Would you consider using multifocal IOLs in patients with comorbidities such as AMD, glaucoma or diabetes?

No, because light dispersion would cause visual disability

Jorge L. Alió

Multifocal IOLs are premium lenses that are manufactured with the purpose of improving near and intermediate vision by dividing the light in different foci. This division of light makes the energy focus on different levels at the visual axis, with a loss of contrast sensitivity in most of the models and a potential for photic phenomena coming from the particular optical image that is created by the light migrating toward different foci.

I consider multifocal IOLs in patients with normal visual potential. Based on my personal experience and on several independent reports by other investigators, I expect good visual and refractive outcomes, normal optical behavior and a good prognosis in terms of neuroadaptation.

With this in mind, I do not use multifocal lenses in patients with potential for macular problems, glaucoma or diabetes mellitus with diabetic retinopathy. Other conditions such as retinal dystrophies (retinitis pigmentosa) are also not to be an indication. The reason for this contraindication is indeed the dispersion of light along the visual axis. Patients with low-contrast sensitivity due to different pathologies would be disabled by multifocal lens dispersion.

Accommodating IOLs are better indicated in these cases, as they do not affect the light distribution along the visual axis and might help near vision. Some lenses with some multifocal capabilities, such as the Crystalens (Bausch + Lomb), due to a very low near vision add, are also a feasible option. While having no negative impact on visual quality, they can offer some improvement in intermediate vision, which is helpful for most of the patients with adequate visual potential of more than 20/30.

In the future, novel designs of lenses with low-contrast sensitivity loss or even no contrast sensitivity loss will find an indication in these problematic cases.

Jorge L. Alió, MD, PhD, is an OSN Europe Edition Editorial Board Member. Disclosure: Dr. Alió has no financial interest in the Crystalens but is a consultant for Bausch + Lomb.

Yes, in well-selected cases

Magda Rau

AMD, glaucoma and diabetes used to be an absolute contraindication for the use of multifocal IOLs. But things have changed in recent years. New multifocal IOLs with improved designs have been produced. We know how different multifocal IOL types and models perform in the eye, what the potential problems are and how to avoid them. On the other hand, an increasing number of patients specifically ask for them and are strongly oriented toward spectacle independence.

Of course, when comorbidities are present, every case must be assessed carefully and individually. Can multifocal lens implantation benefit the patient and for how long? What is the prognosis of the coexisting disease? What is the patient’s life expectancy?

As a general rule, I do not implant multifocal IOLs in patients with dry or wet AMD. The only exception is the initial stage of maculopathy with macular drusen, when no progression has been reported for at least 1 year and no visual field changes have been detected by Amsler grid testing.

Primary open-angle glaucoma, well-compensated by one or two medications and without changes in the visual field, OCT-RNFL or HRT, is not, in my view, a contraindication. There are cases in which long-term medical therapy has induced pupil rigidity, and in these cases, I avoid multifocal IOLs if pupil diameter is less than 3.5 mm. However, diffractive multifocal IOLs, which are not pupil-size dependent, can be considered in patients with narrow pupils.

Diabetes, when it is well-compensated even by insulin treatment, is not a contraindication for the implantation of multifocal IOLs. Before surgery, I perform fluorescein angiography to exclude multiple aneurysms and the presence of peripheral less vascularized retinal areas, not visible on biomicroscopy. In this way, I rule out the risk of progression to diabetic retinopathy, which is a contraindication for the implantation of these lenses.

Magda Rau, MD, is an OSN Europe Edition Editorial Board Member. Disclosure: No products or companies are mentioned that would require financial disclosure.