Customized IOL implantation may be worthwhile

Customized IOL implantation has become a topic of great interest over the past year. The combined implantation of two different multifocal lenses, an apodized diffractive lens (AcrySof ReSTOR, Alcon Laboratories) and a refractive lens (ReZoom, Advanced Medical Optics), has provided patients with good results in near, intermediate, and distance vision because the two IOLs complement one another. In a survey of patients in whom the diffractive lens had been implanted bilaterally and patients in whom one of each IOL had been implanted, the combination approach received higher marks compared with bilateral diffractive lens implantation.

Key Points

Columbia, SC-Customized IOL implantation has become a topic of great interest over the past year. Rick Milne, MD, said that the combined implantation of two different multifocal lenses, an apodized diffractive lens (AcrySof ReSTOR, Alcon Laboratories) and a refractive lens (ReZoom, Advanced Medical Optics), is his procedure of choice for multifocal IOL surgery.

Dr. Milne presented his experience with patients who received the combination treatment and results of a survey comparing patients in whom the two different lenses had been implanted with patients in whom two of the diffractive lenses had been implanted.

"The old focus of cataract surgery was to restore vision loss resulting from the development of cataracts," Dr. Milne said. "The new focus is to optimize vision and not just improve it."

The human visual system, he said, can neuroadapt to dissimilar optics in alternate eyes.

"Multifocal or accommodating IOLs can be used successfully with a monofocal IOL in the opposite eye. Multifocal or accommodating IOLs can be used successfully with a natural crystalline lens in the opposite eye," Dr. Milne said. "Complementary multifocal/accommodating IOLs may provide superior outcomes for many patients compared with symmetrical implants of the same IOL in both eyes, especially at intermediate distance."

Adequate communication with patients preoperatively is vital, he said.

"The IOL should be chosen carefully after listening to each patient's desires, expectations, and fears," Dr. Milne said. The discussion should include an accurate description of the options including the strengths and limitations of each lens and the positive and negative implications of customized matching of IOLs. Patients should be aware that the bilateral procedure often requires postoperative fine-tuning.

Dr. Milne said he tells his patients that he is intentionally making their eyes perform differently to provide them with greater capabilities over a wider range of visual situations.

"Then we celebrate the difference," he continued.

He schedules the surgeries 2 to 3 weeks apart, he said, and emphasizes to patients that they will not realize the desired visual outcomes until both surgeries are done.

Complementary technology

Using the two different lenses together, he explained, works well because the two technologies complement one another. The refractive IOL provides excellent intermediate and distance vision and 100% transmission of light; the drawbacks of the lens include its ability to provide "just good" near vision, its association with a lower reading speed, and the fact that it is pupil-dependent. The diffractive lens, on the other hand, provides excellent near vision and good reading speed and is pupil-independent; the disadvantages of this IOL are the lack of intermediate vision with it, the transmission of less light, and the loss of contrast sensitivity.

Dr. Milne reported the subjective results of a survey of 23 patients in whom the diffractive lens was implanted bilaterally and 29 patients who received the diffractive lens in one eye and the refractive lens in the other eye. All patients with only diffractive lenses had received the lenses at least 6 months previously, and at that point all patients had 20/30 vision and J2 or better vision. In the patients with the two different IOLs, at 1 month after implantation, all patients had 20/40 and J2 or better vision.

A comparison of the patient satisfaction with distance vision in both groups indicated that 98% of the patients with the two different lenses were satisfied or very satisfied, compared with 74% of the patients with bilateral diffractive IOLs. No patients with the combination of lenses expressed dissatisfaction with the IOLs, compared with 26% of patients with bilateral diffractive lenses.

Patient satisfaction also was higher regarding near vision results, with 98% of patients with the two different IOLs claiming that they were satisfied or very satisfied with the outcomes and 0% expressing dissatisfaction, compared with 83% and 17%, respectively, of the patients with the bilateral diffractive lenses, Dr. Milne reported.