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Clinical Sciences
A Contralateral Eye Study Comparing Apodized Diffrative and Full Diffrative Lenses: Wavefront Analysis and Distance and Near Uncorrected Visual Acuity
Marcony Rodrigues de SanthiagoI,II, Marcelo Vieira NettoII, Jackson Barreto JrII, Beatriz de Abreu Fiuza GomesIII, Arthur SchaeferI, Newton Kara-JuniorI
I Department of Cataract Surgery, Universidade de São Paulo - São Paulo/SP, Brazil
II Department of Refractive Surgery, Universidade de São Paulo - São Paulo/SP, Brazil
III Department of Ophthalmology, Universidade Federal do Rio de Janeiro - Rio de Janeiro/RJ, Brazil., Tel.: 55 11 3069.7873
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">In an attempt to alleviate the physiological phenomenon of accommodation loss&#44; which occurs with aging&#44; diffractive optics has been found to be effective for multifocal intraocular lenses &#40;IOLs&#41;&#46; With modern techniques&#44; manufacturers are not only concerned with the far and near foci&#44; but they also aim to optimize the image quality with more complex IOL surfaces&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib8">8</a></p><p id="para20" class="elsevierStylePara elsevierViewall">Considering that the amount of intraocular light scattering and higher-order aberrations&#44; due to refractive or diffractive optics&#44; may lead to a poor retinal image quality&#44; aspheric treatment&#44; in the form of aspheric modified prolate IOL surfaces&#44; has been added to reduce the total amount of spherical aberration in the eye and to improve the optical quality&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib13">13</a> The multifocal diffractive IOL Tecnis ZM900&#44; based on the Huygens-Fresnel principle&#44; has a prolate aspheric anterior surface that reduces spherical aberrations&#46;<a class="elsevierStyleCrossRefs" href="#bib8">8&#44;12</a> The multifocal diffractive ReSTOR SN60D3 lens has a central 3&#46;6-mm apodized optic region where 12 concentric diffractive zones on the anterior surface have a gradual reduction in diffractive step height from the center to the periphery&#46;<a class="elsevierStyleCrossRefs" href="#bib14">14&#44;15</a></p><p id="para30" class="elsevierStylePara elsevierViewall">Since aberrometers measure the shape of a wavefront of light that has propagated through the eye&#8217;s optical system they provide an objective measurement of optical aberrations that include sphere and cylinder&#44; as well as other distortions such as spherical aberrations&#44; coma&#44; or other higher-order aberrations&#46; Wavefront sensors also provide image quality metrics such as the modulation transfer function &#40;MTF&#41;&#44; which displays the ratio of image contrast to object contrast for ocular optics as a function of the spatial frequency of a sinusoidal grating&#46;<a class="elsevierStyleCrossRef" href="#bib16">16</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib21">21</a></p><p id="para40" class="elsevierStylePara elsevierViewall">The aim of this prospective clinical trial is to compare visual performance between a pseudophakic eye with a spherical apodized diffractive multifocal IOL and the other pseudophakic eye with an aspheric diffractive multifocal IOL using the uncorrected distance and near visual acuity&#44; wavefront analysis and the modulation transfer function as outcomes&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">METHODS</span><p id="para50" class="elsevierStylePara elsevierViewall">This prospective comparative clinical study included both eyes of 20 patients&#44; for a total of 40 eyes&#46; After approval by the ethics committee&#44; 20 patients older than 40 years of age with bilateral&#44; visually significant cataracts were enrolled consecutively&#59; the patients received a multifocal IOL Tecnis ZM900 lens in one eye &#40;20 eyes&#59; Advanced Medical Optics&#41; and a spheric multifocal AcrySof ReSTOR SN60D3 lens &#40;20 eyes&#59; Alcon Laboratories&#41; in the other eye&#46; Informed consent was obtained&#44; and the study adhered to the tenets of the Declaration of Helsinki&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">Patients with bilateral&#44; visually significant cataracts with corneal astigmatism lower than 1&#46;0 D &#40;diopters&#41; were eligible for inclusion in the study&#46; Exclusion criteria were any other ocular diseases&#44; such as corneal opacities or irregularity&#44; dry eye&#44; amblyopia&#44; anisometropia&#44; glaucoma&#44; retinal abnormalities&#44; surgical complications&#44; IOL tilt&#44; IOL decentration greater than 0&#46;4 mm &#40;estimated by retroillumination&#41; or incomplete follow-up&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">The patients were examined before surgery and at 1&#44; 7&#44; 30 and 90 days after surgery&#46; At 90 days postoperation&#44; the distance &#40;4 m&#41; and near &#40;0&#46;4 m&#41; uncorrected visual acuities &#40;UCVAs&#41; were measured&#44; as well as the higher-order aberration values and modulation transfer function curve&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">The visual acuity was measured using the Early Treatment of Diabetic Retinopathy Study charts under photopic conditions &#40;target luminance of 90 cd&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46; The visual acuity values were converted to the logarithm of the minimal angle resolution scale &#40;logMAR&#41; for statistical analysis and are therefore presented in decimal scale&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">A defocus curve for each multifocal IOL group was obtained according to previous studies<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;22</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib24">24</a> by plotting the mean monocular and binocular visual acuities against 14 values of defocus &#40;ranging from &#43; 2&#46;0 to &#8722; 5&#46;0 D in 0&#46;5 D steps&#41;&#46; The pseudo-accommodative amplitude was determined with a subjective trial lens-induced accommodation method&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">The wavefront analysis and modulation transfer function curve were obtained using the iTrace aberrometer &#40;Tracey Technologies&#44; Houston&#44; TX&#41;&#44; which uses ray tracing technology to obtain the wavefront data&#46; All aberrations were measured up to the sixth Zernike order&#46; The modulation transfer function curves were obtained by considering the mean value for each spatial frequency of each IOL&#46; The measurements were repeated at least three times to obtain a well-focused aligned image of the eye&#46; Measurements were also taken for the maximum pupil diameter&#44; and the data were then collected and analyzed for a pupil diameter of 5&#46;0 mm&#46; The pupils were dilated with two drops of cyclopentolate &#40;10&#37;&#41; given 15 minutes apart&#46; The measurements were taken 45 minutes after the second cyclopentolate drop was administered&#46; The pupil diameter was measured using the Colvard pupillometer &#40;Oasis Medical&#44; Glendora&#44; CA&#41;&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">All surgeries were performed by one experienced surgeon using standardized small-incision phacoemulsification with the IOL implantation in the capsular bag&#46; A continuous curvilinear capsulorhexis with an approximate 5&#46;0 mm diameter was created&#46; No adverse events were reported&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using SPSS for Windows &#40;version 115&#44; SPSS&#41;&#46; All statistical tests were conducted at an alpha level of 0&#46;05&#46; The analysis was based on a non-normal distribution of the data&#46; The two IOLs were compared between the eyes intraindividually&#46; The nonparametric Wilcoxon paired test was used to compare data between the two IOL groups&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">RESULTS</span><p id="para130" class="elsevierStylePara elsevierViewall">A total of 20 patients &#40;12 men &#91;60&#46;0&#37;&#93; and 8 women &#91;40&#46;0&#37;&#93;&#41; were enrolled in this study&#46; No significant difference was found among the IOL groups for the mean IOL power &#40;<span class="elsevierStyleItalic">p</span>&#61; 0&#46;923&#41;&#46;</p><p id="para140" class="elsevierStylePara elsevierViewall">At 3 months postoperation&#44; all eyes showed improvement in the uncorrected visual acuity &#40;UCVA&#41;&#46; The spherical equivalent was &#43;0&#46;21 &#177; 0&#46;17 in the ReSTOR group and &#43;0&#46;22 &#177; 0&#46;17 in the Tecnis group &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;840&#41;&#46; The mean distance UCVA was 0&#46;74 &#177; 0&#46;20 in the ReSTOR group and 0&#46;76 &#177; 0&#46;22 in the Tecnis group&#46; There was no significant difference among the IOL groups for distance UCVA &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;286&#41;&#46; The mean near UCVA was 0&#46;96 &#177; 0&#46;10 in the ReSTOR group and 0&#46;93 &#177; 0&#46;14 in the Tecnis group&#46; No significant difference was found between the ReSTOR and Tecnis groups &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;963&#41; &#40;<a class="elsevierStyleCrossRef" href="#t1-cln_64p953">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="t1-cln_64p953"></elsevierMultimedia><p id="para150" class="elsevierStylePara elsevierViewall">The results of the defocus curve for both IOL groups and the binocular defocus curve are shown in <a class="elsevierStyleCrossRef" href="#f1-cln_64p953">Figure 1</a>&#46; The Tecnis group showed two peaks at 0&#46;0 and 3&#46;0&#44; and the ReSTOR group showed two peaks at 0&#46;0 and 3&#46;5&#46; When &#8722; 2&#46;00 trial lenses were anteposed&#44; simulating an intermediate target condition&#44; both groups exhibited a visual acuity better than 0&#46;4 logMAR&#46; The binocular defocus curve showed a better performance at the intermediate distance with values better than 0&#46;2 logMAR between the two peaks&#46;</p><elsevierMultimedia ident="f1-cln_64p953"></elsevierMultimedia><p id="para160" class="elsevierStylePara elsevierViewall">The postoperative wavefront analysis &#40;<a class="elsevierStyleCrossRef" href="#t2-cln_64p953">Table 2</a>&#41; revealed total aberration root-mean-square &#40;RMS&#41; values of 0&#46;56 &#177; 0&#46;23 &#956;m &#40;Tecnis&#41; and 0&#46;75 &#177; 0&#46;76 &#956;m &#40;ReSTOR&#41;&#46; No statistically significant difference was found between the ReSTOR and Tecnis groups &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;737&#41;&#46; The mean higher-order aberration values were 0&#46;34 &#177; 0&#46;19 &#956;m &#40;Tecnis&#41; and 0&#46;46 &#177; 0&#46;63 &#956;m &#40;ReSTOR&#41;&#46; No statistically significant difference was found between the two IOL groups &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;575&#41;&#46;</p><elsevierMultimedia ident="t2-cln_64p953"></elsevierMultimedia><p id="para170" class="elsevierStylePara elsevierViewall">When analyzing the higher-order aberrations separately &#40;<a class="elsevierStyleCrossRef" href="#f2-cln_64p953">Figure 2</a>&#41;&#44; the coma values were 0&#46;16 &#177; 0&#46;07 &#956;m &#40;Tecnis&#41; and 0&#46;17 &#177; 0&#46;16 &#956;m &#40;ReSTOR&#41;&#46; No statistically significant difference was found between the groups &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;455&#41;&#46; The spherical aberration values were 0&#46;03 &#177; 0&#46;03 &#956;m &#40;Tecnis&#41; and 0&#46;08 &#177; 0&#46;07 &#956;m &#40;ReSTOR&#41;&#46; The Tecnis IOL showed a significantly lower value for the spherical aberration when compared to the ReSTOR IOL &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;004&#41;&#46;</p><elsevierMultimedia ident="f2-cln_64p953"></elsevierMultimedia><p id="para180" class="elsevierStylePara elsevierViewall">The postoperative modulation transfer function curves were obtained for each IOL group&#46; No statistically significant difference was found between the Tecnis and ReSTOR groups for all spatial frequencies &#40;<a class="elsevierStyleCrossRef" href="#f3-cln_64p953">Figure 3</a>&#41;&#46; The iTrace aberrometer software used to generate the MTF curve also provided the average height for each MTF curve studied&#46; The mean MTF value for each multifocal IOL was 0&#46;278 &#177; 0&#46;099 &#40;Tecnis&#41; and 0&#46;252 &#177; 0&#46;112 &#40;ReSTOR&#41;&#46; No statistically significant difference was found between the Tecnis and ReSTOR groups &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;502&#41;&#46;</p><elsevierMultimedia ident="f3-cln_64p953"></elsevierMultimedia></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">DISCUSSION</span><p id="para190" class="elsevierStylePara elsevierViewall">New IOL designs&#44; including aspheric modified prolate surfaces&#44; aim to reduce the total amount of spherical aberration in the eye&#44;<a class="elsevierStyleCrossRefs" href="#bib21">21&#44;25</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib27">27</a> thereby improving visual quality&#46; However&#44; the combination of far&#44; intermediate and near visual correction with an acceptable optical quality is quite challenging&#46;<a class="elsevierStyleCrossRef" href="#bib28">28</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib29">29</a></p><p id="para200" class="elsevierStylePara elsevierViewall">Since the incoming light through a multifocal IOL generates out-of-focus images that overlap the distant focus image&#44; the image sharpness is generally compromised&#46; In this study&#44; the intraocular optical quality of the diffractive multifocal IOLs was compared using wavefront data and modulation transfer curves that were analyzed with 5&#46;0 mm pupil diameters&#46; In an effort to minimize other effects related to each patient&#8217;s eyes&#44; an apodized diffractive AcrySof SN60D3 ReSTOR was used in one eye&#44; and the full diffractive Tecnis ZM900 was used in the other eye&#46;</p><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">Visual outcomes</span><p id="para210" class="elsevierStylePara elsevierViewall">The Tecnis and ReSTOR IOLs performed similarly in the uncorrected visual acuity for the far and near distances&#46; The two IOLs had a different performance in the defocus curve&#44; with a range of pseudo-accommodative amplitudes better than 0&#46;4 logMAR&#46; The depth of focus seems to be better bilaterally compared to the range of focus of each IOL studied separately&#46; Although not representative of daily activities&#44; the binocular defocusing test&#44; with a mix and match strategy may represent an option for patients who want to be free of glasses&#46;</p><p id="para220" class="elsevierStylePara elsevierViewall">Using the defocus curve&#44; this study showed that the Tecnis IOL performed better than the ReSTOR IOL for intermediate distances of 50 and 100 cm&#44; as previous research<a class="elsevierStyleCrossRef" href="#bib22">22</a> has also shown&#46; Cilino et al&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a> also compared patients implanted binocularly with refractive and diffractive IOLs&#44; and using the mean binocular defocusing curves&#44; they have shown that the diffractive multifocal IOL group &#40;Tecnis&#44; in their case&#41; exhibited a better trend with respect to the refractive &#40;Array and ReZoom&#41; multifocal IOL groups&#46;</p></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle110">Spherical Aberration</span><p id="para230" class="elsevierStylePara elsevierViewall">Intraocular lenses with spherical surfaces contribute to increasingly positive spherical aberrations in the human eye&#46; The aspheric IOLs reduce the total amount of the fourth order Zernike aberration&#44; or the spherical aberration&#46; In our study&#44; a low spherical aberration error was observed in the aspheric IOL compared to a conventional spherical IOL&#44; as previously reported by other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib21">21&#44;25</a>&#8211;<a class="elsevierStyleCrossRefs" href="#bib27">27&#44;30&#44;31</a> Although both IOLs showed low values of spherical aberrations&#44; the Tecnis IOL performed better than the ReSTOR IOL &#40;<span class="elsevierStyleItalic">p</span>&#61; 0&#46;004&#41;&#46; The results in our study agree with those of Toto et al&#46;<a class="elsevierStyleCrossRef" href="#bib22">22</a>&#58; the spherical aberration values were lower with the full diffractive IOL than with the apodized diffractive multifocal IOL&#46;</p><p id="para240" class="elsevierStylePara elsevierViewall">The spheric ReSTOR IOLs tend to increase the spherical aberration levels due to their less prolate periphery compared to the Tecnis aspheric design&#46; Nevertheless&#44; the apodized diffractive surface of the ReSTOR IOL probably behaves as an aspheric surface&#46; It progressively decreases the height of the diffractive steps from the center to the periphery&#44; showing less spherical aberration&#46;<a class="elsevierStyleCrossRefs" href="#bib14">14&#44;15&#44;22&#44;32</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib34">34</a> In addition to the apodized center&#44; the diffractive portion turns into a pure refractive lens at the periphery&#44; which tends to suppress night visual disturbances such as halos and glare&#46;<a class="elsevierStyleCrossRef" href="#bib15">15</a></p><p id="para250" class="elsevierStylePara elsevierViewall">In our study&#44; the mean value of the spherical aberration &#40;0&#46;08 &#956;m &#177; 0&#46;18&#41; for the multifocal ReSTOR IOL was similar to the results of several other studies&#44; such as Zelichowska et al&#46; <a class="elsevierStyleCrossRef" href="#bib34">34</a> &#40;0&#46;09 &#956;m &#177; 0&#46;00 analyzed 6 months after surgery&#41;&#44; Souza et al&#46; <a class="elsevierStyleCrossRef" href="#bib15">15</a> &#40;0&#46;09 &#956;m &#177; 0&#46;05 analyzed 3 months after surgery&#41; and Rocha et al&#46; <a class="elsevierStyleCrossRef" href="#bib32">32</a> &#40;0&#46;09 &#956;m &#177; 0&#46;05 analyzed 2 months after surgery&#41;&#46; However&#44; Toto et al&#46; <a class="elsevierStyleCrossRef" href="#bib22">22</a> found a higher level of spherical aberration &#40;0&#46;13 &#956;m &#177; 0&#46;04 analyzed 6 months after surgery&#41;&#46; Although all of these studies used a 5 mm pupil diameter for data analysis&#44; they used different aberrometer devices&#44; and therefore different technologies&#44; to obtain the wavefront data&#46; It is important to mention that the wavefront data from the diffractive multifocal IOL should be used with caution&#46;<a class="elsevierStyleCrossRef" href="#bib34">34</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib36">36</a></p><p id="para260" class="elsevierStylePara elsevierViewall">According to Charman et al&#46;&#44; <a class="elsevierStyleCrossRefs" href="#bib35">35&#44;36</a> the simultaneous distribution of light on the far and near foci means that two wavefronts of different curvature emerge from the IOL&#59; therefore&#44; it is more difficult for the aberrometer to locate the sample centroids&#44; from which the aberration values are derived&#46; Although we found results similar to other studies using the ray tracing technology&#44; Charman et al&#46;<a class="elsevierStyleCrossRefs" href="#bib35">35&#44;36</a> demonstrated that the Hartmann-Shack aberrometers&#44; which use longer wavelengths of infrared light&#44; are more likely to produce satisfactory results for eyes with diffractive IOLs&#46;</p></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle120">Coma aberrations</span><p id="para270" class="elsevierStylePara elsevierViewall">Spherical aberrations and coma aberrations are the higher-order aberrations that contribute the most to visual disturbances and dissatisfaction in patients following the implantation of a multifocal IOL&#46; Although not statistically significant&#44; a smaller number of coma aberrations were detected in the Tecnis eyes than in the ReSTOR eyes &#40;<span class="elsevierStyleItalic">p</span>&#61; 0&#46;455&#41;&#46;</p><p id="para280" class="elsevierStylePara elsevierViewall">Coma aberrations provide information on whether the IOL is properly centered&#46; Dietze et al&#46;<a class="elsevierStyleCrossRef" href="#bib37">37</a> suggested that correcting the spherical aberration with aspheric IOLs could produce more coma aberrations when the IOL is not centered&#46; This leads us to conclude&#44; indirectly&#44; that our lower rates of decentration could justify the lower incidence of coma aberration errors in both groups&#46; However&#44; a longer follow-up would be more appropriate for this analysis because the asymmetric contraction of a fibrotic capsule could develop and decenter the implanted IOL&#44; as has been demonstrated by several authors&#46;<a class="elsevierStyleCrossRef" href="#bib38">38</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib40">40</a></p></span><span id="cesec80" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle130">Modulation transfer function</span><p id="para290" class="elsevierStylePara elsevierViewall">The modulation transfer function defines how optical systems &#40;e&#46;g&#46;&#44; the IOL in this study&#41; modulate the contrast sensitivity as a function of spatial frequency&#46; In this study&#44; the mean MTF curve was obtained for each IOL group at a 5 mm pupil diameter&#46; Comparing the multifocal diffractive IOLs&#44; the aspheric multifocal Tecnis IOL performed similarly to the apodized multifocal ReSTOR IOL&#46; With the 5 mm analysis&#44; the apodization of the surface may lead the ReSTOR IOL to behave as an aspheric IOL&#44; which could explain its performance in the modulation of contrast&#46;</p><p id="para300" class="elsevierStylePara elsevierViewall">Choi and Schwiegerling<a class="elsevierStyleCrossRef" href="#bib41">41</a> measured the optical properties of multifocal diffractive Tecnis&#44; apodized diffractive ReSTOR and refractive ReZoom IOLs&#46; They concluded that&#44; under dark conditions&#44; the shift in the optical performance of the apodized diffractive lens towards distance vision reduces the artifacts that appear under night driving conditions&#46; These artifacts remain for the zonal refractive and full-aperture diffractive lenses&#46; They also demonstrated that&#44; for 6 mm pupil diameters&#44; the apodized diffractive IOLs shift their performance from near vision to distance vision&#44; whereas the zonal refractive and full-aperture diffractive IOLs continue to balance performance between the far and near distance&#46;</p><p id="para310" class="elsevierStylePara elsevierViewall">Ortiz et al&#46;<a class="elsevierStyleCrossRef" href="#bib33">33</a> studied the modulation transfer function of two multifocal IOLs&#44; a refractive ReZoom and an apodized diffractive ReSTOR &#40;AcrySof&#41;&#46; Unlike our study that analyzed the mean curve of each IOL group with a 5 mm pupil diameter&#44; they studied the spatial frequencies at the 0&#46;5 MTF and the cutoff MTF of the different curves of the IOLs with 3 mm and 5 mm pupil diameters&#46; They found that the pupil diameter had a greater influence on the 0&#46;5 MTF value than on the cutoff MTF value for all IOLs&#46; The 0&#46;5 MTF value was the highest in the AcrySof ReSTOR group with both pupil diameters&#46; The difference in the cutoff MTF values between the groups was not statistically significant with either pupil size&#46; Our study was not designed to specifically use the 0&#46;5 and the cutoff MTF values&#59; rather&#44; we chose to study the curve described by each IOL group&#46;</p><p id="para320" class="elsevierStylePara elsevierViewall">A limitation of our study was that the MTF measurements were done with only a 5&#46;0 mm pupil diameter&#46; In future studies&#44; the modulation transfer function measurements could be done at varying pupil sizes&#46; In addition&#44; subjective questionnaires were not used in this study&#44; which may give a more realistic evaluation of daily living&#46;</p><p id="para330" class="elsevierStylePara elsevierViewall">In a study with a model eye&#44; Artigas et al&#46;<a class="elsevierStyleCrossRef" href="#bib42">42</a> showed that the MTF curves varied according to the pupil size&#44; mainly if a refractive multifocal IOL was studied&#44; which was not the case in the present study&#46; Examining the distance focus with small pupils &#40;2&#46;0 to 3&#46;5 mm&#41;&#44; the previous study has shown that the MTF curve of the refractive multifocal IOL &#40;ReZoom&#41; was noticeably higher than the curve of the multifocal IOLs &#40;ReSTOR and Tecnis ZM900&#41; at all spatial frequencies&#46; Furthermore&#44; when examining the distance focus with larger pupils &#40;4&#46;0 to 5&#46;0 mm&#41;&#44; the MTF curve of the ReZoom IOL was similar to the curves of the other two multifocal IOLs &#40;ReSTOR and Tecnis&#41;&#46;</p><p id="para340" class="elsevierStylePara elsevierViewall">One other limitation of the present study is that the iTrace aberrometer device performs monochromatic measurements&#44; and these results cannot be compared to human polychromatic vision&#46; Although the diffractive IOLs have a high chromatic aberration&#44; they can nevertheless function well in the human eye because the amount of this chromatic aberration is approximately the same&#44; albeit with opposite sign&#44; as the aberration in the refractive part of the eye &#40;cornea and IOL&#41;&#46; It also should be noted that&#44; although the results of the iTrace aberration device could be influenced by the near addition power of the investigated IOLs&#44; as the different near additions cause different patterns of the observed blurred points&#44; the results of the MTF curve were similar between the multifocal IOLs studied&#46;</p><p id="para350" class="elsevierStylePara elsevierViewall">In conclusion&#44; the in vivo assessment of the multifocal IOL performance provides useful objective information about IOL optical quality in vivo&#46; In our study&#44; the contrast transferred for a 5 mm pupil diameter was similar for the diffractive multifocal IOLs&#44; Tecnis ZM900 and ReSTOR&#46; The wavefront assessment showed a lower spherical aberration with both multifocal IOLs&#44; although mainly with the Tecnis IOL&#46; According to this study&#44; both of the diffractive multifocal IOLs studied provide similar distance and near visual acuities&#46; The range of the pseudo-accommodative amplitude seems to be better with the mix and match strategy&#59; however&#44; further assessment of the IOL improvements&#44; such as the combination of asphericity and apodization&#44; will provide important information and help us to make a better preoperative decision regarding the choice of the IOL&#46;</p></span></span></span>"
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        1 => array:2 [
          "identificador" => "cesec10"
          "titulo" => "INTRODUCTION"
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        2 => array:2 [
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          "titulo" => "METHODS"
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        3 => array:2 [
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          "titulo" => "RESULTS"
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        4 => array:3 [
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          "titulo" => "DISCUSSION"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "cesec50"
              "titulo" => "Visual outcomes"
            ]
            1 => array:2 [
              "identificador" => "cesec60"
              "titulo" => "Spherical Aberration"
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            2 => array:2 [
              "identificador" => "cesec70"
              "titulo" => "Coma aberrations"
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            3 => array:2 [
              "identificador" => "cesec80"
              "titulo" => "Modulation transfer function"
            ]
          ]
        ]
        5 => array:1 [
          "titulo" => "REFERENCES"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2009-05-04"
    "fechaAceptado" => "2009-07-07"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "KEYWORDS&#58;"
          "identificador" => "xpalclavsec1584970"
          "palabras" => array:5 [
            0 => "Multifocal intraocular lenses"
            1 => "Aberrometer"
            2 => "Wavefront"
            3 => "Modulation transfer function"
            4 => "Visual acuity"
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    "resumen" => array:1 [
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        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">PURPOSE&#58;</span><p id="spara80" class="elsevierStyleSimplePara elsevierViewall">To evaluate intraindividual visual acuity&#44; wavefront errors and modulation transfer functions in patients implanted with two diffractive multifocal intraocular lenses&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS&#58;</span><p id="spara90" class="elsevierStyleSimplePara elsevierViewall">This prospective study examined 40 eyes of 20 cataract patients who underwent phacoemulsification and implantation of a spherical multifocal ReSTOR intraocular lens in one eye and an aspheric Tecnis ZM900 multifocal intraocular lens in the other eye&#46; The main outcome measures&#44; over a 3-month follow-up period&#44; were the uncorrected photopic distance and near visual acuity and the defocus curve&#46; The visual acuity was converted to logMAR for statistical analysis and is presented in decimal scale&#46; The wavefront error and modulation transfer function were also evaluated in both groups&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS&#58;</span><p id="spara100" class="elsevierStyleSimplePara elsevierViewall">At the 3-month postoperative visit&#44; the mean photopic distance uncorrected visual acuity &#40;UCVA&#41; was 0&#46;74 &#177; 0&#46;20 in the ReSTOR group and 0&#46;76 &#177; 0&#46;22 in the Tecnis group &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;286&#41;&#46; The mean near UCVA was 0&#46;96 &#177; 0&#46;10 in the ReSTOR group and 0&#46;93 &#177; 0&#46;14 in the Tecnis group &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;963&#41;&#46; The binocular defocus curve showed measurements between the peaks better than 0&#46;2 logMAR&#46; The total aberration&#44; higher-order aberration and coma aberration were not significantly different between the groups&#46; The spherical aberration was significantly lower in the Tecnis group than in the ReSTOR group&#46; &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;004&#41;&#46; Both groups performed similarly for the modulation transfer function&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION&#58;</span><p id="spara110" class="elsevierStyleSimplePara elsevierViewall">The ReSTOR SN60D3 and Tecnis ZM 900 intraocular lenses provided similar photopic visual acuity at distance and near&#46; The diffractive intraocular lenses studied provided a low value of coma and spherical aberrations&#44; with the Tecnis intraocular lens having a statistically lower spherical aberration compared to the ReSTOR intraocular lens&#46; In the 5 mm pupil diameter analyses&#44; both intraocular lens groups showed similar modulation transfer functions&#46;</p></span>"
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            "titulo" => "PURPOSE&#58;"
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            "titulo" => "METHODS&#58;"
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          2 => array:2 [
            "identificador" => "ceabs30"
            "titulo" => "RESULTS&#58;"
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            "identificador" => "ceabs40"
            "titulo" => "CONCLUSION&#58;"
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        "etiqueta" => "Figure 1"
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Visual acuity at various defocusing levels in the ReSTOR group and Tecnis group&#46; The values are the mean of the logMAR visual acuity&#46; The binocular defocusing curve showed a good range for the pseudo-accommodative amplitude</p>"
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          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Bar graph showing the wavefront data with a 5 mm pupil diameter for two diffractive multifocal intraocular lenses&#46; The root-mean-square of the total aberration&#44; the higher-order aberration &#40;HOA&#41; and coma aberration were not statistically different between the groups&#46; The spherical aberration was significantly lower in the Tecnis group than in the ReSTOR group &#40;<span class="elsevierStyleItalic">p</span>&#61;0&#46;004&#41;</p>"
        ]
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          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">The modulation transfer function &#40;MTF&#41; curve analyzed for a 5 mm pupil diameter of the IOL groups at different spatial frequencies&#46; The MTF shows the contrast transferred at different spatial frequencies&#46; The aspheric full diffractive multifocal IOL Tecnis ZM900 performed similar to the spherical apodized diffractive multifocal ReSTOR &#40;<span class="elsevierStyleItalic">p</span>&#62;0&#46;05 at all spatial frequencies studied&#41;</p>"
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        "identificador" => "t1-cln_64p953"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spara50" class="elsevierStyleSimplePara elsevierViewall">The visual acuity values were converted to the logarithm of the minimal angle resolution scale &#40;logMAR&#41; for statistical analysis and are thus presented in decimal scale &#177; standard deviation&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="top" scope="col">Intraocular lens&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="center" valign="top" scope="col"><span class="elsevierStyleItalic">n</span>&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="center" valign="top" scope="col">Distance uncorrected visual acuity&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="center" valign="top" scope="col">Distance corrected visual acuity&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="center" valign="top" scope="col">Near uncorrected visual acuity&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="center" valign="top" scope="col">Near corrected visual acuity&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="center" valign="top" scope="col">Spherical equivalent&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" 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">ReSTOR&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;74 &#177; 0&#46;20&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;00 &#177; 0&#46;00&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;96 &#177; 0&#46;10&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;00 &#177; 0&#46;00&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;21 &#177; 0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Tecnis&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;76 &#177; 0&#46;22&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;00 &#177; 0&#46;00&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;93 &#177; 0&#46;14&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;00 &#177; 0&#46;00&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;22 &#177; 0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&#46;286&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&#46;963&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&#46;840&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Visual performance of diffractive multifocal IOLs</p>"
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        "tabla" => array:3 [
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            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="top" scope="col">Mean &#40;&#956;m&#41; &#177; SD</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">P</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="center" valign="top" scope="col">ReSTOR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top" scope="col">Tecnis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">&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" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HOA RMS&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;46 &#177; 0&#46;63 &#956;m&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="center" valign="\n
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                  \t\t\t\t">0&#46;34 &#177; 0&#46;19 &#956;m&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;575&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Coma aberration RMS&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;17 &#177; 0&#46;16 &#956;m&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;16 &#177; 0&#46;07 &#956;m&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;455&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Spherical aberration RMS&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;08 &#177; 0&#46;07 &#956;m&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="center" valign="\n
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                  \t\t\t\t">0&#46;03 &#177; 0&#46;03 &#956;m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;004<a class="elsevierStyleCrossRef" href="#tfn3-cln_64p953">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Total aberration RMS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">0&#46;75 &#177; 0&#46;76 &#956;m&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&#46;56 &#177; 0&#46;23 &#956;m&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="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">0&#46;737&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">statistically significant&#46;</p>"
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          "en" => "<p id="spara60" class="elsevierStyleSimplePara elsevierViewall">Wavefront data with 5 mm pupil diameter</p>"
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      "titulo" => "REFERENCES"
      "seccion" => array:1 [
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          "bibliografiaReferencia" => array:42 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcomes of cataract extraction with multifocal intraocular lens implantation&#59; functional status and quality of life"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => """
                              JC Javitt \n
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                              """
                            1 => """
                              F Wang \n
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                              """
                            2 => """
                              DJ Trentacost \n
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                              """
                            3 => """
                              M Rowe \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              N Tarantino \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0161-6420(97)30265-6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ophthalmology"
                        "fecha" => "1997"
                        "volumen" => "104"
                        "paginaInicial" => "589"
                        "paginaFinal" => "689"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9111250"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cataract extraction with multifocal intraocular lens implantation&#59; a multinational clinical trial evaluating clinical&#46; functional and quality-of-life outcomes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              JC Javitt \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              RF Steinert \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0161-6420(00)00368-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ophthalmology"
                        "fecha" => "2000"
                        "volumen" => "107"
                        "paginaInicial" => "2040"
                        "paginaFinal" => "2048"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11054329"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quantitative performance of bifocal and multifocal intraocular lenses in a model eye&#58; point spread function in multifocal intraocular lenses"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              S Pieh \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              P Marvan \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              B Lackner \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              G Hanselmayer \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              G Schmidinger \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              R Leitgeb \n
                              \t\t\t\t\t\t\t\t
                              """
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archopht.120.1.23"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Ophthalmol"
                        "fecha" => "2002"
                        "volumen" => "120"
                        "paginaInicial" => "23"
                        "paginaFinal" => "28"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11786053"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
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            ]
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prospective functional and clinical comparison of bilateral ReZoom and ReSTOR intraocular lenses in patients 70 years or younger"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => """
                              DF Chang \n
                              \t\t\t\t\t\t\t\t
                              """
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrs.2007.12.053"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Cataract Refract Surg"
                        "fecha" => "2008"
                        "volumen" => "34"
                        "paginaInicial" => "934"
                        "paginaFinal" => "941"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18498998"
                            "web" => "Medline"
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            ]
            4 => array:3 [
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              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Retinal image quality after microincision intraocular lens implantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => """
                              JL Ali&#243; \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              P Schimchak \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              R Mont&#233;s-Mic&#243; \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              A Galal \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrs.2005.01.026"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Cataract Refract Surg"
                        "fecha" => "2005"
                        "volumen" => "31"
                        "paginaInicial" => "1557"
                        "paginaFinal" => "1560"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16129291"
                            "web" => "Medline"
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            5 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "One-year outcomes with new-generation multifocal intraocular lenses"
                      "autores" => array:1 [
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es en pt

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