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Mixing multifocal technologies can provide spectacle independence
Listening to the patient can guide the surgeon in selecting the best multifocal IOL for the second eye, one cataract surgeon says.
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Listening to patients’ evaluation of their vision after implantation of one multifocal IOL can guide the surgeon in selecting the best IOL for each patient’s second eye, according to one surgeon. To provide spectacle independence for patients with varied vision needs, sometimes a different multifocal IOL technology in the second eye may be the best option, Leonardo Akaishi, MD, said.
He began mixing multifocal IOL technologies in selected cataract patients about 8 months ago. He began the practice, he said, because the most common complaint of his more than 900 patients with bilateral AcrySof ReSTOR (Alcon) IOLs was a lack of intermediate vision.
In an interview with Ocular Surgery News, Dr. Akaishi said he prefers to implant the same type of multifocal IOL in both eyes of a patient, but he has learned that catering to each patient’s individual needs can produce excellent results. Rather than automatically implanting mixed or matched multifocal IOLs in every patient, he implants one IOL and chooses the second based on the patient’s satisfaction with his or her postoperative vision in the implanted eye.
“I prefer to use the same IOL,” Dr. Akaishi said. “This is my first choice. But after 2 weeks or 3 weeks with the first implant, if the patient complains about their intermediate vision or needs much light to read, I prefer to implant the other kind of IOL.”
Dr. Akaishi presented his results with mixed and matched multifocal IOLs at the World Ophthalmology Congress in São Paulo, Brazil, where he practices.
The facts
Refractive and diffractive multifocal technologies each offer patients both strengths and weaknesses, Dr. Akaishi said in his presentation.
The ReZoom multifocal (Advanced Medical Optics), which is a refractive lens, provides excellent intermediate vision, 100% transmission of light and excellent distance vision, Dr. Akaishi said. However, he added, it provides relatively weaker near vision and lower reading speed, and its mechanism of action is somewhat dependent on pupil size.
The AcrySof ReSTOR, which is an apodized diffractive lens, provides excellent near vision, good reading speed, and its action is pupil-independent, he said, but intermediate vision and contrast sensitivity are relatively weaker, and some light is scattered rather than transmitted.
The Tecnis Multifocal from AMO is also a diffractive lens. It combines multifocal technology with aspheric technology, which improves contrast sensitivity by compensating for existing spherical aberration in the patient’s eye. The Tecnis was launched in Latin America during the World Ophthalmology Congress.
Implanting the same multifocal IOL style in both eyes may be the best option for some patients, Dr. Akaishi said.
For example, he said, patients who are heavy computer users, daytime drivers and light-to-moderate readers might find refractive lenses to be the most satisfying. On the other hand, heavy readers, detailed craftsmen, night drivers and frequent movie-watchers may be better suited for diffractive lenses, he said.
But Dr. Akaishi said many patients do not fall neatly into just one of these categories.
“Most of my patients … need all kinds of vision,” he said.
The best solution for these patients may be to integrate both refractive and diffractive multifocal technologies, he suggested.
Good results
Dr. Akaishi presented his results comparing spectacle independence in patients with bilateral or mixed multifocal IOL implants.
In 100 patients implanted with bilateral ReSTOR lenses and 100 implanted with bilateral ReZoom lenses, with a mean follow-up time of 4 months, the ReSTOR group reported an average of 89% spectacle independence and the ReZoom group reported an average of 75% spectacle independence.
He also reported on two mixed combinations: ReSTOR-ReZoom and Tecnis-ReZoom.
The ReSTOR-ReZoom group included 88 patients followed for a mean of 2 months, and the Tecnis-ReZoom group included 15 patients followed for a mean of 1 month. Both groups reported being 100% spectacle independent.
In the ReSTOR-ReZoom group, average distance visual acuity was 20/20, and average near visual acuity was comparable to the bilateral ReZoom group but with a higher reading speed. The Tecnis-ReZoom group also had an average distance visual acuity of 20/20, as well as a faster reading speed than either bilateral group.
Dr. Akaishi said his early impressions of the Tecnis-ReZoom combination are that it results in less halos and glare than the ReSTOR-ReZoom combination, less light needed for bilateral near vision, a more comfortable reading distance, more bilateral contrast sensitivity and less spherical aberration.
He said this new combination could be the “complete refractive solution” for a full range of vision for all conditions, although more study is needed.
Invested time
Finding the right solution for presbyopia correction in the many different patients who present to a cataract surgeon takes a bigger time commitment than traditional cataract surgery with monofocal IOLs, Dr. Akaishi told OSN.
“I need to spend time with the patient. Two years ago, I spent a maximum of 5 minutes with each patient. Now I spend 15 or 20 minutes, and my technician spends 2 hours,” he said. “For me, that’s very important. We’re returning to 20 years ago or 30 years ago when the doctor spent a lot of time with the patient.”
Dr. Akaishi said surgeons must know their patients’ characteristics before proceeding with any multifocal IOL implantation, whether matched or mixed.
“It’s very important to remember to talk with the patient before surgery and to know the characteristics of the patient,” he said. “If the patient plays cards, what kind of playing do they do? If your patient plays cards and the cards are 2 meters away on the table, that’s very different from near reading vision.”
If a surgeon adopts the strategy of implanting one multifocal IOL before deciding on the other, he or she must listen closely to the patients praises and complaints, Dr. Akaishi said.
“If the patient closes one eye and then closes the other eye, the patient will see the difference because the quality of the vision is very different” in the multifocal IOL eye and the one with the crystalline lens still in place, he said. “I ask the patient not to compare the visual acuity. Don’t compare the vision for far because it’s very different.”
Listening to the patient will guide a surgeon as to which IOL to implant in the second eye, Dr. Akaishi said.
“Unfortunately we don’t have the perfect IOL at the moment,” he said. “We should do something to help the patients, and 100% of my patients [with the mixed multifocal technologies] are independent of glasses.”
For more information:
- Leonardo Akaishi, MD, can be reached at the Hospital Ophthalmologic of Brasilia, L-2 Sul 607, Brasilia, Asa Sul 70200-670, Brazil; +55-61-34424003; e-mail: leonardoakaishi@hobr.com.br.
- Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.