VISION DETERIORATION AFTER MULTIFOCAL INTRAOCULAR LENS

IMPLANTATION

Aylin Kılıç, MD

Asst Proffesour of Ophthalmology

Medipol University, İstanbul

You've just performed successful, uncomplicated cataract surgery, MF IOL. UCVA: 20/20 BUT….

Multifocal IOL

Visual performance is not perfect ….

Visual problems after MFIOL

• Early Period (1 month )

• Patient physicologic problems– Depression– Demanding attention– Obsession

• IOL design related– Trifocal / bifocal / EDOF– Glare / halo– Old generation diffractive surface

• Residual refractive error – Biometry, calculation mistakes

• Dry eye

Visual problems after MFIOL

• Late Period

• Dry eye

• Ocular problems: high IOP, retinal edema, zonule dehicence– MFIOL may not tolerate minimal decentration or edema

• Posterior capsule opasification,

• Capsule contraction syndrome, tilted IOL– MFIOL more sensitive than monofocal

• 53 years old, male

• OD: 0,7 OS: 1.0 (snellen)

• emmetrop

• Bio and fundus : N

MFIOL, Postop 1 month visit:I cannot see with right eye !!

WHEN ? immediate after surgery

Ask history or preoperative measurements ..

Cataract may mask ambliyopia

• 45 years old, male

• OD: 0,2 OS: 1.0 (snellen)

• emmetrop

• Bio: N

MFIOL OD, Postop 1 month visit:I had perfect vision, but recently I cannot see !!

WHEN ? 3 weeks after operation

NSAI drops may be beneficial to prevent cystoid macular edema

Transient visual loss after MFIOL

• Precorneal film is very important for MFIOL optic performance

• Daytime visual loss• Dry eye is the most common reason ! in old patients

– After surgery steroids, antibiotics, NSAI may cause extra dryness ..

• Meibomitis, blepharitis

• Tear break up time, meniscus

I cannot drive at nights !!mainly 2 reasons

Halo / glare

• IOL design

• Pupil dependency

refractive/diffractive surface

Refractive error

• Biometry mistake

• Check SUBJECTIVE refraction

• DON’T trust autorefractometer

Dysphotopsia and MF IOLs

• Unwanted images

• Each MF IOL design uses a different strategy to produce simultaneous near and distance images.

• When the pupil expands in dim light, more light is permitted to come through the peripheral zone

Halo / Glare /Dysphotpsia

• Photic phenomena

X 3,5 times more in MFIOL vs monofocal

• 7 % of eyes required IOL exchange in old generation diffractive

( Woodward et al J Cataract Refract Surg 2009;35(6):992-997.)

What the patient sees ?

• Temporal darkness• Nose blocks vision nasally• High plus IOLs• High refractive index

• Scintillating vision• High refractive index

• Arc• Capsule overlaps the IOL edge

• Flare• Scotopic symptom, produced by come• Correcting astig or myosis

• Central flash• Edge design

• Haloes

Astigmatism in MFIOL

• Small amount of astigmatism in eyes with MFIOL

– poorer optical quality,

– compromised distance and intermediate visual acuities,

– greater halo effect

HayashiK,ManabeS-i,YoshidaM,HayashiH.Effectofastig- matism on visual acuity in eyes with a diffractive multifocal intraocular lens. J Cataract Refract Surg 2010; 36:1323–1329 .

• RESIDUAL AMETROPIA/ASTIGMATISM

after MFIOL

64%

de Vries NE, Webers CAB, Touwslager WRH, Bauer NJC, de Brabander J, Berendschot TT, Nuijts RMMA. Dissatisfaction

after implantation of multifocal intraocular lenses. J Cataract Refract Surg 2011; 37:859–865.

MFIOLs are more sensitive to posterior capsul opacification

• Loss of contrast sensitivity• Vision quality, halo

Significant PCO was found;

• 54% of eyes with blurred vision and • 47% of eyes with photic phenomenon

( Woodward et al J Cataract Refract Surg 2009;35(6):992-997.)

decentration

ANGLE KAPPA

• Cornea scars and pterygia requires treatment before MFIOLs.• Remove opacification• Achieve regular keratometric values• Asymptomatic peripheral scars are not contraindicated

Corneal Aberrations and MFIOLs

• Whenever a corneal aberration such as coma, spherical aberration or first order ast is increased from zero, a proportionate decrease in contrast follows.

MFIOL is best when …

• Spherical equivalent (SE) is close to plano

• Postoperative regular corneal astigmatism is 0,5 or less

Contraindication

• Keratoplasty• Radial keratotomy• LASIK ?• PRK ?

Placing a MFIOL behind a multifocal cornearuns the risk of additional loss of contrast and reduction in visual quality.

MFIOL after LASIK

• Myopic LASIK induces positive spherical aberration: ASPHERIC MFIOLs

• Hyperopic laser correction induces negative values: SPHERIC MFIOLs

• A spherical multifocal IOL in eyes with hyperopic LASIK compensates the negative spherical aberrations.

MFIOL calculation after LASIK

• Less predictable outcomes: • because all standard formulas for IOL power calculation are

based on keratometric values.

• A major factor in the miscalculation of IOL power • In irregular corneas is the wrong practice of measuring only

the anterior surface with keratometry or corneal topography.

• Due to the altered anterior/posterior corneal curvature relationships after excimer laser vision correction, the keratometer will overestimate corneal power in previously myopic eyes and underestimate

Pupil size and MFIOL

• Large pupil : more glare

• Irregular pupil; atrophic iris, iatrogenic mydriasis, eccentric pupil contraindicated.

Zonullar Issues

• Decentered-tilted MFIOL;• Decreased contrast sensitivity

• Aberrations

• Decreased VA

• Decreased optic quality

• Retinal function

• Optic nerve function

Vision deterioration after MFIOL;

• History;– Preexisting ambliyopia/Strabismus– Preoperative VA– Complaints began immediately ? Or change within

time ?

• UCVA, BCVA• Corneal topography• Dry eye ? Meibomitis?• IOP measurement• Retina/OCT

Unhappy Patient;

• Ametropia

• Posterior capsule opacification

• Photic phenomena due to tilt/decentration

• Retained lens fragment

• Large pupil

Conclusion:

• Visual complaints will be after MF IOL ☺

• Refractive error after MF

• Dry eye

• MF IOL design are most common reasons ,

• and solutions are possible..

Thank you so much !