Adverse visual effects after multifocal IOL implantation resolved in majority of patients

J Cataract Refract Surg. 2009;35(6):992-997.

Issue: August 25, 2009

Undesirable visual outcomes after multifocal IOL implantation were treated successfully in a majority of patients, according to a study.

“Although most patients achieve spectacle independence with multifocal IOL implantation and are satisfied with their vision, some patients have unsatisfactory outcomes that are unique to multifocal IOLs,” the study authors said.

The retrospective study included 43 eyes of 32 patients who reported undesirable visual symptoms after multifocal IOL implantation. Twenty-eight eyes (65%) were implanted with the AcrySof ReSTOR IOL (Alcon) and 15 eyes (35%) were implanted with the ReZoom IOL (Abbott Medical Optics).

Blurred vision was reported in 41 eyes of 30 patients and photic phenomena were reported in 18 eyes of 15 patients; blurred vision and photic phenomena were reported in 16 eyes of 13 patients.

The leading causes of blurred vision were ametropia, dry eye syndrome, posterior capsular opacification and unexplained etiologies. The leading causes of photic phenomena were IOL decentration, retained lens fragments, PCO, dry eye syndrome and unknown etiologies.

Conservative treatment led to improved vision in 35 eyes (81%). Five eyes did not show improvement. IOL exchange was required in three eyes (7%). Treatments included excimer laser refractive surgery, pharmacologic therapy, laser iridoplasty and Nd:YAG laser capsulotomy. However, Nd:YAG capsulotomy should be delayed whenever possible; IOL exchange is markedly more challenging with an open posterior capsule, the authors said.

When a patient expresses dissatisfaction with a multifocal IOL, the doctor should first express empathy and then begin a systematic search for methods to alleviate the problem. This includes evaluating dry eye, macular edema or pathology, posterior capsular fibrosis, residual refractive error, irregular corneal astigmatism and IOL centration. I agree that a YAG capsulotomy should be the last resort, since this increases the underlying risk associated with IOL exchange, if needed. It is interesting to me that one of the patients still had the same complaints after IOL exchange to a monofocal lens, emphasizing the point that no lens implant can satisfy all patients and that there may be some inherent anatomical aspects of certain eyes making them more susceptible to dysphotopsia and other complaints. While this is not an epidemiological study, it is of interest that none of the dissatisfied patients presenting to this tertiary care center had Crystalens implants (Bausch & Lomb), but rather one of the multifocals.

– Jay S. Pepose, MD, PhD
Founder, Pepose Vision Institute Professor of Clinical Ophthalmology, Washington University School of Medicine, St. Louis