My surgery center receives a lot of referrals for IOL exchanges, which has given me experience dealing with unhappy patients. The reasons for patients seeking an exchange are varied, but needless to say, it can be a difficult situation to deal with.
Because most of these cases involve removing a multifocal lens, I have also grown a little hesitant to offer the modality to patients during an initial cataract consultation. However, when the AcrySof IQ ReSTOR +2.5 D IOL with ACTIVEFOCUS optical design was released, I started to rethink this stance.
We recently published a study looking at our outcomes over the prior 10 years performing IOL exchanges.1 Overall, we found that exchanging a multifocal IOL for a monofocal model was feasible and likely to result in a lower refractive prediction error and a higher likelihood of 20/40 or better vision after implantation of the second IOL.
In our population of 29 patients (35 eyes), the No. 1 reason for the IOL exchange was because of complaints of blurred distance vision (60%), followed by photic phenomena (57%), photophobia (9%), and loss of contrast sensitivity (3%). Notably, 29% of patients reported multiple complaints about their vision after the previous cataract surgery.
In addition to the inconvenience factor, there are well-known risks associated with second-time cataract surgery, including capsular scarring, vitreous prolapse, and retinal detachment. These concerns were a significant factor in why I previously did not offer multifocal IOLs during cataract consultations: I just was not confident the existing technology would lead to patients being happy with their vision.
What changed my mind about offering multifocal IOLs was that the central portion of the AcrySof IQ ReSTOR +2.5 D IOL with ACTIVEFOCUS optical design is targeted to distance.2,3 In comparison with other lenses, it is comparable to a monofocal in terms of contrast sensitivity, 2-4 glare and the halos,5 and the distance vision.6
My experience so far with the AcrySof IQ ReSTOR +2.5 D IOL with ACTIVEFOCUS optical design is that its features make it a reasonable option for more patients relative to other multifocal lenses. Interestingly, when we used to think about whether a lens was the right fit for a patient, we tended to think about personality and whether the individual would be willing to accept compromises in the postsurgical vision. With this lens, we are reducing the need for compromise, and we can instead listen to the patient and have a conversation about how best to achieve his or her vision goals, with less dependence on glasses. I have used this lens with classically demanding patients, including other physicians, artists who need clear and crisp vision, and patients who frequently drive at night—all with great success.
In thinking about the wider swath of patients who have an opportunity to receive a multifocal lens, it is worth mentioning that patients with astigmatism are also a consideration, as the AcrySof IQ ReSTOR Toric +2.5 D IOL with ACTIVEFOCUS optical design offers excellent rotational stability7-12 in addition to the other features noted above.
Mini-monovision is a great option for patients seeking additional near focus. Oftentimes, we perform surgery in the first eye (typically the dominant eye) and then follow-up with the patient to see how they feel about their overall vision, particularly the near vision. Most patients are happy to have the same approach in the second eye (ie, plano and emmetropia), but we can always aim for a slight defocus in the contralateral eye to boost the near vision.
With every cataract surgery, I try to ensure the patient is going to be happy with their postoperative vision. Naturally, each patient is going to have different vision goals, and that is why it is important to listen carefully and think about what approach is likely to help them achieve the vision they want. It is also important to have technology at our disposal that provides the best chance of delivering on patients’ expectations for postoperative vision. While I cannot ever promise a patient he or she will have perfect near, intermediate, and distance vision after receiving an AcrySof IQ ReSTOR +2.5 D IOL with ACTIVEFOCUS optical design, the flexibility in customizing the approach with this IOL gives me confidence that patients are going to receive functional vision that will allow them to continue enjoying their hobbies and activities.
1. Kim EJ, Sajjad A, Montes de Oca I, Koch DD, et al. Refractive outcomes after multifocal intraocular lens exchange. J Cataract Refract Surg. 2017;43(6):761-766.
2. Alcon Data on File (April 11, 2016).
3. Alcon Data on File (Oct 17, 2016).
4. Alcon Data on File (Aug 7, 2013).
5. Alcon Data on File (Oct 6, 2016).
6. Vega F, Alba-Bueno F, Millán MS, Varon C, Gil MA, Buil JA. Halo and through-focus performance of four diffractive multifocal intraocular lenses. Invest Ophthalmol Vis Sci. 2015;56(6):3967-3975 (study conducted with corneal model eye with 0.28μ spherical aberration).
7. Potvin R, et al. Toric intraocular lens orientation and residual refractive astigmatism: an analysis. Clin Ophthalmol. 2016;10:1829-1836.
8. AcrySof IQ Toric IOL Directions for Use.
9. Wirtitsch MG, et al. Effect of haptic design on change in axial lens position after cataract surgery. J Cataract Refract Surg. 2004;30(1):45-51.
10. Nejima R, et al. Prospective intrapatient comparison of 6.0-millimeter optic single-piece and 3-piece hydrophobic acrylic foldable intraocular lenses. Ophthalmology. 2006;113(4):585-590.
11. Lane SS, Ernest P, Miller KM, Hileman KS, Harris B, Waycaster CR. Comparison of clinical and patient reported outcomes with bilateral AcrySof Toric or spherical control intraocular lenses. J Refract Surg. 2009;25(10):899-901.
12. Lane SS, Burgi P, Milios GS, Orchowski MW, Vaughan M, Schwarte E. Comparison of the biomechanical behavior of foldable intraocular lenses. J Cataract Refract Surg. 2004;30:2397-2402.
AcrySof, ACTIVEFOCUS and ReSTOR are trademarks of Novartis. All other brand/product names are the trademarks of their respective owners.
