One of the hottest topics in cataract surgery has been the new multifocal and accommodating IOLs. We have all been bombarded over the past year with articles in the trade newspapers and magazines about the ReSTOR, ReZoom, and Crystalens implants. The results are great, patients are happy, physician earn more, what else could you want? As we all know, if it’s too good to be true, it usually is, so what’s the catch?
The biggest concern is the glare and halo issue with ReSTOR and ReZoom, but there are also potential problems with “smeared” distance and poor intermediate vision (ReSTOR) or poor near vision (ReZOOM and Crystalens). Therefore, more articles have now appeared stressing the importance of careful patient selection, preoperative counseling, and neuroadaptation. Obviously, it is critical with any procedure to educate the patient and make sure he or she fully understands the limitations of and has realistic expectations about the treatment. When these IOLs are chosen appropriately, the majority of patients will be satisfied with the results, however, are there too many patients who are unhappy with these lenses? How many patients actually want an IOL exchange? What’s the real scoop?
Most of the published data on this topic has been retrospective or small case studies in non-peer-reviewed articles. Different studies support different lenses or combinations thereof. Not surprisingly, the conclusions either correlate beautifully with the company supporting the study or confirm what we already know about these IOLs. Namely, we should consider mixing and matching the lenses to take advantage of their overlapping strengths depending on the individual patient’s needs. Traditional teaching is to match IOL material and design in both eyes of a patient. The exception to this rule has been safety issues, so that patients with an outdated IOL in one eye receive the safest material and best design available. If a patient has troubling side effects from a particular IOL, then the fellow eye should receive an implant with the least chance of causing such a problem. This is exactly why some ophthalmologists are recommending mixing the new IOL designs.
Recently, Pepose et al reported on the visual performance of a group of patients with either bilateral or combination implantation of Crystalens, ReZoom, and ReSTOR lenses (AJO. 2007; 144:347-357). This was a prospective but nonrandomized study of 49 patients who received either bilateral implantation of one of these three lenses, or a combination of the Crystalens with one of the multifocal lenses. The results showed that photic phenomena are more common in patients receiving a multifocal lens bilaterally or in one eye only. This is a good start, but hopefully there are prospective randomized studies underway. We need to see reliable data, particularly on the true incidence of glare and halo and how visually significant this really is. Otherwise, those of us who are watching from the sidelines may be waiting much longer to get into the game.
Personally, I feel that the risk of dysphotopsias with the ReSTOR and ReZoom lenses is too high. I have spoken with colleagues who implant these lenses, and all have had to remove some. Historically, multifocal IOLs have not fared well, and although there have been significant improvements, I still do not think that these lenses are good enough. Currently, they may be the best option for some patients, but better, truly accommodating IOLs will be available in the near future.
In addition to being a source of ophthalmic news and education, one of the goals of this website is to serve as a forum for the exchange of ideas. The purpose of the editorial features is to initiate discussion among the community. We’ve heard what some high volume surgeons who consult for these lens companies have to say, but now let’s here from you. Are you implanting multifocal lenses, and if so which ones? What has your experience been? Do you mix and match lens styles? If you don’t use these IOLs, then why not?
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