Purpose To analyze the reasons for patient dissatisfaction after phacoemulsification with multifocal intraocular lens (IOL) implantation and the outcomes after intervention. Setting Emory Eye Center, Atlanta, Georgia, USA. Methods This retrospective review comprised eyes of patients dissatisfied with visual outcomes after multifocal IOL implantation. Outcomes analyzed included type of visual complaint, treatment modality for each complaint, and degree of clinical improvement after intervention. Results Thirty-two patients (43 eyes) reported unwanted visual symptoms after multifocal IOL implantation, including in 28 eyes (65%) with an AcrySof ReSTOR IOL and 15 (35%) with a ReZoom IOL. Thirty patients (41 eyes) reported blurred vision, 15 (18 eyes) reported photic phenomena, and 13 (16 eyes) reported both. Causes of blurred vision included ametropia (12 eyes, 29%), dry eye syndrome (6 eyes, 15%), posterior capsule opacification (PCO) (22 eyes, 54%), and unexplained etiology (1 eye, 2%). Causes of photic phenomena included IOL decentration (2 eyes, 12%), retained lens fragment (1 eye, 6%), PCO (12 eyes, 66%), dry-eye syndrome (1 eye, 2%), and unexplained etiology (2 eyes, 11%). Photic phenomena attributed to PCO also caused blurred vision. Thirty-five eyes (81%) had improvement with conservative treatment. Five eyes (12%) did not have improvement despite treatment combinations. Three eyes (7%) required IOL exchange. Conclusions Complaints of blurred vision and photic phenomena after multifocal IOL implantation were effectively managed with appropriate treatment. Few eyes (7%) required IOL exchange. Neodymium:YAG capsulotomy should be delayed until it has been determined that IOL exchange will not be necessary.

Dissatisfaction after multifocal intraocular lens implantation.

Purpose:
The purpose of this study was twofold: first, to prospectively compare visual acuity (VA) scores obtained with Snellen charts versus Early Treatment Diabetic Retinopathy Study (ETDRS) charts in a “real world” retinal practice, and second, to see if there was a difference in visual acuity measurements obtained with ETDRS charts starting at 4 or 2 meters.

Prospective evaluation of visual acuity assessment: a comparison of snellen versus ETDRS charts in clinical practice (An AOS Thesis).

Background
Good unaided distance visual acuity (VA) is now a realistic expectation following cataract surgery and intraocular lens (IOL) implantation Near vision, however, still requires additional refractive power, usually in the form of reading glasses Multiple optic (multifocal) IOLs are available which claim to allow good vision at a range of distances It is unclear whether this benefit outweighs the optical compromises inherent in multifocal IOLs

Objectives
To assess the visual effects of multifocal IOLs in comparison with the current standard treatment of monofocal lens implantation

Search methods
We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2016), Embase (January 1980 to June 2016), the ISRCTN registry (wwwisrctncom/editAdvancedSearch), ClinicalTrialsgov (wwwclinicaltrialsgov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (wwwwhoint/ictrp/search/en) We did not use any date or language restrictions in the electronic searches for trials We last searched the electronic databases on 13 June 2016

Selection criteria
All randomised controlled trials comparing a multifocal IOL of any type with a monofocal IOL as control were included Both unilateral and bilateral implantation trials were included We also considered trials comparing multifocal IOLs with "monovision" whereby one eye is corrected for distance vision and one eye corrected for near vision

Data collection and analysis
We used standard methodological procedures expected by Cochrane We assessed the 'certainty' of the evidence using GRADE

Main results
We found 20 eligible trials that enrolled 2230 people with data available on 2061 people (3194 eyes) These trials were conducted in Europe (13), China (three), USA (one), Middle East (one), India (one) and one multicentre study in Europe and the USA Most of these trials compared multifocal with monofocal lenses; two trials compared multifocal lenses with monovision There was considerable variety in the make and model of lenses implanted Overall we considered the trials at risk of performance and detection bias because it was difficult to mask participants and outcome assessors It was also difficult to assess the role of reporting bias

There was moderate-certainty evidence that the distance acuity achieved with multifocal lenses was not different to that achieved with monofocal lenses (unaided VA worse than 6/6: pooled RR 096, 95% confidence interval (CI) 089 to 103; eyes = 682; studies = 8) People receiving multifocal lenses may achieve better near vision (RR for unaided near VA worse than J3/J4 was 020, 95% CI 007 to 058; eyes = 782; studies = 8) We judged this to be low-certainty evidence because of risk of bias in the included studies and high heterogeneity (I2 = 93%) although all included studies favoured multifocal lenses with respect to this outcome

People receiving multifocal lenses may be less spectacle dependent (RR 063, 95% CI 055 to 073; eyes = 1000; studies = 10) We judged this to be low-certainty evidence because of risk of bias and evidence of publication bias (skewed funnel plot) There was also high heterogeneity (I2 = 67%) but all studies favoured multifocal lenses We did not additionally downgrade for this

Adverse subjective visual phenomena were more prevalent and more troublesome in participants with a multifocal IOL compared with monofocals (RR for glare 141, 95% CI 103 to 193; eyes = 544; studies = 7, low-certainty evidence and RR for haloes 358, 95% CI 199 to 646; eyes = 662; studies = 7; moderate-certainty evidence)

Two studies compared multifocal lenses with monovision There was no evidence for any important differences in distance VA between the groups (mean difference (MD) 002 logMAR, 95% CI -002 to 006; eyes = 186; studies = 1), unaided intermediate VA (MD 007 logMAR, 95% CI 004 to 010; eyes = 181; studies = 1) and unaided near VA (MD -004, 95% CI -008 to 000; eyes = 186; studies = 1) compared with people receiving monovision People receiving multifocal lenses were less likely to be spectacle dependent (RR 040, 95% CI 030 to 053; eyes = 262; studies = 2) but more likely to report problems with glare (RR 141, 95% CI 114 to 173; eyes = 187; studies = 1) compared with people receiving monovision In one study, the investigators noted that more people in the multifocal group underwent IOL exchange in the first year after surgery (6 participants with multifocal vs 0 participants with monovision)

Authors' conclusions
Multifocal IOLs are effective at improving near vision relative to monofocal IOLs although there is uncertainty as to the size of the effect Whether that improvement outweighs the adverse effects of multifocal IOLs, such as glare and haloes, will vary between people Motivation to achieve spectacle independence is likely to be the deciding factor

/pdf/multifocal-versus-monofocal-intraocular-lenses-after-2ypb97izw2.pdf

Multifocal versus monofocal intraocular lenses after cataract extraction

European Multicenter Study of the AcrySof ReSTOR Apodized Diffractive Intraocular Lens

Neurobiology of retinal dopamine in relation to degenerative states of the tissue

AIMS To calculate the diameter of halos perceived by patients with multifocal intraocular lenses (IOLs) and to stimulate halos in patients with refractive multifocal IOLs in a clinical experiment. METHODS Calculations were done to show the diameter of halos in the case of the bifocal intraocular lens. 24 patients with a refractive multifocal IOLs and five patients with a monofocal IOL were asked about their subjective observation of halos and were included in a clinical experiment using a computer program (Glare & Halo, FW Fitzke and C Lohmann, Tomey AG) which simulates a light source of 0.15 square degrees (sq deg) in order to stimulate and measure halos. Halo testing took place monoculary, under mesopic conditions through the distance and the near focus of the multifocal lens and through the focus of the monofocal lens. RESULTS The halo diameter depends on the pupil diameter, the refractive power of the cornea, and distance focus of the multifocal IOL as well as the additional lens power for the near focus. 23 out of 24 patients with a refractive multifocal IOL described halos at night when looking at a bright light source. Only one patient was disturbed by the appearance of halos. Under test conditions, halos were detected in all patients with a refractive multifocal IOL. The halo area testing through the distance focus was 1.05 sq deg ± 0.41, through the near focus 1.07 sq deg ± 0.49 and in the monofocal lens 0.26 sq deg ± 0.13. CONCLUSIONS Under high contrast conditions halos can be stimulated in all patients with multifocal intraocular lenses. The halo size using the distance or the near focus is identical.

https://bjo.bmj.com/content/bjophthalmol/85/7/816.full.pdf

Halo size under distance and near conditions in refractive multifocal intraocular lenses

Purpose: To compare contrast sensitivity and glare disability provided by diffractive and refractive multifocal intraocular lenses (IOLs).

Setting: University Eye Clinic Vienna, Austria.

Method: This study evaluated the contrast sensitivity and glare disability in 29 eyes with a diffractive multifocal IOL (3M815LE) and 12 with a three-piece, five-zone refractive multifocal IOL (AMC Array SSM 26 NB). The Brightness Acuity Tester (Mentor, Inc.) was used with stationary sinusoidal gratings at spatial frequencies of 0.5, 1, 3, 6, 11.4, and 22.8 cycles per degree (cpd) generated on a television monitor (Nicolet CS 2000).

Results: The contrast sensitivity functions of both multifocal IOL groups were within the reference range and were identical at 0.5, 1, and 22.8 cpd spatial frequencies. At 3, 6, and 11.4 cpd, the contrast sensitivity function in the diffractive IOL group was 6, 9, and 10% lower than in the refractive IOL group, and the difference between groups was statistically significant at 6 cpd. When glare was present, contrast sensitivity in the diffractive IOL group was generally in the lower limit of the reference range and remained below at 3 and 6 cpd. Contrast sensitivity in the refractive IOL group remained below the reference range at 3 cpd. At 0.5 and 1 cpd, there were no differences between the groups. At the middle and high spatial frequencies (3, 6, 11.4, 22.8 cpd), contrast sensitivity in the diffractive group was 8, 16, 11, and 12% lower than in the refractive group. At 6 cpd, the between-group difference was statistically significant.

Conclusion: Diffractive multifocal IOLs provided decreased contrast sensitivity and greater glare disability than refractive multifocal IOLs.

Contrast sensitivity and glare disability with diffractive and refractive multifocal intraocular lenses.

Purpose: To evaluate the efficacy of topical anesthesia as an alternative to peribulbar anesthesia in clear corneal cataract surgery. Setting: Department of Ophthalmology, University of Vienna, Austria. Methods: In this prospective, double-blind clinical trial, 36 patients had bilateral cataract surgeries performed from 1 to 3 months apart. Half of the patients had topical anesthesia for the first surgery and peribulbar anesthesia for the second surgery. The other half had peribulbar first and then topical. All surgery was done using a temporal clear corneal approach and bimanual phacoemulsification followed by in-the-bag intraocular lens implantation. Subjective pain was assessed using a visual analog scale of no pain (0%) to worst pain imaginable (100%) and intraoperative motility using a rank scale of adverse motility (−5) to ideal patient cooperation (+5). Results: Subjective pain was comparable whether topical or peribulbar anesthesia was used (mean 10.75 versus 10.97%; P > .6). Patient cooperation (motility) was significantly better when topical anesthesia was used (+2.16 versus +1.11; P = .03). There were no significant differences in complications. A peribulbar block was given in addition to the topical anesthesia in two cases. Conclusions: Topical anesthesia is a safe, effective alternative to peribulbar anesthesia in clear corneal cataract surgery.

Topical versus peribulbar anesthesia in clear corneal cataract surgery.

Purpose To evaluate the reading performance of a diffractive bifocal (811E, Pharmacia) and a refractive multifocal (SA40N, Allergan) intraocular lens (IOL) and compare it with that of a monofocal IOL (811C, Pharmacia) with respect to reading acuity, reading speed based on print size, maximum reading speed, reading distance, and critical print size. Setting Department of Ophthalmology, University of Vienna, Vienna, Austria. Methods This study comprised 120 pseudophakic eyes of 70 patients; each IOL group had 40 eyes. The patients’ age, sex, and best corrected logMAR visual acuity were recorded. Reading acuity and speed were tested monocularly. Reading acuity was determined in logRAD (ie, the reading equivalent of logMAR). Patients with bifocal and multifocal IOLs read with best distance correction and patients with a monofocal IOL, with an addition of +3.0 diopters. Results The age, mean spherical equivalent, cylinder, and best corrected distance visual acuity were comparable among the 3 groups. The mean logRAD reading acuity was 0.17 ± 0.18 (SD) in the 811E group (94.0% of logMAR), 0.31 ± 0.13 in the SA40N group (73.2% of logMAR), and 0.24 ± 0.22 in the 811C group (94.1% of logMAR). The reading acuity in the SA40N group was statistically significantly lower than in the 811E and 811C groups. The best reading distance was 30 cm in the 811E group and 40 cm in the SA40N group. The mean maximum reading speeds in words per minute were comparable: 187.5 ± 26.1 (811E), 171.0 ± 21.1 (SA40N), and 179.4 ± 21.6 (811C). The reading speed, which ranged from logRAD 0.7 to 0.3, and the critical print size in the SA40N group were significantly worse than in the 811E and 811C groups. The mean critical print size in the 811E group was significantly worse than in the 811C group. Conclusion Reading performance was acceptable in the bifocal and multifocal IOL patients, with the diffractive bifocal IOL performing best in a standardized reading test setting.

Reading performance with a refractive multifocal and a diffractive bifocal intraocular lens

Purpose: To determine whether a small clear corneal temporal incision produces less surgically induced astigmatism than a larger incision. Methods: One hundred three consecutive cases of postoperative astigmatism after clear corneal incision cataract surgery were studied for a minimum of 1 year. Only self-sealing incisions from the temporal side were made as follows: 3.2 mm (Group A); 4.0 mm (Group B); 5.2 mm (Group C). We considered the amount and axes of the keratometric readings at different times as well as their course over time. Induced astigmatism was calculated using three methods. Axial changes were also analyzed. Results: Immediately after the surgery, there was a small, surgically induced, withthe-rule astigmatic shift in all groups, which in most cases decreased to near preoperative levels with time. One year postoperatively, mean induced astigmatism was 0.09 diopter (D) in Group A, 0.26 D in Group B, and 0.54 D in Group C. Most cases had minimal axial changes. In Group A, 86% had an axial change of fewer than 30 degrees; in Group B, 76%; and in Group C, 73%. Conclusion: The smallest incision group had the least surgically induced astigmatism and axial change. All incision groups remained stable and had satisfactory clinical results.

Herbert Weghaupt

Papers

Halo size under distance and near conditions in refractive multifocal intraocular lenses

Contrast sensitivity and glare disability with diffractive and refractive multifocal intraocular lenses.

Topical versus peribulbar anesthesia in clear corneal cataract surgery.

Reading performance with a refractive multifocal and a diffractive bifocal intraocular lens

Long-term course of induced astigmatism after clear corneal incision cataract surgery