Create realistic patient expectations for multifocal IOLs, surgeon says

Only a small number of patients who were not given preventive information on glare and halos developed these symptoms.

ByMichela Cimberle

ROME – It should be the surgeon’s responsibility to decide to implant a multifocal IOL, according to Dario Surace, MD, speaking at the meeting of the Italian Ophthalmologic Society here.

“Patients shouldn’t be burdened with prognostics of glare and halos, nor misled with the idea that they will never need spectacles again, as this creates false alarms and false expectations,” he said.

“In our experience, about a fourth of the patients implanted with multifocal IOLs wear glasses for near vision, especially if their daily life encompasses activities requiring prolonged use of the eyes for near vision. We also have reason to believe that preventive information on postoperative glare and halos creates a psychosomatic amplification of these visual perceptions in many of the patients.”

Use of spectacles

At the hospital where Dr. Surace works, 123 patients were bilaterally implanted with multifocal Array SA40N lenses (Allergan). The mean follow-up period was 9 months (ranging from 3 to 18).

“Of these patients, 86% achieved 20/23 uncorrected visual acuity, and 100% were 20/40 or better,” Dr. Surace said. “For near vision, only 22% could read uncorrected J1, but 65% read J2 or J3, which is approximately the letter size of newspapers,” he said.

“All were able to read at least J4. Some patients (13%), although they can read J1, received a +2 spectacle correction at their own request. Almost all of them were indefatigable readers, and reported some soreness after prolonged use of their eyes,” he continued.

For distant vision, the use of glasses was less frequent and more occasional. “However, a questionnaire revealed that 25% to 30% of our patients wore glasses with variable frequency, and that’s why it’s a mistake to promise them that they won’t need glasses after surgery,” Dr. Surace said.

The same questionnaire evaluated the degree of satisfaction on a scale of 1 to 10 at near, intermediate and distant vision.

“We calculated an average of 8.5 for distant and intermediate vision, and a mean of 6.5 for near vision, which became 8.1 with the additional correction of +2, which is a satisfying index,” Dr. Surace said.

Glare and halos

Glare and halos were not seen at all by 40% of the patients, or just slightly perceived by 37%. In 19% of the patients, diffractive phenomena were present, but not disturbing, and only 3% of patients reported difficulties in driving at night, which were not corrected by wearing spectacles.

In almost all cases, these disturbances tended to decrease as time passed.

It takes some time for the brain to get used to the new implant, Dr. Surace explained, and discomfort generally diminishes if the patient is confident and relaxed.

With 23 patients, Dr. Surace tested the idea of not giving preventive information on the potential diffractive effects of these particular lenses. “We implanted these patients bilaterally, and didn’t go into particular detail concerning this aspect. Only one of the patients complained of postoperative glare and halos, and this percentage is lower than in all known statistics,” he said.

In conclusion, Dr. Surace said, too much information makes the patient insecure and anxious about the possible onset of symptoms.

“If the surgeon really believes in this lens, he or she must feel confident that there is no need to worry patients with too much emphasis on potential complications. As a consequence there is generally an improvement,” he said.

A careful selection

The key to success is a careful selection of patients, Dr. Surace said. Astigmatism should be less than 1 D to 1.5 D, or else the aim of not using spectacles will not be achieved.

Patients should be motivated to do without spectacles, but not everybody is willing to give them up, he said.

They should also have realistic expectations. “Don’t select persnickety patients, as they will certainly complain of halos,” he said.

Patients must also be intellectually sound, as this lens requires the brain to adjust to a new situation. The brain receives a number of stimuli, and must learn to choose the clear one, excluding all others.

“It’s a way of seeing that requires some training and therefore some intellectual flexibility,” Dr. Surace said.

A precise calculation of IOL power is important. The implant must always be bilateral, and not too much time should pass between the implant of the first and second lens.

“I performed some of the implants at the same time,” Dr. Surace said.

Realistic expectations

A good surgeon should choose patients carefully, avoid creating groundless anxieties and only make realistic promises, Dr. Surace said.

“Realistically, we can tell our patients that they will feel comfortable without spectacles in situations such as going to a restaurant, going to the movies and doing housework. Furthermore, they’ll be able to read their watches, the speedometer while they are driving and prices when they do their shopping at the supermarket; they will be able to read a newspaper article or play cards with friends,” Dr. Surace said.

“At least 98% of our patients can do all these activities, and these are therefore realistic promises we can make without hesitation.”

For Your Information:

Dario Surace, MD, can be reached at Ospedale Civile Sant’Antonio, Via Facciolati 71, Padua, Italy; +(39) 049-821-6538; fax: +(39) 049-821-6645; e-mail: surax@tin.it.

Allergan, manufacturer of the Array SA40N lens, can be reached at 2525 Dupont Drive, Irvine, CA 92612 U.S.A.; +(1) 714-246-4500; fax: +(1) 714-246-5913; Web site: www.allergan.com.