Why choosing the right multifocal IOL patients is important

Take-home: Surgeons must choose their multifocal intraocular lens candidates carefully and aim for motivated patients with great optics and healthy tear film.

Reviewed by Oliver Findl, MD

Vienna, Austria––The best candidates for multifocal intraocular lenses (IOLs) are highly motivated, have nearly perfect optics, and have healthy tear film. Otherwise, patients could have issues with contrast sensitivity, glare, and haloes.

Various studies have shown that multifocal IOLs can lead to vision issues, including contrast sensitivity, glare, and haloes, reported Dr. Findl, department of ophthalmology, Hanusch Hospital, Vienna, Austria.

For example, a Cochrane meta-analysis led by Daniel Calladine, MRCOPHTH, included 16 trials and 1,600 patients¹. It found that monofocals had less glare and fewer haloes than multifocal IOLs. The analysis also found a trend toward less contrast sensitivity with monofocals.

Dr. Findl also cited a study from Niels E. De Vries, MD, FEBOphth et al., that analyzed patients who were dissatisfied with their multifocal IOLs.² The main cause for their unhappiness was unsatisfactory visual acuity (95%), followed by photic phenomena (38%), or both unsatisfactory visual acuity and photic phenomena (33%).

Astigmatism also led to more dissatisfaction in ametropic patients, with some patients having 1 D and up to 3 D of astigmatism. Issues that led to these problems included large pupil size, trace posterior capsule opacification, and decentration. Nearly half of these patients were treated with photorefractive keratectomy, while others received spectacles.

Monovision

One option to consider in patients is monovision. In a randomized controlled trial³ conducted by Mark Wilkins, MD, FRCOphth, 212 patients were randomized to receive Akreos AO monofocal lenses with mini-monovision, with a 1.25 D difference between eyes or a Tecnis ZM900 diffractive IOL. Those patients with the multifocal IOLs were more likely to be spectacle dependent, but they also were more likely to have their lenses explanted.

Mini-monovision can be a good option, but it usually is accompanied with reduced stereopsis. “These patients do quite well and are less critical with outcomes and have little to no dysphotopsia,” Dr. Findl said.

However, surgeons should let these patients know they will still need reading glasses for long-time reading, poor lighting, or small print. The availability of depth-of-focus IOLs also helps to address problems typically associated with multifocal IOLs, Dr. Findl added.

Yet, another study with important evidence, presented by Nick Mamalis, MD, during the 2008 European Society of Cataract and Refractive Surgeons meeting, focused on safety and lens explantation. Dr. Findl said the report found an overrepresentation of multifocal IOLs that were explanted, mainly due to glare and haloes.

Two kinds of patients who are not good candidates for multifocal IOLs are nighttime drivers and overly critical patients, Dr. Findl added.

References

1. Calladine D, Evans JR, Shah S, Leyland M. Multifocal versus monofocal intraocular lenses after cataract extraction. Cochrane Database Syst Rev. 2012 Sep 12;9:CD003169. 

2. de Vries NE, Webers CA, Touwslager WR, et al. Dissatisfaction after implantation of multifocal intraocular lenses. J Cataract Refract Surg. 2011;37:859-65. 

3. Wilkins MR, Allan BD, Rubin GS, et al. Randomized trial of multifocal intraocular lenses versus monovision after bilateral cataract surgery. Ophthalmology. 2013;120:2449-2455.e1. 

Oliver Findl, MD

e. oliver@findl.at

This article was developed from a presentation that Dr. Findl delivered at the 2015 American Academy of Ophthalmology meeting.