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Accommodative intraocular lens versus standard monofocal intraocular lens implantation in cataract surgery: a systematic review of randomised controlled trials

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Session Details

Session Title: IOL Technology / Accommodative IOLs etc.

Session Date/Time: Saturday 13/09/2014 | 16:00-18:00

Paper Time: 16:06

Venue: Boulevard A

First Author: : H.Ong UK

Co Author(s): :    J. Evans   B. Allan           

Abstract Details

Purpose:

Following cataract surgery and intraocular lens (IOL) implantation, loss of accommodation or postoperative presbyopia occurs and remains a challenge. Accommodative IOLs have been designed to overcome loss of accommodation after cataract surgery. This systematic review aimed to define the extent to which accommodative IOLs improve unaided near visual function, in comparison with monofocal IOLs. The extent of compromise to unaided distance visual acuity and complications associated with their use were also explored.

Setting:

Cochrane Eyes and Vision Group / Moorfields Eye Hospital NHS Foundation Trust

Methods:

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Is- sue 9), Ovid MEDLINE, Ovid MEDLINE in-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily Update, Ovid OLDMEDLINE (January 1946 to October 2013), EMBASE (January 1980 to October 2013), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to October 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 10 October 2013. We included randomised controlled trials (RCTs) that compared implantation of accommodative IOLs to implantation of monofocal IOLs in cataract surgery. Two authors independently screened search results, assessed risk of bias and extracted data. All included trials used the 1 CU accommodative IOL (HumanOptics, Erlangen, Germany) for their intervention group. One trial had an additional arm with the AT-45 Crystalens accommodative IOL (Eyeonics Vision). A separate analysis comparing 1 CU and AT-45 IOL was performed.

Results:

Four RCTs with 229 participants(256 eyes) were included. Age range was 21 to 87 years. All studies were judged to be at high risk of performance bias. Two studies were graded with high risk of detection bias and one with high risk of selection bias. Accommodative IOL group achieved better distance corrected near visual acuity(DCNVA) at six months(-3.10 Jaeger units; 95% CI -3.36 to -2.83, moderate quality evidence). Better DCNVA was seen in the accommodative IOL group at 12-18 months (low quality evidence). Effect on corrected distant visual acuity(CDVA) was less certain. At 6 months there was a standardised mean difference of -0.04 standard deviations(95% CI -0.37 to 0.30, low quality evidence). At 12 months there were two studies finding better CDVA in the monofocal group(0.12 logMAR; 95% CI 0.07 to 0.16) and one finding similar CDVA between both groups(-0.02 logMAR; 95% CI -0.06 to 0.02). Effect of the lenses on reading speed and spectacle independence was uncertain. More cases of posterior capsule opacification(PCO) were seen in accommodative lenses(OR 2.12; 95% CI 0.45 to 10.02, low quality evidence). People in the accommodative lens group were more likely to require laser capsulotomy(OR 7.96; 95% CI 2.49 to 25.45, low quality evidence).

Conclusions:

Participants who received accommodative IOLs had a better near visual acuity. There is some evidence that distance visual acuity with accommodative lenses may be worse but currently the evidence for this is not clearcut. People receiving accommodative lenses appeared to have more posterior capsule opacification and this may be associated with poorer distance vision. Further research is required to improve the understanding of how accommodative IOLs may affect near visual function, and whether they provide any durable gains. Additional trials, with longer follow up, comparing different accommodative IOLs, multifocal IOLs and monofocal IOLs; would help map out their relative efficacy, and associated late complications. Research on control over capsular fibrosis post implantation is needed. Risks of bias, heterogeneity of outcome measures and study designs used, and the dominance of one design of accommodative lens in existing trials (the Human Optics 1 CU) mean that these results should be interpreted with caution. They may not be applicable to other accommodative IOL designs.

Financial Interest:

NONE

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