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Mixing and matching IOLs still has a place in providing multifocality
A study involving different Lentis lenses showed how mix and match works in a variety of patients, leaving most satisfied and spectacle independent.
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Multifocality has made a huge step forward with today’s IOL options, but mix and match still has a place, according to one specialist.
“It is still a great option when we have to respond to patients’ visual complaints after implantation in the first eye. It gives us the opportunity to improve satisfaction by choosing the lens that better responds to their demands,” Magda Rau, MD, said in an interview with Ocular Surgery News.
Rau was a pioneer of multifocal lens implantation and mix and match. When she implanted the first MF4 (Carl Zeiss Meditec) and realized that not all patients were fully satisfied, she started combining it with the Array (Abbott Medical Optics).
“The MF4 was a refractive with a central zone for near, and the Array was a refractive with central zone for distance. It worked very well. I saw that I could get the best of both lenses and minimize the drawbacks,” she said.
In 2003, she started combining the refractive ReZoom (Abbott Medical Optics) with the diffractive ReSTOR (Alcon), and at that time mix and match became routine with many surgeons. Now that IOL technology has evolved to include trifocal and quadrifocal optics, extended depth of field, and asymmetric and toric designs, it is legitimate to ask: Is there still a need for mix and match?
Study with asymmetric IOLs
To answer this question, Rau set up a study with the large family of Oculentis asymmetric IOLs, offering the advantage of the same design with different additions, including the toric option. In group 1 she combined Lentis Comfort and Lentis Mplus X; in group 2, Lentis Mplus X and Lentis Mplus toric X; and in group 3, Lentis Comfort toric with Lentis Mplus toric X. The study included 250 patients.
“In group 1 I included patients who wanted to achieve spectacle independence but were afraid of glare and halos. I started by implanting Comfort in the dominant eye, and if they were satisfied, I implanted the same lens in the fellow eye. If they wanted just a small improvement in near vision, I calculated the second lens slightly in the minus range, something between –0.5 D and –1.25 D — no more than this because the lens would otherwise lose multifocality function and distance vision would decrease. However, if the patients were completely dissatisfied with near vision, the option was Mplus X with +3 D addition in the nondominant eye,” Rau said.
By mixing and matching these lenses, all distances were covered: distance and intermediate with the Comfort and near with the Mplus X, with minimal dysphotopsia.
Group 2 included patients implanted with the Mplus X in the first eye and Mplus toric X in the second eye, both with an addition of 3 D, who had astigmatism between 1.25 D and 1.5 D. Astigmatism of 1.25 D to 1.5 D in the first implanted eye was not corrected and so distance vision decreased. The patients were not satisfied and wanted improvement through astigmatism correction in the other eye. The mean uncorrected visual acuity for distance was 0.78 in the Mplus X eyes and 0.88 in the Mplus toric X eyes. This shows that the correction of slight astigmatism could improve the visual acuity in distance and near.
“Even a small amount of astigmatism should be corrected because it could lead to poor visual acuity,” Rau said.
Group 3 coupled the Comfort toric and Mplus toric X. Rau said that several patients choose the Comfort toric because it is the best in terms of avoiding side phenomena glares and halos and because it is cheaper than the Mplus toric X.
“If they are happy, the Comfort toric in both eyes is a perfectly good solution, but if they want further improvement, we can mix and match with an Mplus toric X in the second eye. The Mplus toric X is the best you can get in the Lentis family. It is customized in 0.01 D steps, but it is the most expensive,” Rau said.
In all groups, visual results were remarkable, Rau said. By combining two IOLs, binocular vision significantly improved monocular results. At all distances, visual acuity was between 20/25 and 20/20.
Postoperative satisfaction was tested with a questionnaire. In the first group, 78% of the patients were very satisfied, 20% satisfied and 2% not satisfied. In the second group, which achieved the highest satisfaction, 88% were very satisfied and 12% satisfied. In the third group, 80% were very satisfied and 20% satisfied.
“Complete spectacle independence was achieved by 90% of the patients in the first group, 100% in the second group and 92% in the third group,” Rau said.
Individual choice
“I like the large spectrum of the Lentis family because the patients like the mix of the same design, which has, beyond doubt, a lot of advantages, especially for brain adaptation,” Rau said.
“Besides these, I do all kinds of mix-and-match combinations in my practice,” she said. “I combine the asymmetric lenses with diffractive lenses, bifocal and trifocal if necessary. Sometimes I implant in one eye the AMO Tecnis, the only lens with a +4 D addition, when a patient wishes to read very small print or do embroidery with dark fibers.”
Mix and match is versatile and can lead to a high degree of satisfaction, but it requires a lot of chair time with the patient, she said. No combination is better than another, but there is one that is best for a specific patient at a specific time.
“I give my patients a questionnaire about work and hobbies and then talk a lot with them before surgery. I want to know if and how they use computers, tablets and smartphones, the sports they practice and check what is their preferred reading distance, how small is the print they want to read and how motivated they are to be completely spectacle-free. I talk with them for a long time and go into a lot of details because patients are sometimes not able to express what they really want,” Rau said.
After surgery in the first eye, she waits 1 or 2 weeks in cataract cases and a few days in clear lens exchange cases and then has a long talk again with patients to find out if they are satisfied and in which way they would like to improve.
“With experience, you learn a lot on the best options to offer and the best combinations to make and grow confidence on the chances you have to make every patient satisfied,” Rau said. – by Michela Cimberle
- For more information:
- Magda Rau, MD, can be reached at Augenklinik Cham, Cham, Bavaria, Germany, 93413; email: info@augenklinik-cham.de.
Disclosure: Rau reports she is an investigator for Oculentis but has no direct financial interest in the product.