Comparison of Optical Performance in Eyes Implanted with Aspheric Foldable, Spherical Foldable, and Rigid PMMA IOLs.

PURPOSE: To compare the optical performance of rigid spherical polymethylmethacrylate (PMMA), foldable spherical, and foldable aspheric intraocular lenses (IOLs). METHODS: Measurements were obtained monocularly from pseudophakic patients with a PMMA IOL (Ophtec PC265y or Rayner 105U), spherical AcrySof MA30 IOL (Alcon Laboratories Inc), or aspheric Tecnis ZA9003 IOL (Abbott Medical Optics). Contrast sensitivity was measured using the Holladay automated contrast sensitivity test with 5.0-mm artificial pupil at 3 and 6 cycles per degree at optimal focus and at several defocus levels. The myopic shift (shift of the optimal focus toward more myopic values at lower spatial frequencies) and depth of focus were determined. Wavefront aberrations were assessed with a Hartmann-Shack wavefront analyzer; straylight was measured using the C-Quant meter (Oculus Optikgeräte GmbH). RESULTS: Nine patients with a spherical rigid PMMA IOL, 19 patients with a spherical foldable IOL, and 24 patients with an aspheric foldable IOL met the inclusion criteria. Eyes with an aspheric IOL showed less spherical aberration than eyes with other IOLs; no differences were found in overall higher order aberrations. No differences in contrast sensitivity at optimal focus and in straylight were found among the IOLs. Eyes with a PMMA IOL showed a larger depth of focus compared to eyes with an aspheric IOL. Eyes with an aspheric IOL had a smaller myopic shift than eyes with other IOLs. CONCLUSIONS: Optical performance differences among the IOLs in this study are small, concurring with similar higher order aberrations found in the three groups. Reduction in myopic shift appears to be the most obvious effect of aspheric IOLs.

Straylight measurements in pseudophakic eyes with natural and dilated pupils: one-year follow-up.

PURPOSE: To compare the amount of straylight in natural pupils and dilated pupils in pseudophakic eyes 6 weeks and 1 year after cataract extraction. SETTING: Laboratory of Experimental Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. METHODS: This study evaluated patients with bilateral age-related cataract who had cataract surgery with implantation of an aspheric Tecnis ZA9003 or spherical Sensar AR40e intraocular lens (IOL). Straylight measurements were performed with a C-Quant straylight meter 6 weeks after surgery (with natural pupils) and 1 year after surgery (with natural and dilated pupils) in a randomly chosen eye. Retroillumination photographs of dilated pupils were taken to document posterior capsule opacification. The main outcome variable for straylight measurements was the logarithmic straylight parameter, log(s). RESULTS: Twenty-two patients were evaluated. There was a statistically significant decrease in straylight in a natural pupil between 6 weeks (mean 1.44 log[s]) and 1 year (mean 1.30 log[s]) postoperatively (P = .012). The straylight parameter was greater after dilation (mean 1.48 log[s]) than with a natural pupil (1.29 log[s]) at 1 year (P = .012). This difference was greater when more anterior capsule was visible in the pupillary area (P = .031). CONCLUSIONS: Straylight decreased significantly in the first year after cataract surgery. Furthermore, it increased with increasing pupil size, which was associated with a capsulorhexis smaller than the pupil. This indicates the capsulorhexis should be as large as possible to prevent straylight, especially under low-luminance conditions when the pupil is large.

Clinical comparison of the optical performance of aspheric and spherical intraocular lenses.

PURPOSE: To compare the optical performance of aspheric Tecnis ZA9003 and spherical Sensar AR40e intraocular lenses (IOLs). SETTING: Laboratory of Experimental Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. METHODS: An aspheric IOL was implanted in 1 eye and a spherical IOL in the other eye of patients with bilateral age-related cataract. Contrast sensitivity was measured using 2 computerized tests (vertical sine-modulated gratings and circular sine-modulated patterns) with cycloplegia and a 5.0 mm artificial pupil under photopic conditions at optimum refractive correction and at several defocus levels. The depth of focus and the myopic shift (shift of optimum focus toward more myopic values at lower spatial frequencies) were determined. Higher-order aberrations were assessed using a Hartmann-Shack wavefront analyzer; straylight was measured with a straylight meter. RESULTS: In the 60 eyes evaluated, there were no statistically significant differences in contrast sensitivity measured at optimum focus, depth of focus, or straylight between the 2 IOLs. The mean spherical aberration was significantly lower with the aspheric IOL (-0.036 microm) than with the spherical IOL (0.064 microm) (P<.001) and the mean myopic shift, statistically significantly smaller (0.05 diopter [D] and -0.47 D, respectively) (P<.001). CONCLUSIONS: Eyes with the aspheric IOL had lower spherical aberration than eyes with the spherical IOL and, related to that, a smaller myopic shift. No significant differences were found between the 2 IOLs in contrast sensitivity measured at optimum focus, depth of focus, or straylight. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Relationship between contrast sensitivity and spherical aberration: comparison of 7 contrast sensitivity tests with natural and artificial pupils in healthy eyes.

PURPOSE: To find a contrast sensitivity test that can be used clinically to evaluate interventions aimed at minimizing spherical aberration and determine the circumstances under which these tests should be performed. SETTING: Laboratory of Experimental Ophthalmology, University of Groningen, Groningen, The Netherlands. METHODS: Contrast sensitivity tests were performed using 2 experimental designs. Design 1 was with a natural pupil under mesopic and photopic conditions. Design 2 was with a 5.0 mm artificial pupil after cycloplegia under photopic conditions only. Two computerized tests (vertical sine-modulated gratings [VSG] and Holladay circular sine-modulated patterns [HACSS]) and 5 chart tests (Pelli-Robson, acuity-measuring letter charts at low contrast [2.5% and 10%], VectorVision, and edge contrast sensitivity) were used. Spherical aberration was assessed with a Hartmann-Shack wavefront analyzer. RESULTS: Forty-nine healthy subjects aged 20 to 35 years (n = 24) and 55 to 70 years (n = 25) participated. Design 2 showed a significant relationship between contrast sensitivity and spherical aberration with the HACSS at 3 cycles per degree (cpd) (P = .03) and 6 cpd (P = .01) and with the VSG at 6 cpd (P = .01). Design 1 yielded no significant relationships. CONCLUSIONS: Using an artificial pupil, a relationship between contrast sensitivity and spherical aberration was established with the VSG and HACSS tests but not with the chart tests. No test showed a relationship using natural pupils under either lighting condition. Chart tests are unsuitable for uncovering contrast sensitivity differences related to differences in spherical aberration, as typically found in healthy phakic eyes.

The Introduction of Bioptic Driving in The Netherlands.

BACKGROUND: In many states of the U.S.A., people with moderately reduced visual acuity e.g., 20/50 - 20/200) can legally drive with the aid of a small, spectacle-mounted ("bioptic") telescope. We conducted a demonstration project to assess the viability of implementing bioptic driving in The Netherlands. In this paper we describe the framework of the project from conception through to realization of our primary objective - the introduction of bioptic driving as a legal option for visually impaired people in The Netherlands. METHODS: The project was based on bioptic driving programs in the U.S.A., which were adapted to fit within current driving training and assessment practices in The Netherlands. The project convened a consortium of organizations including the Netherlands Bureau of Driving Skills Certificates (CBR), service organizations for the visually impaired, and research departments at universities investigating driving and vision. All organizations were educated about bioptic driving and participating professionals were trained in their specific aspects of the project. Media publicity led to significant interest and helped recruitment that enabled the screening and selection of potential participants. OUTCOMES: The project demonstrated that people with moderately reduced visual acuity can be trained to achieve an adequate level of proficient and safe driving (as assessed by the local official driving licensing professionals) when using a bioptic telescope for the road conditions in the Netherlands. Based on the successful project outcomes, a request was made to the Minister to allow bioptic driving in the Netherlands. This request has been accepted; the legal procedures for implementation are in process.

Six patients with bradyopsia (slow vision): clinical features and course of the disease.

OBJECTIVE: Recently, it was discovered that subjects who showed a prolonged response suppression on their electroretinogram (ERG) and had symptoms of photophobia, problems adjusting to bright light, and difficulties seeing moving objects shared a mutation in the RGS9 (regulator of G-protein signaling 9) gene that is involved in the deactivation of photoreceptor responses. The disorder was termed bradyopsia (slow vision). This paper reports the clinical presentation and long-term follow-up of 6 bradyopsia patients. DESIGN: Retrospective observational case series with a follow-up ranging from 6 to 30 years. PARTICIPANTS: Six patients with a homozygous mutation in the RGS9 gene. METHODS: Clinical symptoms and signs were compared between the subjects and between their visits over time. MAIN OUTCOME MEASURES: Symptoms, visual acuity (VA), ocular findings, visual fields, dark-adaptation tests, color tests, fluorescein angiography, and ERG findings. RESULTS: Data showed a consistency in the individual symptoms and ERG recordings, but an extreme variation in VA between visits. Beside some irregularities in the macula in some patients, no other related eye abnormalities were seen. The low-to-subnormal VA varied with background luminance and typically increased by 2 to 3 lines when pinholes were used. Dark-adaptation tests, color tests, and fluorescein angiography were normal. Visual field tests showed a minor diffuse sensitivity loss. No progressive changes were seen over time. CONCLUSIONS: No signs of progression were noted in the 6 bradyopsia patients. Photophobia, impaired movement perception, variable reduced VA that improved with the use of pinholes and ERG abnormalities were typical for the disease.

Changes in spherical aberration after lens refilling with a silicone oil.

PURPOSE: It may be possible to restore accommodation to presbyopic human eyes by refilling the lens capsular bag with a soft polymer. In the present study, optical changes were measured that occurred in a pig eye model after the refilling of the capsular bag. METHODS: The optical power and spherical aberration in 10 isolated pig lenses were measured under different conditions. They were first determined by using a scanning laser ray-tracing technique over an effective pupil size of 6 mm. Second, the contours of the anterior and posterior lens surface were photographed, and a mathematical ray-tracing was performed by using a polynomial fit through the digitized surface contours, to determine optical power and spherical aberration. Third, the lenses were refilled with a silicone oil until their preoperative lens thickness was reached, and scanning laser ray-tracing, contour photography, and mathematical ray-tracing were repeated. Comparisons between the measurements were made to determine how the change from a gradient refractive index to a homogeneous refractive index influenced spherical aberration. The influence of the change in lens contour on spherical aberration after lens refilling was also studied. RESULTS: The natural lenses had a higher lens power than the refilled lenses (49.9 +/- 1.5 D vs. 36.8 +/- 1.5 D; P < 0.001). Moreover, there was a change in sign from negative spherical aberration before lens refilling (-3.6 D) to positive spherical aberration after lens refilling (7.9 D; P < 0.001). The comparison between scanning laser ray-tracing of the natural lens and mathematical ray-tracing of the photographed surface contours of the natural lens to determine the effect of refractive index substitution (i.e., replacement of a gradient refractive index by a homogeneous refractive index) showed a significant change in spherical aberration from -3.6 +/- 2.0 to 11.0 +/- 2.1 D (P < 0.001). The change in lens contour did not result in a significant change in spherical aberration (P = 0.08) before and after lens refilling with an equal refractive index. CONCLUSIONS: The lower lens power of refilled pig lenses compared to natural lenses was due to the lower refractive index of the refill material. Refilling pig lenses with the silicone oil used in this study resulted in an increase in spherical aberration. This increase was mainly caused by the change from a gradient refractive index to a homogeneous refractive index. The change in lens curvature after lens refilling did not result in an increase in spherical aberration. The influence of lens refilling on spherical aberration of human lenses must be determined in similar experiments in human eyes.

Accommodative lens refilling in rhesus monkeys.

PURPOSE: Accommodation can be restored to presbyopic human eyes by refilling the capsular bag with a soft polymer. This study was conducted to test whether accommodation, measurable as changes in optical refraction, can be restored with a newly developed refilling polymer in a rhesus monkey model. A specific intra- and postoperative treatment protocol was used to minimize postoperative inflammation and to delay capsular opacification. METHODS: Nine adolescent rhesus monkeys underwent refilling of the lens capsular bag with a polymer. In the first four monkeys (group A) the surgical procedure was followed by two weekly subconjunctival injections of corticosteroids. In a second group of five monkeys (group B) a treatment intended to delay the development of capsular opacification was applied during the surgery, and, in the postoperative period, eye drops and two subconjunctival injections of corticosteroids were applied. Accommodation was stimulated with carbachol iontophoresis or pilocarpine and was measured with a Hartinger refractometer at regular times during a follow-up period of 37 weeks in five monkeys. In one monkey, lens thickness changes were measured with A-scan ultrasound. RESULTS: In group A, refraction measurement was possible in one monkey. In the three other animals in group A, postoperative inflammation and capsular opacification prevented refraction measurements. In group B, the maximum accommodative amplitude of the surgically treated eyes was 6.3 D. In three monkeys the accommodative amplitude decreased to almost 0 D after 37 weeks. In the two other monkeys, the accommodative amplitude remained stable at +/-4 D during the follow-up period. In group B, capsular opacification developed in the postoperative period, but refraction measurements could still be performed during the whole follow-up period of 37 weeks. CONCLUSIONS: A certain level of accommodation can be restored after lens refilling in adolescent rhesus monkeys. During the follow-up period refraction measurements were possible in all five monkeys that underwent the treatment designed to prevent inflammation and capsular opacification.

The influence of artificial scotomas on eye movements during visual search.

PURPOSE: Fixation durations are normally adapted to the difficulty of the foveal analysis task. We examine to what extent artificial central and peripheral visual field defects interfere with this adaptation process. METHODS: Subjects performed a visual search task while their eye movements were registered. The latter were used to drive a real-time gaze-dependent display that was used to create artificial central and peripheral visual field defects. Recorded eye movements were used to determine saccadic amplitude, number of fixations, fixation durations, return saccades, and changes in saccade direction. RESULTS: For central defects, although fixation duration increased with the size of the absolute central scotoma, this increase was too small to keep recognition performance optimal, evident from an associated increase in the rate of return saccades. Providing a relatively small amount of visual information in the central scotoma did substantially reduce subjects' search times but not their fixation durations. Surprisingly, reducing the size of the tunnel also prolonged fixation duration for peripheral defects. This manipulation also decreased the rate of return saccades, suggesting that the fixations were prolonged beyond the duration required by the foveal task. CONCLUSIONS: Although we find that adaptation of fixation duration to task difficulty clearly occurs in the presence of artificial scotomas, we also find that such field defects may render the adaptation suboptimal for the task at hand. Thus, visual field defects may not only hinder vision by limiting what the subject sees of the environment but also by limiting the visual system's ability to program efficient eye movements. We speculate this is because of how visual field defects bias the balance between saccade generation and fixation stabilization.

Relation between injected volume and optical parameters in refilled isolated porcine lenses.

PURPOSE: This study was performed to elucidate the correlation between added lens refill material and enhanced lens power as well as the correlation between lens refilling volume and accommodative amplitude as determined by equatorial stretching of ex vivo refilled pigs' lenses. METHODS: Nine porcine lenses were refilled with increasing amounts of silicone oil. After each refill step, the lens power, the lens power change, and the lens thickness were measured both in the relaxed state and with a 3-mm larger ciliary body diameter. In addition, the spherical aberration of the refilled lenses was also quantified. RESULTS: Injection of 0.04 mL silicone material into the relaxed lens enhanced the lens power by 1 D. A 0.54-mm increase of the lens thickness in relaxed lenses added 1 D to the lens power. Increasing the lens refilling volume decreased the lens power changes measured at 3-mm ciliary body stretch. Spherical aberration was positive in the refilled lenses and increased with increasing lens refilling volume. CONCLUSION: The correlation found between the refilling volume and the lens power (0.04 mL D(-1)), as well as the correlation between the lens thickness and the lens power (0.54 mm D(-1)), might be important factors to be controlled in conjunction with surgery, as these also determine the lens power in the presence of this refill material. An increasing lens filling volume is associated with decreasing accommodative amplitude. The positive spherical aberration of refilled porcine lenses presents a sharp contrast to the negative aberration of natural pigs' lenses. Different lens contours and the transition from a gradient to a homogeneous refractive index might be responsible for this change in spherical aberration.

Improved mobility and independence of night-blind people using night-vision goggles.

PURPOSE: To investigate whether the use of night-vision goggles (NVGs) by night-blind people improves their mobility and sense of independence under dark circumstances. METHODS: Twenty night-blind subjects with retinitis pigmentosa were requested to walk predetermined routes at night with and without NVGs. The number of unintended contacts with obstacles (hits) and the percentage of preferred walking speed (PPWS) en route were assessed in three different situations: a darkened indoor corridor; a moderately lit outdoor residential area; and a well-lit outdoor shopping area. Assessments were performed before and after a 5-week training period, during which the subjects practiced using NVGs in their own surroundings, registered their experiences in a journal, and filled out questionnaires. RESULTS: The mean number of hits in the darkened corridor declined from eight to two when NVGs were used. Mean PPWS (34%) did not improve. In the residential area, mean hits declined from eight to practically zero and mean PPWS increased from 60% to 72% (after training to 78%). In the shopping area, subjects walked at 93% PPWS without any hits and showed no improvement with NVGs. Subjective scores revealed a good sense of orientation, feelings of safety and tranquility and an increase in independent mobility when NVGs were used. CONCLUSIONS: Using NVGs seems to improve nighttime mobility in dark outdoor conditions by decreasing unintended contacts with obstacles and increasing walking speed. Use of NVGs increased independent activities in these subjects and was generally positively evaluated for everyday outdoor use.

Age-related changes in the functional visual field: further evidence for an inverse Age x Eccentricity effect.

We assessed the performance of younger and older individuals by using the Attended Field of View test, a visual search task in which eye movements were allowed. When adjusting for slower processing in the older age group by log transformation, we observed significant effects of age, eccentricity, and Age x Eccentricity. Contrary to most previous findings, the Age x Eccentricity effect was "inverted" in that the difference between the age groups decreased as a function of eccentricity. The finding that the eccentricity effect of younger individuals was larger than that of older individuals was caused by large age-related differences in sensitivity for centrally located targets, even though differences with regard to foveal resolution were controlled. The results further indicated that, given a brief amount of time, older persons could process a smaller field of view than younger persons. Consequently, older persons were forced to resort to serial scanning for a larger part of the display, whereas younger persons could process a larger area in parallel.

Defects in RGS9 or its anchor protein R9AP in patients with slow photoreceptor deactivation.

The RGS proteins are GTPase activating proteins that accelerate the deactivation of G proteins in a variety of signalling pathways in eukaryotes. RGS9 deactivates the G proteins (transducins) in the rod and cone phototransduction cascades. It is anchored to photoreceptor membranes by the transmembrane protein R9AP (RGS9 anchor protein), which enhances RGS9 activity up to 70-fold. If RGS9 is absent or unable to interact with R9AP, there is a substantial delay in the recovery from light responses in mice. We identified five unrelated patients with recessive mutations in the genes encoding either RGS9 or R9AP who reported difficulty adapting to sudden changes in luminance levels mediated by cones. Standard visual acuity was normal to moderately subnormal, but the ability to see moving objects, especially with low-contrast, was severely reduced despite full visual fields; we have termed this condition bradyopsia. To our knowledge, these patients represent the first identified humans with a phenotype associated with reduced RGS activity in any organ.

Predicting practical fitness to drive in drivers with visual field defects caused by ocular pathology.

Vision, viewing efficiency, visual attention, and on-road driving performance were assessed in 100 participants with central and/or peripheral visual field defects caused by ocular pathology. Driving was evaluated by the Dutch driving license authority making use of the protocol for investigating practical fitness to drive. A smaller percentage of participants with central visual field defects passed the on-road driving test, in comparison with participants with peripheral or mild field defects. The predictive power of a model based on the current vision requirements for driving significantly increased when taking compensatory viewing efficiency into account. The results of the latter model were comparable to those of a model based on tests of visual attention and contrast sensitivity. Despite the increased explained variance of practical fitness to drive when taking higher-order visual functions into account, sensitivity and specificity remained quite low, limiting the use of these tests in identifying unfit drivers. Actual or potential applications of this research include the development of training programs to improve practical fitness to drive in drivers with visual field defects.

Effect of intraocular lens implantation on visual acuity, contrast sensitivity, and depth of focus.

PURPOSE: To determine the role of spherical and irregular aberrations in the optics of the natural eye and after intraocular lens (IOL) implantation in terms of visual acuity, contrast sensitivity, and depth of focus. SETTING: Laboratory of Experimental Ophthalmology, University of Groningen, Groningen, The Netherlands. METHODS: Visual acuity and defocus-specific contrast sensitivity in 11 pseudophakic patients (IOL group) and 27 age-matched phakic subjects were compared. The results were obtained psychophysically. Spherical and irregular aberrations were subsequently estimated by comparing the measured myopic shift (optimum focus of contrast sensitivity at 4 cycles per degree [cpd] compared to that at 16 cpd) and depth of focus with those of theoretical eye models with varying amounts of irregular and spherical aberrations. RESULTS: The best corrected visual acuity and best corrected contrast sensitivity in the IOL group did not significantly differ from that in the phakic group. The depth of focus was larger in the IOL group at a pupil diameter of 6.0 mm (P<.05). Comparison with theoretical eye models suggested a higher amount of spherical aberration in the IOL group; irregular aberration was almost the same in both groups. CONCLUSIONS: There was a higher amount of spherical aberration in the IOL group, related to a larger depth of focus, without loss of contrast sensitivity at optimum focus or loss of visual acuity. This might contribute to better quality of vision in pseudophakic subjects than in presbyopic phakic subjects.

Effect of methods of myopia correction on visual acuity, contrast sensitivity, and depth of focus.

PURPOSE: To psychophysically measure spherical and irregular aberrations in patients with various types of myopia correction. SETTING: Laboratory of Experimental Ophthalmology, University of Groningen, Groningen, The Netherlands. METHODS: Three groups of patients with low myopia correction (spectacles, soft contact lens, and Intacs) and 4 groups with high myopia correction (spectacles, rigid contact lens, Artisan claw lens, and laser in situ keratomileusis [LASIK]) had through-focus contrast sensitivity measurements to establish the myopic shift and depth of focus. From these 2 parameters, spherical and irregular aberrations were determined using theoretical eye models and geometric optics. Visual acuity, stray light, and predictability were also studied. RESULTS: There were no differences in best corrected visual acuity (BCVA) or best corrected contrast sensitivity between the low myopia groups. The Intacs group had a significantly larger depth of focus (P<.05). The results in the soft contact lens group were comparable to those in a human eye model with an average amount of spherical and irregular aberrations. The LASIK group had worse uncorrected visual acuity (UCVA) and best corrected contrast sensitivity than the spectacles, rigid contact lens, and Artisan claw lens groups (P<.05) due to the amount of spherical and irregular aberrations present after LASIK. The low and high myopia spectacles groups had average amounts of spherical and irregular aberrations. CONCLUSIONS: Neither surgical techniques nor contact lenses resulted in BCVA or best corrected contrast sensitivity that surpassed the values measured in the best corrected spectacles groups. The Artisan claw lens performed better than LASIK in UCVA, predictability, and best corrected contrast sensitivity.

Effect of infusion bottle height on lens power after lens refilling with and without a plug.

PURPOSE: To evaluate the influence of intraoperative infusion bottle height on the power of refilled pig lenses. SETTING: Research Laboratory, Pharmacia Intraocular Lens Manufacturing Plant, Groningen, The Netherlands. METHODS: This study comprised 2 groups of pig eyes. In 1 group, the lens was refilled with silicone oil using a plug to close the capsulorhexis; in the other group, no plug was used. The anterior chamber depth, lens thickness, and vitreous chamber depth were measured by A-scan ultrasound. The total refraction was measured with a Hartinger refractometer. Measurements were performed with the infusion bottle at 0 cm, 25 cm, 50 cm, 75 cm, and 100 cm above eye level. Calculations using a model eye were performed to evaluate the change in lens power based on empirical data. RESULTS: The mean change in the power of refilled lenses caused by varying the height of the infusion bottle was 1.8 diopters. Lenses refilled with a plug had a thickness similar to that of natural lenses. Lenses refilled without a plug were significantly thinner (P<.05). The power of lenses refilled with a plug was significantly higher that of lenses refilled without a plug (P<.05). CONCLUSIONS: During lens refilling, infusion bottle height influenced the resulting lens power. Using a plug to close the capsulorhexis resulted in refilled lens dimensions similar to those of the natural lens.

Polymer refilling of presbyopic human lenses in vitro restores the ability to undergo accommodative changes.

PURPOSE: Because presbyopia is thought to be accompanied by increased lens sclerosis this study was conducted to investigate whether refilling the capsule of the presbyopic human lens with a soft polymer would restore the ability of the lens to undergo accommodative changes. METHODS: Accommodative forces were applied to natural and refilled lenses by circumferential stretching through the ciliary body and zonular complex. Nine natural lenses and 10 refilled lenses from donors ranging in age from 17 to 60 years were studied. Two refill polymers with a different Young's modulus were used. The lens power was measured by a scanning laser ray-tracing technique, and lens diameter and lens thickness were measured simultaneously while the tension on the zonules was increased stepwise by outward pull on the ciliary body. RESULTS: In the natural lenses the older lenses were not able to undergo power changes with stretching of the ciliary body, whereas in the refilled lenses, all lenses showed power changes comparable to young, natural lenses. The refilled human lenses had a higher lens power than the age-matched natural lenses. The Young's modulus of the polymers influenced the lens power change when measured with the ciliary body diameter increased by 4 mm. CONCLUSIONS: Refilling presbyopic lenses with a soft polymer enabled restoration of lens power changes with mechanical stretching. Because sclerosis of the lens is an important factor in human presbyopia, refilling the lens during lens surgery for cataract could enable restoration of clear vision and accommodation in human presbyopia.

The effect of visual field defects on driving performance: a driving simulator study.

OBJECTIVES: To investigate the effect of visual field defects on driving performance, and to predict practical fitness to drive. METHODS: The driving performance of 87 subjects with visual field defects due to ocular abnormalities was assessed on a driving simulator and during an on-road driving test. OUTCOME MEASURES: The final score on the on-road driving test and simulator indexes, such as driving speed, viewing behavior, lateral position, time-headway, and time to collision. RESULTS: Subjects with visual field defects showed differential performance on measures of driving speed, steering stability, lateral position, time to collision, and time-headway. Effective compensation consisted of reduced driving speed in cases of central visual field defects and increased scanning in cases of peripheral visual field defects. The sensitivity and specificity of models based on vision, visual attention, and compensatory viewing efficiency were increased when the distance at which the subject started to scan was taken into account. CONCLUSIONS: Subjects with visual field defects demonstrated differential performance on several driving simulator indexes. Driving examiners considered reduced speed and increased scanning to be valid compensation for central and peripheral visual field defects, respectively. Predicting practical fitness to drive was improved by taking driving simulator indexes into account.