Effect of Early-onset Posterior Capsule Opacification on Visual Outcomes in Trifocal Diffractive Pseudophakic Eyes: A Multicenter Prospective Study

doi:10.21203/rs.3.rs-4838703/v1

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Effect of Early-onset Posterior Capsule Opacification on Visual Outcomes in Trifocal Diffractive Pseudophakic Eyes: A Multicenter Prospective Study

https://doi.org/10.21203/rs.3.rs-4838703/v1

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Objective

To elucidate the impact of early-onset PCO on the visual outcomes in patients with hydrophilic trifocal IOLs, and to ascertain the optimal timing for the application of Nd:YAG laser capsulotomy.

Methods

This is a prospective observational study. 189 patients implanted trifocal IOL who underwent Nd:YAG laser posterior capsulotomy were recruited. Patients were classified into four grades according to PCO morphology. The distance, intermediate, and near visual acuity (VA), dysfunction lens index (DLI), contrast sensitivity(CS) and visual function (VF-14) scores were measured before and 1 month after Nd:YAG laser capsulotomy.

Results

Before Nd:YAG laser capsulotomy, a significant correlation was observed between PCO grading and uncorrected distance (UDVA), intermediate (UIVA), near (UNVA) visual acuity, corrected distance VA (CDVA), DLI, and VF-14 scores (All P < 0.001). However, in patients with PCO grade 1 (early-onset), post-capsulotomy UNVA, DLI, medium and high spatial frequency contrast sensitivity under photopic condition and VF-14 scores were significantly improved compared with pre-capsulotomy values (all P < 0.05). The area under the receiver operating characteristic curve for DLI was 0.833 (P < 0.001), with a corresponding cut-off value of 7.28, indicating its usefulness in assessing the need for Nd:YAG laser capsulotomy in cases of early-onset PCO.

Conclusions

Early-onset PCO initially impairs near visual acuity in patients with trifocal IOLs and concurrently diminishes both subjective and objective of visual quality. DLI can effectively assess the severity of PCO, particularly in cases of early-onset PCO, and further determine the optimal timing for Nd:YAG laser capsulotomy.

Health sciences/Diseases/Eye diseases/Lens diseases

Health sciences/Diseases/Eye diseases/Vision disorders

posterior capsule opacification

trifocal diffractive intraocular lens

dysfunction lens index

visual function

Patients with diffractive multifocal IOLs may be more sensitive to PCO, experience more rapid visual loss, and require earlier posterior capsulotomy than patients with monofocal IOLs.

What This Paper Adds

Early-onset PCO initially affects near vision in eyes implanted with trifocal IOLs and also reduces both subjective and objective visual quality.
DLI may serve as an early objective indicator to help determine which patients with early-onset PCO require Nd:YAG laser capsulotomy treatment.

After the implantation of a trifocal intraocular lens (IOL), patients usually obtain stable long-standing vision and a higher rate of being independent of spectacles, which has led to the growing popularity of this technique among patients with cataracts accompanied by presbyopia or high myopia.^1,2 However, it is important to note that some patients with hydrophilic trifocal IOL implants may experience the development of posterior capsule opacification (PCO) within 1 to 3 years after the surgery.³ Reports indicate that PCO incidence with implantation of the AT Lisa Tri 839MP (Carl Zeiss Meditec, Jena, Germany) IOL is approximately 7.5–14.3% at 1 year and 34% at 4 years.^2,4,5 PCO can lead to decreased vision and contrast sensitivity and increased glare.^3,6 Early-onset PCO tends to have a relatively minor impact on the visual function of patients implanted with monofocal IOLs.⁷ However, for patients with multifocal IOLs, the onset of PCO may occur earlier, and it can significantly affect visual acuity(VA) and visual quality compared with monofocal IOLs.^6,7

The most effective treatment for PCO is neodymium:yttrium-aluminum-garnet (Nd:YAG) laser capsulotomy;⁴ however, it results in potential complications, such as cystoid macular edema, elevated intraocular pressure, posterior vitreous detachment, and dislocation or tilting of the intraocular lens.^4,8 Undeniably, the impact of advanced PCO on vision and the requisite need for Nd:YAG treatment are significant.⁷ However, research is limited on the effects of early-onset PCO on the vision and quality of trifocal diffractive pseudophakic eyes. Additionally, definitive criteria for the ideal timing of Nd:YAG laser capsulotomy in trifocal pseudophakic eyes, especially with early-onset PCO, are yet to be established.

This multicenter observational study aimed to examine the effects of early-onset PCO on VA and the subjective and objective visual quality of hydrophilic trifocal diffractive IOLs in pseudophakic eyes and to identify objective indicators for determining the optimal timing of treatment for early-onset PCO.

Study Design and Participants

Between January 2022 and April 2023, 1,276 eyes were implanted with AT Lisa Tri 839MP IOLs by four experienced cataract surgeons from four centers. A standard cataract phacoemulsification procedure was employed, followed by anterior and posterior capsule polishing using the same technique postoperatively. A total of 245 eyes who underwent Nd:YAG laser capsulotomy were screened. Thirty-four eyes were excluded from the study due to the second eye of the same patient receiving Nd:YAG laser treatment. Fourteen eyes were excluded because of loss of follow-up data, three did not achieve a corrected distance VA (CDVA) of 0.1 logarithm of the minimum angle of resolution (logMAR) after laser surgery, two had a previous history of ocular inflammation, two had excluded because of dry eye, one had dislocation of IOL after capsulotomy. Data were obtained from the following four research centers in Shanghai, China: Eye and Ear, Nose, and Throat Hospital, Fudan University; Shanghai Heping Eye Hospital; Shanghai Xinshijie Eye Hospital;and Shanghai Bright Eye Hospital.

The study was approved by the ethics committees of the four hospitals and performed in accordance with the principles of the Declaration of Helsinki (IRB Number: HXYK-SHHP-2020-0004) (ClinicalTrials.gov, identifier NCT06092164). All patients provided written informed consent prior to enrollment.

The inclusion criteria were as follows: (1) age ≥ 20 years; (2) all of the patients had previous uneventful phacoemulsification surgery with AT Lisa Tri 839MP implantation; and (3) patient-reported decrease in VA significantly lower than their postoperative best vision with PCO grading ≥ 1. The exclusion criteria were as follows: (1) other ocular comorbidities, such as corneal, fundus, and optic nerve diseases; (2) postoperative complications; and (3)a history of corneal refractive surgery such as LASIK and LASEK (Supplementary Fig. 1).

Pre-capsulotomy and Post-capsulotomy Examinations

All patients included in this study were examined twice, both before and 1 month after Nd:YAG laser capsulotomy. Patients underwent a comprehensive examination including UDVA at 5 m, UIVA at 80 cm, UNVA at 40 cm, and CDVA at 5 m, using the logarithmic VA charts, intraocular pressure measurements, slit-lamp evaluation, optical coherence tomography (Cirrus HD-OCT, Carl Zeiss Meditec, Dublin, CA), B-scan ultrasonography, optomap (Optos Dayton, Carl Zeiss Meditec AG), and fundoscopy to check for fundus diseases. After mydriasis, retroillumination images of the PCO were evaluated. The dysfunction lens index (DLI) was evaluated using a HOYA iTrace ray-tracing aberrometry system (Tracey Technologies, Houston, TX, USA). Contrast sensitivity (CS) was evaluated using the Optec 6500 (Stereo Optical Co., Inc., Chicago, IL, USA) with optimal distance correction. Functional vision was assessed using the modified VA and Visual Function Index 14 (VF-14).

PCO Grading

PCO grading was performed by two experienced senior ophthalmologists in each center according to a previously reported method:⁹ grade 0 (without PCO), no opacity or opacity appearing only on the peripheral capsule; grade 1, wrinkling or opacity of the capsule limited in a circle 4 mm in diameter and centered on the visual axis, but the posterior polar retina can be viewed clearly; grade 2, central/paracentral opacity worse than grade 1 that slightly affects the detailed observation of the macula, but with no effects on the observation of the cup/disc ratio; grade 3, central/paracentral opacity worse than grade 2, making the cup/disc ratio difficult to ascertain; grade 4, central/paracentral opacity as defined above, but making fundus observation difficult or impossible (Representative images of different PCO grades are shown in Supplementary Fig. 2).

Wavefront Measurement

The objective visual quality of the patients was analyzed using an iTrace ray-tracing system (Tracey Technologies, Houston, TX, USA). Three measurements for each eye were conducted in a dark room. The wavefront was measured in a 3-mm optical zone set by the software, and the DLI recorded for each eye before and 1 month after Nd:YAG laser capsulotomy were included in the study.

Contrast Sensitivity

Monocular contrast sensitivity (CS) was evaluated using the Optec 6500 (Stereo Optical Co., Inc., Chicago, IL, USA) with optimal distance correction. Measurements were undertaken at spatial frequencies of 1.5, 3, 6, 12, and 18 cycles per degree (cpd) without glare, under photopic (background luminance of 85 cd/m²) and mesopic conditions (background luminance of 3 cd/m²). Unseen patches were assigned the value of the last visible patch, ensuring that all participants were able to discern at least one patch. For statistical analysis, the log10 values of contrast sensitivity were utilized, consistent with the methodology of preceding studies.¹⁰

Visual Function Index-14 Questionnaire

Pre-capsulotomy and post-capsulotomy patient satisfaction was assessed using the VF-14 questionnaire.¹¹ The VF-14, ranging from 0 to 100, determines how troublesome vision-related daily activities (e.g., reading and driving) are for patients, with a higher score representing better functioning. Each participant completed a questionnaire under the guidance of four ophthalmologists from the four research centers who recorded the subjective visual quality of the patients before and 1 month after Nd:YAG laser capsulotomy.

Nd:YAG Capsulotomy

Nd:YAG laser capsulotomy was performed by four experienced surgeons from four centers using Lumenis Selecta Duet. After adequate pupil dilatation and local anesthesia in all patients, contact lenses with coupling agents were placed on their corneas to facilitate precise focusing. The energy level of the Nd:YAG laser device was set to 1.6 ~ 1.8 mJ. Focusing was then performed until the posterior capsule was penetrated, and the posterior capsule was circumferentially incised with a diameter of 4 mm to avoid IOL damage. After Nd:YAG laser posterior capsulotomy, patients routinely used a 1% prednisolone acetate ophthalmic suspension (Allergan, Ettlingen, Germany) three times a day for 7 days.

Statistical Analysis

All statistical analyses were performed using SPSS software (version 26.0; SPSS Inc., Chicago, Illinois, USA). All VA data were converted to equivalent logMAR units. Descriptive statistics are reported for quantitative variables as the mean ± standard deviation (SD). Normality was assessed using the Kolmogorov–Smirnov test. A sample size of 189 achieves 79% power to detect a difference of -0.20 between the null hypothesis correlation of 0.00 and the alternative hypothesis correlation of 0.20 using a two-sided hypothesis test with a significance level of 0.05. We conducted correlation analysis and calculated the Pearson correlation coefficient (r). A general linear model was used to analyze the patterns of visual quality changes across the different stages of PCO statistically. Paired-sample t-tests were used to compare VA and VF-14 scores and CS before and after Nd:YAG laser capsulotomy. The area under the receiver operating characteristic (ROC) curve (AUC) was calculated. The optimal cut-off value was determined based on the Youden’s index. P values < 0.05 were considered statistically significant.

Baseline Characteristics

In total, 189 patients (189 eyes) met the inclusion criteria and were subsequently enrolled in the study. The patients’ pre-capsulotomy characteristics are presented in Table 1, with results expressed as the mean ± SD. Patients who experienced PCO had a mean age of 51.69 ± 11.05 years and reported the onset of subjective vision loss at a mean time of 12.23 ± 4.73 months after cataract surgery. The mean time from cataract surgery to PCO requiring Nd:YAG laser capsulotomy was 457.02 ± 149.25 days (Table 1). The 1-year PCO incidence with Nd:YAG laser capsulotomy was 10.2%.

Table 1

The baseline characteristics of patients in the study before Nd:YAG capsulotomy.
Characteristic	Mean ± SD (n = 189)	Range (min, max) (n = 189)
Age (years)	51.59 ± 11.52	20, 78
Males / Females (%)	39%, 61%	-
Axial length (mm)	26.20 ± 2.38	22.05, 31.79
Decreased time of vision (months)	12.23 ± 4.73	4, 24
Difference between Nd:YAG time and operation time (days)	457.02 ± 149.25	124, 715
CCC type, Manual / femtosecond (%)	67%, 33%	-
With / without CTR (%)	47, 53%	-
PCO Grade 1 (n, %)	26 (14%)
PCO Grade 2 (n, %)	58 (31%)	-
PCO Grade 3 (n, %)	56 (30%)	-
PCO Grade 4 (n, %)	49 (25%)	-
CCC: continuous curvilinear capsulorrhexis; CTR: capsular tension ring; PCO: posterior capsule opacity.

Relationship Between PCO Grades and Visual Outcomes Before Laser Capsulotomy

Before undergoing Nd:YAG laser posterior capsulotomy, we identified a significant positive correlation between PCO grade and various measures of VA: UDVA (r = 0.767, p < 0.001), UIVA (r = 0.656, p < 0.001), UNVA (r = 0.688, p < 0.001), and CDVA (r = 0.783, p < 0.001), as illustrated in Fig. 1. These findings suggest an inverse relationship between PCO severity and visual acuity. To further investigate the association between PCO grade and subjective as well as objective visual quality metrics, additional analyses were performed (Fig. 1). The analyses uncovered that both the VF-14 (r = -0.723, p < 0.001) and the DLI (r = -0.808, p < 0.001) scores were inversely correlated with PCO grade. Notably, the DLI demonstrated the most substantial negative relationship with PCO grading.

Comparison of VA and Quality Before and 1 Month After Laser Capsulotomy

Supplementary Fig. 3 displays the mean difference in VA and subjective and objective visual quality results before and after laser capsulotomy in all patients with different grades of PCO (P < 0.001). Additionally, Table 2 outlines the outcomes of VA and subjective and objective visual quality before and 1 month after laser capsulotomy in patients with early-stage PCO (PCO grade 1). Our findings indicate that laser capsulotomy significantly improves the whole-course VA and subjective and objective visual quality in patients with intermediate- to late-stage PCO. However, in patients with early PCO, near visual acuity and subjective and objective visual quality significantly improved after laser capsulotomy.

Table 2

Visual function parameters of PCO of the grade 1 group before and 1 month after Nd:YAG laser capsulotomy.
Characteristic	Pre-capsulotomy (n = 26)	Post-capsulotomy (n = 26)	P value
UDVA (logMAR)	0.006 ± 0.041	0.004 ± 0.049	0.904
UIVA (logMAR)	0.067 ± 0.102	0.004 ± 0.072	0.068
UNVA (logMAR)	0.164 ± 0.102	0.014 ± 0.047	0.000**
CDVA (logMAR)	0.013 ± 0.029	0.000 ± 0.000	0.096
DLI	7.389 ± 2.290	9.723 ± 0.572	0.001*
VF-14 score	70.408 ± 12.247	88.963 ± 8.611	0.000**
UDVA: uncorrected distance visual acuity; UIVA: uncorrected intermediate visual acuity; UNVA: uncorrected near visual acuity; CDVA: best corrected distance visual acuity; logMAR: log of the minimum angle of resolution; DLI: dysfuctional lens index; Data are expressed as mean ± standard deviation (SD). P < 0.05 * P < 0.01

Figure 2 shows the variations in CS at different spatial frequencies for patients categorized under PCO grade 1, both before and after capsulotomy, under both Photopic (as shown in Fig. 2A) and Mesopic (as depicted in Fig. 2B) lighting conditions. Statistically significant improvements in CS were observed post-treatment at spatial frequencies of 6.0 cycles per degree (cpd) (from 1.55 ± 0.27 to 1.86 ± 0.26), 12.0 cpd (from 1.04 ± 0.20 to 1.45 ± 0.31), and 18.0 cpd (from 0.66 ± 0.17 to 0.91 ± 0.29) under Photopic conditions (P < 0.05). No significant changes were noted at other spatial frequencies or under Mesopic lighting (P > 0.05).

Subjective Visual Quality Questionnaire Classification of the PCO Grade 1 Group Before and 1 Month after Nd:YAG Laser Capsulotomy

The VF-14 questionnaire was used to evaluate patient satisfaction. While the mean VF-14 scores in the PCO grade 1 group were significantly improved after capsulotomy, only the near VA satisfaction scores improved significantly (Fig. 3). We found that the patients showed significant improvements in their near vision satisfaction scores when reading small prints, newspapers, or large prints, doing fine work, and writing checks (P < 0.01).

DLI Cut-off Value for Nd:YAG Laser Capsulotomy

Figure 4 presents the AUC and the optimal cut-off value with corresponding sensitivity and specificity of the DLI in discriminating between eyes with logMAR UNVA > 0.1 and those with UNVA ≤ 0.1. The AUC of the DLI was 0.835 (P = 0.000), and the optimal cut-off value of the DLI determined via ROC curve analysis was 7.28, with a sensitivity of 73.9% and a specificity of 84.3%.

Our study reports the effects of early-onset PCO on visual acuity and quality in AT Lisa Tri 839MP trifocal diffractive pseudophakic eyes and, for the first time, utilizes the iTrace system to quantify DLI scores to assess the influence of PCO on VA and visual quality. Our findings indicate that early-onset PCO appeared to affect near VA prior to exerting a detrimental effect on intermediate and distant VA. Moreover, DLI may serve as an early objective indicator that could facilitate the early identification of patients with early-onset PCO who are candidates for Nd:YAG laser capsulotomy.

We conducted a two-year follow-up of 1,276 eyes who were implanted with a AT Lisa Tri 839MP IOLs across four research centers. During the follow-up period, the mean duration from cataract surgery to PCO requiring laser capsulotomy was 457.02 ± 149.25 days. The 1-year PCO incidence with Nd:YAG laser capsulotomy was 10.2%. According to the previous reports, PCO occurred in cases with this IOL approximately 458.00 ± 230.00 days post-surgery,⁴ with a rate of Nd:YAG laser capsulotomy in one year ranging from 7.5–14.3%.^2,4,12,13 In contrast, a study reported that the 1-year incidence of PCO after laser capsulotomy in eyes with hydrophilic acrylic monofocal IOLs of same material and design was reported to be 4.8%.¹⁴ The incidence of PCO necessitating laser capsulotomy one year after implantation of the AT Lisa Tri 839MP IOL is markedly greater than monofocal IOLs. Among the patients with PCO who underwent laser capsulotomy, the distribution of different levels of PCO is as follows: grade 1 PCO accounts for 14%, grade 2 PCO for 31%, grade 3 PCO for 30%, and grade 4 PCO for 25%. Compared to previous research findings, patients with trifocal IOLs tend to undergo laser capsulotomy earlier. This phenomenon suggests that, compared to monofocal IOLs, PCO has a more significant impact on the vision function of trifocal IOLs and tends to occur earlier.¹⁵ Similarly, previous studies ^6,7 have suggested that patients with diffractive multifocal IOLs (MIOLs) may be more sensitive to PCO, experience more rapid visual loss, and require earlier posterior capsulotomy than patients with monofocal IOLs. This has been attributed to reduced contrast sensitivity and lower tolerance for PCO-induced visual impairment in MIOLs.⁶

To date, there are few studies reporting the effect of early-onset PCO on visual outcomes in patients with trifocal IOL. In clinical scenario, we found that patients who had been implanted with trifocal IOL and developed grade 1 PCO often complained of a decrease in their near vision, such as experiencing blurriness while reading books or newspapers. However, their distance and intermediate vision remained unaffected. Upon examination, we discovered that these patients showed a significant decline in near vision as well as in objective visual quality indicators, such as the DLI. Following laser capsulotomy, there was no significant improvement in UDVA and UIVA values compared to the pre-capsulotomy values. However, both UNVA and DLI showed significant improvements. Moreover, patients with early-onset PCO exhibit a marked improvement in medium and high spatial frequency contrast sensitivity under photopic conditions. While medium spatial frequencies play a significant role in daily visual tasks, high spatial frequencies are critical for discerning an object's fine details¹⁶. Additionally, there was a significant improvement in the scores for near vision-related items in the VF-14 questionnaire. Furthermore, the patients reported a substantial increase in satisfaction with their near VA. These findings suggest that early-onset PCO has an earlier effect on near VA in trifocal diffractive pseudophakic eyes than on distance or intermediate VA. The observed decrease in near vision has compromised their capacity to distinguish between fine details. This can be attributed to the diffraction ring of Lisa Tri 839MP, which resulted in a light distribution of 50% in the distance, 20% in the middle, and 30% in the near range.¹⁷ As a result, patients with Lisa Tri 839MP have a higher light requirement when viewing objects, particularly at close distances, and the presence of early-onset PCO further reduces light distribution and contrast sensitivity, leading to a greater impact on the patients’ near vision in the early stages, which worsens as PCO progresses. Based on these findings, if a patient reports a decrease in near vision during clinical follow-up, and other factors causing the reduction in near vision are ruled out, the occurrence of PCO should be considered.

The decision to perform Nd:YAG laser capsulotomy in clinical practice is subjective and relies on visual acuity and slit-lamp examination findings currently.⁶ However, these measures have limitations in accurately assessing visual impairment in individuals with PCO, especially in case of early-onset PCO associated with trifocal IOLs.^18,19 The early-onset PCO observed under slit-lamp are often considered to have minimal impact on visual acuity and may therefore be overlooked. Consequently, there is a pressing need to identify more objective methodologies that can offer improved guidance for clinical interventions in such cases.

DLI is an objective visual quality metric used to evaluate the extent of visual impairment and the lens opacity. Previous research has primarily utilized DLI to assess cataract severity.^20,21 In this study, iTrace wavefront analysis system was employed to examine the correlation between the DLI and PCO grade. Our results revealed a strong linear correlation between the DLI and PCO grade, with a significant increase in the DLI following laser capsulotomy in patients with early-onset PCO. These findings suggests that the DLI can serve as a promising objective indicator to assess the impact of early-onset PCO on visual function and could assist in determining the optimal intervention timing for these patients. To determine the optimal cut-off value of the DLI, we classified eyes into two groups based on logMAR UNVA: one group with logMAR UNVA > 0.1 and the another with logMAR UNVA ≤ 0.1. ROC curve analysis was conducted on these groups, demonstrating that a DLI value of 7.28, with logMAR UNVA ≤ 0.1 as a threshold for visual improvement post-capsulotomy, yielded a sensitivity of 73.9% and specificity of 84.3%, respectively, serving as a criterion for referral for laser capsulotomy for these patients.

This study had some limitations that should be acknowledged. First, the study was limited to a single type of trifocal IOL (AT LISA Tri 839MP). Second, we did not evaluate the effect of PCO morphology on visual function. Future research with larger cohorts, a greater variety of trifocal IOLs and a more comprehensive evaluation of PCO morphology could yield deeper insights into how these factors interplay and influence the early-onset PCO in patients implanted with trifocal IOLs.

Our study found that early-onset PCO initially affects near vision in eyes implanted with trifocal IOLs and also reduces both subjective and objective visual quality. Therefore, ophthalmologists need to pay attention to patients' complaints about decreased near vision and assess the presence of PCO and the potential need for Nd:YAG laser capsulotomy. Moreover, DLI may serve as an early objective indicator to help determine which patients with early-onset PCO require Nd:YAG laser capsulotomy treatment.

Acknowledgements

Jianfeng Luo, PhD, provided assistance with statistics.

Competing interests

All authors declare that they have no conflict of interest.

Funding

This research was funded by the Chinese National Nature Science Foundation, grant number 82171039, and research funds of Shanghai Municipal Health Commission, grant number 201940214.

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There is no conflict of interest

SUPPLEMETARYFIG1.tif
Supplementary Figure 1. Flowchart of recruitment of participants.
SUPPLEMETARYFIG2.tif
Supplementary Figure 2. Representative images of different grades of posterior capsule opacification.
SUPPLEMETARYFIG3.tif
Supplementary Figure 3. Visual function parameters of the study participants (n=189) by mean difference before and one month after Nd:YAG laser capsulotomy. UDVA: uncorrected distance visual acuity; UIVA: uncorrected intermediate visual acuity; UNVA: uncorrected near visual acuity; CDVA: best corrected distance visual acuity; DLI: dysfunctional lens index; Data are expressed as mean difference (95%CI). P values of the differences between subgroups are calculated by generalized linear mixed models with participants as a random effect to account for the repeated-measures design. * P<0.01.

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Effect of Early-onset Posterior Capsule Opacification on Visual Outcomes in Trifocal Diffractive Pseudophakic Eyes: A Multicenter Prospective Study

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Version 1

Abstract

Figures

What Was Known

Introduction

Methods

Study Design and Participants

Pre-capsulotomy and Post-capsulotomy Examinations

PCO Grading

Wavefront Measurement

Contrast Sensitivity

Visual Function Index-14 Questionnaire

Nd:YAG Capsulotomy

Statistical Analysis

Results

Baseline Characteristics

Relationship Between PCO Grades and Visual Outcomes Before Laser Capsulotomy

Comparison of VA and Quality Before and 1 Month After Laser Capsulotomy

DLI Cut-off Value for Nd:YAG Laser Capsulotomy

Discussion

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1