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NR 7-9/2007
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Visual function and
complications after cataract surgery with bilateral multifocal
intraocular lens implantation
Funkcja wzroku i powikłania
po obuocznej operacji zaćmy i wszczepie refrakcyjnych soczewek
wieloogniskowych
Wojciech Lubiński, Jolanta Gronkowska,
Krzysztof Barnyk, Zbigniew Szych, Danuta Karczewicz
Clinic of Ophthalmology, Pomeranian Medical University,
Szczecin, Poland
Head: Danuta Karczewicz MD, PhD |
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| Summary: |
Purpose: To evaluate the
visual function and complications after cataract surgery
with bilateral Array SA 40N
multifocal intraocular lens (IOL) implantation.
Material and methods: This prospective study comprised
40 eyes of selected 20 patients undergoing cataract
surgery with bilateral implantation of Array SA 40N (AMO).
multifocal IOL. Three months after bilateral surgery
distance and near visual acuity, contrast sensitivity,
complications and adverse effects were evaluated.
Patients’ satisfaction was assessed using a subjective
TyPE Questionnaire.
Results: Thirty-five eyes (35/40 – 87.5%) achieved the
uncorrected distance visual acuity 20/40 and the
uncorrected near visual acuity of J5 or better.
Eighty-two and a half percent of the operated eyes
achieved UCDVA 20/20 and J4 or better. Contrast
sensitivity for distance and near measured binocularly
were within normal limits, although for higher spatial
frequency, contrast sensitivity values for near were
slightly above the lower limit of normal range.
Intraoperative and postoperative complications were few
and only in one eye, further surgical intervention was
necessary (IOL recentration). Three patients (3/20 –
15%) reported moderate glare and halo. Overall visual
satisfaction measured with TyPE Questionnaire was very
high (8.7/10).
Conclusions: Bilateral multifocal IOL implantation was
effective and safe in selected cataract patients,
providing very good uncorrected distance and near visual
acuity. Slightly reduced contrast sensitivity and
increased perception of glare/halo were an acceptable
compromise for near, as well as distance vision
improvement. |
| Słowa kluczowe: |
operacja zaćmy, wszczep
soczewki wieloogniskowej, funkcja wzroku, powikłania |
| Key words: |
cataract surgery,
multifocal IOL implantation, visual function,
complications. |
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Introduction
Recently the most common intraocular lens implanted during
cataract surgery is monofocal intraocular lens (IOL). It has a
single focal distance and therefore the patient has to wear
glasses to focus at near distances. Various possibilities have
been proposed to give patients good distance, intermediate and
near vision like accommodating (1) and multifocal IOL.
Refractive as well as diffractive multifocal IOL have the most
success in restoring functional vision after modern cataract
surgery (2,3).
This study was designed to evaluate the visual function and
complications after cataract surgery with bilateral, refractive,
multifocal, intraocular Array SA 40N lens implantation.
Patients and methods
The prospective study included 40 eyes of 20 patients (mean of
age: 53.8 years ± 10.6; 12 women, 8 men) with cataract (LOCS –
NO1/NC1 – 27.5%; NO2/NC2 –37.5%; NO3/NC3 – 32.5%; NO4/NC4 –
2.5%) whom bilaterally implanted AMO Array multifocal SA 40N IOL.
This is a silicone, zonal – progressive, refractive lens with
monofilament haptics (polymethylmethacrylate). It consists of 5
concentric rings alternating between distant-dominant zones
(1,3,4) and near-dominant zones (2,5) with a +3.5 diopter add.
This lens provides intermediate acuity for distances from 50
to150 cm, as well.
Patient’s selection criteria for multifocal IOL are shown in
Table I.
Before the patients had extracapsular cataract extraction by
phacoemulsification and posterior multifocal IOL implantation,
the known information from the literature were given about
advantages and disadvantages of the Array multifocal IOL.
For IOL power calculation SRK/T or Hoffer Q formulas were used.
The refractive target were emmetropia or low hyperopia (0 to +
0.5 D).
Cataract surgery (divide and conquer or phacoaspiration
technique for lens extraction) was performed by one surgeon in
topical anesthesia (Alcaine) through temporal, clear corneal
incision (2.8 – 3.0 mm). Capsulorrhexis diameter was
approximately 5.0 mm. Multifocal IOL was implanted using an
unfolder. The second eye was operated 1 month after the first
one.
Preoperative and postoperative (three months after surgery)
ophthalmic evaluation was performed including: uncorrected and
best corrected distance and near visual acuity at 30 cm (UCDVA,
BCDVA – Snellen Chart; UCNVA, BCNVA – Jaeger Chart), anterior
segment evaluation by slit lamp biomicroscopy, intraocular
pressure measurement, funduscopy, corneal topography (Humphrey
Atlas 993), photopic (an illumination of 85 cd/m2), contrast
sensitivity for distance with and without glare (CSV 1000), and
near ( Functional Acuity Contrast Test – F.A.C.T.), with spatial
frequency 1.5, 3, 6, 12, and 18 cycles per degree, postoperative
complications and adverse effects.
Patients’ satisfaction was assessed using a subjective TyPE
Questionnaire.
The visual acuity results and astigmatism before and 3 months
after surgery were compared using Wilcoxon test. Statistical
significance was set at p< 0.05.
Results
The mean preoperative sphere was + 1.13 ± 1.48 D, (range -5.0 to
+ 4.5 D). The mean cylinder was + 0.60 ± 0.39 D (range 0 to +1.5
D). Three months after surgery the mean sphere was + 0.14 ± 0.35
D (range -1.0 to +1.0 D), the mean cylinder was + 0.70 ± 0.39 D
(range 0 to +1.38 D).
Before and after the surgery, the difference in the mean corneal
astigmatism was not statistically significant. The distribution
of corneal astigmatism before and 3 months after surgery is
shown in Fig. 2.
Distribution of refractive error in eyes implanted with the
Array multifocal IOL is presented in Fig. 3.
Three months after implantation of multifocal IOL the refractive
error in 92.5 % (37/40) of the operated eyes was found to be
between -0.5 and +0.5 D.
Mean uncorrected and best corrected distance and near visual
acuity before and 3 months after cataract phacoemulsification
with the multifocal IOL implantation are shown in Fig. 4a, Fig.
4b.
Three months postoperatively mean visual acuity (uncorrected and
best corrected for distance and near,) were significantly better
(UCDVA: p< 0.000001; UCNVA: p< 0.00006; BCDVA: p<0.00002; BCNVA
p<0.0002).
The cumulative UCDVA and UCNVA 3 months after bilateral
multifocal IOL implantation are shown in Fig. 5.
The UCDVA of 20/40 or better and UCNVA of J5 or better was
achieved in 87.5 % (35/40) of analyzed eyes.
All eyes obtained BCDVA of 20/20 and BCNVA of J4 or better.
82.5% of the operated eyes achieved UCDVA 20/20 and J4 or better.
Mean best corrected distance, contrast sensitivity without and
with glare, measured binocularly was within the normal range and
were significantly better (p< 0.03; p< 0.02) than measured
separately for RE, LE (Fig. 6a, Fig. 6b).
Mean best corrected near contrast sensitivity measured
binocularly was also within the normal range, although for
higher spatial frequency (12, 18 cpd) contrast sensitivity
values were near the lower limit of normal range.
Mean best corrected near contrast sensitivity measured
binocularly was significantly better (p<0.03), than measured
separately for RE, LE (Fig. 6c).
There were not serious intra– and postoperative complications (Table
II).
Intraoperative and postoperative complications were few and only
in one eye, further surgical intervention (IOL recentration),
appeared necessary.
The results of the patients’ satisfaction are shown in Table
III.
Patients’ general satisfaction was very high (8.7/10). Three
patients (3/20 – 15%) reported work difficulties connected with
glare /halo but the level of perception was low. What is worth
note 90% of patients was spectacle-independent for near and
distance (Fig. 7).
Discussion
At a mean follow-up of 3 months after surgery, all the patients
gained better visual acuity. The implantation of the foldable
IOL through 2.8 -3.0 mm did not induce significant astigmatism.
The astigmatism did not affect the postoperative visual acuity
in any case (Fig. 2).
In our study UCDVA of 20/40 and UCNVA of J5 or better received
87.5% (35/40) of eyes (Fig 5). Our functional results are near
data described by other authors. In Pineda-Fernandez et al. (5)
study, all eyes achieved an uncorrected distance visual acuity
of 20/40 or better and an uncorrected near acuity of J5 or
better. Packer et al. (4) reported that 94.1% of eyes achieved
20/40 and J5 visual acuity at distance and near. Javitt and
Steinert (6) reported that 96% of eyes achieved 20/40 or better
distance acuity and J3 or better near acuity.
Although multifocal IOLs provide the ability to read comfortably
and see at the distance without glasses, their implantation can
be a cause of contrast sensitivity loss. Heo et al. (7) noted
the patients with AMO Array IOL implantation had reduced
contrast sensitivity.
Lee J.M. et al. (8) reported the contrast sensitivity being
significantly reduced for nocturnal vision. Montes-Mico and Alio
(9) proved that contrast sensitivity was diminished at 12 cpd
and 18 cpd 3 months after surgery. Lee E.S. et al. (10) study
showed that contrast sensitivity measured 3 months
postoperatively was only slightly below the normal range at 3,
6, and 9 cpd. On the contrary Kim et al. (11) and Bleckmann at
al. (12) achieved contrast sensitivity values within the normal
range. Our results of contrast sensitivity measurements are
consistent with Kim and Bleckman studies results (Fig. 6a,b). We
obtained slightly reduced contrast sensitivity for distance and
near when CS was measured for RE, LE separately but CS was
within normal range when was measured from both eyes
simultaneously, although for higher spatial frequencies CS was
near lower limit of normal range.
Our CS results strongly suggest that multifocal implantation
gives the best results if it is performed in both eyes. In
special circumstances like unilateral traumatic cataract in
young patient multifocal implantation is not contraindicated
even though CS for near and distance is below or near lower
limit of normal. AMO Array can be employed for the visual
rehabilitation in these cases improving near vision while not
impairing distance vision as compared with monofocal IOL (2).
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It is difficult to compare our
patients’ satisfaction results with data published in other
studies because of different questionnaires. Patients’
satisfaction results we compared with data from Leyland et al.
study (13), using the same test TyPE Questionnaire responses (binocular
unaided vision). In our multifocal group (Table III), patients’
satisfaction was almost the same and was very high like in
Leyland study. Only 15% of analyzed patients reported work
difficulties connected with glare/halo and level of perception
of these unwanted phenomena was low (Table III). The frequency
of glare/halo is comparable to data described by other authors
(6) However, none of our patients needed pupil reduction by 0.5%
pilocarpine to reduce halos (14) and none wanted IOL exchange
for a monofocal IOL because they were very satisfied with their
distance and near acuity.
Many authors described in multifocal group problems with driving
at night, so multifocal IOL is contraindicated in professional
drivers because of the increased limitation in night vision
(14). It was no problem in our group of patients; they were
mainly older women that in our country usually do not drive a
car, so it was not a problem for them.
In our multifocal group 90% (18/20 patients) (Fig. 7) never
needed glasses for distance and near vision. This very good
result is better than described by others (Leyland – 24%, Lee –
70%, Pineda – Fernandez 31%). One of the explanations might be
very accurate selection of the patients for multifocal IOL, good
power calculation of IOL, meticulous surgery and patients not to
old with good brain plasticity giving possibility for quick
neuroadaptation for new optic conditions. We received an
excellent distribution of refractive error after multifocal IOL
implantation (Fig. 3). In almost 93% of analyzed eyes,
postoperative refraction was within ± 0.5D. This result is much
better than those described in Lee E.S., Centurion (15) or
Pineda-Fernandez study (61.0%; 76.7%; 56.0% respectively). This
difference may partially result for different formula and
systems used for IOL calculation (USG method or laser
interferometry method), experience of physician performing IOL
calculation, differences in the target refraction among
different investigators. When choosing IOL power our target was
emmetropia or low hyperopia whereas for example in the study by
Lee E.S. et al. (10), the target refraction was myopia closest
to emmetropia.
In our series of eyes with multifocal IOL implantation, there
was not serious intra- and postoperative complications (Table
II). In one eye rupture of posterior capsule appeared and the
lens was implanted into the ciliary sulcus. The lens power was
adjusted to -0.5 D less than the value of the power calculation.
In the first day after surgery lens decentration was observed.
After recentration of this lens visual acuity for distance and
near was 20/20 and J4 respectively. It is worth to know that the
three pieces AMO Array IOL, opposite to one-piece diffractive
Restore lens (Alcon), may be possibly placed in the ciliary
sulcus (16). It is a very important advantage in complicated
cases especially in patients with previously implanted
multifocal IOL in one eye.
In conclusion our first experiences with bilateral multifocal
IOL implantation suggest that this procedure is effective and
safe in selected cataract patients, providing very good
uncorrected distance and near visual acuity. Slightly reduced
contrast sensitivity and increased perception of glare/halo were
an acceptable compromise for near as well as distance vision
improvement.
References:
1. Macsai MS, Padnick-Silver L, Fontes BM: Visual outcomes after
accommodating intraocular lens implantation. J Cataract Refract
Surg 2006, 32, 628-33.
2. Belluci R: Multifocal intraocular lenses. Current Opinion in
Ophthalmology 2005, 16, 33-37.
3. Lane SS, Morris M, Nordan L, Packer M, Tarantino N, Wallace
RB: Multifocal intraocular lenses. Ophthalmol Clin North Am
2006, 19, 89-105.
4. Packer M, Fine IH, Hoffman RS: Refractive lens exchange with
the Array multifocal intraocular lens. J Cataract Refract Surg
2002, 28, 421-424.
5. Pineda-Fernandez A, Jaramilli J, Celis V, Vargas J, DiStacio
M, Galindez A, Del Valle M: Refractive outcome after bilateral
multifocal intraocular lens implantation. J Cataract Refract
Surg 2004, 30, 685-688.
6. Steinert R, Aker B, Trentacost D, Smith P, Tarantino N: A
Prospective Comparative Study of the AMO ARRAY Zonal –
Progressive Multifocal Silicone Intraocular Lens and a Monofocal
Intraocular Lens. Ophthalmology 1999, 106, 1243-1255.
7. Heo JY, Kim YH, Joo CK: Clinical results of AMO ARRAY
multifocal intraocular lens. J Korean Ophthalmol Soc 1999, 40,
978-986.
8. Lee JM, Seo KR, Kim EK: Comparison of optical aberrations and
contrast sensitivity between monofocal and multifocal
intraocular lens. J Korean Ophthalmol Soc 2002, 10, 1882-1886.
9. Montes-Mico R, Alio JL: Distance and near contrast
sensitivity function after multifocal intraocular lens
implantation. J Cataract Refract Surg 2003, 29, 703-711.
10. Lee ES, Lee SY, Jeong SY, Moon YS, Chin HS, Cho JS, Oh JH:
Effect of postoperative refractive error on visual acuity and
patients satisfaction after implantation of the Array multifocal
intraocular lens. J Cataract Refract Surg 2005, 31, 1960-1965.
11. Kim JH, Kim HB, Lim SJ: Clinical results of AMO ARRAY
multifocal intraocular lens. J Korean Ophthalmol Soc 2001, 42,
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12. Bleckmann H, Schmidt O, Sunde T, Kaluzny J: Visual results
of progressive multifocal posterior chamber intraocular lens
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13. Leyland MD, Langan L, Goolfee F, Lee N, Bloom PA:
Prospective randomized double – masked trial of bilateral
multifocal, bifocal or monofocal intraocular lenses. Eye 2002,
16, 481-490.
14. Hunkeler JD, Coffman TM, Paugh J et al.: Characterization of
visual phenomena with the Array multifocal intraocular lens. J
Cataract Refract Surg 2002, 28, 1195-1204.
15. Centurion VA: A visual performance with AMO Array multifocal
refractive intraocular lens. In Agarwal S, Agarwal A, Pallikaris
IG et al, eds, Refractive Surgery. New Dehli, Jaypee Brothers,
2000, 526-532.
16. Aralikatti AK, Tu KL, Kamath GG, Philips RP, Prasad S:
Outcomes of sulcus implantation of Array mutifocal intraocular
lenses in second – eye cataract surgery complicated by vitreous
loss. J Cataract Refract Surg 2004, 30, 155-160.
Praca wpłynęła do Redakcji 20.02.2007 r. (940)
Zakwalifikowano do druku 05.07.2007 r.
Adres do korespondencji (reprint requests to):
Wojciech Lubiński MD, PhD
Clinic of Ophthalmology, Pomeranian Medical University
Powstańców Wlkp. 72 str.
70-111 Szczecin, Poland.
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