Toric Trifocal IOL Treatment With High Astigmatism and Hyperopia vs SMILE Enhancement After Trifocal IOL Treatment With High Astigmatism and Hyperopia
Phase: NA
Conditions: Astigmatism High Both, Pseudophakia, Hyperopia
Sponsor: Eye Hospital Pristina Kosovo

 
 
 
 
 
 
TORIC TRIFOCAL IOL  
TREATMENT WITH HIGH 
ASTIGMATISM AND 
HYPEROPIA  
VS 
RELEX SMILE ENHANCEMENT  
Dr. Faruk Semiz 
Head of Ophthalmology 
15 June 2020 
info@eyehospital-ks.com 

 Toric trifocal IOL treatment with high astigmatism and hyperopia 
vs 
SMILE enhancement after trifocal IOL treatment with high astigmatism and hyperopia 
 
Authors: 
Dr. Faruk Semiz, Dr. Anita Syla Lokaj, Dr. Njomza Hima Musa, Ph.Doc. Dr. Olcay Semiz 
 
 
Affiliation(s): 
Department of Ophthalmology, Eye Hospital, Pristina - Kosovo 
 
Corresponding author: 
Dr. Faruk Semiz 
Pristina, 10000  
Republic of Kosovo  
 
faruksemiz@yahoo.com 
anitasylaj@live.com 
 
njomzahima@yahoo.com  
 
 
 
Abstract 
 
Purpose: 
The aim of this study was to assess visual and refractive outcomes after toric trifocal lens implantation 
and also visual outcomes after laser vision correction with SMILE to correct residual refraction after 
6 months trifocal lens (IOL) implantation. Another objective was to proof that SMILE surgery in 
pseudophakic patients with trifocal  IOL is safe, effective, and predictable in a large cohort of patients. 
 
Setting: 
One site in Prishtina, Eye Hospital, Kosovo 
 
Design: 
Non-randomized prospective comparative study 
 
Methods: 
This prospective comparative study reviewed 40 eyes treated with trifocal toric lens implanatation in 
the first group and 40 eyes in the second group were treated with Relex SMILE for the reduction of 
the residual refractive error following 6 months after trifocal lens implantation. First group’s patients 
received a toric trifocal IOL implantation, second’s group patients received a spheric trifocal IOL 
and SMILE enhancement after 6 months.  
 
The SMILE surgery was performed with the VisuMax device (Carl Zeiss Meditec, Jena, Germany). 
After laser treatment the lenticule was extracted through the SMILE incision (size between 2 – 4 
mm). For the treatment of pseudophakic eyes the IOP increase during the laser treatment has to be 
very low. Vetter et al. have shown that the IOP increase with the VusMax device is only up to 63+/- 
22 mmHg (Vetter et al, Intraocular Pressure During Corneal Flap Preparation: Comparison Among 
Four Femtosecond Lasers in Porcine Eyes, Journal of Refractive Surgery • Vol. 27, No. 6, 2011) .   

The mean length of follow-up was 6 months (range 1 to 12 months) and mean interval between 
trifocal lens implantation and SMILE surgery was 6 months. Visual acuity (VA) at distance was 
tested at 5 m, VA at intermediate distance at 80 cm and VA at near vision at 40 cm. Other outcome 
measurements are refraction, patient satisfaction, and quality of life. The latter was evaluated at the 
last available visit. 
 
Results: 
The analysis included 40 eyes of 20 patients implanted with the trifocal IOL and 40 eyes of 20 patients 
implanted with the trifocal toric IOL, with no clinically signiﬁcant differences between groups.  4 
eyes of 2 patients of the 2nd group (SMILE after trifocal), patients were unhappy. Those patients 
underwent fresh lenticule implantation after 3 months and improved within 1week post op.  
 
Conclusion: Relex Smile surgery in pseudophakic patients with trifocal IOL was shown to be safe, effective, and 
predictable in a large cohort of patients. In conclusion, the current study demonstrates that both the 
non-toric and toric versions of the trifocal IOL evaluated here provide excellent functional vision to 
patients, with good distance, intermediate and near uncorrected VA, a wide range of vision and good 
contrast sensitivity.  
 
Key words: 
SMILE in pseudophakic patients, trifocal IOL, toric trifocal IOL 
 
 
 
INTRODUCTION 
 
The current state of the art for the correction of aphakia and presbyopia after lens extraction and 
refractive lensectomy is the implantation of multifocal intraocular lenses (IOL). In this study, the trifocal IOL 
types AT LISA TRI 839MP  and toric   AT LISA TRI TORIC 939MP  (Carl Zeiss Meditec, Jena, Germany) were 
assed. 
 
MATERIAL AND METHODS 
 
Population of the study 
 
In this prospective non-randomized study patients with spherical  hypermetropia of >4 D in combination with high 
astigmatism of >3.0 D were treated. The first group of 40 eyes of 20 patients underwent refractive lensectomy, 
followed by implantation of the diffractive trifocal IOL type AT LISA TRI 839MP (Carl Zeiss Meditec, Jena, 
Germany) and 6 months later SMILE surgery. In 40 eyes of 20 patients in the second group IOL type AT LISA TRI 
TORIC 939MP were implanted. All patients were adequately consulted preoperatively about this type of IOLs and 
they were verbally consented. The study is adherent to the tenets of the Declaration of Helsinki. All patient are 
between 20- 45 years old. 
 
Inclusion and exclusion criteria 
 
The included patients were seeking spectacle independence with pre-operative high spherical  hypermetropia over 
4 D or higher and  astigmatismus  >2 D or higher. Some patients had amblyopia or strabismus (accommodative 
esotropia) suitable for refractive lens exchange. 
 

Exclusion criteria were history of glaucoma, retinal detachment, corneal disease, irregular corneal astigmatism, 
abnormal iris, macular degeneration, advanced retinopathy, neuro ophthalmic disease, cataract, keratoconus, history 
of ocular inflammation, or previous ocular surgery 
 
Preoperative and postoperative assessments 
 
Prior to the surgical procedure, a complete ocular examination was done, including slit lamp examination, Goldman 
applanation tonometry, measurement of uncorrected distance visual acuity (UDVA), corrected distance visual 
acuity (CDVA) and corrected near visual acuity (CNVA), manifest refraction, keratometry and biometry (IOL 
Master v.4.3, Carl Zeiss Meditec, Jena, Germany), corneal topography (ATLAS, Carl Zeiss Meditec, Dublin, USA) 
and fundoscopy. The IOL Master and keratometry data were used to corroborate the Atlas 9000; other biometric 
data (axial length, white-to-white, anterior chamber depth) from the IOL Master were used for the IOL sphere 
calculation, considering results from the SRK-T, Haigis, Hoffer Q and Holladay formulas. In this study we used the 
Hoffer Q formula. Toric IOL calculations were made using the keratometric data from the Zeiss ATLAS 9000 and 
IOL Master and zcalc.  
 
Postoperative evaluation was performed on 1st day, 1 week, 1st month, 3rd month and 6th month after the second 
eye surgery. The postoperative protocol was identical to preoperative one with the additional evaluation of 
monocular and binocular uncorrected (UIVA) intermediate visual acuity (80 cm)  and monocular and binocular near 
visual acuity (40 cm) under the photic condition. Careful assessment of the status of IOL was done to look for 
any posterior capsular opacity (PCO) or malposition. 
 
Surgical technique 
 
All 
surgeries 
were 
performed 
by 
one 
experienced 
surgeon 
using 
a 
standard 
technique 
of 
sutureless phacoemulsification. In all cases, topical anesthesia was administered and pharmacologic mydriasis was 
induced using a combination of tropicamide and phenylephrine (10.0%). A mean clear corneal microincision of 
2.2 mm was made with a knife according to position of the preop highest K value of the patient. A paracentesis was 
made 60 degree to 80 degree, clockwise from the main incision, and the anterior chamber was filled with an 
ophthalmic viscoelastic (OVD) after phacoemulsification/lensectomy and removal of clear lens. The IOL was 
subsequently implanted through the main incision using the BLUEMIXS 180 injector (Carl Zeiss meditec, Jena, 
Germany) for trifocal IOL ,  VISCOJECTTM  BIO injector for toric trifocal IOL and then the OVD was removed. 
Postoperative pharmacologic treatment is performed with the combination of antibiotic and steroidal anti-
inflammatory drops. 
 
Intraocular lens 
 
Both AT LISA TRI 839MP and AT LISA TRI TORIC 939MP (for significant regular astigmatism) IOLs are 
designed for aphakia correction after crystalline lens removal. They are designed to be implanted into an intact 
capsular bag as a microincision IOL, and no enlargement of the incision (1.8 mm) is needed with the Bluemixs 
injector. The IOL material is a biocompatible hydrophilic copolymer with UV filter. The IOL material has 25% of 
water content at 35° C. The IOLs are trifocal within a lens diameter of 4.3 mm and bifocal between 4.3 mm and 
6 mm diameter. The add powers within the 4.3 mm diameter are 1.66 diopters to intermediate and 3.33 diopters to 
near distance. The add power between the 4.3 mm and 6 mm diameter is 3.75 diopters.  
 

Results  
 
Uneventful surgery? 
 
Visual acuity 
 
In group 1 (IOL + SMILE) 6 months’ post-op the UCVA values are mostly better in near and intermediate than pre-
op CDVA, but for far vision we found a decrease in many cases. After post-IOL SMILE enhancements, UCVA 
values increased for near, intermediate and far distance.  
 
6 months after SMILE treatment the number of eyes is highest with an increase of 0.1 for near vision between post-
op UCVA and pre-op UCVA (SMILE treatment day). For intermediate distance the highest number eyes have 
increased 0.2 between post-op UCVA and pre-op UCVA (SMILE treatment day).For far distance the highest number 
of eyes have increased 0.3 between post-op UCVA and pre-op UCVA (SMILE treatment day). 
 
In group 2 (toric IOL), 6 months’ post-op the UCVA are better than CDVA pre-op at all distances. In groups 2, for 
all distances (near, intermediate and far), after 3 months, the number of eyes having the same post-op UCVA like 
pre-op CDVA is highest. And in this group 2, after 6 months, the number of eyes with an increase of 0.1 of post-op 
UCVA over pre-op CDVA is highes. Also in group 2, after 6 months, the number of eyes with an increase of 0.2 of 
post-op UCVA over pre-op CDVA is highest. The results are also shown in Figure X.  
 
Conclusion 
 
The non-toric and toric trifocal IOLs provided good distance, intermediate and near vision to patients, with a wide 
range of vision and good contrast sensitivity. 
 
In conclusion, the current study demonstrates that both the non-toric and toric versions of the trifocal IOL evaluated 
here provide excellent functional vision to patients, with good distance, intermediate and near uncorrected VA, a 
wide range of vision and good contrast sensitivity. Relex Smile surgery in pseudophakic patients with trifocal IOL 
was safe, effective, and predictable in a large cohort of patients. It is noteworthy that the decision for a treatment 
strategy (toric IOL or non-toric IOL with SMILE in s second step) should be made carefully, to select the appropriate 
method for the patient . During phaco surgey the positions of incisions should be determined according to the angle 
of the highest K value of the patient. For high astigmatic patients, toric trifocal IOL are highly effective. 
 
 
 
 
 
 
 

 
 
 
  
6 Month after trifocal 
6 months after Relex Smile without glassess  
Difference 
Nr. 
  
1Day 
1Weak 
1Month 
3Month 
6Month 
1Day 
1Weak 
1Month 
3Month 
6Month 
 
1 
Refaction 
+6.50, +2.5ax75 
 
Near 
0.8 cc 
0.50 
0.80 
0.80 
0.80 
0.80 
0.80 
0.80 
0.90 
0.90 
0.90 
0,1 
Intermediate 
0.7 cc 
0.60 
0.60 
0.70 
0.70 
0.70 
0.70 
0.70 
0.80 
0.80 
0.80 
0,1 
Far 
0.6 cc 
0.30 
0.3 
0.50 
0.50 
0.50 
0.50 
0.60 
0.70 
0.70 
0.70 
0,1 
2 
Refaction 
+6.00, +2.00 AX 96 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.70 cc 
0.60 
0.60 
0.70 
0.80 
0.80 
0.80 
0.90 
0.90 
0.90 
0.90 
0,2 
Intermediate 
0.40 cc 
0.40 
0.50 
0.50 
0.60 
0.60 
0.70 
0.70 
0.70 
0.70 
0.70 
0,7 
Far 
0.60 cc 
0.30 
0.40 
0.40 
0.40 
0.40 
0.60 
0.60 
0.80 
0.80 
0.80 
0,2 
3 
Refaction 
+4.50, +2.0 AX 110 
  
  
  
  
  
  
  
  
  
  
 
Near 
1.0 cc 
0.80 
0.80 
0.80 
1.00 
1.00 
0.9 
0.90 
0.90 
1.00 
1.00 
0 
Intermediate 
0.90 cc 
0.70 
0.70 
0.70 
0.90 
0.90 
0.80 
0.80 
0.90 
1.00 
1.00 
0,1 
Far 
0.80 cc 
0.30 
0.30 
0.50 
0.60 
0.60 
0.70 
0.70 
0.80 
0.90 
0.90 
0,1 
4 
Refaction 
+5.00, +2.50 AX 65 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.90 cc 
0.70 
0.70 
0.80 
0.80 
0.80 
0.90 
0.90 
0.90 
1.00 
1.00 
0,1 
Intermediate 
0.80 cc 
0.60 
0.60 
0.70 
0.70 
0.70 
0.80 
0.80 
0.80 
0.90 
0.90 
0,1 
Far 
0.70 cc 
0.30 
0.40 
0.50 
0.60 
0.60 
0.70 
0.70 
0.70 
0.80 
0.80 
0,1 
5 
Refaction 
6.25, +2.75 AX 113 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.70 cc 
0.50 
0.60 
0.70 
0.70 
0.70 
0.70 
0.70 
0.70 
0.80 
0.80 
0,1 
Intermediate 
0.60 cc 
0.40 
0.50 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0.70 
0.70 
0,1 
Far 
0.50 cc 
0.20 
0.30 
0.30 
0.40 
0.40 
0.50 
0.50 
0.50 
0.60 
0.60 
0,1 
6 
Refaction 
+60, +2.25 AX 70 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.80 cc 
0.60 
0.60 
0.70 
0.70 
0.70 
0.70 
0.80 
0.90 
0.90 
0.90 
0,1 
Intermediate 
0.70 cc 
0.50 
0.50 
0.60 
0.60 
0.60 
0.60 
0.70 
0.80 
0.80 
0.80 
0,1 
Far 
0.60 cc 
0.30 
0.30 
0.40 
0.40 
0.40 
0.50 
0.60 
0.70 
0.70 
0.70 
0,1 
7 
Refaction 
+5.50, +3.00 AX 95 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.70 cc 
0.50 
0.50 
0.60 
0.70 
0.70 
0.70 
0.70 
0.70 
0.80 
0.80 
0,1 
Intermediate 
0.60 cc 
0.40 
0.40 
0.50 
0.60 
0.60 
0.60 
0.60 
0.60 
0.70 
0.70 
0,1 
Far 
0.50 cc 
0.70 
0.70 
0.70 
0.80 
0.80 
0.50 
0.50 
0.50 
0.60 
0.70 
0,2 
8 
Refaction 
+6.00, +2.75 AX 85 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.80 cc 
0.60 
0.60 
0.60 
0.70 
0.70 
0.70 
0.80 
0.80 
0.80 
0.80 
0 
Intermediate 
0.60 cc 
0.40 
0.40 
0.40 
0.50 
0.50 
0.60 
0.60 
0.60 
0.60 
0.60 
0 
Far 
0.50 cc 
0.20 
0.20 
0.30 
0.40 
0.40 
0.50 
0.70 
0.70 
0.70 
0.70 
0,2 
9 
Refaction 
+4.25, +3.25 AX 75 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.80 cc 
0.60 
0.60 
0.70 
0.80 
0.80 
0.80 
0.80 
0.80 
0.90 
0.90 
0,1 
Intermediate 
0.70 cc 
0.50 
0.50 
0.60 
0.70 
0.70 
0.70 
0.70 
0.70 
0.80 
0.80 
0,1 
Far 
0.60 cc 
0.30 
0.30 
0.40 
0.40 
0.40 
0.60 
0.60 
0.60 
0.70 
0.70 
0,1 
10 
Refaction 
+4.50, +2.75AX 105 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.80 cc 
0.60 
0.60 
0.80 
0.80 
0.80 
0.80 
0.80 
0.80 
0.90 
0.90 
0,1 

Intermediate 
0.70 cc 
0.50 
0.50 
0.70 
0.70 
0.70 
0.70 
0.70 
0.70 
0.80 
0.80 
0,1 
Far 
0.60 cc 
0.30 
0.30 
0.40 
0.40 
0.40 
0.60 
0.70 
0.60 
0.70 
0.70 
0,1 
               
  
6 Month after trifocal 
6 months after Relex Smile without glassess  
Differenc
e 
Nr
. 
  
1Da
y 
1Wea
k 
1Mont
h 
3Mont
h 
6Mont
h 
1Da
y 
1Wea
k 
1Mont
h 
3Mont
h 
6Month 
 
11 
Refaction 
+7.00, +2.00 AX 100 
 
Near 
0.70 cc 
0.60 
0.60 
0.60 
0.60 
0.60 
0.70 
0.70 
0.70 
0.80 
0.80 
0,1 
Intermediat
e 
0.60 cc 
0.50 
0.50 
0.50 
0.50 
0.50 
0.60 
0.60 
0.60 
0.70 
0.70 
0,1 
Far 
0.50 cc 
0.20 
0.30 
0.30 
0.40 
0.40 
0.50 
0.50 
0.50 
0.60 
0.60 
0,1 
12 
Refaction 
+7.00, +2.50 AX 80 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.60 cc 
0.50 
0.50 
0.50 
0.50 
0.50 
0.60 
0.60 
0.60 
0.70 
0.70 
0,1 
Intermediat
e 
0.50 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.50 
0.50 
0.50 
0.60 
0.60 
0,1 
Far 
0.40 cc 
0.10 
0.10 
0.30 
0.30 
0.30 
0.40 
0.40 
0.40 
0.50 
0.50 
0,1 
13 
Refaction 
+5.00, +2.00 AX 95 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.90 cc 
0.60 
0.60 
0.60 
0.70 
0.80 
0.80 
0.90 
0.90 
0.90 
0.90 
0 
Intermediat
e 
0.80 cc 
0.50 
0.50 
0.50 
0.60 
0.70 
0.70 
0.80 
0.80 
0.90 
0.90 
0,1 
Far 
0.70 cc 
0.40 
0.40 
0.40 
0.50 
0.50 
0.60 
0.70 
0.70 
0.80 
0.80 
0,1 
14 
Refaction 
+5.50, +2.00 AX 90 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.90 cc 
0.50 
0.70 
0.70 
0.70 
0.70 
0.80 
0.80 
0.90 
0.90 
0.90 
0 
Intermediat
e 
0.70 cc 
0.40 
0.60 
0.60 
0.60 
0.60 
0.70 
0.70 
0.80 
0.80 
0.80 
0,1 
Far 
0.60 cc 
0.30 
0.30 
0.30 
0.40 
0.40 
0.60 
0.60 
0.70 
0.70 
0.70 
0,1 
15 
Refaction 
+7.50, +2.50 AX 65 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.50 cc 
0.40 
0.40 
0.40 
0.50 
0.50 
0.50 
0.50 
0.60 
0.60 
0.70 
0,2 
Intermediat
e 
0.40 cc 
0.30 
0.30 
0.30 
0.40 
0.40 
0.40 
0.40 
0.50 
0.50 
0.60 
0,2 
Far 
0.30 cc 
0.10 
0.10 
0.20 
0.20 
0.20 
0.30 
0.30 
0.40 
0.40 
0.50 
0,2 
16 
Refaction 
+7.00,+2.75 AX 115 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.50 cc 
0.50 
0.50 
0.50 
0.50 
0.50 
0.50 
0.50 
0.60 
0.60 
0.70 
0,2 
Intermediat
e 
0.40 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.50 
0.50 
0.60 
0,2 
Far 
0.30 cc 
0.10 
0.10 
0.20 
0.20 
0.20 
0.30 
0.30 
0.40 
0.40 
0.50 
0,2 
17 
Refaction 
+5.75, +2.00 AX 105 
  
  
  
  
  
  
  
  
  
  
 
Near 
1.00 cc 
0.80 
0.80 
0.80 
0.80 
0.80 
1.00 
1.00 
1.00 
1.00 
1.00 
0 
Intermediat
e 
0.90 cc 
0.70 
0.70 
0.70 
0.70 
0.70 
0.90 
0.90 
0.90 
1.00 
1.00 
0,1 
Far 
0.80 cc 
0.40 
0.40 
0.40 
0.50 
0.50 
0.80 
0.80 
0.80 
0.90 
0.90 
0,1 
18 
Refaction 
+5.75, +2.25 AX 65 
  
  
  
  
  
  
  
  
  
  
 
Near 
1.00 cc 
0.70 
0.70 
0.70 
0.70 
0.70 
0.90 
0.90 
1.00 
1.00 
1.00 
0 
Intermediat
e 
0.90 cc 
0.60 
0.60 
0.60 
0.60 
0.60 
0.70 
0.70 
0.80 
0.80 
0.80 
-0,1 
Far 
0.80 cc 
0.40 
0.40 
0.40 
0.50 
0.50 
0.80 
0.80 
0.90 
0.90 
0.90 
0,1 
19 
Refaction 
+4.75, +2.00 AX70 
  
  
  
  
  
  
  
  
  
  
 
Near 
1.00 cc 
0.70 
0.70 
0.70 
0.80 
0.80 
1.00 
1.00 
1.00 
1.00 
1.00 
0 

Intermediat
e 
0.90 cc 
0.60 
0.60 
0.60 
0.70 
0.70 
0.90 
0.90 
0.90 
0.90 
0.90 
0 
Far 
0.80 cc 
0.40 
0.40 
0.50 
0.60 
0.60 
0.80 
0.80 
0.90 
0.90 
0.90 
0,1 
20 
Refaction 
+4.75, +2.50AX 115 
  
  
  
  
  
  
  
  
  
  
 
Near 
1.00 cc 
0.70 
0.70 
0.70 
0.70 
0.70 
0.80 
0.80 
0.90 
0.90 
0.90 
0,2 
Intermediat
e 
0.90 cc 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0.70 
0.80 
-0,1 
Far 
0.80 cc 
0.30 
0.30 
0.40 
0.50 
0.50 
0.70 
0.70 
0.80 
0.90 
0.90 
0,1 
 
  
6 Month after trifocal 
6 months after Relex Smile without glassess  
Differenc
e 
Nr
. 
  
1Day 
1Wea
k 
1Mont
h 
3Mont
h 
6Mont
h 
1Da
y 
1Wea
k 
1Mont
h 
3Mont
h 
6Mont
h 
 
21 
Refaction 
+5.50, +3.00 AX 60 
 
Near 
0.70 cc 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0.70 
0.70 
0.70 
0.70 
0 
Intermediat
e 
0.60 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.60 
0.60 
0.60 
0.60 
0 
Far 
0.50 cc 
0.30 
0.30 
0.30 
0.30 
0.30 
0.50 
0.70 
0.70 
0.70 
0.70 
0,2 
22 
Refaction 
+6.00,+2.00 AX 20 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.70 cc 
0.60 
0.60 
0.60 
0.60 
0.60 
0.70 
0.70 
0.70 
0.70 
0.70 
0 
Intermediat
e 
0.60 cc 
0.40 
0.40 
0.50 
0.50 
0.50 
0.50 
0.50 
0.50 
0.50 
0.50 
-0,1 
Far 
0.50 cc 
0.30 
0.30 
0.30 
0.40 
0.40 
0.60 
0.60 
0.60 
0.70 
0.70 
0,2 
23 
Refaction 
+6.25, +3.25 AX120 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.40 cc 
0.50 
0.50 
0.50 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0,2 
Intermediat
e 
0.30 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.50 
0.50 
0,2 
Far 
0.20 cc 
0.20 
0.20 
0.20 
0.20 
0.20 
0.30 
0.30 
0.30 
0.40 
0.40 
0,2 
24 
Refaction 
+6.75, +3.0 AX 65 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.30 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.50 
0.50 
0.50 
0.50 
0.50 
0,2 
Intermediat
e 
0.20 cc 
0.30 
0.30 
0.30 
0.30 
0.30 
0.40 
0.40 
0.40 
0.40 
0.40 
0,2 
Far 
0.10 cc 
0.10 
0.10 
0.10 
0.20 
0.20 
0.30 
0.30 
0.30 
0.30 
0.30 
0,2 
25 
Refaction 
+5.00, +2.00 AX 90 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.80 cc 
0.60 
0.60 
0.60 
0.70 
0.70 
0.80 
0.80 
0.80 
0.90 
0.90 
0,1 
Intermediat
e 
0.70 cc 
0.50 
0.50 
0.50 
0.60 
0.60 
0.70 
0.70 
0.70 
0.80 
0.80 
0,1 
Far 
0.60 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.60 
0.60 
0.60 
0.70 
0.70 
0,1 
26 
Refaction 
+5.50, +2.50 AX 125 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.80 cc 
0.70 
0.70 
0.70 
0.70 
0.70 
0.80 
0.80 
0.80 
0.90 
0.90 
0,1 
Intermediat
e 
0.70 cc 
0.60 
0.60 
0.60 
0.60 
0.60 
0.70 
0.70 
0.70 
0.80 
0.80 
0,1 
Far 
0.60 cc 
0.40 
0.40 
0.40 
0.50 
0.50 
0.60 
0.60 
0.60 
0.70 
0.70 
0,1 
27 
Refaction 
+6.00, +2.25 AX 60 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.50 cc 
0.50 
0.50 
0.50 
0.50 
0.50 
0.50 
0.50 
0.60 
0.60 
0.60 
0,1 
Intermediat
e 
0.40 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.50 
0.50 
0.50 
0,1 
Far 
0.20 cc 
0.10 
0.10 
0.10 
0.20 
0.20 
0.30 
0.30 
0.40 
0.40 
0.40 
0,2 
28 
Refaction 
+6.00, +2.75 AX98 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.40 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.50 
0.50 
0.50 
0.60 
0.60 
0,2 

Intermediat
e 
0.30 cc 
0.30 
0.30 
0.30 
0.30 
0.30 
0.40 
0.40 
0.40 
0.50 
0.50 
0,2 
Far 
0.20 cc 
0.20 
0.20 
0.20 
0.20 
0.20 
0.30 
0.30 
0.30 
0.40 
0.40 
0,2 
29 
Refaction 
+9.00, +2.0 AX 115 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.20 cc 
0.20 
0.20 
0.30 
0.30 
0.40 
0.50 
0.50 
0.50 
0.60 
0.60 
0,4 
Intermediat
e 
0.20 cc 
0.20 
0.20 
0.20 
0.20 
0.30 
0.40 
0.40 
0.40 
0.50 
0.50 
0,3 
Far 
0.10 cc 
0.10 
0.10 
0.20 
0.20 
0.20 
0.30 
0.30 
0.30 
0.40 
0.40 
0,3 
30 
Refaction 
+9.00, +2.50 AX 55 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.30 cc 
0.40 
0.40 
0.40 
0.50 
0.50 
0.50 
0.60 
0.60 
0.60 
0.60 
0,3 
Intermediat
e 
0.20 cc 
0.30 
0.30 
0.30 
0.40 
0.40 
0.40 
0.50 
0.50 
0.50 
0.50 
0,3 
Far 
0.10 cc 
0.20 
0.20 
0.20 
0.30 
0.30 
0.30 
0.40 
0.40 
0.40 
0.40 
0,3 
 
  
6 Month after trifocal 
6 months after Relex Smile-without glassess  
Differenc
e 
Nr. 
  
1Day 
1Weak 
1Month 
3Month 
6Month 
1Day 
1Weak 
1Month 
3Month 
6Month 
 
31 
Refaction 
+8.00, +2.75 AX 50 
 
Near 
0.30 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.50 
0.50 
0.60 
0.60 
0.50 
0,1 
Intermediat
e 
0.20 cc 
0.20 
0.20 
0.30 
0.30 
0.30 
0.40 
0.40 
0.50 
0.50 
0.30 
0,1 
Far 
0.10 cc 
0.10 
0.10 
0.20 
0.20 
0.20 
0.30 
0.30 
0.40 
0.40 
0.40 
0,3 
32 
Refaction 
+8.50, +2.25 AX 
136 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.30 cc 
0.40 
0.40 
0.40 
0.40 
0.40 
0.50 
0.50 
0.60 
0.50 
0.50 
0,1 
Intermediat
e 
0.20 cc 
0.30 
0.30 
0.30 
0.20 
0.30 
0.40 
0.40 
0.30 
0.30 
0.30 
0 
Far 
0.10 cc 
0.20 
0.20 
0.20 
0.30 
0.30 
0.30 
0.30 
0.40 
0.40 
0.40 
0,2 
33 
Refaction 
+10.00, +2.0 AX 90 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.20 cc 
0.20 
0.20 
0.30 
0.30 
0.30 
0.40 
0.40 
0.50 
0.50 
0.50 
0,3 
Intermediat
e 
0.10 cc 
0.10 
0.10 
0.20 
0.20 
0.20 
0.30 
0.30 
0.40 
0.40 
0.40 
0,3 
Far 
0.10 cc 
0.10 
0.10 
0.20 
0.20 
0.20 
0.20 
0.20 
0.30 
0.30 
0.30 
0,2 
34 
Refaction 
+10.00, +2.50 AX 
90 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.20 cc 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0.40 
0.40 
0.40 
0.40 
0,1 
Intermediat
e 
0.10 cc 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0 
Far 
0.10 cc 
0.20 
0.20 
0.20 
0.20 
0.20 
0.30 
0.30 
0.30 
0.30 
0.30 
0,1 
35 
Refaction 
+5.00, +2.25 AX 90 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.80 cc 
0.80 
0.80 
0.80 
0.80 
0.80 
0.80 
0.80 
0.90 
0.90 
0.90 
0,1 
Intermediat
e 
0.70 cc 
0.70 
0.70 
0.70 
0.70 
0.70 
0.70 
0.70 
0.90 
0.90 
0.70 
0 
Far 
0.60cc 
0.40 
0.40 
0.40 
0.50 
0.50 
0.60 
0.60 
0.70 
0.70 
0.80 
0,4 
36 
Refaction 
+5.25, +2.25 AX 96 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.80 cc 
0.80 
0.80 
0.80 
0.80 
0.80 
0.70 
0.80 
0.90 
0.90 
0.90 
0,1 
Intermediat
e 
0.70 cc 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0.60 
0.70 
0.70 
0,1 
Far 
0.60 cc 
0.30 
0.40 
0.40 
0.40 
0.40 
0.60 
0.70 
0.70 
0.80 
0.80 
0,5 
37 
Refaction 
+7.50, +4.25 AX 75 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.30 cc 
0.30 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0,1 

Intermediat
e 
0.20 cc 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0 
Far 
0.10 cc 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0 
38 
Refaction 
+8.00, +4.50 AX 
115 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.30 cc 
0.30 
0.30 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0.40 
0,1 
Intermediat
e 
0.20 cc 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0 
Far 
0.10 cc 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0 
39 
Refaction 
+8.50, +4.0 AX 105 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.30 cc 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0 
Intermediat
e 
0.20 cc 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0 
Far 
0.10 cc 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0 
40 
Refaction 
+9.00, +4.0 AX 75 
  
  
  
  
  
  
  
  
  
  
 
Near 
0.30 cc 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0.30 
0 
Intermediat
e 
0.20 cc 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0.20 
0 
Far 
0.10 cc 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0.10 
0 
 
 
 
Toric Trifocal  
  
pre w glasses 
pre w glasses 
post 1st day 
post 1 week 
post 1 month 
Post 3 month 
Post 6 month 
Eye sph 
cly 
angle 
near  inter. 
far 
near İnter. 
far near İnter. 
far 
near İnter. 
far near İnter. 
far near İnter. 
far 
1 
5,5 2,75 
110 
0,9 
0,8 
0,7 
0,7 
0,6 0,4 
0,8 
0,6 0,5 
0,8 
0,6 0,5 
0,9 
0,8 0,7 
0,9 
0,8 0,9 0 
0 
2 
7 3,75 
95 
0,5 
0,4 
0,3 
0,3 
0,2 0,1 
0,4 
0,2 0,1 
0,4 
0,3 0,2 
0,5 
0,4 0,3 
0,6 
0,5 0,4 0,1 
0,1 
3 
6,5 3,25 
90 
0,8 
0,7 
0,6 
0,5 
0,4 0,3 
0,6 
0,5 0,3 
0,7 
0,5 0,4 
0,8 
0,7 0,6 
0,9 
0,8 0,7 0,1 
0,1 
4 5,25 2,75 
80 
0,9 
0,8 
0,7 
0,7 
0,6 0,4 
0,7 
0,6 0,5 
0,8 
0,7 0,6 
0,9 
0,8 0,7 
1 
0,9 0,8 0,1 
0,1 
5 
7 2,25 
100 
0,8 
0,7 
0,6 
0,5 
0,4 0,3 
0,6 
0,5 0,3 
0,7 
0,6 0,5 
0,8 
0,7 0,6 
0,9 
0,8 0,7 0,1 
0,1 
6 6,25 
2,5 
70 
0,9 
0,8 
0,7 
0,6 
0,5 0,4 
0,7 
0,6 0,4 
0,7 
0,6 0,5 
0,9 
0,8 0,7 
0,9 
0,8 0,8 0 
0 
7 
4,5 
2 
45 
0,9 
0,7 
0,8 
0,6 
0,5 0,4 
0,7 
0,6 0,5 
0,8 
0,7 0,6 
0,9 
0,7 0,9 
0,9 
0,8 0,9 0 
0,1 
8 
5 
2 
95 
0,9 
0,7 
0,8 
0,6 
0,5 0,4 
0,7 
0,6 0,4 
0,7 
0,6 0,5 
0,8 
0,6 0,7 
0,9 
0,9 0,8 0 
0,2 
9 
5,5 
4 
85 
0,5 
0,4 
0,3 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,4 
0,2 0,1 
0,5 
0,4 0,3 
0,7 
0,6 0,5 0,2 
0,2 
10 
6,5 
2 
75 
0,7 
0,6 
0,5 
0,4 
0,3 0,2 
0,5 
0,4 0,3 
0,6 
0,5 0,4 
0,7 
0,6 0,5 
0,8 
0,7 0,6 0,1 
0,1 
11 5,75 
2,5 
70 
0,8 
0,7 
0,6 
0,4 
0,3 0,2 
0,5 
0,4 0,3 
0,6 
0,5 0,4 
0,8 
0,7 0,6 
0,9 
0,8 0,7 0,1 
0,1 
12 6,25 2,25 
115 
0,8 
0,7 
0,6 
0,5 
0,4 0,3 
0,6 
0,5 0,4 
0,7 
0,6 0,5 
0,8 
0,7 0,6 
0,9 
0,8 0,7 0,1 
0,1 
13 4,75 
2 
120 
0,9 
0,8 
0,7 
0,5 
0,4 0,3 
0,6 
0,5 0,4 
0,7 
0,6 0,5 
0,9 
0,8 0,7 
0,9 
0,8 0,7 0 
0 
14 
5,5 2,75 
95 
0,8 
0,7 
0,6 
0,5 
0,4 0,3 
0,5 
0,4 0,3 
0,6 
0,5 0,4 
0,8 
0,7 0,6 
0,9 
0,8 0,7 0,1 
0,1 
15 5,75 
3 
90 
0,8 
0,7 
0,6 
0,4 
0,3 0,2 
0,4 
0,3 0,2 
0,6 
0,5 0,4 
0,8 
0,7 0,6 
0,9 
0,8 0,7 0,1 
0,1 
16 
6,5 3,25 
90 
0,7 
0,6 
0,5 
0,5 
0,3 0,2 
0,7 
0,4 0,3 
0,7 
0,5 0,4 
0,7 
0,6 0,5 
0,8 
0,7 0,6 0,1 
0,1 
17 
4,5 3,25 
95 
0,5 
0,3 
0,4 
0,4 
0,3 0,1 
0,4 
0,3 0,2 
0,5 
0,4 0,3 
0,6 
0,5 0,4 
0,7 
0,6 0,5 0,2 
0,3 
18 
5 
4 
90 
0,6 
0,5 
0,4 
0,5 
0,4 0,2 
0,5 
0,4 0,2 
0,5 
0,4 0,3 
0,6 
0,5 0,4 
0,7 
0,6 0,5 0,1 
0,1 
19 
8 
3,5 
105 
0,4 
0,3 
0,2 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,4 
0,3 0,2 
0,4 
0,3 0,2 0 
0 

20 
8 
3 
90 
0,4 
0,3 
0,2 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,4 
0,3 0,2 
0,4 
0,3 0,2 0 
0 
21 
6 3,25 
95 
0,7 
0,5 
0,4 
0,4 
0,3 0,1 
0,5 
0,3 0,1 
0,6 
0,4 0,3 
0,7 
0,5 0,4 
0,8 
0,6 0,5 0,1 
0,1 
22 6,75 
4 
105 
0,6 
0,4 
0,2 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,5 
0,4 0,3 
0,7 
0,5 0,4 0,1 
0,1 
23 
7 
3,5 
65 
0,3 
0,2 
0,1 
0,1 
0,1 0,1 
0,1 
0,1 0,1 
0,2 
0,1 0,1 
0,3 
0,2 0,1 
0,5 
0,4 0,3 0,2 
0,2 
24 3,75 4,25 
120 
0,7 
0,5 
0,4 
0,5 
0,3 0,2 
0,5 
0,3 0,2 
0,6 
0,4 0,3 
0,7 
0,6 0,4 
0,7 
0,6 0,5 0 
0,1 
25 
8,5 3,75 
100 
0,2 
0,1 
0,1 
0,1 
0,1 0,1 
0,2 
0,1 0,1 
0,3 
0,2 0,1 
0,4 
0,3 0,2 
0,5 
0,4 0,3 0,3 
0,3 
26 
8,5 
2,5 
80 
0,3 
0,2 
0,2 
0,2 
0,1 0,1 
0,2 
0,1 0,1 
0,3 
0,1 0,1 
0,4 
0,2 0,2 
0,5 
0,4 0,3 0,2 
0,2 
27 
7 
2,5 
75 
0,5 
0,3 
0,2 
0,3 
0,2 0,1 
0,4 
0,2 0,2 
0,5 
0,3 0,2 
0,6 
0,4 0,3 
0,7 
0,5 0,4 0,2 
0,2 
28 
10 
3 
85 
0,3 
0,2 
0,1 
0,2 
0,1 0,1 
0,2 
0,1 0,1 
0,3 
0,2 0,2 
0,5 
0,3 0,2 
0,6 
0,4 0,3 0,3 
0,2 
29 
9,5 3,75 
100 
0,4 
0,3 
0,1 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,5 
0,4 0,3 
0,5 
0,4 0,3 
0,6 
0,3 0,4 0,2 
0 
30 
4 3,25 
70 
0,5 
0,4 
0,2 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,5 
0,3 0,2 
0,6 
0,5 0,4 0,1 
0,1 
31 
4 3,25 
65 
0,7 
0,6 
0,4 
0,4 
0,3 0,2 
0,4 
0,3 0,2 
0,5 
0,4 0,3 
0,7 
0,6 0,5 
0,8 
0,7 0,6 0,1 
0,1 
32 4,75 
3,5 
115 
0,7 
0,6 
0,5 
0,3 
0,2 0,1 
0,4 
0,3 0,2 
0,5 
0,4 0,3 
0,6 
0,5 0,4 
0,8 
0,7 0,6 0,1 
0,1 
33 3,25 
4,5 
60 
0,6 
0,4 
0,4 
0,2 
0,1 0,1 
0,2 
0,1 0,1 
0,4 
0,2 0,2 
0,7 
0,5 0,4 
0,8 
0,7 0,6 0,2 
0,3 
34 4,75 2,75 
90 
0,7 
0,6 
0,5 
0,6 
0,5 0,3 
0,6 
0,5 0,4 
0,7 
0,5 0,4 
0,8 
0,6 0,5 
0,9 
0,8 0,6 0,2 
0,2 
35 
5 
3,5 
85 
0,7 
0,5 
0,4 
0,6 
0,3 0,2 
0,6 
0,4 0,2 
0,7 
0,4 0,2 
0,8 
0,6 0,5 
0,8 
0,7 0,6 0,1 
0,2 
36 6,75 
3 
105 
0,6 
0,5 
0,4 
0,4 
0,3 0,2 
0,4 
0,3 0,2 
0,5 
0,4 0,3 
0,6 
0,5 0,4 
0,8 
0,7 0,6 0,2 
0,2 
37 
5,5 
3,5 
30 
0,8 
0,6 
0,5 
0,7 
0,5 0,3 
0,7 
0,5 0,3 
0,8 
0,6 0,4 
0,9 
0,7 0,6 
0,9 
0,8 0,7 0,1 
0,2 
38 
5 
3 
150 
0,8 
0,6 
0,5 
0,7 
0,5 0,3 
0,7 
0,6 0,4 
0,8 
0,6 0,5 
0,9 
0,7 0,6 
0,9 
0,8 0,7 0,1 
0,2 
39 9,75 
3,5 
90 
0,5 
0,3 
0,2 
0,4 
0,2 0,1 
0,4 
0,3 0,2 
0,5 
0,3 0,2 
0,6 
0,4 0,3 
0,6 
0,5 0,4 0,1 
0,2 
40 
9 3,75 
90 
0,5 
0,2 
0,2 
0,3 
0,2 0,1 
0,3 
0,2 0,1 
0,4 
0,2 0,1 
0,4 
0,3 0,2 
0,6 
0,5 0,4 0,1 
0,3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

 

 

 
 
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
0
0
0
0
0
0
0
Post op UCVA - pre op CDVA difference over 40 eyes 
trifocal near ( 40 cm)
UCVA 1D
UCVA 1W
UCVA 1M
UCVA 3M
UCVA 6M
 

 
 
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
0
0
0
0
0
0
0
Post op UCVA - pre op UCVA differences over 40 eyes
SMILE near (40 cm) 
Pre op is at SMILE operation day
UCVA 1D
UCVA 1W
UCVA 1M
UCVA 3M
UCVA 6M
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
0
0
0
0
0
0
0
Post op UCVA - pre op CDVA difference over 40 eyes
Trifocal intermediate ( 80 cm)
UCVA 1D
UCVA 1W
UCVA 1M
UCVA 3M
UCVA 6M

 
 
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
0
0
0
0
0
0
0
Post op UCVA - pre op UCVA difference over 40 eyes
SMILE intermediate (80 cm). 
pre op is at SMILE operation  day
UCVA 1D
UCVA 1W
UCVA 1M
UCVA 3M
UCVA 6M
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
0
0
0
0
0
0
0
0
Post op UCVA - pre op CDVA difference over 40 eyes
trifocal far ( 5 m)
UCVA 1D
UCVA 1W
UCVA 1M
UCVA 3M
UCVA 6M

 
 
 
 
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0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
0
0
0
0
0
0
0
0
Post op UCVA - pre op UCVA difference over 40 eyes
SMILE far ( 5 m)
pre op is at SMILE operation day
UCVA 1D
UCVA 1W
UCVA 1M
UCVA 3M
UCVA 6M

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