Controversies In Refractive Surgery: Does Keratoconus Mix With Multifocal Intraocular Lenses

Multifocal intraocular lens (IOL) implantation is generally not considered in patients with keratoconus; however, it may provide good optical results in selected patients based on case reports. The purpose of this study was to evaluate patient satisfaction and clinical outcomes in this patient population.

Private practice.

This is a retrospective single-center, non-comparison study. All patients with frank keratoconus who had undergone a trifocal IOL implantation between 2016 and 2019 were invited to participate in this study (18 eyes of 9 patients were included). Postoperatively, refractive outcomes, contrast sensitivity, and ocular aberrations were recorded. A questionnaire was used for determining patient satisfaction and their quality of life. The mean follow-up time was 31.22 ± 6.38 months.

Postoperatively the patients’ uncorrected distance visual acuity improved from 1.13 ± 0.93 logMAR to 0.10 ± 0.17 (p˂0.001), corrected distance visual acuity went from 0.10 ± 0.11 to 0.05 ± 0.09 (p=0.19), mean refractive spherical equivalent changed from -4.34 ± 4.31 to 0.05 ± 0.51 D (p˂0.001), and manifest astigmatism from 2.44 ± 1.92 to 0.88 ± 1.81 D (p=0.017). A postoperative MRSE of less than ± 0.50 D was achieved in 17 eyes (94%). Three eyes (17%) lost 1 line of best corrected visual acuity and no patient lost two or more lines. The patients were independent of glasses in 78% for all distances. One patient who required an IOL exchange due to photic phenomena was lost to follow-up.

Despite being a controversial procedure in patients with corneal ectasia, a trifocal IOL implantation provided relatively predictable refractive outcomes and spectacle independence in most of this small cohort of patients with stable frank keratoconus. Given the small sample size it is not possible to reliably define which patients would benefit from the trifocal IOL technology, and which would not. An IOL exchange procedure should be presented as an option in case of unwanted refractive results or photic phenomena before surgery.