in the field of ACL&#44; instead of generating a single extended focal point perfectly continuous&#44; the diffractive polyfocal optics of these lenses generates several focal points&#44; close but separate&#46; This justifies that the visual results obtained in patients are approximately &#40;or only minimally better&#41; in the range of low addition bifocal diffractive IOLs&#44; with their advantages and limitations previously mentioned in the comparative studies with diffractive trifocal models&#46; Possibly&#44; the functional differences between these 2 diffractive EDOF models would be related to the different EC approach&#46; The Symfony lens&#44; with a negative EC that seeks to compensate the average corneal EC of the human eye&#44; should present a better optical performance&#44; in mesopic and scopic conditions with larger pupil diameters&#44; than the AT LARA lens that presents a profile without added EC&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Pinhole stenopeic effect lenses</span><p id="par0200" class="elsevierStylePara elsevierViewall">Another subtype of EDOF IOL are the so-called small opening IOLs&#46; These lenses are designed with a central hole and a mask that blocks out unfocused peripheral light rays that can degrade image quality&#46; Reducing the pupil aperture allows only the focused central light to reach the retina&#44; which reduces the size of the circle of confusion and improves the resolution of the image&#44; increasing the depth of focus&#46; The IC-8 lens &#40;AcuFocus Inc&#46;&#44; Irvine&#44; CA&#44; USA&#41; is a monobloc hydrophobic acrylic rear camera IOL that incorporates a 3&#46;23<span class="elsevierStyleHsp" style=""></span>mm diameter non-diffractive opaque mask with a central aperture of 1&#46;36<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">Another small opening lens on the market is the XtraFocus Pinhole Implant &#40;Morcher&#44; Stuttgart&#44; Germany&#41;&#44; intended for implantation in the ciliary sulcus as a piggyback lens&#46; The device is made of a black hydrophobic acrylic material that blocks visible light but is transparent to infrared light above 750<span class="elsevierStyleHsp" style=""></span>nm &#40;to allow examination of the retina through the opaque material with optical coherence tomography&#41;&#46; Its total diameter is 14<span class="elsevierStyleHsp" style=""></span>mm with a central opening of 1&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">These IOLs are especially recommended for treating patients with highly irregular corneas from previous trauma&#44; keratoconus&#44; radial keratotomy or penetrating keratoplasties&#46; Recently&#44; a prospective study<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> reported excellent visual results in eyes with severe corneal irregularities&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In this type of IOLs&#44; perfect centering is particularly essential&#46; Distance vision is degraded when lighting conditions decrease&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> and in these circumstances patients may even experience undesirable visual disturbances &#40;halos&#44; glare&#41; when their pupil size exceeds the opaque lens mask&#46; The implanted eye can be left emmetropic or with a residual myopic blur of -0&#46;75 to -0&#46;5 D in one eye&#44; especially with bilateral implants&#46; A multicenter prospective trial<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> with 105 patients revealed excellent visual performance&#44; safety&#44; patient satisfaction and tolerance to residual astigmatism after unilateral implantation of IC-8 and an aspherical monofocal lens in the opposite eye&#46; Another multicenter retrospective study<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> with 126 consecutive patients with monocular implants found that more than half of the patients implanted with the IC-8 IOL were completely independent of spectacles&#46; Two other studies<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">86&#44;87</span></a> evaluated binocular and monocular implantation of this small aperture IOL in cataract patients and found that bilateral implantation of the IC-8 IOL produced a larger extended range of focus&#44; with improved intermediate and near vision&#46; However&#44; it is contradictory that in one of these studies&#44; monocular implantation of the IOL enabled a significantly higher overall satisfaction index and better halos perception scores&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a> while in the other study overall satisfaction and independence from glasses were better with bilateral implants&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Good results have also recently been reported in patients implanted after a previous corneal LASIK procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a> A recent prospective randomized study with 38 patients compared bilateral implantation of Symfony versus IC-8 in the non-dominant eye and an aspherical monofocal lens in the opposite eye&#46; In both groups&#44; a mini-monovision effect was sought&#44; leaving -0&#46;75 D of residual myopia in the non-dominant eye&#46; Both EDOF strategies provided very good far vision&#44; but with superior results in the IC-8 group&#44; and good and similar intermediate and near vision in low vision conditions in both groups&#46; The referred subjective satisfaction was greater in the group of the IC-8 lens&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">EDOF lenses with zonal refractive designs</span><p id="par0225" class="elsevierStylePara elsevierViewall">The first LIO EDOF model to use this strategy&#44; along with modifications to the EC&#44; was the Mini WELL lens &#40;Sifi&#44; Catania&#44; Italy&#41;&#46; It is a hydrophilic biconvex lens with 3 differentiated optical zones&#59; 2 sections within a central diameter of 3<span class="elsevierStyleHsp" style=""></span>mm&#44; where the human eye has an insignificant amount of AE&#44; where a distribution of positive and negative AEs is introduced to achieve an increase in the depth of focus&#46; The peripheral section between 3 and 6<span class="elsevierStyleHsp" style=""></span>mm of the optics has an aspherical monofocal design to achieve optimal distance vision&#44; even in low vision conditions<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">90</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; Several studies reported that the Mini WELL IOL<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">91&#8211;93</span></a> provided good postoperative functional results at far and intermediate distances and improved visual acuity at reading distance&#44; causing very few dysphotopsies&#46; In another study&#44; Savini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> obtained similar results with a diffractive bifocal lens with an addition of &#43;2&#46;5 D&#44; in distant and near vision&#44; but it was superior at intermediate distances&#46; In a comparative study with an IOL with the same platform but with monofocal aspherical optics&#44;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a> the Mini WELL lens showed better performance at intermediate and near distances&#44; without worsening distant vision or contrast sensitivity&#44; but with greater dysphotopia perception&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">A laboratory study<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">96</span></a> compared image quality with 3 models of EDOF IOLs in monochromatic &#40;green&#41; and polychromatic conditions&#46; Any lens will get a worse quality in polychromatic conditions due to the ACL&#44; and the analysis showed that the Mini WELL IOL had a worse MTF in polychromatic light conditions in the far focus than the Symfony and AT LARA IOLs&#59; furthermore&#44; it had a greater drop in MTF compared to the evaluation with monochromatic light than the other 2 models&#46; Both diffractive IOLs with an &#34;achromatic&#34; profile are more resistant to the negative effects of ACL&#46; In contrast&#44; the optical quality of the Mini WELL IOL is relatively less affected by defocus&#44; showing a more horizontal defocusing curve than the 2 diffractive models&#44; which both share a certain bicuspid shape&#46; Finally&#44; the refractive zonal design of the Mini WELL exhibited a high level of pupil dependence that should be taken into account in preoperative decision making&#46; It has been demonstrated in vitro that ACL and EC have an important impact on visual quality&#44; and undoubtedly this should have a certain impact on the visual quality of patients&#46; The correction of both aberrations allows the MTF of multifocal lenses to be improved in the laboratory&#44; together with the subsequent subjective visual experience&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Another EDOF model available with a zonal refractive optics is the Suprahob Infocus IOL &#40;Appasamy As&#46;&#44; Chenai&#44; India&#41;&#46; This IOL is acrylic with yellow chromophore and has a central zone of 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm for near vision &#40;&#43;3&#46;50 D&#41;&#44; a larger middle peripheral zone for intermediate vision and an external zone for distance vision&#46; Published evidence is very limited with this IOL&#46; A prospective study with 63 patients<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a> compared the results of the Supraphob Infocus IOL with its monofocal counterpart&#46; The EDOF model was better for intermediate and near distances without affecting distance vision or contrast sensitivity&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Another model with similar optical performance is the LIO Lucidis IOL &#40;Swiss Advanced Vision&#44; SAV-IOL SA&#44; Neuchatel&#44; Switzerland&#41;&#46; It is a bizonal&#44; hydrophilic acrylic monobloc refractive&#47;aspheric IOL with a total optical diameter of 6<span class="elsevierStyleHsp" style=""></span>mm&#44; with an aspherical central area of 1<span class="elsevierStyleHsp" style=""></span>mm and an addition&#47;EDOF power of &#43;3&#46;0 D&#46; Optically&#44; the Lucidis IOL uses both refraction and an aspherical element&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Only one published retrospective study<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> has been found comprising 45 eyes with monocular or bilateral implants&#44; with uncorrected far visual performance inferior to other EDOF models but with better results in intermediate and near vision&#44; near normal contrast sensitivity and good satisfaction as well as independence from spectacles&#46; The authors state that it could be a valid alternative for patients with age-related macular degeneration&#46; As mentioned above&#44; &#34;traditional&#34; segmental refractive lenses such as Lentis Mplus or Lenstec SB with their low power addition models could also be included in this sub-group of EDOF IOLs&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">IOL with modifications of the spherical lens aberration</span><p id="par0250" class="elsevierStylePara elsevierViewall">This is a very recent EDOF lens subtype&#44; in which modifications in the asphericity of the optics would create an extension of the focal point without excessively degrading the image quality obtained&#46; In contrast with refractive or diffractive zone optics&#44; this technology does not split light and therefore could also be called enhanced single vision lenses for intermediate vision&#46; This could mitigate some of the adverse visual phenomena of some of the EDOF models mentioned above&#46; Other models&#44; such as the Mini WELL or Lucidis IOLs&#44; combine zone refractive technology with EC modifications of these different areas in their optics and therefore have not been included in this category of our classification&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Conventional aspherical single-focus IOLs have a fixed negative EC in the range of -10 to -20&#956; m to compensate for the corneal average positive EC&#46; These new EDOF IOLs increase the total negative IOL EC by creating a continuous progressive increase in the diopter power of the lens from the periphery to the center&#46; This design causes the central and peripheral rays entering through the pupil not to converge identically&#44; thus causing an extension of the focuses on the retina and providing depth of focus &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; As negative EC increases&#44; the focal area is extended but the resolution power and contrast sensitivity of the eye decreases&#46; The value of induced EC is crucial to maximize its beneficial effect without introducing too many harmful effects &#40;blurring&#47;loss of contrast sensitivity&#41;&#46; Ideally&#44; these IOLs should be designed to induce a greater amount of negative EC in eyes with corneas with a greater amount of positive EC&#46; Laboratory studies limit the amount of depth of focus this technology could induce to 1 D&#59; therefore&#44; in some of the current initial studies researchers point to a myopic result of -0&#46;5&#8722;0&#46;75 D in one of the eyes to obtain some mini-monovision effect binocularly&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">The first EDOF IOL in this category to be marketed was the Tecnis Eyehance ICB00 lens &#40;Johnson &#38; Johson Vision Care&#44; Inc&#46;&#44; USA&#41;&#44; which shares the same hydrophobic acrylic platform as its single-focus precursor Tecnis ZBC00&#44; but a modified aspherical front surface and -0&#46;27 m &#956;AE&#46; This improved aspherical lens creates a continuous power profile &#40;progressively increasing from the periphery to the center of the lens&#41;&#44; which is intended to extend the depth of focus&#44; thus improving intermediate and near vision compared to a standard monofocal IOL&#46; A recent prospective study with 40 patients<span class="elsevierStyleSup">99</span> compared the results of Tecnis Eyehance with those of the precursor monofocal model&#44; with the EDOF lens achieving better uncorrected intermediate vision and greater independence from spectacles in intermediate vision without deterioration of distance vision or visual quality&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">In July 2019&#44; the authors&#8217; group started a prospective study with another EDOF lens model in this category&#44; the IsoPure lens &#40;BVI-Physiol SA&#44; Li&#232;ge&#44; Belgium&#41;&#44; with very promising initial visual results&#46; Based on the hydrophobic glistening-free platform of 4 closed haptics of its previous aspherical monofocal precursor&#44; the IsoPure lens combines a continuous progressive aspherical profile over the entire optical zone&#44; which is unique as it is combined on both the front and rear surfaces of the optics and adjusted for each dioptric power of the lens&#46; To date&#44; there are no published studies&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">These promising initial results with this group of EDOF lenses&#44; which we could also call extended range monofocals&#44; should be confirmed in future studies with a much larger number of patients and longer follow-up&#46; It would be useful to include also patients with ocular comorbidities to assess their performance in these circumstances&#44; and compare it with that of standard monofocal lenses&#46; In addition&#44; their visual outcomes should be evaluated under different conditions&#44; such as environments with low ambient lighting&#44; different pupil sizes&#44; or lens offsets&#44; factors that can undoubtedly modify the behavior of optics with high negative EC values&#46; Finally&#44; these lenses could become an interesting option for standard cataract surgery&#59; especially for patients who wish to improve their independence from eyeglasses but do not wish to undergo the undesirable visual phenomena of zonal diffractive and refractive lenses as well as for those who suffer from certain comorbidities that are currently generalized contraindications for multifocal IOL implantation&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Over the past few years&#44; many EDOF IOLs have been developed that have allowed us to expand the portfolio of lenses available&#44; in an effort to combine some of the advantages of multifocal and others of monofocal lenses&#46; In 2017&#44; a working group of the American Academy of Ophthalmology &#40;AAO&#41; published a consensus statement on EDOF IOLs&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a> It provides benchmarks for classifying an implant as an EDOF IOL and recommendations on how to evaluate lens performance under standard conditions &#40;photopic&#44; mesopic&#44; and glare&#41;&#46; It specified the minimum visual acuity levels of the implant in far and intermediate vision and the extension of focus in the blur curve&#44; compared to a reference monofocal implant that should serve as control in validation studies&#46; The AAO established these criteria to help researchers evaluate current and future EDOF IOLs objectively in a framework that would then facilitate comparison between all of them&#46; So far&#44; none of the existing EDOF lenses have met all of these clinical requirements in any of the published studies&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0280" class="elsevierStylePara elsevierViewall">The options for surgical correction of presbyopia have multiplied over the past 2 decades&#46; At present&#44; achieving independence in optical correction after lens surgery has become an option&#46; However&#44; as surgeons&#44; we still face the dilemma of offering our patients a better quality of life without depending on spectacles but with a somewhat worse visual quality using multifocal lenses&#44; or the opposite with single vision lenses&#46; EDOF lenses&#44; in our opinion&#44; especially those based on modified monofocal optical systems&#44; will bring these two alternatives closer together&#46; As discussed above&#44; comparative studies between lenses have several drawbacks and limitations&#44; and furthermore the lens with the best result in a certain parameter is definitely not going to be the best lens for all patients&#46; Therefore&#44; we must consider that the success in the correction of presbyopia with lens surgery must be based on 4 processes&#58; first&#44; to carry out an exhaustive preoperative clinical evaluation of the patient&#59; second&#44; to carry out a meticulous preoperative planning and a technically perfect surgical intervention&#59; third&#44; to know in depth the technical characteristics and previous results of the lenses available in our portfolio&#44; especially considering their design&#44; the blurring curves and the usual incidence of associated dysphotopic phenomena&#59; and finally&#44; to consider the personality&#44; professional and leisure activities of our patients with their visual needs&#44; and to try to evaluate their degree of motivation for eyeglass independence and their expectations&#44; through a personal preoperative&#44; honest and detailed discussion&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Perhaps today&#44; in 2020&#44; we could consider trifocal diffractive lenses&#44; with its pros and cons&#44; to be the <span class="elsevierStyleItalic">gold</span> standard in the surgical lens correction of presbyopia&#46; In the next few years we will witness the development of innovative and very interesting optical technologies&#44; such as new polyfocal diffractive platforms&#44; ingenious strategies for EDOF lenses such as axicons or spiral phase elements&#44; or even new adjustable IOLs&#44; or perhaps filling gels for the lens sac&#44; with which we will expand and improve the alternatives that we offer to our patients as surgeons&#46; Laboratory tests&#44; particularly clinical studies with large series of patients&#44; with standardized evaluations and long follow-up times&#44; will determine the true performance of these new lenses&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interest</span><p id="par0290" class="elsevierStylePara elsevierViewall">The authors have no commercial or financial interest in any of the products mentioned in this article&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">During the last 12 months&#44; Rafael Bilbao-Calabuig has received fees as a medical consultant from Physiol SA&#44; and for participating as a speaker in conferences&#47;congresses of Physiol SA and Alcon&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">Felix Gonzalez-Lopez has received honorary awards for participating as a speaker at Johnson&#38;Johnson Vision Care conferences&#47;congresses&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">Fernando Llovet-Osuna has received fees as a medical consultant from Johnson&#38;Johnson Vision Care&#44; Rayner and Alcon&#44; and for participating as a speaker at Johnson&#38;Johnson Vision Care and Alcon conferences&#47;congresses&#46;</p></span></span>"
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              "titulo" => "Pinhole stenopeic effect lenses"
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              "titulo" => "IOL with modifications of the spherical lens aberration"
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    "fechaRecibido" => "2020-04-28"
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            0 => "Lens surgery"
            1 => "Phacoemulsification"
            2 => "Intraocular lenses"
            3 => "Multifocal lenses"
            4 => "Accommodative lenses"
            5 => "EDOF lenses"
            6 => "Monovision"
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            0 => "Cirug&#237;a cristaliniana"
            1 => "Facoemulsificaci&#243;n"
            2 => "Lentes intraoculares multifocales"
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            4 => "Lentes EDOF"
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            6 => "Visi&#243;n combinada"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Presbyopia is the progressive and irreversible loss of accommodation due to aging&#46; It is one of the main causes of loss of quality of life in people from 45 years of age&#44; due to the&#44; often novel&#44; dependence on spectacles&#46; The eagerness to correct it by ophthalmologists driven by the desire of millions of people who suffer from it&#44; has become one of the main drivers for the development of intraocular lens &#40;IOL&#41; technology over the last twenty years&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">This review briefly presents the different alternatives that have allowed us to improve the crystalline lens surgical approach of presbyopia&#59; from monofocal lenses and monovision technique&#44; accommodation&#44; refractive&#44; and diffractive multifocal lenses&#44; and finally the most recent focus or extended depth or focus&#47; field lenses known as EDOFs&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Each IOL has its advantages&#44; limitations and disadvantages&#46; Furthermore&#44; there is no single lens that suits the needs of all patients&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">It is necessary to know the variety of lenses available&#44; and to have an in-depth understanding of their optical properties&#44; as well as the impact that these will have later on their clinical performance and on the visual quality of the patients&#46; This should help us to select the best alternative for each of them&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La presbicia es la p&#233;rdida progresiva e irreversible de la acomodaci&#243;n debido al envejecimiento&#46; Es una de las principales causas de disminuci&#243;n de la calidad de vida en personas a partir de los 45 a&#241;os derivada de la&#44; muchas veces novedosa&#44; dependencia de las gafas&#46; El af&#225;n por corregirla por parte de los oftalm&#243;logos&#44; impulsados por el deseo de millones de personas que la padecen&#44; se ha convertido en uno de los principales motores de desarrollo de la tecnolog&#237;a de las lentes intraoculares &#40;LIO&#41; durante los &#250;ltimos veinte a&#241;os&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Esta revisi&#243;n repasa las distintas alternativas que han permitido ir mejorando el enfoque quir&#250;rgico cristaliniano de la presbicia&#59; desde las lentes monofocales y la t&#233;cnica de la monovisi&#243;n&#44; a las lentes acomodativas&#44; pasando por las lentes multifocales refractivas y difractivas y terminando con las m&#225;s recientes lentes de foco o campo extendido conocidas como EDOF&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Cada una de estas LIOs tiene sus ventajas&#44; limitaciones e inconvenientes&#59; y adem&#225;s&#44; no existe la lente que se adapte a las necesidades de todos los pacientes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Es necesario conocer la variedad de lentes disponibles&#44; y comprender en profundidad tanto sus propiedades &#243;pticas como el impacto que &#233;stas van a tener luego en su rendimiento cl&#237;nico y en la calidad visual de los pacientes&#46; Esto nos deber&#237;a ayudar a poder seleccionar la mejor alternativa para cada uno de ellos&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bilbao-Calabuig R&#44; G&#243;nzalez-L&#243;pez F&#44; Llovet-Rausell A&#44; Ortega-Usobiaga J&#44; Tejerina Fern&#225;ndez V&#44; Llovet-Osuna F&#46; Correcci&#243;n de la presbicia tras cirug&#237;a cristaliniana &#191;D&#243;nde nos encontramos en 2020&#63; Arch Soc Esp Oftalmol&#46; 2021&#59;96&#58;74&#8211;88&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Single lens&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eyeonics Crystalens &#40;Eyeonics&#44; Inc&#46;&#44; Aliso Viejo&#44; CA&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tetraflex KH-3500 &#40;Lenstec Inc&#46;&#44; St&#46; Petersburg&#44; FL&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ICU lens &#40;Human Optics AG&#44; Erlangen&#44; Germany&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Double lens&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Syncrony IOL &#40;Visiogen Inc&#46;&#44; Irvine&#44; CA&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lumina IOL &#40;AkkoLens International&#44; Breda&#44; Netherlands&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Multifocal IOL</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Refractive multifocal IOL</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bifocal &#34;classical&#34; refractive IOL &#40;rotational symmetry&#41;&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ReZoom &#40;Johnson &#38; Johnson&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M-flex MIOL &#40;LIO Rayner&#44; West Sussex&#44; UK&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymmetrically distributed refractive IOLs&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lentis Mplus&#44; Lentis MPlusX&#44; Lentis Comfort &#40;Oculentis GmbH&#44; Berlin&#44; Germany&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SBL-3&#44; LS-313 and SBL-2 &#40;Lenstec Inc&#46;&#44; St&#46; Petersburg&#44; FL&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Precizon Presbyopic &#40;Ophtec BV&#44; Groningen&#44; The Netherlands&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Multifocal Diffractive IOL</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bifocal diffractive IOL&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Restor &#40;Alcon&#44; Fort Worth&#44; TX&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;Johnson &#38; Johnson&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AT Lisa &#40;Carl Zeiss&#44; Germany&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trifocal diffractive IOL&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FineVision Micro F&#44; POD-F&#44; Triumph &#40;BVI-PhysIol&#44; Li&#232;ge&#44; Belgium&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AT Lisa tri 839<span class="elsevierStyleHsp" style=""></span>M<span class="elsevierStyleHsp" style=""></span>P &#40;Carl Zeiss&#44; Germany&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PanOptix IOL &#40;Alcon&#44; Fort Worth&#44; TX&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Synergy &#40;Johnson &#38; Johnson Vision Care Inc&#46;&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Extended Depth of Focus &#40;EDOF&#41; IOL</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">EDOF IOL with low addition diffractive optics&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Symfony XZR00 &#40;Johnson &#38; Johnson Vision Care Inc&#46;&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AT LARA 829<span class="elsevierStyleHsp" style=""></span>M<span class="elsevierStyleHsp" style=""></span>P &#40;Carl Zeiss Meditec&#44; Jena&#44; Germany&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Xact Mono-EDoF &#40;Santen&#44; Japan&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">EDOF LIO with pinhole effect&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IC-8 &#40;AcuFocus Inc&#46;&#44; Irvine&#44; CA&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">XtraFocus Pinhole &#40;Morcher&#44; Stuttgart&#44; Germany&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">EDOF IOL with zonal refractive designs&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mini WELL &#40;Sifi&#44; Catania&#44; Italy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suprahob Infocus &#40;Appasamy As&#46;&#44; Chennai&#44; India&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lucidis IOL &#40;Swiss Advanced Vision&#44; SAV-IOL SA&#44; Neuch&#226;tel&#44; Switzerland&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">EDOF IOL with modified spherical aberration monofocal designs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tecnis Eyehance ICB00 &#40;Johnson &#38; Johson Vision Care&#44; Inc&#46;&#44; USA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IsoPure &#40;BVI-Physiol SA&#44; Li&#232;ge&#44; Belgium&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">EDOF IOL with monofocal design and elements in transition&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vivity &#40;Alcon Laboratories&#44; Inc&#46;&#44; Fort Worth&#44; TX&#44; EE&#46;UU&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at0050"
            "detalle" => "Table "
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">FineVision Micro F Physiol &#40;10&#8722;35 D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AT Lisa tri Zeiss &#40;0&#8722;32 D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PanOptix Alcon &#40;13&#8722;34 D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intermediate addition &#40;D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;1&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;1&#46;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;2&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Addition nearby&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;3&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;3&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;3&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Focus energy away&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;85&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intermediate focus energy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;14&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Focus energy near&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;71&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Loss of energy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asfericity &#40;&#956;m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Platform material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hydrophilic &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hydrophilic &#40;25&#37;&#41; hydrophobic surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hydrophobic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Optics 6&#46;15<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Optics 6<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Optics 6<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total 10&#46;75<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dish 11<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total 13<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diffractive system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Convoluted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EnLighten&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Smooth Micro Phase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Technical characteristics of the 3 main trifocal IOLs&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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            0 => array:3 [
              "identificador" => "bib0005"
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                0 => array:2 [
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                      "Revista" => array:5 [
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            1 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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            2 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
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            3 => array:3 [
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                0 => array:2 [
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                  "contribucion" => array:1 [
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            5 => array:3 [
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            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Clinical experience with the WIOL-CF accommodative bioanalogic intraocular lens&#58; Czech national observational registry"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5301/ejo.5000653"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Ophthalmol&#46;"
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            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcomes after accommodative bioanalogic intraocular lens implantation"
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                      "Revista" => array:6 [
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            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Accommodating intraocular lenses&#58; a critical review of present and future concepts"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00417-006-0391-6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Graefes Arch Clin Exp Ophthalmol&#46;"
                        "fecha" => "2007"
                        "volumen" => "245"
                        "paginaInicial" => "473"
                        "paginaFinal" => "489"
                        "link" => array:1 [ …1]
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            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of near vision&#44; intraocular lens movement&#44; and depth of focus with accommodating and monofocal intraocular lenses"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrs.2013.05.049"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Cataract Refract Surg&#46;"
                        "fecha" => "2013"
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                        "paginaInicial" => "1872"
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            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of visual results with accommodating intraocular lenses versus mini-monovision with a monofocal intraocular lens"
                      "autores" => array:1 [
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrs.2012.08.059"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Cataract Refract Surg&#46;"
                        "fecha" => "2013"
                        "volumen" => "39"
                        "paginaInicial" => "48"
                        "paginaFinal" => "55"
                        "link" => array:1 [ …1]
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            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Benefits and barriers of accommodating intraocular lenses"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
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