This systematic review and network meta-analysis compares outcomes of presbyopia-correcting intraocular lenses frequently recommended in clinical practice.
Key Points
Question
Which intraocular lenses (IOLs) are most effective for correcting presbyopia?
Findings
In this systematic review and bayesian network meta-analysis, 27 studies comprising 2605 patients were included from randomized clinical trials. The greatest improvement in visual acuity considering uncorrected near visual acuity was achieved with trifocal IOLs and bifocal diffractive IOLs, while trifocal IOLs and extended depth-of-focus IOLs ameliorated uncorrected intermediate visual acuity.
Meaning
If multifocal lenses are considered following cataract surgery, these findings indicate that bilateral implantation of trifocal IOLs might be an optimal option for individuals in whom presbyopia needs to be corrected.
Abstract
Importance
A bayesian network meta-analysis (NMA) can help compare the various types of multifocal and monofocal intraocular lenses (IOLs) used in clinical practice.
Objective
To compare outcomes of presbyopia-correcting IOLs frequently recommended in clinical practice through a bayesian NMA based on a systematic review.
Data Sources
Medline (PubMed) and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched on May 15, 2021, from inception.
Study Selection
Based on the research question, randomized clinical trials assessing multifocal IOLs in patients who underwent bilateral cataract extraction were searched. Nonrandomized studies, studies in patients with unilateral or contralateral cataract extractions, duplicated studies, conference abstracts, and nonpeer-reviewed articles were excluded.
Data Extraction and Synthesis
Descriptive statistics and outcomes were extracted. The NMA was conducted to compare different types of IOLs. The mean differences for continuous variables, odds ratios for binary variables, 95% credible intervals (CrIs), and ranks of interventions were estimated.
Main Outcomes and Measures
The outcomes examined included binocular visual acuities by distance and optical quality, including glare, halos, and spectacle independence.
Results
This NMA included 27 studies comprising 2605 patients. For uncorrected near visual acuity, trifocal IOLs (mean difference, −0.32 [95% CrI, −0.46 to −0.19]) and old bifocal diffractive IOLs (mean difference, −0.33 [95% CrI, −0.50 to −0.14]) afforded better visual acuity than monofocal IOLs. Regarding uncorrected intermediate visual acuity, extended depth-of-focus IOLs provided better visual acuity than monofocal IOLs. However, there were no differences between extended depth-of-focus and trifocal diffractive IOLs in pairwise comparisons. For uncorrected distant visual acuity, all multifocal IOLs were comparable with monofocal IOLs. There were no statistical differences between multifocal and monofocal IOLs regarding contrast sensitivity, glare, or halos.
Conclusions and Relevance
For patients considering a multifocal IOL due to presbyopia, bilateral implantation of a trifocal IOL might be an optimal option for patients without compromising distant visual acuity.
Introduction
In recent years, various types of presbyopia-correcting intraocular lenses (IOLs) have been developed to achieve clear intermediate and near visual acuity without glasses following cataract surgery. These include conventional multifocal (bifocal, trifocal, quadrifocal), accommodative, and extended depth-of-focus (EDOF) IOLs.1,2,3,4,5 In contrast to the standard monofocal IOLs that provide patients with good visual acuity at 1 focal point,1 multifocal IOLs can produce more than 1 focus based on refractive or diffractive optics, thereby affording adequate far and near vision.4 Thus, they minimize spectacle dependency after cataract surgery. However, patients may experience difficulties, such as reduced contrast sensitivity, glare, halos, or blurred vision, which may stem from the structural principles of multifocal IOLs.2
In most previous reviews, presbyopia-correcting multifocal IOLs were superior to monofocal IOLs in terms of near and intermediate vision. However, neither comprehensive comparisons of different IOLs6,7,8 nor, to our knowledge, systematic reviews based on direct and indirect comparisons among various types of multifocal IOLs have conducted. Furthermore, it remains controversial whether multifocal IOLs are beneficial in terms of visual quality.
Here, we conducted a systematic review and bayesian network meta-analysis (NMA) to simultaneously compare various types of multifocal IOLs, using all relevant evidence to comprehensively compare and rank them.
Methods
The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and its extension statement for NMAs.9 We registered the protocol in PROSPERO (CRD42021247359).
We searched randomized clinical trials (RCTs) assessing multifocal IOLs in patients who underwent bilateral cataract extraction on Medline (PubMed) and the Cochrane Central Register of Controlled Trials (CENTRAL) on May 15, 2021, from inception (eMethods in the Supplement). A PRISMA flowchart summarizes the meta-analysis selection process (eFigure 1 in the Supplement). We identified 219 and 196 studies on PubMed and CENTRAL, respectively. Two reviewers (J-Y.C. and J.-Y.H.) independently screened titles and abstracts manually in duplicate. Three reviewers (J-Y.C., J.-Y.H., and S-H.K.) carefully reviewed the full texts and selected articles meeting the eligibility criteria. Conflicts were resolved consensually by discussion with a third researcher (S-H.K.). Non-RCTs, studies focusing on identical types of IOLs, studies in patients with unilateral or contralateral cataract extractions, duplicated studies, conference abstracts, and nonpeer-reviewed articles were excluded. The language was restricted to English or Korean. Excluded studies, reasons for exclusion, and risk of bias assessment10 for the selected articles are described in the eMethods in the Supplement. Two reviewers (J-Y.C. and J.-Y.H.) manually extracted the original data from the selected studies, and 2 other reviewers (S-H.K. and N.K.) verified the extraction.
To compare and contrast different IOL types, we focused on binocular visual acuity, contrast sensitivity (under photopic and mesopic conditions), and patient-reported outcomes (glare, halos, and spectacle independence). The eMethods in the Supplement summarize the NMA study outcomes. We classified IOLs into the following types: monofocal, bifocal diffractive (old/new), bifocal refractive (old/new), accommodative, trifocal, or EDOF (eMethods in the Supplement). Bifocal IOLs have been available for a long time; therefore, it is necessary to distinguish between the initially released and the currently used, advanced models. We conducted the NMA (a random-effect model) using R version 3.5.1 (R Foundation) with the gemtc and BUGSnet packages.11 Network plots for each outcome were constructed to assess network geometry and show all possible direct and indirect comparisons (Figure 1 and eTables 1-3 in the Supplement). We examined the transitivity assumption by comparing deviance information criteria from consistency and inconsistency models (eMethods in the Supplement). Although we included RCTs, several studies showed a high risk of bias. Therefore, we additionally conducted an additional NMA on uncorrected visual acuity excluding high-risk studies.
Figure 1. Network Diagram.
EDOF indicates extended depth of focus.
We present NMA estimates as mean differences (MDs) for visual acuity and contrast sensitivity, risk ratios for glare, halos, and spectacle independence, 95% credible intervals (CrIs), and the ranking of treatments using surface under the cumulative ranking curve (SUCRA) plots. A higher SUCRA value for a specific outcome indicates a higher cumulative probability of a specific IOL type being ranked best in terms of that outcome. We also present forest plots that were created to compare multifocal with monofocal IOLs and league tables that illustrate pairwise comparisons between the different IOL types. The numbers of studies and IOL types included in the NMA for each outcome differed based on data availability. Raw data and geometric networks are provided in the eMethods in the Supplement.
Results
We included 27 RCTs reporting on and comparing binocular visual outcomes or optical quality for NMA (eFigure 1 in the Supplement). We synthesized outcomes from 2605 patients from 27 studies, comparing 8 types of IOLs for bilateral cataract extraction and summarized the study characteristics in the Table. The smallest study reported data from 25 patients, while the largest included 225 patients. The mean person follow-up time was 0.57 years. Most studies (23 of 27 [85.2%]) reported postoperative outcomes from 3 to 6 months, and 7 studies (25.9%) reported long-term outcomes, including visual acuity at 1 year postsurgery.17,21,24,25,29 Nineteen studies (70.3%) were conducted at a single center, while 8 (29.6%) were multicenter studies.12,14,24,26,27,32,34,36 Most samples included more female individuals, and the mean age was typically older than 60 years, consistent with the previously reported epidemiology of cataracts (eTable 4 in the Supplement). The most reported outcome measures were uncorrected near visual acuity (UNVA) and uncorrected distant visual acuity (UDVA).
Table. Characteristics of Included Studies in Meta-analysis.
| Source | Location | Follow-up, mo | No. of patients | |||||
|---|---|---|---|---|---|---|---|---|
| Accommodative | Bifocal diffractive | Bifocal refractive | EDOF | Trifocal diffractive | Monofocal | |||
| Alió et al,12 2011 | Spain | 3 | NA | 21 (Old) | NA | NA | NA | 13 |
| 19 (New) | ||||||||
| Alió et al,13 2011 | Austria, Spain | 6 | NA | 84 (Old) | 70 (New) | NA | NA | 72 |
| 78 (New) | ||||||||
| Alió et al,14 2018 | France, Germany, Spain | 6 | NA | 34 (New) | NA | NA | 15 | NA |
| Ang et al,15 2013 | Philippines | 6 | 31 | 62 (New) | NA | NA | NA | NA |
| Bilbao-Calabuig et al,16 2016 | Spain | 3 | NA | 11 (New) | NA | NA | 12 | NA |
| Cillino et al,17 2008 | Italy | 12 | NA | 16 (Old) | 16 (Old) | NA | NA | 16 |
| 15 (New) | ||||||||
| Cochener et al,18 2018 | France | 6 | NA | NA | NA | 20 | 40 | NA |
| Dyrda et al,19 2018 | Spain | 3 | NA | 64 (New) | 64 (New) | NA | NA | 32 |
| Gil et al,20 2012 | Spain | 3 | NA | 13 (Old) | 11 (New) | NA | NA | NA |
| 33 (New) | ||||||||
| Harman et al,21 2008 | UK | 18 | 30 | NA | 30 (Old) | NA | NA | 30 |
| Javitt and Steinert,22 2000 | Austria, Germany, US | 6 | NA | NA | 124 (Old) | NA | NA | 111 |
| Jonker et al,23 2015 | The Netherlands | 6 | NA | 13 (New) | NA | NA | 15 | NA |
| Kaymak et al,24 2017 | France, Germany, Spain | 12 | NA | 36 (New) | NA | NA | 16 | NA |
| Leyland et al,25 2002 | UK | 12 | NA | NA | 44 (Old) | NA | NA | 16 |
| Maxwell et al,26 2017 | US | 6 | NA | 155 (New) | NA | NA | NA | 165 |
| Mester et al,27 2007 | Germany | 6 | NA | 25 (Old) | 25 (Old) | NA | NA | NA |
| Mojzis et al,28 2014 | Czech | 3 | NA | 15 (New) | NA | NA | 15 | NA |
| Mojzis et al,29 2017 | Czech | 12 | NA | 18 (New) | NA | NA | 20 | NA |
| Martínez Palmer et al,4 2008 | Spain | 3 | NA | 58 (Old) | 32 (New) | NA | NA | 24 |
| Pedrotti et al,30 2020 | Italy | 3 | NA | NA | NA | 25 | NA | 25 |
| Peng et al,31 2012 | China | 6 | NA | 50 (New) | NA | NA | NA | 51 |
| Pepose et al,32 2014 | US | 6 | 26 | 52 (New) | NA | NA | NA | |
| Rasp et al,33 2012 | Austria | 12 | NA | 28 (Old) | 30 (New) | NA | NA | 29 |
| 56 (New) | ||||||||
| Reinhard et al,34 2021 | Belgium, France, Germany, Italy, Portugal, Spain | 6 | NA | NA | NA | 145 | NA | 66 |
| Schojai et al,35 2020 | Germany | 3 | NA | NA | NA | 18 | NA | 18 |
| Shah et al,36 2015 | France, Germany, Italy, the Netherlands, Spain, UK | 6 | NA | 108 (New) | NA | NA | NA | 100 |
| Webers et al,37 2020 | The Netherlands | 3 | NA | NA | NA | 15 | 15 | NA |
Abbreviations: EDOF, extended depth of focus; NA, not applicable.
Visual Acuity
Figure 2 shows the overall rankings of each IOL type for binocular uncorrected visual acuity (see eFigure 4 in the Supplement for corrected visual acuities at various distances). UNVA was synthesized from 19 studies. For near distances, trifocal and bifocal diffractive lenses (old and new) showed higher SUCRA values than other lens types (Figure 2A). However, the league table shows that the CrI of each pairwise comparison of the top 3 IOLs included zero (eFigure 3 in the Supplement). Notably, all multifocal IOLs exhibited better probability than monofocal IOLs. All other types of IOLs showed a lower MD (implying better visual acuity) than monofocal IOLs, without including zero in the 95% CrI (Figure 3). For UNVA, trifocal diffractive IOLs showed the largest difference to monofocal IOLs (MD, −0.32 [95% CrI, −0.46 to −0.19]), followed by old-generation bifocal diffractive lenses with a value of −0.33 (95% CrI, −0.50 to −0.14). The league table summarizes the MDs for all comparisons (eFigure 3 in the Supplement).
Figure 2. Surface Under the Cumulative Ranking Curves for Visual Acuities.
EDOF indicates extended depth of focus.
aHigher rankings are associated with smaller outcome values.
Figure 3. Forest Plot for Uncorrected Visual Acuities Comparing Monofocal Intraocular Lenses (IOLs).
CrI indicates credible interval; EDOF, extended depth of focus.
Uncorrected intermediate visual acuity (UIVA) was analyzed using data from 11 studies. Figure 2B shows that 3 IOLs (accommodative, EDOF, and trifocal diffractive) had consistently higher probability of better ranking than monofocal and new-generation bifocal IOLs. The MDs of multifocal IOLs were consistently lower than those of monofocal IOLs. However, only the EDOF CrI did not include zero, and the accommodative IOLs exhibited the widest range of CrIs, with the lowest MD of −0.19 (95% CrI, −0.57 to 0.19) (Figure 3).
For UDVA, 23 studies reported outcomes, most frequently measured using the Early Treatment Diabetic Retinopathy Study at a 4-m distance. All IOLs had similar SUCRA values, except for old- and new-generation bifocal diffractive IOLs. Comparisons between monofocal and other IOLs showed small MDs compared with other distances. In addition, all CrIs of multifocal IOLs included zero when compared with monofocal IOLs.
The corrected or distant-corrected visual acuities yielded a tendency similar to that seen in the uncorrected outcomes. However, the highest SUCRA value for distant-corrected near visual acuity was found for trifocal diffractive IOLs, not for old-generation bifocal diffractive IOLs (eFigure 4A in the Supplement). In our distant-corrected intermediate visual acuity analysis, only EDOF lenses were comparable with monofocal IOLs because all other IOLs failed to make the network (eFigure 5 in the Supplement). Similar to the UDVA plot, the SUCRA plot for corrected distant visual acuity ranked the monofocal IOLs highest (eFigure 4C in the Supplement). Moreover, the MDs among the IOLs were small, consistent with UDVA results. Compared with monofocal IOLs, the CrIs of old- and new-generation bifocal diffractive IOLs did not include zero (eFigures 5-6 in the Supplement).
Contrast Sensitivity
Only 6 studies16,23,26,29,32,37 reported binocular contrast sensitivity according to IOL type. Four studies had 4 treatment arms under photopic conditions, while 6 studies had 5 treatment arms under mesopic conditions. Compared with monofocal IOLs, the CrIs of multifocal IOLs (accommodative [only reported under mesopic conditions], newly developed bifocal diffractive, EDOF, and trifocal diffractive IOLs) at 3, 6, 12, and 18 cycles per degree included zero under both photopic and mesopic conditions (Figure 4).
Figure 4. Binocular Contrast Sensitivity.
CPD indicates cycle per degree; CrI, credible interval; EDOF, extended depth of focus; IOL, intraocular pressure.
Glare, Halo, and Spectacle Independence
Several studies reported glare or halos as measures of visual quality. However, one obstacle to our meta-analysis was the variability in outcome measurements. Five studies that included 8 types of IOLs assessing halos as well as 6 studies examining 6 types of IOLs in terms of glare were analyzed. Reported visual symptoms showed a wide range of CrIs, including 1, compared with monofocal IOLs. Considering spectacle independence, we identified 7 studies that examined 8 IOL types. Compared with monofocal IOLs, both old-generation bifocal diffractive and bifocal refractive IOLs showed a high-risk ratio of spectacle independence at any distance (eFigure 7 in the Supplement).
Sensitivity Analysis and Inconsistency Assessment
A traffic light plot shows the results of the risk of bias assessment (eFigure 2 in the Supplement). Six studies had a high risk of bias. The domains with fewer studies evaluated as low risk were bias due to selection of reported results and bias due to randomization. The sensitivity analysis excluding high-risk studies showed results consistent with the base case (eFigure 8 in the Supplement). All multifocal IOLs except for old-generation bifocal refractive IOLs provided better UNVA than monofocal IOLs. There was no difference among the multifocal IOLs, in line with the base case. EDOF lenses showed a smaller MD than monofocal IOLs with zero not included in their CrIs at intermediate distances. UDVA did not differ among IOLs.
The UNVA inconsistency assessment, our primary outcome, yielded deviance information criteria of 82.64 and 83.67 for consistency and inconsistency, respectively (eMethods in the Supplement). There was no remarkable difference in the distribution of the effect modifiers (eMethods in the Supplement). The included RCTs were generally similar, as we limited studies to those on bilateral cataract surgery, and presbyopia-correcting cataract surgery aims to obtain a specific range of visual acuity. The transitivity assumption was thus plausible.
Discussion
Our NMA provided simultaneous pairwise analyses across numerous multifocal IOLs. We presented IOL rankings based on direct and indirect evidence regarding corrected/uncorrected distant, intermediate, and near vision, as well as visual quality factors including contrast sensitivity, glare, and halos. Our results showed that bilateral implantation of trifocal IOLs is beneficial with best near visual acuity and good intermediate visual acuity with no significant decrease in contrast sensitivity or increase in glare and halos. For patients for whom intermediate visual acuity is more important, EDOF IOLs might thus be the better choice.
Several systematic reviews of multifocal IOLs have been published since the early 2000s.6,7,38,39,40,41,42 Notably, the Cochrane review titled “Multifocal Versus Monofocal Intraocular Lenses After Cataract Extraction” was first published in 2001 and was updated in 20167,38,40,42,43,44,45 because presbyopia has not yet been addressed and because multifocal IOLs with a new concept are still being developed. In 2014, a Cochrane review comparing accommodative and monofocal IOLs concluded that a small gain in near visual acuity at 6 months postoperatively and a loss of far visual acuity at 12 months postoperatively.7 The most recent Cochrane review from 2020 compared trifocal and bifocal IOLs and concluded that trifocal IOLs may be better at improving UIVA at 1 year. There were no differences regarding near and far visual acuity.42 The authors commented that future research should include the comparison of both trifocal and specific bifocal IOLs that correct intermediate visual acuity to evaluate important outcomes such as contrast sensitivity and quality of life. Herein, we thus applied a bayesian NMA to overcome the drawbacks of traditional meta-analyses, allowing us to compare a specific type of multifocal IOLs with a number of other IOL types. We last searched on May 15, 2021, and included the most up-to-date RCTs as well as the recently developed EDOF IOLs, which increases the relevance of our study for current clinical settings.
For binocular UNVA, all types of multifocal IOLs afforded better visual acuity than monofocal IOLs without overlapping CrIs. Regarding binocular UIVA, trifocal and EDOF IOLs provided improvements relative to monofocal IOLs without overlapping CrIs; however, accommodative and newly developed bifocal diffractive IOLs failed to show improvements when compared with monofocal IOLs. For binocular UDVA, most multifocal IOLs were comparable with monofocal IOLs. All multifocal IOLs showed consistently better performance than monofocal IOLs for near and intermediate vision, consistent with previous reports.1,39,40,41 Intermediate vision is a well-known drawback of bifocal IOLs, which only possess 2 focal points for near and far distances.40,46 Furthermore, Yoon et al47 and Yang et al48 have reported no statistically significant differences in binocular UNVA and UIVA between trifocal and bifocal IOLs, while no meta-analyses have compared different multifocal IOLs, to our knowledge.
Regarding subjective visual quality, we observed that far vision, contrast sensitivity, and quality of vision following bilateral implantation were comparable for presbyopia-correcting multifocal and monofocal IOLs. Despite the advantage of visual acuity at various distances, lower contrast sensitivity has been reported for multifocal IOLs compared with monofocal IOLs,12,38,49,50 especially under mesopic conditions.19,51 These effects seem to be inherent in the structural characteristics of multifocal IOLs that divide light power in 2 or more foci. In line with our results, there were no differences between multifocal and monofocal IOLs in terms of binocular contrast sensitivity, although monocular contrast sensitivity was significantly lower for multifocal IOLs than for monofocal IOLs in a prospective clinical trial involving bilateral cataract surgery.52
Limitations
Our review has several limitations. First, the included studies measured visual acuity using different intermediate (66-80 cm) and near (33 and 40 cm) distances. We attempted to analyze acuity at each distance; however, the numbers of available values were too limited to build a network. Therefore, we comprehensively assessed UIVA and UNVA with a limited range of distances. More than 50% of studies performed measurements at 40 cm for near and 2 feet or 70 cm for intermediate distances. Although we expected some heterogeneity, the results were consistent with those for distance-corrected visual acuity. Additionally, on including intermediate visual acuity measured at 60 and 90 cm, we observed that the estimated ranks and MDs were similar to our base case results. The observed differences do not have direct clinical relevance because we could not determine if there are differences in visual acuity at different distances. Therefore, no recommendations should be made based on these findings; rather, the present review adds to the existing data to help identify potential hypotheses to pursue in future clinical trials. Further studies will be required to perform in-depth evaluations of UIVA and UNVA by unifying distances and to identify potential differences in visual acuity across distances.
Second, we could not analyze some clinically important measurements, including defocus curves, higher-order aberrations, and patient-reported outcomes such as postoperative satisfaction, because they were not represented quantitively or essential numbers were not provided. Limited results were thus selected for the meta-analysis, as measurements varied across studies and each measurement was conducted under different circumstances regarding pupil size, illuminance, or distance of visual acuity measurements. Furthermore, most studies included more female individuals and had a mean age older than 60 years. Results from younger/older individuals or samples with a different male:female ratio may yield different results. Therefore, a variety of measurements and patient ages should be considered in further studies to compare the visual outcomes of various IOL types in a more comprehensive way.
Third, subjective variability has been noted in glare, halos, and spectacle independence measurements, and most studies did not use objective scoring systems.17,41 Therefore, we converted outcomes into binary form and interpreted results restrictively. Further meta-analyses are necessary to assess optical quality including patient satisfaction and quality of life.
Fourth, because we also included RCTs that did not provide details regarding randomization methods, we had some concerns regarding the risk of bias because of randomization and result selection. However, our sensitivity analysis that excluded high-risk studies yielded results that were consistent with our main NMA. Additional systematic reviews with more RCTs assessing newer IOLs are warranted to mitigate the possibility of bias.
Fifth, we used only 2 databases, and potentially relevant articles might not have been included in the present review. However, our study represents the systematic review with the highest number of RCTs on bilateral cataract surgery to date. Sixth, we did not consider postoperative adverse events to compare safety between different IOL types.
Despite these limitations, our review, including the largest number of relevant studies to date and providing SUCRA ranks for various IOL types and different outcome measures, provides comprehensive clinical evidence. Our examination of the effectiveness and stability of almost every type of presbyopia-correcting multifocal IOL will be helpful for optimal IOL selection to fit each patient’s maximum visual needs. In spite of some heterogeneity caused by differences across measured multifocal vs monofocal IOLs after cataract extraction distances, trifocal and EDOF IOLs demonstrated better visual performance in the overall range of distances. In particular, trifocal provided better visual acuity than monofocal IOLs. However, this finding does not imply that trifocal IOLs should be used for patients merely because they afford better near and intermediate visual acuities without added glare or halos. Because we only analyzed outcomes for the same IOLs implanted binocularly, our results cannot be applied to patients who undergo unilateral or contralateral cataract surgery. Besides, because all included studies were RCTs comparing groups only in terms of multifocality, the included patient samples may differ from the general population in terms of health status, personality, and attitudes toward medical care. The high cost of multifocal IOLs and insurance reimbursement should also be considered for the selection of presbyopia-correcting IOLs, together with individual patient needs in real-world settings. Additional studies related to cost-effectiveness are needed.
Conclusions
In conclusion, we used a bayesian NMA to compare various multifocal and monofocal IOLs, using 27 RCTs comprising 2605 patients. For patients considering a multifocal IOL caused by presbyopia, bilateral implantation of a trifocal IOL would be an optimal option for those who want to be spectacle-free. Further studies are warranted to evaluate which IOLs are most effective for presbyopia correction across various distances.
eMethods.
eFigure 1. PRISMA flow chart of study selection
eFigure 2. Traffic light plot for assessing the risk of bias
eFigure 3. Pairwise comparison for uncorrected visual acuities
eFigure 4. SUCRA for visual acuities
eFigure 5. Forest plot for corrected visual acuities compared with monofocal IOL
eFigure 6. Pairwise comparison for corrected visual acuities
eFigure 7. Pairwise comparison for quality of vision
eFigure 8. Forest plot for corrected visual acuities compared with monofocal IOL from the studies without high risk of bias
eTable 1. Detailed information regarding network geometry
eTable 2. Detailed information on network geometry by treatment
eTable 3. Detailed information on network geometry by pairwise comparison
eTable 4. Characteristics of included studies in the meta-analysis
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods.
eFigure 1. PRISMA flow chart of study selection
eFigure 2. Traffic light plot for assessing the risk of bias
eFigure 3. Pairwise comparison for uncorrected visual acuities
eFigure 4. SUCRA for visual acuities
eFigure 5. Forest plot for corrected visual acuities compared with monofocal IOL
eFigure 6. Pairwise comparison for corrected visual acuities
eFigure 7. Pairwise comparison for quality of vision
eFigure 8. Forest plot for corrected visual acuities compared with monofocal IOL from the studies without high risk of bias
eTable 1. Detailed information regarding network geometry
eTable 2. Detailed information on network geometry by treatment
eTable 3. Detailed information on network geometry by pairwise comparison
eTable 4. Characteristics of included studies in the meta-analysis