[Optical benchtop evaluation of special intraocular lens optics]. / Optische Bank-Evaluierung für spezielle Intraokularlinsenoptiken.

Intraocular lenses (IOL) featuring complex optical designs can pose a challenge in understanding their performance, which may hinder making an informed decision when selecting suitable lenses for patients. This underlines the importance of collecting optical quality data of IOLs and making them available. The deployment of benchtop systems for IOL testing offers not only insights into the design features of various IOL solutions but also provides a platform for objective comparisons of special optics designs, including information about their susceptibility to photic phenomena. Recent advances in IOL testing have improved the ability to predict functional effects on visual acuity and contrast sensitivity from objective optical quality metrics. This, for instance, can be used to study monofocal lenses and the impact of asphericity on vision and IOLs tolerance to misalignment. Monofocal-plus IOLs consistently show only a slight improvement in the depth of focus when tested on the optical bench and in clinical settings. Although the pupil dependence found in this technology may limit the advantages of monofocal-plus over standard monofocal technology to extend the range of vision, it is the key to reduce photic phenomena. Refractive and diffractive extended depth of focus (EDOF) IOLs can effectively enhance intermediate vision, with the latter offering a slightly broader depth of focus but potentially increasing the risk of dysphotopsia. However, the limitation of EDOF IOLs is that they often fail to deliver spectacle independence for reading, which can be overcome by trifocal technology. Still, the available trifocal IOLs differ in their location of intermediate and near foci and the susceptibility to produce glare effects. Therefore, the knowledge from optical benchtop testing of IOLs can support optimizing the IOL selection by aligning the patient's visual needs with the IOL's properties, setting the right expectations, and assessing the risk profile for the occurrence of photic phenomena, potentially leading to improved decision-making.

Ectasia Detection by Anterior Segment Optical Coherence Tomography in Scheimpflug Tomographically Normal Keratoconus Fellow Eyes.

PURPOSE: The purpose of this study was to determine whether the Scheimpflug tomographically normal fellow eyes of keratoconus patients are also classified as normal using an ectasia screening algorithm based on anterior segment optical coherence tomography (AS-OCT). METHODS: This monocentric cross-sectional study included 22 very asymmetric ectasia patients with tomographically significant keratoconus in 1 eye and normal Scheimpflug tomography in the fellow eye. Twenty-two eyes of 22 healthy subjects served as a control group. We performed corneal tomography using Pentacam AXL (Oculus, Wetzlar, Germany) and used Belin/Ambrósio Enhanced Ectasia total deviation index as well as Belin ABCD keratoconus classification to identify Scheimpflug tomographically normal eyes. We also performed AS-OCT using Anterion (Heidelberg Engineering, Heidelberg, Germany) and analyzed for the presence of ectasia using the Screening Corneal Objective Risk of Ectasia (SCORE) algorithm, with positive values indicating ectasia suspect tomography. RESULTS: The SCORE value was positive in 9.1% (n = 2) of the healthy eyes, in 45.5% (n = 10) of the Scheimpflug tomographically normal eyes of keratoconus patients and in all eyes (n = 22) with tomographically significant keratoconus. The Scheimpflug tomographically normal eyes of keratoconus patients had higher SCORE values compared with healthy controls (P < 0.001). The median (interquartile range) SCORE value was -1.7 (1.3) in healthy controls, -0.5 (2.2) in Scheimpflug tomographically normal eyes of keratoconus patients, and 11.1 (11.0) in tomographically significant keratoconus eyes. CONCLUSIONS: The Scheimpflug tomographically normal fellow eyes of keratoconus patients had higher AS-OCT-based SCORE values than healthy controls, with positive SCORE values found in 46% of the eyes, indicating early tomographic ectatic changes.

Characterizing glare effects associated with diffractive optics in presbyopia-correcting intraocular lenses.

PURPOSE: To objectively quantify glare of intraocular lenses (IOLs) using a diffractive principle to extend the visual range and to identify models with increased susceptibility to inducing glare. SETTING: David J Apple Laboratory, Heidelberg, Germany. DESIGN: Laboratory investigation. METHODS: Glare was assessed by means of a straylight parameter with a standard C-Quant intended for 7 degrees. In addition, 2 C-Quant modifications were used to test lower angles (ie, 2.5 degrees and 3.5 degrees). The following IOL models were assessed: PanOptix, AT Lisa Tri, Synergy, and Triumf, the latter 2 with chromatic aberration correction at distance. Straylight from trifocal IOLs was compared against a monofocal W-60R lens. The C-Quant test was performed through the studied IOLs by using additional optical components attached to their ocular. RESULTS: Straylight (deg 2 sr -1 ) of the control was <1 at all tested angles, with the trifocal models showing comparable straylight at 7 degrees. At 3.5 degrees, Triumf's straylight increased to 15.5 ± 0.6, followed by Synergy (6.2 ± 1.1), PanOptix (4.1 ± 0.3), and AT Lisa Tri (2.0 ± 0.8). The chromatic aberration-correcting models demonstrated correspondingly higher straylight (Synergy: 18.8 ± 1.3; Triumf: 17.3 ± 0.5) at 2.5 degrees compared with PanOptix (4.3 ± 0.4), AT Lisa Tri (2.1 ± 0.1), and monofocal IOLs yielding minimal or no increase. CONCLUSIONS: Trifocal IOLs induced increased straylight, but it was limited to lower angles, which may cause difficulties detecting these effects using a standard clinical approach. The latest IOL designs featuring chromatic aberration correction at far focus seem more susceptible than the established trifocal IOLs to inducing a glare phenomenon.

Longitudinal Evaluation of Biomechanical Indices in Fellow Eyes of Patients With Keratoconus Classified as Having Very Asymmetric Ectasia With Normal Topography.

PURPOSE: To evaluate the biomechanical longitudinal variability and progression of tomographically normal fellow eyes of patients with keratoconus. METHODS: Of 513 patients with keratoconus, 30 patients with tomographically normal fellow eyes were included in this study. Tomographic and biomechanical parameters of the Pentacam and Corvis ST (Oculus Optikgeräte GmbH) were analyzed in multiple follow-up examinations, including the ABCD grading, Belin/Ambrósio Enhanced Ectasia total deviation index (BAD-D), Corvis Biomechanical Index (CBI), Corvis Biomechanical Factor (CBiF), and Tomographic and Biomechanical Index (TBI). A mixed regression model was applied. The results were compared to a healthy control group (n = 17) and a keratoconus group (n = 20). RESULTS: Within a maximum observation period of 3.3 years, no fellow eye (0%) showed a progression to tomographically evident keratoconus. No significant change in tomographic or biomechanical parameters was detected over the study period. The indices BAD-D, CBI, CbiF, and TBI exhibited a certain variability over time, whereas the tomographic ABC parameters and maximum keratometry barely changed. This was also shown in the control group and for all parameters in the keratoconus group, except the TBI. CONCLUSIONS: During the observation period none of the normal fellow eyes progressed to tomographically detectable keratoconus. However, biomechanical parameters CBI, CbiF, and TBI showed pathological values in 43.3% of eyes and certain variability. Subsequent studies with a longer observation period are warranted to confirm the biomechanical trends seen in this study and to rate the ability of single measurements to diagnose early keratoconus. [J Refract Surg. 2024;40(1):e48-e56.].

Endothelial Cell Loss in Patients with Phakic Intraocular Lenses. / Endothelzellverlust bei phaken Intraokularlinsen.

Although the safety of phakic intraocular lenses (pIOLs) has been continuously improved over 70-years of development, high endothelial cell losses can occur even with current pIOL models. Numerous studies have demonstrated that the distance of a pIOL to the corneal endothelium plays a crucial role in the extent of endothelial cell loss. For this reason alone, higher endothelial cell loss tends to be observed with anterior chamber lenses than with posterior chamber lenses. Adequate preoperative anterior chamber depth is essential, at least for iris-fixed pIOLs, in order to ensure a safe distance from the endothelium. However, the anterior chamber becomes shallower with age and therefore it may be useful to consider patient age in the safety criteria. Although endothelial cell loss is generally low with current pIOL models, regular monitoring of the endothelial cell density remains essential due to large interindividual differences in patients with pIOLs. If the endothelial cell loss is greater than expected and the follow-up visits confirm the trend, the pIOL should be explanted without delay. The endothelial reserve should be considered on an individual basis by taking into account patient age, physiological endothelial cell loss, and loss due to further surgery. With careful indication and long-term patient care, pIOLs remain a safe treatment option.

Refractive Outcomes of Cataract Surgery in Patients With Intrastromal Femtosecond Laser Treatment of Presbyopia (INTRACOR).

PURPOSE: To evaluate the outcomes of cataract surgery with intraocular lens (IOL) implantation in patients who underwent intrastromal femtosecond laser treatment of presbyopia (INTRACOR). METHODS: This was an interventional case series of 8 patients (10 eyes) who presented for cataract surgery 6.1 ± 3.2 years (mean ± standard deviation [SD]) after INTRACOR (Technolas Perfect Vision GmbH) treatment. A monofocal IOL was implanted in 9 eyes (7 patients) and a small-aperture IOL was implanted in 1 eye. The IOL power was calculated without adjustments using biometry obtained after the INTRACOR treatment. For additional calculations, keratometry obtained before the INTRACOR treatment was used. Postoperative examinations included visual acuity testing, manifest refraction, defocus curve, ocular biometry, corneal tomography, aberrometry, anterior segment optical coherence tomography, and slit-lamp examination. RESULTS: After the cataract surgery, the mean ± SD uncorrected distance visual acuity was 0.37 ± 0.17 logMAR, the corrected distance visual acuity was 0.10 ± 0.10 logMAR, and the manifest refraction spherical equivalent, adjusted to infinity, was +0.39 ± 0.63 diopters (D). Intermediate and near visual acuity, both uncorrected and distance-corrected, and distance-corrected defocus curves varied considerably among patients. Using biometry performed after INTRACOR, the traditional IOL power calculation formulas produced hyperopic outcomes, with the mean ± SD prediction error ranging from +0.72 ± 0.34 to +0.96 ± 0.41 D. Although the mean ± SD prediction error decreased (range: -0.34 ± 0.56 to -0.15 ± 0.53 D) when using keratometry obtained before INTRACOR, the accuracy remained low due to high variability. CONCLUSIONS: In patients with cataract who had previous INTRACOR treatment, IOL power calculation could be inaccurate, with a tendency toward hyperopic outcomes. These results require confirmation in more extensive studies. [J Refract Surg. 2023;39(10):676-682.].

In vivo comparison of implantation behavior and laboratory analysis of two preloaded intraocular lens injectors.

PURPOSE: We evaluated implantation behavior and injector damage of two different IOL injector systems, the Multisert and the AutonoMe. DESIGN: Prospective, randomized, comparative study with laboratory investigation. METHODS: We examined used injectors from 48 bilateral cataract cases and assessed video recordings of each Implantation. All eyes were intraindividually randomized for treatment with one of the two IOL injectors. Implantation videos were reviewed for inadvertent events and the time for different implantation steps was determined. The injector nozzle tips were examined using light and scanning electron microscopy (SEM). Damage was graded using the Heidelberg Score for IOL injector damage (HeiScore). Three months postoperatively, IOLs were assessed for material changes. RESULTS: Implantation was without critical events in 96 of 96 eyes. Mean implantation time was 41.90 ± 7.11 s with the Multisert and 52.22 ± 12.06 s with the AutonoMe. In the AutonoMe group, we observed 4 eyes (8.3%) with a failed docking attempt, 28 eyes (58.3%) with a haptic adherence, one case (2.1%) of straight leading haptic and 2 cases (4.2%) of intrawound IOL manipulation. There were no events observed in the Multisert group. The mean HeiScore values were 0.87 ± 0.61 and 3.68 ± 0.47 for the AutonoMe and Multisert. 3 months postoperatively, IOL material changes were absent. CONCLUSIONS: Both injectors allowed safe and controlled implantation. Using Multisert, implantation behavior was more consistent. The injectors showed different damage profiles with a higher damage score for the Multisert.The study is registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien; reference number: DRKS00007837).

Diagnostic Techniques to Increase the Safety of Phakic Intraocular Lenses.

Preoperative and postoperative diagnostics play an important role in ensuring the safety of patients with phakic intraocular lenses (pIOLs). The risk of endothelial cell loss can be addressed by regularly measuring the endothelial cell density using specular microscopy and considering the endothelial cell loss rate and the endothelial reserve in accordance with the patient's age when deciding whether to explant a pIOL. The anterior chamber morphometrics, including the anterior chamber depth and the distance between the pIOL and the endothelium, measured using Scheimpflug tomography and anterior segment optical coherence tomography (AS-OCT), can help to assess the risk of the endothelial cell loss. In patients undergoing posterior chamber pIOL implantation, accurate prediction of the vault and its postoperative measurements using AS-OCT or Scheimpflug tomography are important when assessing the risk of anterior subcapsular cataract and secondary glaucoma. Novel approaches based on ultrasound biomicroscopy and AS-OCT have been proposed to increase the vault prediction accuracy and to identify eyes in which prediction errors are more likely. Careful patient selection and regular postoperative follow-up visits can reduce the complication risk and enable early intervention if a complication occurs.

Imaging Function and Relative Light Transmission of Explanted Opacified Hydrophilic Acrylic Intraocular Lenses.

We evaluated the influence of intraocular lens (IOL) opacification on the optical performance of explanted hydrophilic acrylic IOLs. We performed a laboratory analysis of 32 Lentis LS-502-1 (Oculentis GmbH, Berlin, Germany) IOLs, explanted due to opacification, in comparison with six clear unused samples of the same IOL model. Using an optical bench setup, we obtained modulation transfer function (MTF), Strehl ratio, two-dimensional MTF, and United States Air Force (USAF) chart images. In addition, we assessed light transmission through the IOLs. The MTF values of opacified IOLs at 3-mm aperture were similar to those of clear lenses, with the median (interquartile range) values of 0.74 (0.01) vs. 0.76 (0.03) at the spatial frequency of 50 line pairs per millimeter in clear and opacified IOLs, respectively. The Strehl ratio of opacified lenses was not lower than that of clear lenses. The USAF-chart analysis showed a considerable reduction in brightness in opacified IOLs. The median (interquartile range) relative light transmission of opacified IOLs in comparison to clear lenses was 55.6% (20.8%) at the aperture size of 3 mm. In conclusion, the explanted opacified IOLs had comparable MTF values to those of clear lenses but significantly reduced light transmission.

Complementary system vs conventional trifocal intraocular lens: comparison of optical quality metrics and unwanted light distribution.

PURPOSE: To evaluate the ARTIS Symbiose complementary intraocular lens (IOL) system, consisting of the MID and PLUS models, in comparison with a conventional trifocal IOL (AcrySof IQ PanOptix). SETTING: The David J. Apple Center for Vision Research, Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany. DESIGN: Laboratory investigation. METHODS: Modulation and phase transfer functions were obtained in polychromatic light using an optical bench setup. Simulated visual acuity (VA) values were derived from optical quality metrics weighted by neural contrast sensitivity. United States Air Force (USAF) chart images were acquired and processed. Furthermore, the light distribution beyond the center of a polychromatic point spread function was assessed. RESULTS: The peak simulated VA values of ARTIS Symbiose MID were at 0 diopters (D) of defocus (-0.02 logMAR) and at -1.5 D (0.00 logMAR); of ARTIS Symbiose PLUS, they were at 0 D of defocus (-0.01 logMAR) and at -2.5 D (0.01 logMAR). AcrySof IQ PanOptix demonstrated 3 peaks: at 0 D of defocus (-0.02 logMAR), at -1.75 D (0.03 logMAR), and at -2.5 D (0.02 logMAR). The summation of USAF chart images in the simulated binocular IOL system produced a slightly better image quality at -1.0 D and -1.5 D than AcrySof IQ PanOptix. The IOLs yielded comparable light spread across the studied range except for a localized intensity spike of the ARTIS Symbiose IOLs. CONCLUSIONS: The complementary IOL system may yield better monocular intermediate VA compared with the conventional trifocal IOL. However, the effect of binocular summation in terms of VA and the perception of photic phenomena still needs to be investigated.

Monofocal intraocular lens with enhanced intermediate function as substitute for multifocal intraocular lens in positive dysphotopsia.

Purpose: To present a case of a 62-year-old patient implanted with multifocal intraocular lenses (IOLs) who underwent a bilateral IOL exchange due to positive dysphotopsia. In an attempt to reduce the symptoms and compensate for the loss of multifocality, we implanted an aspheric monofocal IOL with enhanced intermediate function in one eye and a spherical monofocal IOL in the other eye. Observations: The patient presented with complaints of halo and glare, measured with a simulator, following the implantation of segmented multifocal IOLs two years earlier. The uncorrected distance visual acuity (UDVA) was 20/20 in both eyes. Before presentation at our clinic, a laser capsulotomy had been performed on the right eye. We proceeded with a bilateral IOL exchange. Because of capsular insufficiency in the right eye, we implanted a spherical monofocal three-piece IOL in the ciliary sulcus with optic capture. In the left eye, we used a monofocal IOL with an enhanced intermediate function. Two weeks postoperatively, UDVA (monocularly) was 20/20 in OD and OS, the uncorrected intermediate visual acuity (UIVA) was 20/32, and the uncorrected near visual acuity (UNVA) was 20/50. Binocularly, UDVA was 20/20, UIVA was 20/25 and UNVA was 20/25. The patient reported a marked decrease in halos and glare. Conclusions and importance: When planning IOL exchange surgery, in cases of intolerance to multifocal IOLs, the clinician should consider the dilemma of loss of multifocality. Recent developments in monofocal IOL technology present new options to improve visual function in cases of multifocal IOL explantation.

Diagnostic imaging techniques in patient with liquefied aftercataract imitating intraocular lens opacification.

An 81-year-old patient was referred for an intraocular lens (IOL) exchange surgery because of a presumed IOL opacification. Using diagnostic imaging techniques such as anterior segment optical coherence tomography (OCT) and Scheimpflug imaging, we revealed that the presumed IOL opacification was in fact a liquefied aftercataract. As a result, an intraocular surgery was avoided and the patient was successfully treated with a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy.

Development and Verification of an Adjustment Factor for Determining the Axial Length Using Optical Biometry in Silicone Oil-Filled Eyes.

The aim of this prospective clinical study was to establish and verify an adaptation for axial length (AL) measurement in silicone oil (SO)-filled pseudophakic eyes with a Scheimpflug and partial coherence interferometry (PCI)-based biometer. The AL was measured with a Pentacam AXL (OCULUS Optikgeräte GmbH, Wetzler, Germany) and IOLMaster 700 (Carl Zeiss Meditec, Jena, Germany). The coefficients of variation (CoV) and the mean systematic difference (95% confidence interval (CI)) between the devices were calculated. After implementing a setting for measuring AL in tamponaded eyes with a Pentacam based on data of 29 eyes, another 12 eyes were examined for verification. The mean AL obtained with the Pentacam was 25.53 ± 1.94 mm (range: 21.70 to 30.76 mm), and with IOLMaster, 24.73 ± 1.97 mm (ranged 20.84 to 29.92 mm), resulting in a mean offset of 0.80 ± 0.08 mm (95% CI: 0.77, 0.83 mm), p < 0.001. The AL values of both devices showed a strong linear correlation (r = 0.999). Verification data confirmed good agreement, with a statistically and clinically non-significant mean difference of 0.02 ± 0.04 (95% CI: -0.01, 0.05) mm, p = 0.134. We implemented a specific adaptation for obtaining reliable AL values in SO-filled eyes with the Pentacam AXL.

[Cataract surgery and the small eye: relative anterior microphthalmos, high hyperopia and nanophthalmos]. / Die Kataraktchirurgie und das kleine Auge: Relativer anteriorer Mikrophthalmus, hohe Hyperopie und Nanophthalmus.

Relative anterior microphthalmos, nanophthalmos and high-grade hyperopia are small eyes with different characteristic morphological relationships between the anterior segment and axis length. This article discusses the intraoperative challenges and surgical approaches to solutions for cataract operations in patients with one of the three named morphological alterations. Additionally, the article addresses possible comorbidities including glaucoma and preoperative planning.

Laboratory Investigation of Preclinical Visual-Quality Metrics and Halo-Size in Enhanced Monofocal Intraocular Lenses.

INTRODUCTION: This study aims to compare preclinical visual-quality metrics and halo size of intraocular lenses (IOL) with enhanced intermediate vision to a standard monofocal lens. METHODS: Three monofocal- IOL models with an extended-depth-of-focus (EDoF) intended for monocular implantation (Tecnis ICB00, AE2UV/ZOE, and IsoPure) and one for monovision (RayOne EMV) were compared against a standard monofocal lens (Tecnis ZCB00). An optical-metrology station was used in the assessment of IOLs' optical quality in polychromatic light. The imaging quality was compared with metrics derived from the optical transfer function. Halo size was estimated from the projection of the point spread function under scotopic pupil. RESULTS: The monofocal IOL showed the highest image quality at the far focus. The ICB00's, the AE2UV/ZOE's, and the IsoPure's performance at - 1D was superior to that of the monofocal lens. The monocular defocus tolerance of the RayOne EMV was comparable with that of the ZCB00. The RayOne EMV's intermediate range was improved in a monovision configuration (- 1D offset). This approach, however, yielded the largest halo area, i.e., 53% of the ZCB00's halo, compared to 34% for the IsoPure, 14% for the AE2UV/ZOE, and 8% for the ICB00. CONCLUSION: The mono-EDoF models have a clear advantage over the standard monofocal lens by expanded imaging capability beyond - 0.5D. Although the RayOne EMV provided the largest (binocular) visual-range extension, it was at the expense of monocular vision and higher susceptibility to halo. The ICB00's and the AE2UV/ZOE's halo-profile was similar to that of the ZCB00, indicating their low potential to induce photic phenomena.

Clinical Outcomes of a New Hybrid Monofocal IOL With Extended Depth of Focus.

PURPOSE: To evaluate a new extended depth of focus intraocular lens (IOL), the xact Mono-EDOF ME4 (Santen Pharmaceuticals), Conformitè Europëenne-marked as a monofocal IOL, which has four diffractive rings intended to enhance intermediate vision. METHODS: Results are reported for 47 IOLs implanted in 28 patients who underwent cataract surgery and implantation of the xact Mono-EDOF ME4 IOL in one (9 patients) or both (19 patients) eyes. Postoperative follow-up examinations included visual acuity testing (monocular and binocular; uncorrected distance visual acuity [UDVA], corrected distance visual acuity [CDVA], uncorrected intermediate visual acuity [UIVA], distance-corrected intermediate visual acuity [DCIVA]), defocus curve and contrast sensitivity testing, and dysphotopsia evaluation. RESULTS: Follow-up at 6 months postoperatively revealed a monocular UDVA of 0.08 ± 0.15 logMAR, binocular UDVA of -0.02 ± 0.09 logMAR, monocular CDVA of -0.07 ± 0.08 logMAR, binocular CDVA of -0.09 ± 0.09 logMAR, monocular UIVA (70 cm) of 0.18 ± 0.16 logMAR, binocular UIVA (70 cm) of 0.09 ± 0.12 logMAR, monocular DCIVA (70 cm) of 0.25 ± 0.14 logMAR, and binocular DCIVA (70 cm) of 0.13 ± 0.11 logMAR. Defocus curve testing demonstrated a functional defocus of 1.25 diopters at 0.20 logMAR for monocular and 1.50 diopters at 0.20 logMAR for binocular testing. The contrast sensitivity corresponded to the age-appropriate normal values. Patients reported low levels of halo and glare. CONCLUSIONS: The xact Mono-EDOF ME4 IOL showed good functional results for far and intermediate distance visual acuity while inducing a low level of photic phenomena. [J Refract Surg. 2021;37(9):601-608.].

Preloaded injectors used in a clinical study: videographic assessment and laboratory analysis of injector nozzle damage.

PURPOSE: To evaluate quality and duration of implantation of 2 preloaded intraocular lens (IOL) injectors and assess postimplantation damage. SETTING: The David J. Apple Center for Vision Research, Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany. DESIGN: Prospective, randomized, comparative study with laboratory investigation. METHODS: Implantation videos and postuse injectors from 60 paired eyes of 30 bilateral cataract patients were included. Patient eyes were randomly assigned for implantation with 2 different preloaded injectors: the AutonoMe with a Clareon IOL (Alcon Laboratories, Inc.) and the iSert with a Vivinex IOL (Hoya Corp.). Videos were reviewed for events during the implantation procedure, and the duration of each step of implantation. Injector nozzles were examined under light and scanning electron microscopy. Damage was graded and correlated with the IOL power. Three months postoperatively IOLs were assessed for material changes. RESULTS: IOL delivery was without any critical events in 60 of the 60 eyes. The implantation took 56 seconds with the AutonoMe and 44 seconds with the iSert (P < .05). Most AutonoMe injectors (29; 97%) showed no damage or slight deformation. In most of the iSert injectors (25; 80%), short or extended cracks were present, and damage lengths correlated with the IOL power. All IOLs were free of material changes, including glistenings, 3 months postoperatively. CONCLUSIONS: Both preloaded IOL injectors allowed a safe and convenient IOL delivery. Implantation of the Clareon IOL took, on average, slightly longer than that of the Vivinex IOL, mostly due to a slower IOL unfolding. The AutonoMe showed less nozzle tip damage than that of the iSert.