Accuracy of IRAS GT interferometer

and potential acuity meter

prediction of visual acuity
after phacoemulsification
Prospective comparative study
Cécile Le Sage, MD, Christian Bazalgette, DBO, Bernard Arnaud, MD,
Clair-Florent Schmitt-Bernard, MD, PhD

ABSTRACT
Purpose: To assess and compare the accuracy of 2 methods of predicting visual acuity
after phacoemulsification.

Setting: Department of Ophthalmology, Montpellier, France.

Methods: This prospective study evaluated 47 eyes of 47 patients having uneventful

phacoemulsification over a 1-month period. All the patients had mild to moderate
cataract. Visual acuity recovery was predicted using the white-light IRAS GT姞 inter-
ferometer on the 3- and 8-degree wide test area and the Guyton-Minkowski potential
acuity meter (PAM). Best corrected visual acuity was evaluated 1 day before and
1 month after surgery.

Results: Both the interferometer and PAM underestimated the retinal visual capacity.
Three-degree white-light interferometry gave significantly better mean predicted results
than 8-degree interferometry and the PAM. There was no statistically significant dispar-
ity between predicted and postoperative results with 3-degree interferometry (1.04 ⫾
0.57 logMAR; – 0.09 ⫾ 0.27 decimal) (P ⫽ .0647) and a statistically significant disparity
with 8-degree interferometry (0.89 ⫾ 0.59 logMAR; – 0.13 ⫾ 0.27 decimal) and the PAM
(0.66 ⫾ 0.62 logMAR; – 0.22 ⫾ 0.24 decimal) (P ⫽ .0001). The predicted values were
widely dispersed; the correlation indices were 0.38 with the PAM (P ⫽ .091), 0.39 with
3-degree interferometry (P ⫽ .001), and 0.49 with 8-degree interferometry (P ⫽ .0005).

Conclusions: Three-degree white-light interferometry gave more accurate results than

8-degree interferometry and the PAM. The wide dispersion of results and unsatisfactory
correlation indices show the tests are poor predictors of individual acuity. They should
be used semiquantitatively and the results interpreted in relation to the clinical data.
Qualitative methods may be useful in confirming or refuting visual recovery capacity
ascertained by quantitative systems. J Cataract Refract Surg 2002; 28:131–138
© 2002 ASCRS and ESCRS

© 2002 ASCRS and ESCRS 0886-3350/02/$–see front matter

Published by Elsevier Science Inc. PII S0886-3350(01)01118-X
 VISUAL ACUITY RECOVERY AFTER PHACOEMULSIFICATION
T he considerable contribution of cataract surgery to
the patient’s quality of life began with its early de-
velopment. Phacoemulsification further improved the
popularity of this surgery as its duration is short and
visual rehabilitation is fast. Thus, patients expect early
and reliable visual recovery, and a poor visual outcome is
disappointing to patients and surgeons, especially after
uneventful phacoemulsification.
Poor visual recovery after phacoemulsification is fre-
quently linked to undiagnosed retinal disease, which can
be related to fundoscopy difficulty in cases of severe
cataract, or to retinal or corneal pathology, which makes
prediction of visual recovery unreliable.
Various methods to predict retinal acuity and the
risk/benefit ratio after extracapsular cataract extraction
(ECCE) have been developed. Several are based on ret-
inal qualitative indices. These include electroretinogra-
phy,1–3 visual evoked potentials,1,2,4,5 color vision
tests,6 blue-field entoptic tests,7–9 and B-scan ultra-
sonography.2 Others are based on quantitative criteria
using pinhole techniques (J. Lowry, “Pinhole Tech-
niques Are Called Reliable, Easy, and Inexpensive,”
Ophthalmology Times, September 1, 1986, pages 1, 31,
35), laser or white-light interferometry,10 –13 and poten-
tial acuity meter (PAM) assessment.14,15
In this prospective study, we analyzed the predicted
results of visual recovery after phacoemulsification using
2 technologically different quantitative methods: white-
light interferometry and the PAM assessment. We sta-
tistically estimated the results of both systems. To our
knowledge, no similar comparison of these methods has
been published.
Accepted for publication July 30, 2001.
From Service d’Ophtalmologie, CMC Gui de Chauliac, Montpellier,
France.
Gaston Le Sage, Institut National des Statistiques et des Etudes
Economiques, Montpellier, France, provided statistical analysis and Mi-
kaël Tritz, Ecole d’Ingénierie, Bourges, France, helped translate from
German.
None of the authors has a financial or proprietary interest in any material
or method mentioned.
Reprint requests to Dr. Clair-Florent Schmitt-Bernard, Antigone Oph-
talmologie, Le Jardin Du Centre, Rue De L’Epire, 34000 Montpellier,
France. E-mail: cfsb@mnet.fr/cfsb@igh.cnrs.fr.
132 J CATARACT REFRACT SURG—VOL 28, JANUARY 2002
Patients and Methods
This study comprised 47 eyes of 47 patients
(30 men, 17 women) having cataract surgery over a
1-month period, the single criterion for their inclusion.
No patient had previous ocular surgery. All patients
had phacoemulsification with in-the-bag intra-
ocular lens implantation by the same surgeon (B.A.)
with no postoperative complications over a 2-month
follow-up.
The patients’ demographics are shown in Table 1.
The mean age of the patients was 70.38 years ⫾ 15.84
(SD) (range 19 to 92 years); 70% were older than
70 years, fitting the general population requesting
cataract surgery. All patients had mild to moderate cat-
aract. Five patients (#2, 5, 10, 19, 33) had high myopia
(range –9.0 to –15.0 diopters [D]); 4 (#3, 23, 31, 45)
had posterior subcapsular cataract; 4 (#9, 15, 28, 42)
had atrophic age-related macular degeneration
(ARMD) and 1 (#16) exudative ARMD; 2 (#13, 35)
had retinitis pigmentosa; 1 (#43) was amblyopic;
1 (#40) had a complex syndrome comprising corneal
dystrophy, aniridia, and nystagmus; and 1 (#47) had
open-angle glaucoma.
Preoperatively, a single evaluator performed a
clinical examination. This included slitlamp and fundo-
scopic evaluations and intraocular pressure measure-
ment. The best corrected visual acuity (BCVA) was
evaluated using the decimal scale 1 day before and
1 month after surgery.
Prediction of visual acuity recovery was per-
formed by a single trained examiner by the 2 meth-
ods available in the Department of Ophthalmology:
the white-light IRAS GT威 interferometer (Randwall
Instruments) on the 3- and 8-degree wide test area or
the Guyton-Minkowski PAM (Mentor O&O Inc.).
One drop of tropicamide was instilled 30 minutes before
to obtain adequate pupil dilation in photopic condi-
tions. To ensure their cooperation, all patients received
a thorough description of the instrument and its
technique.
The IRAS GT is a white-light interferometer. The
light emitted from an incandescent source is focused on
a holographic grating that splits the single coherent
source into 2 equally strong coherent lights. A relay lens
system projects the 2 slit sources near the nodal point of
the eye, where coherent light waves emanating from
 VISUAL ACUITY RECOVERY AFTER PHACOEMULSIFICATION

Table 1. Patient characteristics and visual acuities.

Decimal VA (LogMAR VA)

Age
Patient (Years) Sex Preop IF-3 IF-8 PAM Postop

1 75 M 0.40 (0.40) 0.80 (0.10) 0.67 (0.17) 0.80 (0.10) 0.90 (0.05)
2 64 F 0.40 (0.40) NA 1.00 (0.00) 0.50 (0.30) 0.80 (0.10)
3 64 F 0.20 (0.70) 0.33 (0.48) 0.33 (0.48) 0.40 (0.40) 0.90 (0.05)
4 80 F 0.40 (0.40) 1.00 (0.00) 0.67 (0.17) 0.50 (0.30) 0.90 (0.05)
5 70 F 0.40 (0.40) 0.67 (0.17) 0.67 (0.17) 0.50 (0.30) 0.60 (0.22)
6 70 F 0.40 (0.40) 0.50 (0.30) 0.67 (0.17) 0.80 (0.10) 0.60 (0.22)
7 80 F 0.30 (0.52) 0.80 (0.10) 0.67 (0.17) 0.33 (0.48) 0.90 (0.05)
8 63 F 0.40 (0.40) 1.00 (0.00) 1.00 (0.00) 0.40 (0.40) 0.80 (0.10)
9 92 F 0.10 (1.00) NA 0.05 (1.30) 0.50 (0.30) 0.10 (1.00)
10 61 F 0.20 (0.70) 0.80 (0.10) 0.33 (0.48) 0.25 (0.60) 0.30 (0.52)
11 69 F 0.40 (0.40) 0.80 (0.10) 0.67 (0.17) 0.80 (0.10) 0.80 (0.10)
12 28 M 0.40 (0.40) 1.00 (0.00) 1.00 (0.00) 0.80 (0.10) 1.00 (0.00)
13 68 M 0.10 (1.00) 0.02 (1.60) 0.02 (1.60) 0.10 (1.00) 0.10 (1.00)
14 88 M 0.40 (0.40) 1.00 (0.00) 0.80 (0.10) 0.50 (0.30) 0.80 (0.10)
15 82 F 0.20 (0.70) NA 0.05 (1.30) 0.10 (1.00) 0.30 (0.52)
16 78 F 0.40 (0.40) 1.00 (0.00) 1.00 (0.00) 0.40 (0.40) 0.50 (0.30)
17 64 F 0.30 (0.52) 0.67 (0.17) 0.40 (0.40) 0.50 (0.30) 0.70 (0.15)
18 77 F 0.20 (0.70) 0.50 (0.30) 0.50 (0.30) 0.28 (0.55) 0.50 (0.30)
19 78 F 0.40 (0.40) 0.80 (0.10) 0.40 (0.40) 0.50 (0.30) 0.70 (0.15)
20 79 F 0.30 (0.52) 0.67 (0.17) 0.67 (0.17) 0.33 (0.48) 0.90 (0.05)
21 74 F 0.40 (0.40) 0.80 (0.10) 1.00 (0.00) 0.66 (0.18) 0.90 (0.05)
22 77 M 0.50 (0.30) 0.80 (0.10) 0.67 (0.17) 0.80 (0.10) 0.90 (0.05)
23 30 M 0.05 (1.30) 0.02 (1.60) 0.02 (1.60) 0.50 (0.30) 0.80 (0.10)
24 57 M 0.40 (0.40) 0.50 (0.30) 0.50 (0.30) 0.33 (0.48) 1.00 (0.00)
25 74 M 0.40 (0.40) 0.80 (0.10) 0.80 (0.10) 0.50 (0.30) 1.00 (0.00)
26 85 M 0.40 (0.40) 0.80 (0.10) 0.80 (0.10) 0.66 (0.18) 0.80 (0.10)
27 76 F 0.20 (0.70) 0.50 (0.30) 0.50 (0.30) 0.40 (0.40) 1.00 (0.00)
28 78 F 0.30 (0.52) 0.02 (1.60) 0.33 (0.40) 0.50 (0.30) 0.50 (0.30)
29 79 F 0.40 (0.40) 0.33 (0.40) 0.20 (0.70) 0.50 (0.30) 0.80 (0.10)
30 85 M 0.40 (0.40) 1.00 (0.00) 0.80 (0.10) 0.80 (0.10) 1.00 (0.00)
31 62 F 0.16 (0.80) 0.25 (0.60) 0.30 (0.52) 1.00 (0.00) 0.70 (0.15)
32 73 F 0.40 (0.40) 1.00 (0.00) 0.80 (0.10) 0.66 (0.18) 1.00 (0.00)
33 75 M 0.10 (1.00) 0.33 (0.40) 0.25 (0.60) 0.28 (0.55) 0.60 (0.22)
34 76 M 0.40 (0.40) 0.67 (0.17) 0.67 (0.17) 0.50 (0.30) 0.70 (0.15)
35 80 F LP NA NA NA LP
36 80 F 0.16 (0.80) 0.67 (0.17) 0.67 (0.17) 0.50 (0.30) 1.00 (0.00)
37 62 M 0.40 (0.40) 0.80 (0.10) 0.67 (0.17) 0.66 (0.18) 0.60 (0.22)
38 73 F 0.40 (0.40) 1.00 (0.00) 0.80 (0.10) 0.80 (0.10) 0.80 (0.10)
39 78 F 0.10 (1.00) 0.67 (0.17) 0.40 (0.40) 0.20 (0.70) 1.00 (0.00)
40 23 F 0.05 (1.30) 0.40 (0.40) 0.80 (0.10) NA 0.10 (1.00)

J CATARACT REFRACT SURG—VOL 28, JANUARY 2002 133

 VISUAL ACUITY RECOVERY AFTER PHACOEMULSIFICATION

Table 1. (cont.)

Decimal VA (LogMAR VA)

Age
Patient (Years) Sex Preop IF-3 IF-8 PAM Postop

41 74 F 0.30 (0.52) 0.67 (0.17) 0.50 (0.30) 1.00 (0.00) 0.90 (0.05)
42 76 F 0.40 (0.40) 1.00 (0.00) 1.00 (0.00) 1.00 (0.00) 0.80 (0.10)
43 19 M 0.05 (1.30) 0.50 (0.30) 0.40 (0.40) 0.28 (0.55) 0.50 (0.30)
44 81 M 0.30 (0.52) 0.67 (0.17) 0.67 (0.17) 0.50 (0.30) 0.60 (0.22)
45 78 F 0.40 (0.40) 0.20 (0.70) 0.40 (0.40) 0.66 (0.18) 0.50 (0.30)
46 80 F 0.40 (0.40) 0.80 (0.10) 0.67 (0.17) 1.00 (0.00) 0.90 (0.05)
47 73 M 0.40 (0.40) 1.00 (0.00) 1.00 (0.00) 0.80 (0.10) 0.90 (0.05)
VA ⫽ visual acuity; IF-3 ⫽ 3-degree interferometry; IF-8 ⫽ 8-degree interferometry; PAM ⫽ potential acuity meter; LP ⫽ light perception; NA ⫽
not applicable

each source interfere and form a series of black-and- Results

white lines on the retina. Orientation of the lines can be
set vertically, horizontally, or diagonally by rotating the
holographic grating. The equivalent acuity depends on
the interaction angle between the interfering wave
fronts. The distance between these lines defines Snellen
visual acuity from 20/800 to 20/20 independent of the
patient’s refraction. The gratings and Snellen letters do
not have direct correlation because of the higher fre-
quency components of the Snellen letters. A 3- or 8-de-
gree area of central retina can be evaluated depending on
the diaphragm aperture.
The Guyton-Minkowski PAM projects a Snellen
chart ranging from 20/400 to 20/20 in a small beam
of light (0.15 mm diameter aperture). The light beam
is aimed through the less opaque area of the lens. The
diopter control is set at the spherocylindrical equiva-
lent of the patient’s refraction (–10.0 to ⫹13.0 D).
In patients with myopia greater than –10.0 D, the
measurement was done with the best spectacle
correction.
Statistical Analysis
Preoperative and postoperative visual acuities were
compared with the results of the predictive tests, and
their statistical significance was analyzed using the Wil-
coxon matched test as the distribution did not fit a
Gaussian pattern. The Altman and Bland test was used
to determine the dispersion of results, and their correla-
tion was calculated by the Spearman correlation test.
Decimal visual acuity was expressed as a logMAR equiv-
alent for data analysis.16
The mean preoperative BCVA was 0.57 ⫾ 0.27
logMAR (range light perception [LP] to 0.30) and
0.27 ⫾ 0.54 decimal (range LP to 0.50). The mean
postoperative BCVA was (0.19 ⫾ 0.25) logMAR (range
LP to 0.00) and 0.64 ⫾ 0.56 decimal (range LP to 1.0).
The predicted visual acuity was significantly closer to the
final visual acuity with 3-degree interferometry (0.27 ⫾
0.40 logMAR; 0.54 ⫾ 0.40 decimal) than with 8-degree
interferometry (0.33 ⫾ 0.39 logMAR; 0.47 ⫾ 0.41 dec-
imal) or the PAM (0.31 ⫾ 0.23 logMAR; 0.49 ⫾ 0.59
decimal) (Figure 1).
The 3 methods of prediction displayed a non-Gaus-
sian curve of distribution of results. There was no statis-
tically significant disparity between predicted and
postoperative results with 3-degree interferometry
(1.04 ⫾ 0.57 logMAR; – 0.09 ⫾ 0.27 decimal) (P ⫽
.0647) and a statistically significant disparity with 8-de-
gree interferometry (0.89 ⫾ 0.59 logMAR; – 0.13 ⫾
0.27 decimal) and the PAM (0.66 ⫾ 0.62 logMAR;
– 0.22 ⫾ 0.24 decimal) (P ⫽ .0001). Therefore, the
mean predictive results with 3-degree interferometry
significantly matched the final visual acuity, and all
3 tests underestimated postoperative visual acuity. The
mean underestimation was less than 1 line (decimal
scale) with 3-degree interferometry, making it the most
accurate method of predicting visual acuity recovery.
There was no significant difference in the level of
dispersion of results between 3-degree interferometry
(– 0.81 to 0.60 logMAR) and 8-degree interferometry
(– 0.79 to 0.51 logMAR) (P ⫽ .0001), 3-degree inter-

134 J CATARACT REFRACT SURG—VOL 28, JANUARY 2002

 VISUAL ACUITY RECOVERY AFTER PHACOEMULSIFICATION
ferometry and the PAM (– 0.58 to 0.30 logMAR) (P ⫽
.0216), or 8-degree interferometry and the PAM (P ⫽
.003) (Figure 2). Therefore, even though 3-degree inter-
ferometry appeared to be the best predictor, the disper-
Figure 2. (Le Sage) Dispersion of predicted versus final visual
acuity. Top: 3-degree interferometry (IF-3°). Middle: 8-degree inter-
ferometry (IF-8°). Bottom: PAM (x- and y-axis ⫽ logMAR scale).
J CATARACT REFRACT SURG—VOL 28, JANUARY 2002
Figure 1. (Le Sage) Variation be-
tween predicted and actual postoper-
ative visual acuity (black bar ⫽
3-degree interferometry; white bar ⫽
8-degree interferometry; gray bar ⫽
PAM; y-axis ⫽ acuity, decimal scale).
sion test showed that individual prediction may be
overestimated or underestimated from ⫹0.25 to – 0.15
lines on the decimal scale around the mean result. This
was also true with 8-degree interferometry (⫹0.31 to
– 0.16 lines, decimal) and the PAM (⫹0.50 to – 0.26
lines, decimal). The PAM had a wider dispersion of
results than either interferometry method when individ-
ually results were considered; the difference was not sta-
tistically significant, however.
There was a significantly poor individual correla-
tion between predicted and postoperative visual acuities
with all 3 methods: 3-degree interferometry (r ⫽ 0.39,
P ⫽ .01); 8-degree interferometry (r ⫽ 0.49, P ⫽
.0005); PAM (r ⫽ 0.38, P ⫽ .0091).
Discussion
In this comparative study, 3-degree white-light in-
terferometry was more reliable in predicting postopera-
tive visual acuity than 8-degree interferometry or the
PAM; the mean prediction with 3-degree white-light
interferometry was approximately 1 line (decimal scale)
from the final visual acuity. However, all 3 methods
underestimated postoperative visual acuity, which may
have relatively little effect on patient satisfaction. It may
be of concern to surgeons evaluating the risk/benefit
ratio of cataract surgery. All 3 methods had a tendency
toward poor prediction of individual acuity as the dis-
persion of results was significantly wide and the correla-
tion indices unsatisfactory. Thus, none of the methods
can predict final visual acuity in a linear mode and a
prediction of poor visual recovery may not reflect an
individual’s visual capacity.
All the patients in our study had mild to moderate
cataract. There were no cases of mature cataract, which
is more likely to induce a false negative (underestimated)
135
 VISUAL ACUITY RECOVERY AFTER PHACOEMULSIFICATION
predicted visual acuity. Other conditions reported to
induce inaccurate prediction of visual recovery are pos-
terior subcapsular cataract, high myopia, ARMD, cys-
toid macular edema, retinal detachment, amblyopia,
nystagmus, glaucoma, and miosis.17–23
In our study, 4 of the 5 myopic patients displayed a
strong disparity in predicted visual acuity and final vi-
sual acuity between the 2 interferometry tests and be-
tween the interferometer and the PAM. The orientation
of the light rays reaching adjacent areas of the retina may
be a cause of this disparity.19,20 Thus, the 3 methods
seemed inaccurate in predicting final acuity in eyes with
high myopia. This is in contrast to the results of Datiles
et al.,24 who report accurate predicted acuity in 3 cases
of high myopia. Datiles et al. stress that the low preop-
erative visual acuity in high myopia may be the result of
amplified distortion when the light passes through even
a moderate cataract.
The predicted acuity was underestimated by inter-
ferometry in all 4 patients with posterior subcapsular
cataract and by the PAM in 3 of the patients. The results
support the findings of Lasa and coauthors21 and
Schraub and coauthors,23 who used a Rodenstock威 reti-
nometer and the PAM to predict acuity. Both groups
hypothesize that this underestimation is linked to the
increased central density of the opacity in a nuclear cat-
aract; the opacity is more diffuse and regular, giving
more reliable values.
As previously described,17,18,21,25 interferometry
accurately predicted visual acuity in patients with atro-
phic ARMD and overestimated it in the patient with
exudative ARMD. The PAM results were more accurate
in the case of exudative ARMD.
The postoperative visual acuity matched the pre-
dicted outcome with all 3 methods in patients with pig-
ment epithelium retinopathy, which agrees with the
findings in a previous study.26 The results in the patient
with amblyopia were also accurate, which is in contrast
to previous studies showing overestimation in such cas-
es.9 In the patient with nystagmus, interferometry over-
estimated and the PAM underestimated final visual
acuity, as reported in a previous study.27 However, con-
clusions cannot be made based on the evaluation of a
single individual.
There was a significant disparity among the 3 meth-
ods in predicting visual acuity recovery after phacoemul-
sification. The best results were obtained with 3-degree
136 J CATARACT REFRACT SURG—VOL 28, JANUARY 2002
interferometry. This in agreement with the results of
Goldmann and coauthors,20 who suggest that small
fields are more accurately centered on the fovea and may
be more accurate in patients suspected of having macu-
lar disease. This prevents test recognition from the
parafoveal retina.
In our study, a single trained examiner performed all
visual acuity prediction tests after providing patients a
detailed explanation. This increased the reliability of the
results. Miller et al.29 propose that the poor correlation
indices in their series of 82 patients obtained with both
interferometry (r ⫽ 0.03) and the PAM (r ⫽ 0.07) were
the result of the technician’s lack of experience as well as
the patients’ ages and associated diseases, which lead to
poor cooperation. These biases result in a poor estima-
tion of visual acuity recovery and thus contradictory
outcomes among studies.25,28 –31
Few studies have compared the use of interferom-
etry and the PAM in ECCE. Most did not provide
a statistical analysis to determine whether interferom-
etry or the PAM is significantly accurate. Spurny and
coauthors25 compared a white-light interferometer
(Lotmar visometer, Haag-Streit) with the PAM in
54 eyes having cataract surgery or neodymium:YAG
laser capsulotomy. Predictions were more accurate
with the visometer than the PAM, supporting our
results. Strong30 compared the Rodenstock laser
interferometer, Lotmar visometer, and white-light
IRAS interferometer in 14 eyes. The laser interferome-
ter was the most accurate, but no statistical analysis
was reported. Graney et al.28 found laser interferometry
and the PAM less accurate than a clinical index based on
age, preoperative visual acuity, number of current pre-
scription medications, and the ability to read a newspa-
per. Nevertheless, these studies had several biases as
different ophthalmologists performed the prediction
tests and all patients were from middle- or upper-class
families. However, the PAM was statistically more accu-
rate in predicting acuity than laser interferometry. In a
prospective study of 35 eyes, Datiles et al.24 found that
the PAM and laser interferometer were equally good
predictors in cases of mild to moderate cataract. Gold-
stein et al.31 found better results with the Lotmar vi-
someter than with the IRAS interferometer. Therefore,
it appears that these studies had several strong examiner
and patient biases, which may account for the contra-
dictory results.
 VISUAL ACUITY RECOVERY AFTER PHACOEMULSIFICATION
Conclusion
Our findings suggest that the interferometer and
the PAM are accurate predictors of postoperative vi-
sual acuity in healthy eyes with moderate cataract.
Conversely, both instruments lack reliability in eyes
with retinal disorders. These methods are suited to
daily practice as they are fast and easy and give reliable
prediction of visual recovery in most patients having
phacoemulsification.
However, we believe that the instruments should be
used semiquantitatively and the results be interpreted in
relation to the clinical data. The results must also be
assessed on an individual basis considering their wide
dispersion, especially in patients with associated ocular
pathology. In this respect, qualitative methods may help
confirm or refute the capacity for visual recovery ascer-
tained by quantitative systems.
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