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Refractive outcomes after bilateral multifocal intraocular lens implantation

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Refractive outcomes after bilateral multifocal intraocular lens implantation
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  Refractive outcomes after bilateral multifocalintraocular lens implantation  Angel Pineda-Ferna ´ndez, MD, Jorge Jaramillo, MD, Vanessa Celis, MD, Jose´ Vargas, MD,Mauro DiStacio, MD, Alicia Galı´ndez, MD, Mercedes Del Valle, MD  Purpose:  To evaluate the efficacy and safety of bilateral multifocal intraocularlens (IOL) implantation after cataract surgery. Setting:  Oftalmolo´gico de Valencia-CEOVAL, Valencia, Venezuela.  Methods:  This retrospective study evaluated patient charts for the patient selec-tion method, preoperative evaluation, surgical technique, postoperative visual andrefractive outcomes, and complications. It included 70 eyes of 35 patients whohad lens extraction with bilateral implantation of an Array multifocal IOL. Fourteeneyes of 7 patients had hyperopia with presbyopia, and 56 eyes of 28 patients hadcataract.  Results:  All eyes achieved an uncorrected distance acuity of 20/40 or better andan uncorrected near acuity of J5 or better. Six patients (18%) reported moderatehalos, and 22 patients (63%) occasionally wore glasses. Conclusion:  Bilateral multifocal IOL implantation was effective and safe in cata-ract and hyperopic patients with presbyopia, providing good uncorrected distanceand near acuities.  J Cataract Refract Surg 2004; 30:685–688  ©  2004 ASCRS and ESCRS pendence on spectacles for distance and near vision, C ataract surgery with implantation of a monofocal which increases the patient’s satisfaction and quality of intraocular lens (IOL) in patients with cataract islife. 1–8 Packer and coauthors 4 report implantation of thethe most frequently chosen option of surgeons world- Array IOL as an alternative for presbyopic patients who wide. It provides excellent distance vision. However,are motivated to reduce dependence on spectacles. Al-most patients need spectacle correction for near vi-thoughmanystudiesshowgooddistanceandnearvisualsion postoperatively.acuity results, 1–7 multifocal IOLs have been associatedThe AMOArray   multifocal IOL has ringsofvary- with an increased incidence of side effects such as halosing optical power with multiple transition zones thatat night and glare. 1,2,4,9 allowfocusfordistance,intermediate,andnearvision. 1–3 This study evaluated the visual and refractive out- Array IOL implantation is associated with reduced de-comes and postoperative complications of bilateral Array IOL implantation in patients with and withoutcataract performed at 1 eye surgery center.  Accepted for publication July 1, 2003.FromCentroOftalmolo´  gicodeValencia-CEOVAL(Pineda-Ferna ´ ndez, Jaramillo, Celis, Vargas, Galı´ ndez, Del Valle), and Centro Me ´ dico Patients and Methods Guerra Mendez (DiStacio, Galı´ ndez, Del Valle), Valencia, Venezuela.  A retrospective study was performed to evaluate uncor- None of the authors has a financial or proprietary interest in any  recteddistanceacuity,uncorrected nearacuity,bestspectacle- material or method mentioned. corrected visual acuity (BSCVA), manifest refraction, and Reprint requests to Angel Pineda-Ferna ´ ndez, MD, Avenida Bolivar  complications 3 months after bilateral implantation of  Norte, Edificio Torre Venezuela, Piso 2, Centro Oftalmolo´  gico de  multifocal Array IOLs. Patients were selected to receive the Valencia-CEOVAL, Valencia, Venezuela. E-mail: angelpinedaf@  yahoo.com.  multifocal IOL based on the following criteria: older than 󰂩 2004 ASCRS and ESCRS 0886-3350/04/$–see front matterPublished by Elsevier Inc. doi:10.1016/S0886-3350(03)00664-3  REFRACTIVE OUTCOMES WITH BILATERAL MULTIFOCAL IOL S 45 years, bilateral cataract or hyperopia of more than  2.0 diopters (D), preoperative keratometric cylinder lessthan 1.0 D, no preexisting ocular pathology other than cata-ract, potential postoperative visual acuity of 20/40 or better,and patient motivation after they received an explanationthat the surgery could improve distance and near vision andthat there was the possibility of postoperative visual aberra-tions such as halos at night and glare.Preoperative and postoperative examinations includeddistance visual acuity (Snellen chart), near vision at 30 cm with and without best distance correction using an illumi-nated near reading chart (Presby Corp.), slitlamp biomicros-copy, intraocular pressure measurement, manifest refraction, Figure 1.  (Pineda-Ferna´ ndez) Preoperative SE compared to the fundoscopy, and corneal topography. The preoperative mea- postoperative change in SE. The linear regression line shows the surements for IOL power calculation were done by a single correlation between the intended correction and the achieved technician. The patients had applanation axial length mea- correction. surement (Nidek Echo Scan US3300). The corneal curvature was estimated using an automated keratometer (Nidek Auto Three months after surgery, the mean sphere Ref/keratometer ARK-700). The SRK/T formula was used  was  0.14  0.87 D (range  0.75 to  1.25 D), the for IOL power calculation; the target was emmetropia or low  mean cylinder was  0.68  0.29 D (range  0.25 to hyperopia (0 to  0.5 D).  1.00 D), and the mean spherical equivalent (SE) was The Array Lens    0.24  0.52 D (range  1.25 to  1.00 D). Figure  All patients received an AMO Array SA40N IOL. This  1 shows the predictability. Eighty-seven percent of eyes zonal-progressive multifocal lens has extruded poly(methyl had an SE within  1.00 D of emmetropia and 56%, methacrylate) monofilament haptics. The optic has 5 zones  within  0.50 D. Among hyperopic patients, 80% had of power with up to   3.5 D of add at the IOL plane for no change in BSCVA from preoperatively to postopera- near and distance acuity and to provide intermediate acuity  tively, 20% gained 1 line of BSCVA, and no eye lost for distances from 50 to 150 cm. lines of BSCVA. Surgical Technique   All eyes achieved an uncorrected distance acuity of  Ninety percent of surgeries were done by 2 surgeons  20/40 or an uncorrected near acuity of J5 (Figure 2). (A.P., J.J.), and the remaining 10% were done by another  One eye had superior decentration of the IOL that surgeon (M.D.). All used topical or peribulbar anesthesia. A   was noted under mydriasis 2 weeks after surgery (Figure 3.0 mm, temporal, clear corneal self-sealing incision was 3). The uncorrected distance acuity was 20/200, and made with a diamond knife. The capsulorhexis was created slitlampexamination showedresidual cortex intheinfe-  with the goal of overlapping the IOL optic for 360 degrees. rior capsular bag, which was immediately aspirated in  A standard divide-and-conquer or phaco-flip technique wasusedforlensextractiondependingonthesurgeon’spreferenceand patient’s lens density. Results Seventy eyes of 35 patients had lens extraction withbilateralimplantationofanArraymultifocalIOL.Four-teen eyes of 7 patients had hyperopia with presbyopia,and 56 eyes of 28 patients had cataract. The mean ageof the patients was 61.54 years    11 (SD) (range 46to78years).Themeanpreoperativesphereinhyperopiceyes was  4.50  2.50 D (range  2.00 to  9.50 D), Figure 2.  (Pineda-Ferna´ndez) Cumulative uncorrected distance and the mean cylinder was   0.50    0.48 D (range acuity and uncorrected near acuity 3 months after bilateral multifocalIOL implantation.  0.25 to   1.00 D).  J CATARACT REFRACT SURG—VOL 30, MARCH 2004 686  REFRACTIVE OUTCOMES WITH BILATERAL MULTIFOCAL IOL S Discussion Some studies report that bilateral multifocal IOLsprovide distance vision similar to that with monofocalIOLs. 1,6–8 Others report better near vision and a greaterdepth of focus with multifocal IOLs than with monofo-cal IOLs. 1–7 In our study, all eyes achieved an uncor-rected distance acuity of 20/40 or better and anuncorrected near acuity of J5 or better. Packer andcoauthors 4 report that 94.1% of eyes achieved 20/40and J5 of monocular visual acuity at distance and near,andJavittandSteinert 2 reportthat96%ofeyesachieved20/40 or better distance acuity and J3 or better near Figure 3.  (Pineda-Ferna´ ndez) Multifocal IOL decentration caused acuity. These 3 studies show similar results in terms of  by residual cortex in the inferior capsular bag. final uncorrected distance and near acuities 3 monthsafter surgery. Many studies report less frequent use of the operating room. One month after the reoperation, spectacles for near-vision activities postoperatively inthe uncorrected distance acuity had improved to 20/40 multifocal IOL patients than in monofocal IOL pa-and the uncorrected near acuity was 20/40 (J5). One tients. 1,6,7 It has also been reported that patients withpatient developed cystoid macular edema that resolved multifocal IOLs have fewer limitations in their ability  withmedicaltreatment.Onepatientdevelopedaretinal to perform social and overall activities without glassesdetachment 4 months after uneventful surgery. This than control patients with monofocal IOLs. 1,3 patient required retinal surgery and had a final acuity  Although multifocal IOLs provide the ability toof counting fingers. read comfortably and see at distance without glasses, A 3-question survey was administered 3 months theirimplantationisrelatedtoalossofcontrastsensitiv-postoperatively to assess patient satisfaction. Patients ity, particularly at low-contrast levels, 2 and unwanted were asked how often they wore glasses. Twenty-two photic phenomena such as halos and glare. 1,2 In ourpatients (63%) occasionally wore glasses, 11 (31%) study, 2 patients (6%) reported significant halos andnever wore glasses, and 2 (6%) always wore glasses. glare around lights at night, and 6 patients (18%) re-Patients were asked to rate the effect of glare and ported moderate halos that did not disturb daily activi-halos on general daily activities, reading text on shiny  ties. However, none of these patients wanted IOLpaper,anddrivingatnight. Twopatients (6%) reported exchange for a monofocal IOL because they were very significant halos and glare around lights at night; how- satisfiedwiththeirdistance andnearacuities. Theywereever, they reported they were very satisfied with their offered pilocarpine 0.5% to reduce halos based on a uncorrected distance and uncorrected near acuities. study that showed most patients report improvementThey were offered pilocarpine 0.5% to reduce halos. in halos with pupil reduction methods. 9 Halos existSix patients (18%) reported moderate halos that did on the retinal image because the spread of light is outnot disturb daily activities. All patients who reported of focus. Also, theoretical optics suggest that retinalhalos and glareafter surgerydid not want IOL exchange blur circles (ring halos) are influenced by myopicfor a monofocal IOL. refraction. 10,11 Patients were asked how satisfied they were with One study suggests that individual refractive out-the surgery. Twenty-five patients (71%) said they were comesinfluence visualsensationsandthatsimpleremedi-very satisfied and 9 (26%), satisfied. One patient (3%) ation with overcorrection may mitigate these unwanted was very unsatisfied with her near vision, although it visual sensations. 9 In our study, the mean SE was was 20/30 (J4) in both eyes; she said she had not   0.24    0.52 D using the SRK/T formula for IOLexpected to need spectacles for near vision for any  power calculation. Multifocal IOL implantation is con-traindicated in some cases, such as professional driversactivity.  J CATARACT REFRACT SURG—VOL 30, MARCH 2004  687  REFRACTIVE OUTCOMES WITH BILATERAL MULTIFOCAL IOL S sive multifocal silicone intraocular lens and a monofocal  who drive at night, because of the increased limitation intraocular lens. Ophthalmology 1999; 106:1243–1255 in night vision. 8,9 2. Javitt JC, Steinert RF. Cataract extraction with multifo- Multifocal IOL decentration is not well tolerated. cal intraocular lens implantation; a multinational clinical One of our patients with significant IOL decentration  trial evaluating clinical, functional, and quality-of-lifeoutcomes. Ophthalmology 2000; 107:2040–2048 had an uncorrected distance acuity of 20/200. One 3. Sedgewick JH, Orillac R, Link C. Arraymultifocal intra- month after the IOL was recentered, the uncorrected ocular lens in a charity hospital training program; a  distance acuity improved to 20/40 and the uncorrected resident’s experience. J Cataract Refract Surg 2002; 28: near acuity was J5. 1205–12104. Packer M, Fine IH, Hoffman RS. Refractive lens ex-changewiththeArraymultifocalintraocularlens.JCata- Conclusion  ract Refract Surg 2002; 28:421–4245. Javitt JC, Wang F, Trentacost DJ, et al. Outcomes of  Overall, patients in our study were satisfied with cataract extraction with multifocal intraocular lens im- their distance and near vision and with the surgery, plantation;functionalstatusandqualityoflife. Ophthal- although some reported moderate halos and glare post-  mology 1997; 104:589–5996. Vaquero-Ruano M, Encinas JL, Millan I, et al. AMO operatively. The biggest advantage of multifocal IOL  Array multifocal versus monofocal intraocular lenses: implantation is that it can provide good uncorrected long-term follow-up. J Cataract Refract Surg 1998; 24: distance and near visual acuities, reducing dependence 118–123 on spectacles. A successful refractive outcome can be  7. Brydon KW, Tokarewicz AC, Nichols BD. AMO Array multifocal lens versus monofocal correction in cataract obtained with proper patient selection, motivation, and surgery. J Cataract Refract Surg 2000; 26:96–100 expectations; accurate preoperative biometry and IOL 8. Orme ME, Paine AC, Teale CW, Kennedy LM. Cost- power calculations; and good surgical technique. En- effectiveness of the AMO Array multifocal intraocular hanced results might be obtained with refinements in-  lensincataractsurgery.JRefractSurg2002;18:162–1689. HunkelerJD,CoffmanTM,PaughJ,etal.Characteriza- cluding immersion or partial coherence interferometry  tionofvisualphenomenawiththeArraymultifocalintra- axial length measurements, corneal topography, and a  ocularlens.JCataractRefractSurg 2002; 28:1195–1204 next-generation IOL calculation formula such as the 10. Lohmann CP, Fitzke FW, O’Brart D, et al. Halos—a  Holladay II.  problem for all myopes? A comparison between specta-cles, contact lenses, and photorefractive keratectomy.Refract Corneal Surg 1993; 9(suppl):S72–S75 References  11. O’Brart DPS, Lohmann CP, Fitzke FW, et al. Distur-1. Steinert RF, Aker BL, TrentacostDJ, et al. A prospective bances in night vision after excimer laser photorefractivekeratectomy. Eye 1994; 8:46–51comparative study of the AMO ARRAY zonal-progres-  J CATARACT REFRACT SURG—VOL 30, MARCH 2004 688
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