Wilkes Barre, PA-Bilateral implantation of the apodized diffractive IOL (AcrySof ReSTOR, Alcon Laboratories) appears to result in a high rate of complaints about intermediate vision that can be completely mitigated by implanting the ReSTOR IOL in one eye and the second-generation refractive multifocal IOL (ReZoom, Advanced Medical Optics) contralaterally, according to a study by Frank A. Bucci Jr., MD, a private practitioner in Wilkes-Barre, PA.
He reported that in a series he accrued of 55 patients with bilateral ReSTOR implantation, 15 (27.2%) voluntarily offered complaints about intermediate vision that were found to correlate with poor results on intermediate uncorrected visual acuity (UCVA) testing. Considering only the 34 lensectomy patients in the group, the rate of spontaneous complaints about intermediate vision increased from one in four patients to one in three.
In contrast, none of 26 refractive lensectomy or 13 cataract surgery patients who had received the ReSTOR IOL in one eye and the ReZoom contralaterally complained about their intermediate vision. That clinical finding was consistent with their having significantly better mean binocular intermediate UCVA compared with the ReSTOR-ReSTOR patients, J2.39 versus J3.81, respectively.
Notably, the benefit of improved intermediate vision in patients with the two different IOLs implanted was achieved without any sacrifice of near UCVA.
Mean binocular near UCVA was J1.00 in the ReSTOR-ReSTOR group compared with J1.07 for the patients who received the ReSTOR-ReZoom combination.
A synergistic combination
"Although there are no hard data to support the warning, ophthalmologists are often cautioned not to mix IOL technologies. However, the combination of these two IOLs appears to be an exception that works well," said Dr. Bucci. "The unique optical characteristics of each implant appear to be complementary and offset the drawbacks of the other. The synergistic combination results in very high rates of spectacle independence and patient satisfaction."
He noted he began implanting the ReSTOR bilaterally after it became available in the United States in June 2005, but unfortunately found an unacceptably high proportion of patients were experiencing significant visual dysfunction at intermediate distance. Describing a few cases, Dr. Bucci noted that several patients complained about being unable to see the computer for work, a homemaker complained about poor vision for cooking, and a carpenter was experiencing difficulties with woodworking.
While the patients with complaints were accumulating, five previous patients with lensectomy who had the Array multifocal IOL (AMO) implanted unilaterally years prior presented for possible second eye surgery. Implantation of the ReSTOR IOL in the fellow eye resulted in excellent outcomes.
"These were some of the happiest patients I ever encountered in my practice and it seemed logical to me that if the ReZoom is an improved version of the Array, the combination of the ReZoom with the ReSTOR would be even better," Dr. Bucci said.
At the time of his report, he had a series of 65 patients in the ReSTOR-ReZoom group, but he analyzed data for the first 39 who had an average follow-up of 12 weeks.
Dr. Bucci also analyzed complaints of the ReSTOR-ReSTOR group by procedure type and patient age and found that the indication for surgery was refractive lensectomy in 12 (80%) of the 15 patients who complained while only three were cataract patients. Ten (91%) of the 11 lensectomy patients were under 60 years old.
"Clearly the younger, refractive surgery patients were more likely to complain about their intermediate vision than the older, cataract patients, and that is easily understandable considering the numerous functional and cultural differences between these population groups," Dr. Bucci said. "Older cataract surgery patients are from a more accepting generation who tend to have more reasonable outcome expectations, are more likely to be retired, and tend to be less active than their refractive surgery counterparts. The latter patients have higher expectations by nature and because they are both paying more for their surgery and are coming to it with excellent corrected vision.