Daniel Kritzinger MD
The performance and safety of the latest generation of multifocal IOLs gives surgeons the opportunity to offer presbyopic patients a truly customised solution for their visual needs with high levels of patient satisfaction, according to Daniel Kritzinger MD.
“There are so many modalities available today with bifocal, trifocal and extended depth of focus (EDOF) lenses in addition to traditional monovision with monofocal IOLs. The goal I feel should always be individualised decision-making, whichever approach one prefers to take. We are in a position where we can address our patients’ needs and deliver high levels of spectacle independence,” he said at the World Ophthalmology Congress 2020 Virtual.
Dr Kritzinger, in private practice at Visiomed Eye Laser Centre, Johannesburg, South Africa, said it was important not to get drawn into a sterile monofocal versus multifocal IOL debate.
“There is no one-size-fits-all solution for every presbyopic cataract patient, but I strongly feel that if total spectacle freedom is high on the agenda for the patient and surgeon, then they will definitely have the best chance of achieving this result using a multifocal intraocular lens. I see no other way of achieving that,” he said.
With only about 6% of cataract procedures involving a presbyopia-correcting IOL, the preference for most surgeons today is a monovision approach using a monofocal IOL, noted Dr Kritzinger. Issues of haloes and glare and reduced contrast sensitivity associated with multifocal IOL implantation have definitely hampered their uptake but are far less of an issue with modern lenses, he said.
As evidence, he cited the fact that IOL exchange rates for unhappy multifocal patients have dropped dramatically over the past decade.
“In addition, a lot of the reasons for unsatisfactory results are actually treatable and if you address residual refractive errors postoperatively as well as posterior capsule opacification (PCO), up to 80% of these unhappy cases could be resolved,” he said.
Dr Kritzinger stressed the importance of managing patient expectations and selecting a lens based on factors such as lifestyle, occupation and needs.
“Published results and studies have confirmed that spectacle independence is far more possible and likely when implanting a multifocal IOL than just relying on monofocal monovision. A 2017 meta-analysis showed a mean spectacle independence rate of over 80% with multifocal lenses,” he said.
He added that evolving lens technology along with artificial intelligence applications and the ability to assess preoperatively the patient’s objective behavioural data will allow more personalised and precise lens selection in the future.
The importance of rigorous preoperative assessment in implanting multifocal IOLs was also emphasised by Professor Marie-José Tassignon, who used a case study of an unhappy multifocal IOL patient to illustrate some of the key issues that may arise in such cases.
The 52-year-old female patient with an uneventful medical history was hyperopic in both eyes, with a visual acuity of 10/10 in her right eye and 4/10 in the fellow eye with amblyopia. Although she was satisfied with her multifocal implant in the immediate postoperative period, she started experiencing visual difficulties in her left eye one month to six weeks after her surgery.
The corneal topography showed a regular corneal surface of normal curvature with a small amount of regular astigmatism (0.53D in the right eye and 0.70D in the left eye).
“What was interesting was her axial length: 20.64 mm for the right eye and 20.38 mm for the left eye, which is an outlier. She had a normal retinal correspondence in the right eye, but she had cyclorotation of the macula in the left eye,” said Prof Tassignon, Professor and Head of Ophthalmology Department, University Hospital, Antwerp, Belgium.
Orthoptic examination, which is mandatory in such eyes said Prof Tassignon, showed that she had no strabismus or diplopia, a small hyperphoria and esophoria, poor fusion and poor stereopsis. Examination of the problem eye revealed a decentred lens, an irregular anterior capsulorhexis and fibrotic tissue.
“This proliferative tissue was caused by a reaction of the capsular bag to the presence of the foreign body intraocular lens. I used a bimanual technique to pull off the fibrotic tissue and clean out the capsular bag while supporting the zonules as much as possible. The next step was to restore the anterior capsulorhexis and reposition the IOL. After clean up, I decided to leave the lens as it was now well centred and the Purkinje reflex was okay,” she said.
Several lessons could be drawn from the case, concluded Prof Tassignon.
“Orthoptic examination is mandatory in all cases of refractive outliers whether the patient is hyperopic or a high myope. Fundus examination should also be done carefully including retinal correspondence. Patients with amblyopia and poor fusion are bad indications for multifocal implantation unless they present a certain degree of suppression. Patients with high ametropia are also bad candidates in general for these lenses, but if there is good quality of vision immediately after implantation then later complaints might be related to IOL foreign body reaction,” she said.
If this is the case, peeling of the proliferative tissue might improve patient’s quality of vision and does not require IOL exchange.
