Large range of options ushers in era of

Multifocal IOLs

Better patient selection leads to better results in an era of personalised visual care. Dermot McGrath reports

The performance and safety implantation have definitely hampered of the latest generation their uptake but are far less of an issue of multifocal IOLs gives with modern lenses, he said. surgeons the opportunity As evidence, he cited the fact that IOL to offer presbyopic exchange rates for unhappy multifocal patients a truly customised solution patients have dropped dramatically over for their visual needs with high levels the past decade. of patient satisfaction, according to “In addition, a lot of the reasons Daniel Kritzinger MD, president of the for unsatisfactory results are actually Southern African Society of Cataract and treatable and if you address residual Refractive Surgery. refractive errors postoperatively

“There are so many as well as posterior capsule modalities available today opacification (PCO), up to with bifocal, trifocal and 80% of these unhappy cases extended depth of focus could be resolved,” he said. (EDOF) lenses in addition Dr Kritzinger stressed the to traditional monovision importance of managing with monofocal IOLs. The patient expectations goal I feel should always be and selecting a lens based individualised decision-making, on factors such as lifestyle, whichever approach one prefers to Daniel Kritzinger MD occupation and needs. take. We are in a position where “Published results and studies we can address our patients’ needs have confirmed that spectacle independence and deliver high levels of spectacle is far more possible and likely when independence,” he said at the World implanting a multifocal IOL than just Ophthalmology Congress 2020 Virtual. relying on monofocal monovision. A 2017

Dr Kritzinger, in private practice meta-analysis showed a mean spectacle at Visiomed Eye Laser Centre, independence rate of over 80% with Johannesburg, South Africa, said it was multifocal lenses,” he said. important not to get drawn into a sterile He added that evolving lens technology monofocal versus multifocal IOL debate. along with artificial intelligence applications

“There is no one-size-fits-all solution and the ability to assess preoperatively the for presbyopia correction in cataract patient’s objective behavioural data will patients, but I strongly feel that if total allow more personalised and precise lens spectacle freedom is high on the agenda selection in the future. for the patient and surgeon, then they The importance of rigorous will definitely have the best chance of preoperative assessment in implanting achieving this result using a multifocal multifocal IOLs was also emphasised by intraocular lens. I see no other way of Professor Marie-José Tassignon, who used achieving that,” he said. a case study of an unhappy multifocal

With only about 6% of cataract IOL patient to illustrate some of the key procedures involving a presbyopiaissues that may arise in such cases. correcting IOL, the preference for most The 52-year-old female patient with an surgeons today is still a monovision uneventful medical history was hyperopic approach using a monofocal IOL, noted in both eyes, with a visual acuity of 10/10 in Dr Kritzinger. Issues of haloes and her right eye and 4/10 in the fellow eye with glare and reduced contrast sensitivity amblyopia. Although she was satisfied with associated with multifocal IOL her multifocal implant in the immediate

There is no one-size-fits-all solution for presbyopia correction in cataract patients... but they will have the best chance of achieving this result using a multifocal IOL Daniel Kritzinger MD postoperative period, she started experiencing visual difficulties in her left eye one month to six weeks after her surgery.

The corneal topography showed a regular corneal surface of normal curvature with a small amount of regular astigmatism (0.53D in the right eye and 0.70D in the left eye).

“What was interesting was her axial length: 20.64 mm for the right eye and 20.38 mm for the left eye, which is an outlier. She had a normal retinal correspondence in the right eye, but she had cyclorotation of the macula in the left eye,” said Prof Tassignon, Professor and Head of Ophthalmology Department, University Hospital, Antwerp, Belgium.

Orthoptic examination, which is mandatory in such eyes said Prof Tassignon, showed that she had no strabismus or diplopia, a small hyperphoria and esophoria, poor fusion and poor stereopsis. Examination of the problem eye revealed a decentred lens, an irregular anterior capsulorhexis and fibrotic tissue.

“This proliferative tissue was caused by a reaction of the capsular bag to the presence of the foreign body intraocular lens. I used a bimanual technique to pull off the fibrotic tissue and clean out the capsular bag while supporting the zonules as much as possible. The next step was to restore the anterior capsulorhexis and reposition the IOL. After clean up, I decided to leave the lens as it was now well centred and the Purkinje reflex was okay,” she said.

Several lessons could be drawn from the case, concluded Prof Tassignon.

“Orthoptic examination is mandatory in all cases of refractive outliers whether the patient is hyperopic or a high myope. Fundus examination should also be done carefully including retinal correspondence. Patients with amblyopia and poor fusion are bad indications for multifocal implantation unless they present a certain degree of suppression. Patients with high ametropia are also bad candidates in general for these lenses, but if there is good quality of vision immediately after implantation then later complaints might be related to IOL foreign body reaction,” she said.

If this is the case, peeling of the proliferative tissue might improve patient’s quality of vision and does not require IOL exchange.

Daniel Kritzinger: drkritzinger@visiomed.co.za