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Comparisons of the in-the-bag stabilities of single-piece and three-piece intraocular lenses for age-related cataract patients: a randomized controlled trial
- Xiaojian Zhong†1,
- Erping Long†1,
- Wan Chen1,
- Wu Xiang1,
- Zhaochuan Liu1,
- Hui Chen1,
- Jingjing Chen1,
- Zhuoling Lin1,
- Haotian Lin1Email author and
- Weirong Chen1Email author
© The Author(s). 2016
Received: 19 December 2015
Accepted: 22 June 2016
Published: 8 July 2016
To compare the in-the-bag stability and visual function of single-piece intraocular lenses (IOLs) and three-piece IOLs.
A total of 65 patients with age-related cataracts (80 eyes) were enrolled and randomly assigned to receive in-the-bag implantation of either a single-piece IOL (40 eyes) or a three-piece IOL (40 eyes). Follow-up visits were conducted at 1 week, 1 month and 3 months postoperatively. Visual acuity, refraction and total aberration were examined. IOL position stability (including axial movement, decentration and tilt) was measured using a Scheimpflug imaging system.
At the 3-month follow-up visit, single-piece IOLs did not exhibit significant axial movement (0.07 ± 0.30 mm, p = 0.13) compared with their axial position at 1 week postoperatively, whereas three-piece IOLs displayed forward axial movement of −0.22 ± 0.23 mm (p < 0.0001). The mean manifest spherical equivalence (SE) of eyes with single-piece IOL was 0.15 ± 0.18D, whereas in eyes with three-piece IOLs, the mean manifest SE was −0.34 ± 0.15D (p < 0.001). There was no statistically significant difference in IOL decentration, tilt, uncorrected visual acuity, best-corrected visual acuity or total spherical aberration between the two groups.
Three months after implantation, single-piece IOLs exhibit better axial stability and more stable refractive outcome than three-piece IOLs, but both IOLs perform equally well in terms of decentration, tilt, visual acuity and total aberration.
ClinicalTrial.gov, NCT02609997, 11/18/2015, retrospectively registered.
Rapid advances in cataract surgery techniques and intraocular lens (IOL) technology have enabled the transition of cataract surgery from blindness relief to refractive correction . An ideal IOL is the critical component to achieve the refractive target of cataract surgery. Biocompatibility, rate of posterior capsule opacification (PCO) and visual quality have all been suggested as critical characteristics of an ideal IOL and widely investigated. Stability of IOL position was also recently proposed as a critical factor due to its close correlation with postoperative visual function. An IOL forward movement of 0.29 mm along the visual axis has been associated with a myopic shift of −0.4D . Meanwhile, Wang and colleagues recently reported that 0.5-mm decentration of an aspheric IOL could eliminate its aberration-correcting effect . Moreover, poor stability could even lead to IOL exchange as well as additional surgery, which both surgeons and patients wish to avoid.
As the supporting element, haptics are crucial to maintaining the position of the IOL. Various haptic designs have been compared in terms of the position stability of IOLs. Haptic designs of single-piece versus three-piece IOLs are often compared because these are the most commonly used types. Single-piece IOLs have soft and broader haptics that are manufactured from the same material as the optic, usually hydrophobic or hydrophilic acrylic, whereas three-piece IOLs have rigid haptics that are composed of poly methyl methacrylate (PMMA). Clinical studies comparing these haptic designs have yielded conflicting results regarding their position stability in the capsular bag, the most-recommended site for IOL fixation in an uneventful cataract surgery.
Most previous studies have measured the IOL position based on Purkinje reflections . However, this measurement is time-consuming, and patients are reluctant to cooperate during image acquisition . In addition, Purkinje measurement does not detect anterior chamber depth (ACD) and thus fails to reveal the IOL position along the axis. By contrast, clinical Scheimpflug systems based on rotating Scheimpflug imaging can acquire enough 3-dimensioinal data points within a reasonably short period, usually seconds, and are one of the best methods to estimate IOL position .
To better compare the intracapsular stability of single-piece and three-piece IOLs, we measured IOL positions using rotating Scheimpflug imaging systems and tested the visual quality of patients implanted with these IOLs.
The protocol for this trial is available as supplementary information; see Additional file 1.
A total of 65 patients with age-related cataracts (80 eyes) were enrolled between December 2012 and December 2013 from Zhongshan Ophthalmic Center (ZOC) , which is China’s largest eye hospital and is located in Guangzhou city, South China.
Inclusion and exclusion criteria
The inclusion criteria
Patients with a diagnosis of bilateral age-related cataracts
Age between 60 and 85 years.
The exclusion criteria
Diagnosis of vision-impairing diseases other than cataracts, severe refractive error (preoperative spherical equivalent of either eye > −6.00D or +5.00D);
History of ocular trauma; past refractive surgery or other ophthalmic surgery;
Capsular or zonular disorders that might affect the post-operative centration of IOLs, e.g., pseudo-exfoliation syndrome or Marfan syndrome;
Surgical complications including severe hyphema, iris injury, repeated IOL implantation during surgery, failure to achieve in-the-bag IOL implantation and corneal sutures.
Randomization and masking
Intraoperative and postoperative procedures
All patients underwent standard phacoemulsification cataract extraction performed by a single experienced cataract surgeon (WRC). Topical anesthesia consisting of a single drop of 0.5 % proparacaine (Alcaine, Alcon Laboratories, Inc, Texas, USA), was administered three times at 5-min intervals prior to surgery. A 3.2-mm temporal corneal incision was followed by 5.5-mm capsulorhexis, hydrodissection and phacoemulsification of the nucleus, irrigation/aspiration of the remaining cortex, in-the-bag implantation of the IOL and final hydration of the incision. The target refraction was set at emmetropia for all patients.
Postoperative topical therapy included 0.3 % tobramycin and 0.1 % dexamethasone eye drops (Tobradex, Alcon Laboratories, Inc, Texas, USA) four times per day and 0.3 % tobramycin and 0.1 % dexamethasone eye ointment (Tobradex, Alcon Laboratories, Inc, Texas, USA) every night for one month.
Follow-up protocol and assessment methods
The sample size calculation was based on power analysis. Power analysis adopts a hypothesis-testing method to determine the sample size according to several parameters, which include the pre-specified significance level, desired power level and expected effect size. Assuming a two-tailed alpha of 0.05, a probability of 0.2 for beta error (80 % power) and the reported results of similar research  as our reference rate, 40 participants per group were required.
Demographic and clinical information were recorded at baseline. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS ver. 17.0.1, SPSS Inc., Chicago, IL, USA). The normality of the data distribution was assessed using the Kolmogorov-Smirnov test. An unpaired t test was performed to compare means of continuous variables that exhibited normal distributions (axial movement, decentration, tilt, visual acuity, refraction and total aberration) between the two groups. Continuous variables without a normal distribution were compared using the Mann–Whitney U test. Categorical variables such as sex were compared using Fisher’s exact probability test. Because of the nested structure of the eyes, we additionally applied a generalized estimating equation with a working covariance matrix of unstructured correlations to analyze repeated measures data. All statistical tests were two-tailed, and a p-value below 0.05 was considered statistically significant. The results are presented as the mean ± standard deviation (SD).
Baseline characteristics of the participants in the present study comparing the in-the-bag stabilities of single-piece and three-piece intraocular lenses
(Single piece IOL)
Mean ± SD
Mean ± SD
73.3 ± 9.3 years
71.4 ± 7.7 years
(Range 60–85 years)
(Range 61–83 years)
23.42 ± 1.35 mm
23.53 ± 1.18 mm
2.67 ± 0.45 mm
2.75 ± 0.49 mm
In-the-bag stability of single-piece and three-piece IOLs at 3 months
Mean ± SD
Mean ± SD
0.07 ± 0.30 mm
−0.22 ± 0.23 mm*
221 ± 167 μm
198 ± 165 μm
1.06 ± 0.49°
1.01 ± 0.45°
Visual function of eyes with single-piece and three-piece IOLs at 3 months
Mean ± SD
Mean ± SD
0.04 ± 0.06 (logMAR)
0.04 ± 0.08 (logMAR)
0.02 ± 0.09 (logMAR)
0.03 ± 0.08 (logMAR)
0.15 ± 0.18 D
−0.34 ± 0.15 D
0.03 ± 0.06 μm
0.02 ± 0.07 μm
IOL position stability is closely related to postoperative visual function. Various factors affect position stability. Our study compared the position stability of single-piece and three-piece aspheric IOLs in a clinical scenario. The results revealed that single-piece IOLs moved less than three-piece IOLs along the visual axis and therefore had greater axial stability. The forward movement of three-piece IOLs caused a slight myopic shift, whereas the refractive status of single-piece IOLs remained stable. This result is consistent with previous studies [9, 10].
In a laboratory study of the biomechanical properties of IOLs with different haptic designs , Lane et al. demonstrated that the optic of a single-piece IOL exhibits significantly less axial movement than that of three-piece IOLs during haptic compression. After implantation in the capsular bag, the haptics undergo compression, particularly in the case of capsular contraction, and soft haptics exert less force on the optic, resulting in less axial movement of the IOL. Axial movement beyond a certain extent will lead to “refractive surprises” and unsatisfactory visual function. In the worst scenario, a refractive surprise would require IOL exchange . Therefore, single-piece IOLs might be more appropriate for implantation in the capsular bag due to better position stability.
Decentration and tilt of single-piece and three-piece spherical IOLs have been investigated in multiple studies . Our observations of aspheric IOLs are consistent with these studies and indicate that the decentration and tilt of both types of IOLs are not clinically significant. Aspheric IOLs are unique in that they pose greater demands on centration. McKelvie et al. investigated the association of IOL decentration and tilt with aberration and suggested decentration greater than 0.5 mm and tilt greater than 4° are clinically significant for aspheric IOLs . In our study, the decentration and tilt were within these limits in both groups, and the total aberration in both groups was close to zero, consistent with McKelvie’s results.
Previous comparisons of the position stability of different IOLs have primarily used Purkinje imaging to measure IOL position in the eye. For this method, a point-light source is fixed at a certain distance in front of the eye. The patient is asked to stare at the light source, and reflections of the light source form at the front cornea, back of the cornea and anterior surface of IOL. The image of these reflections is recorded, and the distances between any two reflections are measured and used to calculate the decentration and tilt of the IOL . The Purkinje method is the gold standard for measuring IOL decentration and tilt . However, the use of the Purkinje method among patients with age-related cataracts is hindered by low compliance by elderly subjects. Keeping the eyelids wide open and staring at a light source for a certain time can be challenging for these patients. Furthermore, the Purkinje method cannot measure the axial position of the IOL. Our study used a rotating Scheimpflug imaging system (Pentacam) to measure the position of the IOL in the eye. Rosales et al. determined that Purkinje and Scheimpflug have comparable accuracy and repeatability . An advantage of the Scheimpflug imaging system is that the image acquisition time is 3 s or less; thus, most patients are able to cooperate well. Few clinical studies have employed the Scheimpflug imaging system, and further studies are needed to confirm its diagnostic value.
The results and interpretation of the current study must be understood within the context of its strengths and limitations. Few clinical studies have used a rotating Scheimpflug imaging device to compare stability in the capsular bag between single-piece and three-piece IOLs. The process of image acquisition and data generation is independent of the operator; the measurement is therefore objective, and the results provide additional clinical evidence. This is the major strength of the present study. However, our study features several limitations as well. First, patients were followed up only for three months. This short follow-up period is not fully adequate to determine if single-piece IOLs or three-piece IOLs are more appropriate for implantation in the capsular bag. Second, the sample size of the present study was insufficient to detect differences in decentration and tilt. Third, fellow-eye comparison was not performed due to ethical considerations. Despite these limitations, the results of this study are useful given the lack of clinical investigations of aspheric IOLs with different haptic designs. Further studies with longer follow-up periods, larger sample sizes and more rigorous designs are needed.
In summary, the current study compared the position stability of single-piece and three-piece aspheric IOLs using a rotating Scheimpflug imaging system. The axial movement of single-piece IOLs was significantly less than that of three-piece IOLs. The forward movement of the three-piece IOL was associated with myopic shift. The aspheric IOLs were similar in the amount of decentration, tilt, visual acuity and total aberration. Further studies are needed to evaluate the long-term stability and visual function of these IOL designs.
ACD, anterior chamber depth; IOL, intraocular lenses; PCO, posterior capsule opacification; PMMA, poly methyl methacrylate; SD, standard deviation; SE, spherical equivalent; ZOC, Zhongshan Ophthalmic Center
We thank Dr. Runzhong Liu for data analysis.
This clinical study was supported by the National Natural Science Foundation of China (81270980, 81570889, and 91546101), the Guangdong Technology Programs (2009B080701017), the Guangdong Provincial Natural Science Foundation for Distinguished Young Scholars of China (2014A030306030), and Collaboration Funds of Clinical Research Center of Zhongshan Ophthalmic Center, Sun Yat-sen University (3030901011044, 3031101023). The sponsors of the study played no role in the study protocol design, data collection, data analysis, data interpretation, manuscript preparation, or the decision to submit the manuscript for publication.
Availability of data and materials
All the data supporting the conclusions of this article is included within the article.
Involved in the design of the study (X.J.Z., H.T.L., W.R.C.); conduct of the study (X.J.Z., H.T.L., J.J.C., Z.C.L., Z.L.L., E.P.L.); collection, management, analysis, and interpretation of the data (X.J.Z., E.P.L., H.T.L., J.J.C., Z.C.L., C.W., W.X., H.C.); preparation of the manuscript (X.J.Z., E.P.L., H.T.L., W.C., W.X., H.C.); and critical revision of the manuscript (X.J.Z., E.P.L., H.T.L., J.J.C., Z.L.L., Z.C.L., W.C., W.R.C.). All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
All study procedures were performed in accordance with the tenets of the Declaration of Helsinki, and the study was approved by the Ethics Committee of the Zhongshan Ophthalmic Center. Written informed consent was obtained from all the study participants. This study was registered with ClinicalTrials.gov (NCT02609997).
The research protocol was approved by the Institutional Review Board/Ethics Committee of Sun Yat-sen University (Guangzhou, China). Informed written consent was obtained from each participating patient, and the tenets of the Declaration of Helsinki were followed throughout this study. To allow confidential evaluation of Scheimpflug imaging systems, the Pentacam and the Slit-Lamp procedures used in this study, this trial was registered with the Clinical Research Internal Management System of ZOC. This study was registered with ClinicalTrials.gov (NCT02609997). The authors confirm that all ongoing and related trials for this study are registered.
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