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Perspective Chapter: Strategies for Achieving Full-Range of Vision – Multifocal IOLs and Surgical Options for Correcting Residual Refractive Errors

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Mateja Jagić, Maja Bohač, Ante Barišić, Dino Šabanović, Sara Blazhevska and Lucija Žerjav

Reviewed: 27 February 2024 Published: 30 April 2024

DOI: 10.5772/intechopen.114371

Loss of Vision IntechOpen
Loss of Vision Edited by Mateja Jagić

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Loss of Vision [Working Title]

Dr. Mateja Jagić and Dr. Maja Bohač

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Abstract

Currently, cataract is considered one of the leading causes of visual impairment and blindness globally. Due to the development of surgical techniques and intraocular lenses (IOL) design, patient’s demands for complete spectacle independence have grown continuously. Today, the procedure of multifocal IOL implantation is an option for providing a full-range of vision. Although technology has advanced, there are still some drawbacks, such as lower optical quality postoperatively and postoperative residual refractive error, which also greatly reduces spectacle independence, visual quality, and patient satisfaction. Basic options for residual refractive error are the prescription of glasses or contact lenses, but in patients who require life without optical aids, corneal refractive surgery has proven to be a safe and predictable solution. Predominantly, laser-assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) correction methods are applied, with an emphasis on Aberration-free excimer ablation profiles that do not include wavefront-guided treatments, given the uncertain methods of analyzing higher order aberrations (HOA) in patients with implanted multifocal IOLs.

Keywords

  • spectacle independence
  • cataract
  • multifocal intraocular lenses
  • residual refractive error
  • LASIK
  • PRK

1. Introduction

Cataract is one of the leading causes of blindness globally, with a substantial increase in the prevalence of visual impairment observed in the last three decades. According to the World Health Organization (WHO) report on vision, there are at least 1 billion people with preventable moderate or severe visual impairment or blindness, including 94 million caused by cataract [1, 2]. By 2030, the number of people worldwide aged ≥60 years is estimated to increase 1.4 billion. Given most people over the age of 60 years will develop cataract, the number of people with this condition will also increase substantially [3].

Although many breakthroughs have been made since the inception of Vision 2020 and decreasing blindness prevalence has been achieved during the past decades, the number of blind people continues to increase rapidly [4, 5].

Cataract and presbyopia are the major cause of blindness and vision impairment in the world as a result of the aging population [6]. Along with 94.0 million people visually impaired or blind due to cataract, [2] approximately 1.1. billion people are affected by presbyopia [7]. Currently, around 26% of total population is presbyopic, where the prevalence of presbyopia globally ranges from 43 to 89% for adults aged ≥45 years old [7, 8, 9, 10, 11, 12, 13]. About 90% of the global burden of presbyopia occurs in low- and middle-income settings, where presbyopia correction coverage rates are only 10% because of a lack of awareness and access to affordable interventions, and the costs due to uncorrected presbyopia both to the patient and to society are higher than those in high-income settings [13, 14]. Nearly half of the presbyopic patients remain uncorrected, especially in developing countries [9]. As many as 80% of the uncorrected presbyopic patients faced difficulty in performing near-vision-related tasks such as reading, writing, and using mobile devices, which could impact patients’ productivity [9, 15]. Likewise, uncorrected presbyopia could pose an economic burden for patients by affecting their work productivity, where they require near vision use to perform work-related tasks. With an increasing population and an aging society, more people will be at risk for common causes of vision loss in the upcoming years [1, 16]; as a prerequisite to combating this growing burden of both cataract and presbyopia, there is a need for greater access to vision care services across the globe for timely screening and optimized correction of aforementioned, especially in the working-age population.

Successful global initiatives targeting improving cataract surgical rate and quality, especially in regions with lower socioeconomic status [17].

The rates of cataract surgery are increasing globally, and postoperative outcomes are improving, yet challenges to reducing the cataract burden remain [18, 19]. Highly cost-effective interventions can offer enormous economic benefits to individuals and nations with relatively low costs. Correcting oncoming presbyopia simultaneously during cataract extraction and intraocular lens (IOL) implantation has been proven to be practical and economical [20, 21, 22].

There are various strategies for correcting presbyopia and cataract in clinical practice. Implantation of bilateral monofocal IOL is a conventional surgical strategy for correcting cataract, when targeting emmetropia, it presents lower spectacle independence due to poor intermediate and near visual acuity. Conversely, surgical strategies for both cataract and presbyopia, with higher spectacle independence and greater full-range visual acuity (for distance, intermediate, and near) include, but are not limited to, bilateral implantation of monofocal IOLs targeting monovision, extended depth of focus IOLs, diffractive bifocal IOLs with the same or different near additional power (blended vision), refractive bifocal IOLs, trifocal IOLs [21, 23, 24, 25]. Facing diverse strategies, surgeons are expected to customize patient management with satisfactory effectiveness. One of the most common causes of patient dissatisfaction after multifocal intraocular lens (MFIOL) implantation is residual refractive error.

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2. Methods

A retrospective study was conducted on patients who underwent implantation of one of the variants of multifocal IOLs during a 10-year period. The visual outcome at distance, intermediate and near, spectacle independence along with patient satisfaction rate and residual refractive error were examined.

Meticulous preoperative examination and careful patient selection with a focus on biometry, ophthalmologic findings, and preoperative astigmatism were performed. The main ophthalmic inclusion criteria were clear cornea without topographic irregularities (irregular or asymmetrical astigmatism), no macular pathology or glaucomatous optic nerve damage, and systemic diseases that might affect postoperative vision (such as diabetes mellitus). Biometry and corneal topography were mandatory and appropriate lens design was chosen according to the amount of corneal astigmatism (toric IOL in astigmatism >0.75D). According to the patient’s work habits and demands, one of the listed multifocal IOLs was chosen: diffractive bifocal IOL with low addition (LOW ADD), diffractive extended depth of focus (EDOF), hybrid diffractive EDOF, trifocal, and quadrifocal IOL.

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3. Results

3.1 Visual acuity

3.1.1 Distance visual acuity

Our results during a 10-year follow-up showed that all patients had visual acuity better than 0.05 logMar, and almost 70% of patients achieved uncorrected distance visual acuity of 0.00 logMAR, while 10% of patients had uncorrected distance visual acuity worse than 0.1 logMAR. Mean uncorrected distance visual acuity (UDVA) was 0.033 logMar (range 0.03–0.039 between groups) as presented in Figure 1, and mean best-corrected distance visual acuity (BCDVA) was 0.024 logMar (range 0.02–0.028 between groups) as presented in Figure 2.

Figure 1.

Comparison of uncorrected visual acuity at distance, intermediate, and near between eyes with different presbyopia-correcting IOLs implanted (values are presented in logMar).

Figure 2.

Comparison of best corrected visual acuity at distance, intermediate, and near between eyes with different presbyopia-correcting IOLs implanted (values are presented in logMar).

3.1.2 Intermediate visual acuity

In the first generations of MFIOLs, the optical design did not allow good vision at intermediate, while, according to our experience, the advancements in technology, mean value of uncorrected visual acuity at intermediate better than 0.1 logMAR was achieved. With newer lens designs such as trifocal, quadrifocal, and EDOF, even better continuity and range of vision at intermediate have been achieved. Mean uncorrected intermediate visual acuity (UIVA) was 0.043 logMar (range 0.037–0.049 between groups), as presented in Figure 1, and mean best corrected intermediate visual acuity (BCIVA) was 0.027 logMar (range 0.018–0.038 between groups), as presented in Figure 2.

3.1.3 Near visual acuity

Newer generations of lenses have led to an improvement in the quality of vision both near and intermediate, especially for trifocal and quadrifocal IOLs. Mean uncorrected intermediate visual acuity (UNVA) was 0.036 logMar (range 0.028–0.057 between groups), as presented in Figure 1, and mean best corrected intermediate visual acuity (BCNVA) was 0.026 logMar (range 0.015–0.049 between groups) as presented in Figure 2.

3.2 Spectacle independence

In the literature, there is no clear division between the need for spectacle correction for distance, intermediate, or near. Reported global spectacle independence was ≥80%. In studies where visual acuity for distance, intermediate, and near was separated, spectacle independence was reported for distance in 80% of cases, intermediate in 100% of cases, and near in 70% of cases when implanting various models of IOLs [23, 26, 27, 28].

In our previous experience, the need for spectacle correction was highest in patients with refractive bifocal IOLs implanted, in most cases for near-work tasks. After implantation of newer models of presbyopia-correcting IOLs, spectacle independence is significantly greater in comparison to first models of refractive bifocal IOLs, while correction is mostly required for certain activities at intermediate and near distances, depending on IOL design. The highest spectacle independence was observed in patients with hybrid diffractive EDOF, trifocal, and quadrifocal IOLs (Table 1).

IOL designSpectacle correction need
Overall (%)For intermediate/near (%)
Diffractive IOL with low add5.12.6
Diffractive EDOF IOL5.72.9
Hybrid diffractive EDOF IOL2.11.2
Trifocal IOL (AT LISA)2.50.8
Quadrifocal IOL2.60.7

Table 1.

Presenting relationship between the need for spectacle correction in total and percentage of spectacle correction need for intermediate and near distance after implantation of various presbyopia-correcting IOLs.

3.3 Patient satisfaction

Studies have shown that overall patient satisfaction with multifocal lenses is good. Our experiences have shown very high patient satisfaction after implantation of multifocal IOLs (Figure 3).

Figure 3.

Graphical presentation of satisfaction rate in patient with different models of presbyopia-correcting IOLs implanted.

Overall patient satisfaction after MFIOL implantation is significantly influenced by preoperative assessment, careful patient selection, and counseling but also varied depending on the preoperative refraction, where the highest satisfaction grade after MFIOL implantation was achieved in patients with high and low hyperopia, as shown in Table 2.

Preoperative refractionSatisfaction grade (scale 1–10)
High hyperopia9.72 (range 6–10)
Low hyperopia9.14 (range 4–10)
Plano – presbyopia8.69 (range 3–10)
High myopia8.23 (range 4–9)
Low myopia8.07 (range 2–10)

Table 2.

Grade of patient satisfaction after MFIOL implantation depending on the type of preoperative refractive error.

The most common causes of patient dissatisfaction after MFIOL implantation are: blurred vision (94.7%) and photic phenomena (38.2%) [29]. The most common causes associated with these symptoms are residual refractive error in 65.5% of eyes, opacification of the posterior capsule in 15.8% of eyes, large pupil diameter in 14.5% of eyes, and wavefront anomalies (HOA) in 11.8% of eyes [30, 31, 32, 33, 34, 35]. In our study, visual disturbances were associated with residual refractive error, photic phenomena (halo and glare), and posterior capsule opacifications. Photic phenomena in were also associated with dry eye (5%), and decentration of the IOL (11%). Most common causes of patient dissatisfaction after MFIOL implantation in our facility are shown in Figure 4.

Figure 4.

Graphical presentation of postoperative complication accounted for causes of dissatisfaction in different models of presbyopia-correcting IOLs.

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4. Residual refractive error after MFIOL implantation

Despite advances in cataract surgery and intraocular lenses, unsatisfactory postoperative visual outcome may occur as a result of residual refractive error. A recent report analyzed the refractive results of more than 17,000 eyes after cataract surgery and found that emmetropia was achieved in only 55% of eyes. These results emphasized how important residual refractive error is after cataract surgery.

There are various reasons that can lead to residual refractive error after refractive lens replacement. They can be divided into preoperative, intraoperative, and postoperative causes [36].

Preoperative causes include misjudgment of the postoperative effective MFIOL position, errors in measuring the axial length of the eye, inappropriate selection of MFIOL power, limitations of intraocular lens power calculation formulas (especially in extreme ametropia), and lack of precision in MFIOL manufacturing [36, 37]. categories include surgical variation of incision size and position, and capsulorhexis. These factors can affect the final IOL position in the capsular bag and are surgeon-dependent. Unintentional surgically induced astigmatism (SIA) can also be a cause of refractive error after cataract surgery [38].

Postoperative causes that can affect refraction are related to wound healing, changes in corneal curvature, and IOL displacement due to postoperative capsular fibrosis and contraction [38, 39].

Various causes affect not only spherical refractive error but also astigmatism. It is estimated that one-third of patients undergoing cataract surgery or refractive lens exchange (RLE) have corneal astigmatism greater than 1.00D, where the percentage depends on the study population [39, 40]. Although there is an option of toric IOLs for astigmatism correction, despite their noted efficacy, it is reported that up to 47% of eyes had ≥0.5D, and up to 16% of eyes had ≥1.0D of residual astigmatism [41, 42]. Common causes are postoperative IOL rotation, poor IOL position, cumulative errors in power calculating, influence of posterior corneal astigmatism, and pupil size [43].

Literature points out that typical reliability error of subjective refraction ranges from ±0.34D to ±0.51D [44, 45], and it is affected by various factors such as attention, duration of a concentrated visual task (e.g., close work, pressure on eyelids, and pupil size/depth of field) [46, 47, 48]. Small shifts in the sphere, amount of astigmatism, and its axis can be related to these factors. Postoperative refractive error ≥ 0.50D is considered clinically significant, where causes of unexpected spherical errors are easily identified; however, the same cannot apply to unexpected astigmatic errors postoperatively [49].

After implantation of spherical MFIOLs, the axis of SIA did not correlate with the axis or amount of preoperative astigmatism. However, the severity of SIA was related to the axis of preoperative astigmatism. When preoperative astigmatism is low (≤1.00D), and predominantly against the rule (ATR), SIA can be up to 1.00D [50].

4.1 Keratorefractive surgical strategy for correcting residual refractive error after MFIOL implantation

Correction of residual refractive errors after MFIOL implantation initially includes prescription of glasses or contact lenses. In the case of the patient’s desire for complete spectacle/contact lens independence, either corneal surgery (incisional procedures, excimer laser correction procedures) or intraocular surgery (IOL exchange, piggyback IOL implantation) is considered. In the case of low residual astigmatic error, the option of incisional techniques (LRI, AK) can be considered, while in the case of high ametropia or unavailability of technology, new intraocular procedures are recommended. Excimer laser correction of residual refractive errors in pseudophakic patients proved to be safe and predictable as an adjustment of final results. The advantages compared to intraocular surgery are greater flexibility achievement of satisfactory results, and the avoidance of trauma caused by additional intraocular procedures.

The safety of LASIK and PRK in pseudophakic patients has already been reported in several studies. In general, the procedure is recommended to be performed at least 6–12 weeks after intraocular procedure due to potential complications related to corneal incision integrity, subclinical corneal edema, and IOL stability. If a residual refractive error is expected during the preoperative examination, a corneal flap can be made before the lens is implanted (a procedure called Bioptics). This enables earlier and less traumatic correction of residual ametropia after stabilizing the refractive error. Before planning excimer laser correction, there are challenges in assessing residual refractive error due to the existence of multiple focal points (causing artifacts in subjective refraction) and changes in refraction depending on lighting conditions and pupil size.

According to the published literature, automatic refractometry, which is often used as a starting point in determining subjective refraction, shows a tendency for more negative values (~ 1.0D for sphere; ~ 0.5D for cylinder), as well as retinoscopy (≤ 0.5D for sphere and cylinder). Different methods have been proposed for the accurate assessment of subjective refraction in patients after MFIOL implantation. Currently, there is a consensus that keratometric values are the starting point in refraction assessment, given that IOL implantation does not have a significant impact on them, and then visual acuity must be checked by evaluating the defocusing curve (Figure 5).

Figure 5.

Aberrometry report in patient with implanted MFIOL.

Currently, most authors suggest aspheric treatments for the correction of residual refractive errors after MFIOL implantation, since Hartmann-Shack aberrometers are not able to analyze the exact values of the higher order aberrations (HOA) and scattering due to the limitation imposed by the lens sampling. Pyramidal aberrometers, such as Schwind Peramis (Schwind Eye Tech Solutions, Kleinostheim, Germany), in contrast to other methods, is sampling wavefront in the very last stage of the optical path, and is sampled with 45,000 points at maximum pupil dilation, which corresponds to a much higher resolution. Therefore, it could provide better HOA analysis after MFIOL implantation [51, 52, 53, 54, 55].

According to our experience, the percentage of patients who required additional correction postoperatively in most cases correlated with the percentage of patients who opted for excimer laser enhancement after MFIOL implantation, with variations between different types of IOLs. Lower percentage of LASIK enhancements in diffractive LOW ADD and EDOF group was due to the fact that overall spectacle correction was required mostly for intermediate and/or near-work tasks, which was proactively discussed with patients before deciding on lens design. Higher percentage of surgical enhancement observed in patients with implanted trifocal and quadrifocal IOLs has been reported due to higher patient demands for better vision, regardless of working distance (Figure 6).

Figure 6.

Graphical presentation of spectacle correction and excimer laser enhancement rate in groups with different presbyopia-correcting IOLs implanted.

At our center, 42 patients (eyes) out of 2119 MFIOL-implanted eyes opted for LASIK enhancement with the Free Aberration™ program (Schwind AMARIS 750S and 1050RS; Schwind Eye Tech Solutions, Kleinostheim, Germany) 6 months after MFIOL implantation (Table 3).

IOL designN (Eyes) implanted/ N (Eyes) treated w. Lasik%
Diffractive IOL with low add588/132.21
Diffractive EDOF IOL252/62.50
Hybrid diffractive EDOF IOL984/161.62
Trifocal IOL (AT LISA)211/52.36
Quadrifocal IOL84/22.38

Table 3.

Number and percentage of eyes treated with LASIK after implantation of different presbyopia-correcting IOLs.

The mean spherical and cylindrical correction values were + 0.45D (range − 1.75D to +2.00D) and − 0.91D (range − 3.00D to 0D), and after LASIK they decreased to +0.05D (range from −0.25D to +1.00D) and − 0.18D (range from −0.50D to 0 D) (Figure 7). Corrections were based on the best subjective refraction.

Figure 7.

Comparison of sphere and cylinder correction before and after LASIK enhancement.

Figure 8 shows that there was a simultaneous improvement in visual acuity with a reduction in residual refractive error for all distances.

Figure 8.

Uncorrected visual acuity on distance, intermediate, and near before and after LASIK enhancement.

See Figure 9.

Figure 9.

Slit lamp presentation of well-positioned corneal flap (red arrows) 1 month postoperatively in patient with a previously implanted MFIOL.

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5. Conclusion

Modern cataract surgery with implantation of multifocal intraocular lenses continuously raises patients’ expectations to complete spectacle independence. Advances in technology have enabled cataract surgery to develop from being concerned primarily with correcting aphakia into a procedure refined to achieve the best possible postoperative refractive result. Today, after MFIOL implantation, patients have satisfactory visual acuity at all working distances and a high percentage of independence from glasses, and overall patient satisfaction is high.

Despite surgical technique and IOL technology development, refractive surprise occurs occasionally causing patient’s dissatisfaction after MFIOL implantation. Therefore, enhancements are often necessary to provide spectacle independence for distance and near vision for patients after MFIOL implantation. In addition to conservative treatments (correction with glasses and contact lenses), residual refractive error can be safely and predictably treated with excimer laser correction surgery, where LASIK and PRK are the most commonly used methods in clinical practice. The advantages compared to other surgical options are greater flexibility, achieving good and predictable results and avoidance of trauma caused by additional intraocular procedures.

Further improvements in MFIOL technology, biometric technology and IOL formulas, preoperative counseling, postoperative assessment, and management of residual refractive error are needed to further improve outcome and increase patient satisfaction.

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Written By

Mateja Jagić, Maja Bohač, Ante Barišić, Dino Šabanović, Sara Blazhevska and Lucija Žerjav

Reviewed: 27 February 2024 Published: 30 April 2024

© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.