June 2018


Cataract editor’s corner of the world
Young patients express high satisfaction in visual acuity with multifocal IOLs

by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer

Tecnis Symfony IOL after cataract surgery in a male patient, 37 years old with congenital cataracts; UDCVA of 10/10 and J1.5 at 40 cm

Tecnis MFIOL after cataract surgery in a female patient, 36 years old with bilateral posterior subcapsular cataracts; UDCVA of 10/10 and J1 at 33 cm
Source: Luisa Malheiro, MD

In this month’s “Cataract editor’s corner of the world,” we delve into the results of a study presented at the XXXV Congress of the ESCRS. It looks at patient satisfaction with MFIOL implantation but in a younger patient cohort. One would think that younger patients undergoing cataract surgery would prefer to have a presbyopia-correcting IOL since they are not used to needing reading aids yet. If you read on you will see what the outcome of the study is. No matter what the age of the patient, full disclosure on expectations and outcomes is important to achieve good results.
Read on to learn more about the use of MFIOLs and EDOF IOLs in a younger patient cohort.

Rosa Braga-Mele, MD,
Cataract editor

Multifocal and extended depth of focus IOL implantations in patients under 40 years of age were well tolerated and visually efficacious, according to a recent study

Multifocal IOLs provide a high degree of spectacle independence for all ranges of vision following implantation in presbyopic patients undergoing cataract surgery. But what about patients at pre-presbyopic ages? Are there any limitations? According to the results of a recent study, it seems that physicians can expect the same visual acuity outcomes using multifocal IOLs in younger patients as those achieved in older, presbyopic patients. Patient selection is important, with lifestyle, occupation, and patient expectations playing major roles and perfectionist personalities being the hardest to manage. Also, physicians need to watch for blurred vision from ametropia when implanting multifocals and anticipate the appearance of photopic phenomena and decreased contrast sensitivity.
The study was shown in an e-poster at the XXXV Congress of the ESCRS. Results demonstrated a high level of satisfaction with the visual acuity achieved 6 months following surgery in the study that evaluated the refractive and visual outcomes and patient satisfaction after cataract surgery of multifocal (MFIOL) or extended depth of focus (EDOF) IOL implantations in patients under 40 years of age. The study demonstrated that multifocal or EDOF IOL implantation is a feasible and valuable option for the restoration of both distance and near visual acuity in young patients who need to undergo cataract surgery, according to the first author of the poster, Luisa Malheiro, MD, Department of Ophthalmology, Centro Hospitalar Universitario do Porto, Portugal.

Retrospective study of 15 eyes

The study was a retrospective analysis of 15 eyes of nine patients who underwent cataract surgery with multifocal/EDOF lens implantation between June 2011 and November 2016. The patients were 44% male and 56% female, with ages ranging from 29–40 years (mean age of 37 years). They underwent ophthalmological examinations preoperatively and at 1 month, 3 months, and 6 months postoperatively. The reasons for cataract surgery included: cataract and high hyperopia (in two eyes), congenital cataract (in three eyes), posterior subcapsular cataract (in six eyes), traumatic cataract (in one eye), and total cataract (in three eyes). Uncorrected distance visual acuity (UCDVA; logMAR), best corrected distance visual acuity (BCDVA; logMAR), uncorrected near visual acuity (UCNVA; Jaeger scale: at 33 and 40 cm), manifest refraction, spectacle dependency, patient satisfaction after surgery, complications, and reinterventions were analyzed.
Following cataract surgery, the patients received one of three lenses; two eyes received the Tecnis MFIOL (Johnson & Johnson Vision, Santa Ana, California), nine eyes received the AT LISA trifocal IOL (Carl Zeiss Meditec, Jena, Germany), and four eyes received the Tecnis Symfony EDOF IOL (Johnson & Johnson Vision). In six of the eyes, toric versions of the devices were implanted: four Tecnis Symfony toric IOLs and two AT LISA toric trifocal IOLs. Three patients were submitted to unilateral multifocal IOL implantation, one of which had unilateral eye trauma, another of which received a monofocal IOL implanted in the fellow amblyopic eye, and the last of which had a total unilateral cataract in one eye.

The study’s outcomes

The mean preoperative BCDVA was logMAR 0.4 and improved to logMAR 0.9 at 6 months after surgery (P=.02). BCDVA remained unchanged in 86% of the eyes from the third postoperative month until the end of the follow-up period. Near visual acuity remained stable in 80% of the eyes during the 6 months of follow-up time.
All of the patients who received extended depth of focus lenses (n=4) achieved uncorrected near visual acuity of J 1.5 at 40 cm. The near uncorrected visual acuity at 6 months in eyes with multifocal IOLs was J 1 in 45% and J 1.5 in 55% of eyes.
The preoperative sphere was 2.16 and the preoperative cylinder was 0.89. Postoperatively, the sphere was 0.07 and the cylinder was 0.13. There was a significant improvement in the postoperative refractive status, for sphere (P=.05) and for cylinder (P=.12), 3 months after surgery. The refractive status remained stable until 6 months after surgery and until the end of the follow-up period. One patient from the sample was dependent on spectacles for distance visual acuity.
All of the patients in this study expressed a high degree of satisfaction, subjectively, with their postoperative visual acuity outcomes.

Posterior capsule opacification

No complications were reported either during the surgery or within the 6-month follow-up period. Similarly, no reinterventions were necessary up to 6 months after surgery. Of the 15 eyes operated on, two eyes developed posterior capsule opacification (PCO) in a mean time of 2.2 years after surgery and underwent capsulotomy with Nd:YAG laser with visual improvement.
“Visual outcomes achieved with multifocal or extended depth of focus IOL implantation were good and remained stable during the follow-up time,” Dr. Malheiro said. “All of the patients achieved spectacle independence for distance and near visual acuity, except in one patient who remained dependent on spectacles for distance visual acuity.”

Agreement and disagreement

Hyperopia can be a strong indication for multifocals, at any age. An unrelated study that implemented bilateral multifocal IOL implantation (Acri.LISA 366D, Carl Zeiss Meditec) in 85 moderate to high hyperopic patients (170 eyes) substantiated the level of satisfaction seen in Dr. Malheiro’s outcomes, showing a satisfactory full range of vision in high hyperopes, comparable to that obtained in low to moderate hyperopes.1
In another unrelated investigation that studied the outcomes of refractive lens exchange in pre-presbyopic eyes, the study coordinators found that the implantation of a diffractive MFIOL (ReSTOR MFIOL, Alcon, Fort Worth, Texas) gave good distance and near contrast sensitivity under photopic and mesopic conditions, and although mesopic contrast sensitivity was reduced at distance and near compared to that achieved under photopic conditions, the performance was comparable to that with the natural lens preoperatively.2
Young eyes, however, have not always responded well to multifocals, as was shown in a different study of presbyopic (n=17) and non-presbyopic patients (n=7; aged under 45 years) with monocular cataracts who received ReSTOR MFIOLs as part of a study that evaluated the visual acuity and subjective satisfaction of different aged monocular cataract patients with ReSTOR MFIOLs. It revealed near and intermediate vision in young eyes that was worse than that of the contralateral clear lens eyes and with lower subjective satisfaction (compared to the presbyopic patients in the same study). However, pre-presbyopic patients were very satisfied with their distance vision, according to the study outcomes.3


1. Fernandez-Vega L, et al. Visual and refractive outcomes in hyperopic pseudophakic patients implanted with the Acri.LISA 366D multifocal intraocular lens. Am J Ophthalmol. 2009;148: 214–220.
2. Ferrer-Blasco T, et al. Contrast sensitivity after refractive lens exchange with diffractive multifocal intraocular lens implantation in hyperopic eyes. J Cataract Refract Surg. 2008; 34:2043–8.
3. Li JH, et al. Comparison of visual acuity in pseudophakic eyes with multifocal intraocular lens versus fellow eyes with clear lens. Zhonghua Yan Ke Za Zhi. 2010;46:691– 6.

Editors’ note: Dr. Malheiro has no financial interests related to her comments.

Contact information

Malheiro: luisamalheiro90@gmail.com

Young patients express high satisfaction in visual acuity with multifocal IOLs Young patients express high satisfaction in visual acuity with multifocal IOLs
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