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Clear lens extraction followed by implantation of a multifocal IOL is becoming more widely adopted as a treatment for presbyopia in many centres throughout Europe, according to presentations at the XX ESCRS Congress.

Michael Knorz MD

Michael Knorz MD told the conference that PreLex, an abbreviated form of presbyopic lens exchange, is currently the only refractive option available with enough of a clinical track record to be recommended in presbyopic patients.
“LASIK is limited to low myopia and moderate hyperopia. Otherwise, there are too many side effects and furthermore, it cannot correct presbyopia.
“With phakic IOLs you do need a certain anterior chamber depth. They are also difficult to implant in shallow hyperopic eyes. And except for one design, the Vivarte, they cannot correct presbyopia,” Dr Knorz said.
That leaves clear lens exchange. The surgical technique is easy and the risk of retinal detachment might be increased in myopia but it is not increased in hyperopic eyes.

Moreover, clear lens exchange with the AMO SA40 multifocal IOL actually enables the correction of both the ametropia and the presbyopia, Dr Knorz said.
He noted that at his centre, PreLex is offered as an alternative to LASIK and phakic IOLs to presbyopic patients over 40 years with ametropia ranging from +8.0 D to –12 D.
In a study involving 52 eyes of 26 patients undergoing presbyopia lens exchange and implantation of the SA40 multifocal IOL, uncorrected distance visual acuity was 20/40 or better in 96% and uncorrected near visual acuity was J 3 or better in 86% after three months follow-up. In addition, 96% were within 1.0 D of emmetropia.
Dr Knorz performed all procedures using intracameral lidocaine. He created a posterior limbal incision at the steepest meridian and performed relaxing incisions for any remaining astigmatism over 1.0 D.

He operated on the second eye after seven days. He performed LASIK after three months in those cases with residual ametropia.
“Presbyopic lens exchange is an excellent option in presbyopic ametropia especially for hyperopes. There is however a new quality of vision which means that the patient has to learn to read again and to accommodate using simultaneous vision.
“Halos must also be expected. It’s also important to perform LASIK if there is any residual ametropia because residual ametropia is far more critical in a multifocal IOL than it is with a standard lens,” Dr Knorz said.

Tayo Akingbehin MD

British ophthalmologist Tayo Akingbehin MD reported similar results with PreLex. He also stressed the importance of careful patient selection.
In a retrospective study involving 72 eyes of 36 ametropic patients who underwent implantation of the AMO Array for cataracts or presbyopia, the mean UCVA was 20/16 (range: 20/14 - 20/30) for distance and J 3 (range J 2 – J 6) for near. All eyes were within 0.75 D of emmetropia and had less than 1.0 D of astigmatism, he said.
Furthermore, 26 patients, or 72%, had a UCVA for distance of 20/20 or better and 24 eyes, or 66%, had a UCVA for near of J2 or better after a follow-up of six to 30 months. A further nine, or 25%, of the remaining eyes had an uncorrected visual acuity of 20/30 and J4 or better and one eye had a UCVA of 20/60.

Optical side effects included eight cases of halos, which resolved over time. One patient, a high myope, had difficulty adjusting to the new optical system but this was also resolved. No patients required IOL exchanges.
The patients in the study included 12 men and 24 women with a mean age of 62 years, with a range of 35 to 79 years. Twenty-three eyes were myopic preoperatively with a mean spherical equivalent (SE) of -7.9 D.
Thirteen were hyperopic with mean SE of +4.15 D (range +1.50 D) and a maximum cylinder of 2.5 D. The patients either had cataracts or had opted for presbyopic lens exchange when they learned they were unsuitable for LASIK. Dr Akingbehin and his associates performed the phaco using topical anaesthesia in 62 eyes and peribulbar anaesthesia in 10 eyes.

Astigmatism was corrected by opposite clear corneal incision in eight eyes and by radial keratotomy in eight eyes. The IOLs ranged in power form 10 D to 30 D.
Dr Akingbehin noted that patients for whom multifocal IOLs are contraindicated include those with an obsessive personality, those with a profession that involves a lot of night driving, and those who had undergone previous corneal refractive surgery.
“The Array IOL has fulfilled our expectations and is a reasonable alternative IOL for correction of presbyopia,” he added. The results of a French study indicated that the use of multifocal IOLs generally gives good results in myopic patients but the procedure is less reliable in older patients and in those with high myopia.

Serge Zaluski MD

In a retrospective study involving 50 eyes of 25 patients who underwent bilateral cataract extraction and implantation of SA40 multifocal IOLs, the mean UCVA improved from 20/60 to 20/30 and 92% had a mean near visual acuity from J1 to J2 after a mean follow-up of eight months, Serge Zaluski MD said.
The patients in the study included 11 women and 14 men ranging in age from 45 to 90 years. Their preoperative SE ranged from + 0.50 to – 10.5 D (at least one eye was myopic) and axial lengths from 22.68 mm to 28.99 mm.
Dr Zaluski noted that 52% of eyes had a postoperative uncorrected distance visual acuity of 20/30 or better and 74% had a postoperative BCVA better than 20/30.
In addition, their mean SE improved from - 4.20 D to - 0.34 D and 88% were within 1.0 D of emmetropia. However, two eyes in the study were myopic postoperatively because of a mistake in the ordering of the lenses.

The best results were obtained in the patients who were less highly myopic and those of a less advanced age, Dr Zaluski observed.
For example, the mean postoperative BCVA was 20/25 among those with 6.0 D or less of preoperative myopia, compared to 20/30 among those with more than 6.0 D of preoperative myopia.
Similarly, the mean BCVA was 20/20 among those less than 60 years of age, compared to 20/25 among those between 60 and 75 years. It was 20/30 among patients over 75.
“This procedure seems to be efficient for cataract surgery in low and moderate myopias. Results are less favourable in those aged over 70, with an axial length greater than 26 mm and an initial myopia greater than –6.0 D,” Dr Zaluski said.

Michael Knorz MD
FreeVis LASIK Zentrum, Mannheim University, Germany
Email: knorz@eyes.de

Tayo Akingbehin MD, FRCS, FRCOphth
Drayton House Clinic, Southport, England
Email: tayo@draytonhouseclinic.com

Serge Zaluski MD
Centre of Ophthalmology, Perpignan, France
Email: serge.zaluski@wanadoo.fr

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