Gender differences impact multifocal IOL choice, outcome

Magda Rau

Gender differences have an effect on the experiences and outcomes of multifocal IOLs and should be taken into account when choosing the best implantation procedure and the right multifocal IOLs, according to a clinician.

“Gender medicine has gained full recognition as medical science and can offer as well in ophthalmology an interesting new perspective from which to evaluate our results and even make choices in our clinical practice,” Magda Rau, MD, said.

Dr. Rau’s observations are based on more than 2,000 multifocal lenses of all types implanted over 12 years, and on several studies in which groups of her patients were analyzed. Two years ago, her findings concerning gender-related differences in multifocal IOL preferences and satisfaction raised interest and curiosity.

“Some behaviorists insist that behavioral patterns have remained much the same since the Stone Age,” she said. “It was fascinating to find in my patients’ expectations, reactions and priorities the persistence of ancestral behavioral patterns: Men, who were originally hunters, desire a wide, clear, uninhibited view into the far distance, while women — avid collectors — primarily require good vision at close range.”

Men and women have different requirements regarding reading glasses, she noted. Women, on average, require between +0.25 D and +0.5 D higher addition compared to men of the same age group. She said this difference is because women, on average, read more than men and “are more interested in details.”

“[Women] have shorter arms and also prefer a shorter reading distance. Look at a man reading his newspaper: his arms are quite extended, while a woman bends the elbows at 90· approximately,” Dr. Rau said. “In one of our studies, we found that at the same age of 42 years, the preferred average reading distance is 43 cm for men and 38 cm for women.”

Gender-based differences

Adaptation is also remarkably different in men and women, according to Dr. Rau. Women adapt more often and more quickly to multifocality and rarely complain about glare and halos, she said.

“Women are generally more flexible, more adaptable, more capable of dealing with changes. Men are anxious to get results, while women go through the adaptation period with more patience and acceptance. As a consequence, they use the new optical system better. They practice and learn more quickly,” she noted.

On average, there are more women asking for multifocal lenses than men, according to Dr. Rau’s statistics. Women more often seek spectacle independence for aesthetic, as well as practical, reasons. She said the varied aspects of women’s modern lives, including personal lives in the home and holding a job in different working environments, require different vision distances.

“And also, of the many near tasks of a woman’s life, there is one that mandatorily cannot be done with spectacles on your nose, which is put on your make-up,” she said. “Men, even when they shave, don’t need to get so close to the mirror.”

Gender-based multifocal IOL selection

Dr. Rau’s experience with multifocal lenses began 12 years ago with the MF4 (Carl Zeiss Meditec; not available in the U.S.), a refractive lens with a central near-powered zone.

“At that time, I found that women were satisfied with the lens, but men were not. I adopted a practical solution and started to combine the MF4 with central zone for near with the AMO Array, a refractive lens with central zone for distance vision,” she said.

A while later, a sufficient body of experience allowed Dr. Rau to conclude that multifocal lenses with central zone for distance — at that time, the Array — were good lenses for men, while the MF4, with central zone for near, was preferred by the majority of women.

“Men’s priority with multifocal IOLs was a perfect distance vision, the ‘hunter vision,’ we might say,” Dr. Rau said. “They were also highly disturbed by halos and glare when driving at night, while only [a] few women reported this as a complaint. Women’s priorities were reading and other near-vision daily tasks, for which they were prepared to accept some compromise on distance vision.”

When new multifocal lenses were developed, Dr. Rau observed again that the Tecnis (Abbott Medical Optics), a diffractive IOL with two foci for near and distance, was a favorite of women rather than men.

“At this point, I started using multifocal lenses also in clear lens exchange procedures and was able to include in my observations also young professional women. It was interesting, because in my previous series of patients, who were older cataract patients, there were still more defined gender role differences. Women were mostly staying at home, and men were, or had been, working outside the home. This could more easily explain the different approach to vision as a practical need in relation to the different daily tasks and work activities,” Dr. Rau said.

What she expected with the younger generation was a definite shift of women’s preference toward the distance-dominant lenses. To her surprise, young professional women were still happy with the +4 D addition of the Tecnis, the only multifocal IOL with such a high addition, she said.

At that time, the refractive ReZoom (AMO) became her favored choice for men, because of the distance-powered central zone.

“In my male patients, I usually start with this lens in the dominant eye, and if they are satisfied, I implant a second one in the nondominant eye. Fine-tuning this second lens to a slight plus or minus allows me to improve near vision or to further potentiate distance vision, according to individual needs,” she said. “If patients are not satisfied, I do mix and match.”

In women, the procedure is basically the same but Dr. Rau starts with a diffractive IOL such as Tecnis, ReSTOR (Alcon) or Acri.Lisa (Carl Zeiss Meditec; not available in the U.S.), or refractive lenses with a near-powered central zone such as MF4. Only for women who frequently use the computer does she consider implanting a ReZoom in the dominant eye.

Dr. Rau has also recently started implanting an asymmetric design, as well as a diffractive refractive construction. These designs are crucial to reducing halos and glare. – by Michela Cimberle

• Magda Rau, MD, can be reached at Augenklinik Cham, Cham, Bavaria, Germany, 93413; 49-99-7186-1078; e-mail: rau@augenklinik-cham.de.

This is a remarkable article that takes a unique perspective on choosing premium IOLs for patients. Gender medicine is definitely a twist on the traditional way of practicing medicine, and in some areas it is unquestionably better suited. However, one must be cautious in the area of premium IOL technologies that we, as physicians, do not assume we know what the patient’s needs are based solely on gender. It is extremely important not to generalize. I still feel it is essential to ask patients what level of vision they value the most (distance, intermediate or near) and to find out what their individual needs are. It is necessary to examine the eyes and based on anatomy/pathology, ocular dominance, refraction, current refractive correction, etc., determine which IOL technology fits that patient best. It is also important to explain the possible outcomes to our patients, including the fact that they may need to wear some form of corrective lenses after surgery or that they may experience visual dysphotopsias, so that we can turn a complication into an expectation and perhaps abate their complaints and anxieties. Also, one must remember that there are many premium IOL technologies that can assist in meeting the patient’s needs both with multifocal IOLs and accommodative IOLs. So, although an interesting spin on “prescribing” premium IOL technology to one’s patients, one must remember to examine the whole patient and determine the patient’s needs with their input

– Rosa Braga-Mele, MD, FRCSC
OSN Cataract Surgery Section Editor