Clinical Results of Diffractive, Refractive, Hybrid Multifocal, and Monofocal Intraocular Lenses

To present the outcomes of hybrid multifocal and monofocal intraocular lenses (IOLs) and to compare with refractive and diffractive multifocal IOLs (MFIOLs).  Three hundred twenty eyes (160 patients) underwent cataract surgery with randomized IOLs bilateral implantation. Changes in uncorrected and distance-corrected logMAR distance, intermediate and near (UNVA and DCNVA) visual acuity (VA), contrast sensitivity (CS), presence of dysphotopsia, spectacle independence, and patient satisfaction were analyzed.  Postoperative VA in the hybrid (OptiVis) group was improved in all distances (p < 0.001). OptiVis acted superiorly to monofocal IOLs in UNVA and DCNVA (p < 0.001 for both) and to refractive ones in DCNVA (p < 0.005). Distance, mesopic, without glare CS in OptiVis was lower than in the monofocal group and similar to other MFIOLs. No differences in dysphotopsia pre- and postoperatively and spectacle independence in near for OptiVis and refractive MFIOLs were detected.  patients were more satisfied than those with monofocal IOLs (p=0.015).  After cataract surgery, patients with OptiVis improved VA in all distances. Near and intermediate VA was better than monofocal, and DCNVA was better than the refractive group. CS was lower in OptiVis than in the monofocal group, but there was no difference between MFIOLs. Patient satisfaction was higher in OptiVis than in the monofocal group.

Related papers:

title: Multifocal versus monofocal intraocular lenses after cataract extraction.
abstract: Good unaided distance visual acuity is now a realistic expectation following cataract surgery and intraocular lens (IOL) implantation. Near vision, however, still requires additional refractive power, usually in the form of reading glasses. Multiple optic (multifocal) IOLs are available which claim to allow good vision at a range of distances. It is unclear whether this benefit outweighs the optical compromises inherent in multifocal IOLs.



The objective of this review was to assess the effects of multifocal IOLs, including effects on visual acuity, subjective visual satisfaction, spectacle dependence, glare and contrast sensitivity, compared to standard monofocal lenses in people undergoing cataract surgery.



We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 2), MEDLINE (January 1946 to March 2012), EMBASE (January 1980 to March 2012), the metaRegister of Controlled Trials (mRCT) (), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 6 March 2012. We searched the reference lists of relevant articles and contacted investigators of included studies and manufacturers of multifocal IOLs for information about additional published and unpublished studies.



All randomised controlled trials comparing a multifocal IOL of any type with a monofocal IOL as control were included. Both unilateral and bilateral implantation trials were included.



Two authors collected data and assessed trial quality. Where possible, we pooled data from the individual studies using a random-effects model, otherwise we tabulated data.



Sixteen completed trials (1608 participants) and two ongoing trials were identified. All included trials compared multifocal and monofocal lenses but there was considerable variety in the make and model of lenses implanted. Overall we considered the trials at risk of performance and detection bias because it was difficult to mask patients and outcome assessors. It was also difficult to assess the role of reporting bias. There was moderate quality evidence that similar distance acuity is achieved with both types of lenses (pooled risk ratio (RR) for unaided visual acuity worse than 6/6: 0.98, 95% confidence interval (CI) 0.91 to 1.05). There was also evidence that people with multifocal lenses had better near vision but methodological and statistical heterogeneity meant that we did not calculate a pooled estimate for effect on near vision. Total freedom from use of glasses was achieved more frequently with multifocal than monofocal IOLs. Adverse subjective visual phenomena, particularly haloes, or rings around lights, were more prevalent and more troublesome in participants with the multifocal IOL and there was evidence of reduced contrast sensitivity with the multifocal lenses.



Multifocal IOLs are effective at improving near vision relative to monofocal IOLs. Whether that improvement outweighs the adverse effects of multifocal IOLs will vary between patients. Motivation to achieve spectacle independence is likely to be the deciding factor.

title: Comparison of outcomes with multifocal intraocular lenses: a meta-analysis
abstract: To compare the clinical outcome of different multifocal intraocular lenses (IOLs) based on information reported in the international literature.  All comparative clinical trials that involved implanting at least one multifocal IOL in patients with cataract or presbyopia were extracted from the literature. Clinical outcomes included uncorrected near visual acuity, uncorrected distance visual acuity, visual acuity, spectacle independence, and halos. Random effects meta-analyses were conducted to compare outcomes for the different IOL types.  Twenty papers were identified describing 11 monofocal IOLs and 35 multifocal IOLs (19 diffractive, including 12 ReSTOR®, 14 refractive, and two accommodative) patient cohorts. Multifocal and monofocal uncorrected distance visual acuity was 0.165 (0.090–0.240) and 0.093 (0.088–0.098), respectively. Compared with monofocal IOLs, multifocal IOLs produced better uncorrected near visual acuity (0.470 [0.322–0.618] versus 0.141 [0.131–0.152]; P < 0.0001), resulting in higher spectacle independence (incidence rate ratio [IRR] 3.62 [2.90–4.52]; P < 0.0001). Compared with refractive multifocal IOLs, diffractive multifocal IOLs produced a similar uncorrected distance visual acuity (0.105 [0.098–0.111] versus 0.085 [0.029–0.140]; P ≤ 0.78, not significant) and better uncorrected near visual acuity (0.217 [0.118–0.317] versus 0.082 [0.067–0.098]; P < 0.0001) resulting in higher spectacle independence (IRR 1.75 [1.24–2.48]; P < 0.001). Compared with other multifocal IOLs, ReSTOR produced a better uncorrected distance visual acuity (0.067 [0.059–0.076] versus 0.093 [0.088–0.098]; P < 0.0001) and better uncorrected near visual acuity (0.064 [0.046–0.082] versus 0.141 [0.131–0.152]; P < 0.006), resulting in higher spectacle independence (IRR 2.06 [1.26–1.36]; P < 0.004). Halo incidence rates with different types of multifocal implants did not differ significantly.  Multifocal IOLs provide better uncorrected near visual acuity than monofocal IOLs, leading to less need for spectacles. Multifocal IOL design might play a role in postsurgical outcome, because better results were obtained with diffractive lenses. ReSTOR showed better uncorrected near visual acuity, uncorrected distance visual acuity, and higher spectacle independence rates compared with other multifocal IOLs.

title: Cataract extraction with multifocal intraocular lens implantation: a multinational clinical trial evaluating clinical, functional, and quality-of-life outcomes.
abstract: Two million cataract extractions are performed annually in the United States. The procedure is nearly always accompanied by implantation of a monofocal intraocular lens (IOL), which corrects the patient's distance vision. The authors' objective was to measure visual function and quality-of-life outcomes associated with bilateral implantation of a multifocal IOL, which corrects distance and near vision, and to compare the outcomes with those of the standard therapy.



A prospective, randomized, double-masked, clinical trial was conducted at eight sites in the United States, seven sites in Germany, and one site in Austria.



Participants included 245 cataract patients, 127 of whom received the multifocal IOL bilaterally and 118 of whom received a monofocal IOL of nearly identical construction bilaterally.



Clinical data included visual acuity (VA), complications, and adverse events. Quality-of-life data were collected using a previously validated survey instrument at baseline, after first eye surgery, and after second eye surgery.



At 3 months after surgery, patients who had received multifocal IOLs had significantly better uncorrected and distance corrected binocular near VA compared with patients who had received monofocal IOLs (mean uncorrected VA, 20/26 multifocal vs. 20/40 monofocal; mean distance corrected VA, 20/28 multifocal vs. 20/45 monofocal; P < 0.0001). Additionally, 96% of patients who had received multifocal IOLs and 65% of patients who had received monofocal IOLs achieved both 20/40 and J3 (Jaeger) or better uncorrected, binocular distance and near visual acuities (P < 0. 0001). Patients who had received multifocal IOLs were more likely than patients who had received monofocal IOLs to never wear glasses overall (32% multifocal vs. 8% monofocal; P < 0.0001). On a 4-point scale, patients who had received multifocal IOLs on average reported having between "a little bit" and "some" glare or halo, whereas patients who had received monofocal IOLs reported between "none" and "a little bit" of glare or halo (1.57 vs. 0.43; P < 0.001). Patients who had received multifocal IOLs rated their vision without glasses better overall at near and at intermediate distances (P < or = 0.002) and demonstrated better visual function for near tasks and social activities.



Cataract patients who received multifocal IOLs at time of surgery obtained better uncorrected and distance corrected near VA and reported better overall vision, less limitation in visual function, less spectacle dependency, and more glare or halo than those who received traditional monofocal IOLs.

title: Effect of intraocular lens asphericity on quality of vision after cataract removal: an intraindividual comparison.
abstract: To determine the effect of intraocular lens (IOL) asphericity on quality of vision after cataract removal.



Intraindividual, prospective, randomized clinical trial.



Twenty-six cataract patients received 2, one-piece, blue-light-filtering hydrophobic acrylic IOLs each.



One eye was implanted with a spherical (SN60AT, Alcon) and the contralateral eye with an aspheric (SN60WF, Alcon) IOL with -0.2 mum spherical aberration (SA). All trial-specific measurements (corneal topography, wavefront sensing, high-contrast visual acuity [HCVA], contrast sensitivity [CS]) were performed 6 months after surgery. A paired Student t-test or Wilcoxon test was used to check intergroup differences.



Absolute values and intraindividual differences (Delta(i)) of corneal and ocular higher order aberrations and best-corrected visual Strehl ratio based on the optical transfer function (BCVSOTF) values for virtual pupil diameters of 3, 4, 5, and 6 mm were computed. Photopic and mesopic HCVA, photopic, and high-mesopic CS as well as high-mesopic disability glare (DG) were measured using the Frankfurt-Freiburg Contrast and Acuity Test System.



No intergroup difference of demographic data, pupillometry, and corneal aberrations were observed. Coma and trefoil root mean square and SA were significantly lower in the aspheric group resulting in higher BCVSOTF, mesopic HCVA, and photopic and high mesopic CS. All Delta(i) values with exception of photopic HCVA and DG indicated significantly better performance of the aspheric IOL.



An aspheric IOL with -0.2 microm SA provide higher quality of vision than spherical IOL in terms of retinal image quality, mesopic HCVA and CS.



Proprietary or commercial disclosures may be found after the references.

title: Spherical aberration and contrast sensitivity in eyes implanted with aspheric and spherical intraocular lenses: a comparative study.
abstract: To determine whether implantation of an intraocular lens (IOL) with a modified anterior aspheric surface results in reduced spherical aberration and improved contrast sensitivity after cataract surgery.



Prospective, comparative, interventional case series.



In an intraindividual randomized prospective study of 25 patients with bilateral cataract, an IOL with a modified anterior surface (Tecnis Z9001; Advanced Medical Optics, Santa Ana, California, USA; group 1) was compared with biconvex lens with spherical surfaces (ClariFlex; Advanced Medical Optics; group 2). Ocular aberrations for a 5.0-mm pupil and 6.0-mm pupil were measured with Hartmann-Shack aberrometer. Quality of vision was measured by visual acuity and contrast sensitivity under mesopic and photopic conditions. All patients were followed up for three months.



No statistically significant difference in postoperative uncorrected and best-corrected distance vision acuity after a follow-up of three months existed between the groups. Postoperative contrast sensitivity testing revealed significant differences between the groups under photopic and mesopic conditions. These differences reached statistical significance under photopic conditions at three spatial frequencies and under mesopic conditions at all spatial frequencies. When analyzing higher-order aberrations, the difference between the groups was statistically significant at the 5.00-mm and 6.00-mm pupil diameters, with the group 1 inducing less higher-order aberration and also less spherical aberration compared with group 2.



Results show the Tecnis Z9001 IOL with a modified anterior aspheric surface induced significantly less higher-order aberration and spherical aberration compared with the ClariFlex IOL. Contrast sensitivity revealed better values under photopic and mesopic conditions with the Tecnis Z9001 IOL.

title: Clinical evaluation of the OptiVis™ multifocal intraocular lens
abstract: IntroductionThe purpose of this study was to evaluate the efficacy of the OptiVis™ Multifocal Intraocular Lens (IOL) in patients undergoing bilateral crystalline lens replacement following extracapsular extraction by phacoemulsification.MethodsThis was a prospective 6-month, open-label, nonrandomized clinical trial of subjects undergoing bilateral implantation with the OptiVis Multifocal IOL. Of the 121 eyes enrolled, 88 eyes of 44 subjects completed the entire 6-month trial.ResultsAfter 6 months, the majority of eyes had a distance best-corrected visual acuity of 20/20 or better, with 89.8% achieving that outcome, and 100% with 20/32 or better. At an intermediate distance, most eyes (90.9%) had a distance corrected intermediate visual acuity of 20/40 or better, and 53.4% had an acuity of 20/32 or better. At a near distance, most eyes (95.5%) had a distance corrected near visual acuity of 20/40 or better by month 6. The most commonly reported adverse event was mild-to-moderate halos (n=30, 36%) and mild-to-moderate glare (n=15, 18%). In addition, there was one case of cystoid macular edema, one posterior capsular opacification, and one case of severe corneal edema. Postoperative contrast sensitivity was comparable with normal phakic subjects ≥60 years of age.ConclusionThe OptiVis Multifocal IOL provided satisfactory visual acuity at distance, near, and intermediate with no apparent reduction in contrast sensitivity. Additional, longer-term follow-up studies are planned.

title: Reproducibility and responsiveness of the VF-14. An index of functional impairment in patients with cataracts.
abstract: To assess the test-retest reliability and responsiveness of the VF-14, which is an index of functional impairment in patient with cataracts.



Observational longitudinal study. Patients were enrolled prior to undergoing their first cataract surgery between July 15 and December 15, 1991, and they were followed up for 1 year after surgery.



Patients were recruited from 72 ophthalmologists' practices in three US cities.



Five hundred fifty-two patients who had undergone a surgical procedure in only one eye by the 4-month postoperative follow-up (responsiveness analyses) and a subset of these (n = 426) who had not subsequently undergone surgery for the second eye by the 12-month postoperative follow-up (reproducibility analyses).



Two health status measures (the VF-14 and the Sickness Impact Profile, two global measures of a patient's trouble and satisfaction with his or her vision, and best corrected visual acuity in each eye.



The VF-14 is highly reproducible, with an intraclass correlation coefficient of .79 when patient-rated criteria are used to define stable patients. The intraclass correlation coefficient was lower (.57 to .71) when various measures of visual acuity were used to define stable patients. The VF-14 is also about three times more responsive to a change in vision than the Sickness Impact Profile, which is a generic health status measure (effect size of approximately 1.00 vs 0.30). Estimates of the responsiveness of the VF-14 and the Sickness Impact Profile were not associated with preoperative visual acuity in the operated on or better eye. Responsiveness of the VF-14, however, was higher in patients with greater self-rated trouble with vision preoperatively.



The VF-14 was reproducible in stable patients during an 8-month period, and it was more responsive to clinically significant changes in vision than was a generic health status measure (ie, the Sickness Impact Profile).

title: One-year outcomes with new-generation multifocal intraocular lenses.
abstract: To compare new-generation multifocal intraocular lenses (IOLs) with monofocal IOLs.



Randomized prospective clinical trial.



Sixty-two consecutive patients with cataract, seen between January of 2005 and January of 2006 at the Department of Ophthalmology of Palermo University Hospital in Italy, were bilaterally implanted with monofocal (AR 40, Advanced Medical Optics [AMO], Santa Ana, CA; 15 patients), multifocal refractive (Array SA40N, AMO; 16 patients), multifocal refractive (ReZoom, AMO; 15 patients), or multifocal diffractive pupil-independent (Tecnis ZM900, AMO; 16 patients) IOLs.



Bimanual phacoemulsification.



Primary outcomes were far, near, and intermediate visual acuity of the 4 IOL-implanted groups. Secondary outcomes were defocusing curves, contrast sensitivity, patients' quality of life (7-item visual function questionnaire [VF-7], halos and glare presence, overall satisfaction), and spectacle independence. Snellen visual acuity was measured as uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), uncorrected near visual acuity (UCNVA), best distance corrected near visual acuity (BDCNVA), best corrected near visual acuity (BCNVA), uncorrected intermediate visual acuity (UCIVA), and best distance corrected intermediate visual acuity (BDCIVA).



UCNVA was 20/50 in the monofocal IOL group, compared with 20/32 or better in the multifocal IOL groups (P<0.0005). The monofocal IOL group exhibited a lower BDCNVA than the multifocal IOL groups (P<0.0005). The diffractive multifocal IOL group performed better than either refractive group (P = 0.007). UCIVA was significantly different (P = 0.001) among the groups: monofocal (AR 40) 20/32; multifocal refractive (Array SA40N) 20/30; multifocal refractive (ReZoom) 20/25; and multifocal diffractive (Tecnis ZM900) 20/30. Defocusing curves with -3.00 diopter lens exhibited a better trend in the diffractive group. The refractive multifocal IOL groups exhibited lower contrast sensitivities at 3 cycles/degree (P = 0.038). The VF-7 mean score was significantly lower in the monofocal than the multifocal IOL groups (P = 0.002). Night halos were more common in the refractive groups (P<0.01). Spectacle independence was 20% in the monofocal IOL group, 43.7% and 53.3% in the refractive multifocal IOL groups, and 87.5% in the diffractive multifocal IOL group (P<0.05).



Multifocal IOLs provide a greater depth of focus and higher patient satisfaction, and make intermediate and near visual tasks easier than do monofocal lenses. New-generation, diffractive, pupil-independent multifocal IOLs provide better near vision, equivalent intermediate vision, less unwanted photic phenomena, and greater spectacle independence than either monofocal or refractive multifocal IOLs.

title: Comparing the 1CU accommodative, multifocal, and monofocal intraocular lenses: a randomized trial.
abstract: To compare the binocular near vision performance in patients implanted with the 1CU accommodating intraocular lens (IOL) with a multifocal and monofocal IOL.



Prospective, randomized, double-masked clinical trial.



Ninety patients presenting for cataract surgery to the Department of Ophthalmology, Hillingdon Hospital were randomized to receive the 1CU accommodative IOL, a multifocal IOL, or a monofocal IOL (control group).



Patients underwent bilateral sequential phacoemulsification with implantation of 1 of the 3 IOL types and were assessed at 3 and 18 months after second-eye surgery.



Logarithm of the minimum angle of resolution distance and near visual acuities (VAs) (unaided and distance corrected), contrast sensitivity, and accommodative amplitude (near point and defocusing) were measured at 3 and 18 months. Reading speed was assessed at 18 months, and glare symptoms and spectacle independence were compared using a standardized questionnaire.



Mean unaided and distance-corrected binocular near VAs were similar in the 1CU and multifocal and were significantly higher than the control group's (P<0.02). There was no significant difference in reading speed between any of the groups, but critical print sizes were similar in the 1CU and multifocal groups and significantly better than the control group's (P = 0.02). The accommodative range was highest in the multifocal group and lowest in the control group, and there was no significant difference between the 1CU and control groups for defocus or near point at 18 months. Of the 1CU group and control group, 71.4% and 63.2%, respectively, experienced no glare at 18 months, compared with only 25% of the multifocal group (P = 0.01). Of the 1CU group and multifocal group, 19% and 27.3%, respectively, were completely spectacle independent at 18 months; none of the control group was (P = 0.05).



The 1CU accommodating IOL provides improved near vision compared with a monofocal IOL. There is a discrepancy between the near function and accommodative amplitude measured in the 1CU. The multifocal provides excellent near acuity, but photopic phenomena remain a problem inherent in the lens design.

title: Visual function after monocular implantation of apodized diffractive multifocal or single‐piece monofocal intraocular lens: Randomized prospective comparison
abstract: To compare visual function after phacoemulsification with implantation of a multifocal intraocular lens (IOL) or a monofocal IOL.  Department of Ophthalmology, Affiliated Hospital of Qingdao University Medical College, Qingdao, Shandong, China.  This study comprised patients with unilateral cataract who had phacoemulsification with implantation of an AcrySof ReSTOR SA60D3 multifocal IOL (multifocal group) or an AcrySof SA60AT single‐piece monofocal IOL (monofocal group). Postoperative visual function, including uncorrected (UDVA) and corrected (CDVA) distance visual acuity; uncorrected (UNVA), corrected (CNVA), and distance‐corrected near visual acuity; and contrast sensitivity were evaluated 1 week, 1 month, and 6 months postoperatively. Patient‐reported vision and spectacle independence in the 2 groups were also compared.  Of the 161 eyes, 72 were in the multifocal group and 89 were in the monofocal group. The multifocal group had statistically significant better UNVA than the monofocal group from 1 week postoperatively to the final follow‐up and statistically significant better CNVA at 6 months (both P<.05). There were no statistically significant differences in UDVA or CDVA between the 2 groups over the 6‐month follow‐up. The multifocal group had statistically significantly better pseudoaccommodation than the monofocal group; the monofocal group had significantly better contrast sensitivity (both P<.05). Patients with the multifocal IOL reported being more satisfied than those with the monofocal IOL.  The multifocal IOL provided better near visual acuity and more spectacle independence than the monofocal IOL. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

title: Aberration and contrast sensitivity comparison of aspherical and monofocal and multifocal intraocular lens eyes
abstract: Higher‐order aberrations and contrast sensitivity were evaluated in patients who underwent phacoemulsification cataract extraction followed by implantation of aspherical, monofocal or multifocal intraocular lens (IOL) replacements.

title: Multifocal versus monofocal intraocular lenses in cataract surgery: a systematic review.
abstract: To assess the visual effects of multifocal intraocular lenses (IOLs) compared with the current standard treatment of monofocal IOL implantation.



Systematic literature review and meta-analysis of randomized controlled trials.



The study was performed according to the Cochrane Collaboration methodology. Computer database and manual searches were made to identify all randomized trials comparing multifocal IOL implantation with a monofocal control group. Data were extracted using a standardized form and analyzed using Review Manager software. When study reporting allowed meaningful comparison, meta-analysis was performed. The chi-square test was used to examine heterogeneity between studies. Odds ratios were calculated for dichotomous outcomes and standardized mean differences for continuous variables.



There is no single outcome measure that can be thought of as summarizing the efficacy of an IOL. A number of different outcomes had to be examined. The primary outcomes for this review were distance and near visual acuity (unaided and corrected) and spectacle dependence. The secondary outcomes for this review included depth of field, contrast sensitivity, glare, subjective assessment of quality of life or visual function, and surgical complications.



Eight trials were identified. There was significant variability among the trials in the outcomes reported. Distance acuity was similar in multifocal and monofocal IOLs. Unaided near vision tended to improve with the multifocal IOL. This resulted in decreased spectacle dependence with use of the multifocal IOL. Adverse effects included reduced contrast sensitivity and the subjective experience of halos around lights.



Multifocal IOLs are effective at improving near vision relative to monofocal IOLs. Whether that improvement outweighs the adverse effects of multifocal IOLs will vary between patients, with motivation to achieve spectacle independence likely to be the deciding factor.

title: Multifocal versus monofocal intraocular lenses after cataract extraction.
abstract: Good unaided distance visual acuity is now a realistic expectation following cataract surgery and intraocular lens implantation. Near vision however still requires additional refractive power, usually in the form of reading glasses. Multiple optic (multifocal) intraocular lenses are available that are claimed to allow good vision at a range of distances. It is unclear whether this benefit outweighs the optical compromises inherent in multifocal intraocular lenses.



The objective of this review is to assess the effects of multifocal intraocular lenses, including effects on visual acuity, subjective visual satisfaction, spectacle dependence, glare and contrast sensitivity, compared to standard monofocal lenses.


SEARCH STRATEGY
We searched the Cochrane Controlled Trials Register - CENTRAL (which includes the Cochrane Eyes and Vision Group specialised register), MEDLINE and EMBASE. The reference lists of relevant articles were searched. Investigators of included studies and manufacturers of multifocal intraocular lenses were contacted for information about additional published and unpublished studies.



All randomised controlled trials comparing a multifocal intraocular lens of any type with a monofocal intraocular lens as control were included. Both unilateral and bilateral implantation trials were included.



Data were collected and trial quality assessed. Where possible, statistical summary measures were calculated, otherwise data were tabulated.



One ongoing and six completed trials were identified. There was significant variability between the trials in the outcomes reported. Unaided distance acuity was similar in multifocal and monofocal intraocular lenses (Peto odds ratio 1.27 (95% Confidence Interval (CI) 0.76 to 2.11)), with a small increase in the proportion of multifocal intraocular lens participants achieving less than 6/6 best corrected visual acuity (Peto odds ratio 1.64 (95% CI 1.10 to 2.42)). Unaided near vision tended to improve with the multifocal intraocular lenses. This resulted in decreased spectacle dependence with use of the multifocal intraocular lenses (Peto odds ratio 0.16 (95% CI 0.11 to 0.23)). Adverse effects included reduced contrast sensitivity and the subjective experience of haloes around lights.



Multifocal intraocular lenses are effective at improving near vision relative to monofocal intraocular lenses. Whether that improvement outweighs the adverse effects of multifocal intraocular lenses will vary between patients, with motivation to achieve spectacle independence likely to be the deciding factor.

title: Multifocal intraocular lenses in cataract surgery: literature review of benefits and side effects.
abstract: This literature review looks at the current status of multifocal intraocular lenses (IOLs) in cataract surgery. The results of implantation of multifocal IOLs of diffractive, refractive, and hybrid diffractive-refractive design are described with regard to uncorrected near and distance visual acuity and spectacle independence. The occurrence of photic phenomena and contrast sensitivity loss with multifocal IOLs are also addressed.


FINANCIAL DISCLOSURE
Neither author has a financial or proprietary interest in any material or method mentioned.

title: Visual Outcomes After Cataract Surgery: Multifocal Versus Monofocal Intraocular Lenses.
abstract: To evaluate visual outcomes, spectacle independence, and quality of life among nonastigmatic and astigmatic patients who received AcrySof IQ ReSTOR toric or nontoric multifocal intraocular lenses (IOLs) (Alcon Laboratories, Fort Worth, TX) compared with those who received commercially available nontoric monofocal IOLs after bilateral cataract removal.



This randomized, patient- and observer-technician-masked study was conducted at 20 sites in Europe. Patients were randomized to receive monofocal (nontoric only) or multifocal (nontoric or toric, as needed) IOLs. Primary efficacy endpoints included percentage of patients achieving binocular uncorrected distance and near acuity of 0.1 logMAR or better (20/25 Snellen), spectacle independence, and scores on the National Eye Institute Refractive Error and Quality of Life questionnaire domains. Safety endpoints included adverse events and refractive error within 0.5 and 1.0 diopters.



In the multifocal group (n = 108) versus the monofocal group (n = 100), significantly more patients achieved uncorrected distance and near acuity of 0.1 logMAR or better (45.7% vs 2.1%; P < .0001) and spectacle independence (73.3% vs 25.3%; P < .0001) at 6 months. The percentage of patients who achieved uncorrected distance visual acuity of 20/40 or better at 6 months was 92% in the multifocal group and 97% in the monofocal group. National Eye Institute Refractive Error and Quality of Life scores were significantly better for dependence on correction in the multifocal group (P < .0001) and for glare in the monofocal group (P = .0157); other domain scores were similar between groups. No significant trends in study device-related adverse events were observed.



Monofocal and multifocal IOLs provided good clinical outcomes. More patients receiving multifocal IOLs attained better uncorrected visual acuity at a range of distances and spectacle independence compared with patients who received monofocal IOLs. Monofocal IOLs were associated with better patient-reported scores for glare compared with multifocal IOLs; however, scores for patient satisfaction were significantly better in the multifocal group.

title: Visual performance with accommodating and multifocal intraocular lenses.
abstract: To compare the visual functional outcomes with accommodating and multifocal intraocular lenses (IOLs).



Our retrospective comparative study included 51 patients (60 eyes) received implantation of an accommodating IOL (Tetraflex; 16 patients, 20 eyes), a refractive multifocal IOL (ReZoom; 18 patients, 20 eyes), or a diffractive multifocal IOL (ZMA00; 17 patients, 20 eyes). Subjective refraction, visual acuity, contrast sensitivity (CS), intraocular aberration, and subjective photic phenomena were detected at 3mo after surgery.



The spherical equivalent in the three groups was -0.38±0.54 D, 0.14±0.56 D, and 0.35±0.41 D, respectively. No statistically significant differences were found in uncorrected and corrected distance visual acuity and uncorrected intermediate visual acuity among the groups (P=0.39). The ReZoom group had significantly better distance-corrected intermediate visual acuity than the ZMA00 group (P=0.003). The ZMA00 group had significantly better near visual acuity than the other groups (P<0.05). Better contrast sensitivity values were observed in the Tetraflex group under most of the spatial frequencies conditions (P=0.025). The total aberration was lowest in the ZMA00 group (P=0.000), and the spherical aberration was highest in the Tetraflex group (P=0.000). The three groups had similar frequency of ghosting and glare, and the Tetraflex group had a low rate of halos (P=0.01).



Both accommodating and multifocal IOLs can successfully restore distance and uncorrected intermediate visual acuities. Tetraflex accommodating IOLs perform better in CS and with less halos of photic phenomena. ReZoom refractive multifocal IOLs have better performance in distance-corrected intermediate visual acuity than ZMA00 diffractive multifocal IOLs, and the latter achieved better near visual acuity and efficiently decreased the optical aberration.

title: Intermediate visual function with different multifocal intraocular lens models
abstract: To compare visual acuity at different distances after bilateral implantation of 1 of 4 multifocal intraocular lenses (IOLs).  Fernández‐Vega Ophthalmological Institute, Oviedo, Spain.  This study evaluated consecutive patients who had bilateral implantation of a spherical multifocal IOL with a +4.00 diopter (D) addition (add) (AcrySof ReSTOR SN60D3) or an aspheric multifocal IOL with a +4.00 D add (AcrySof ReSTOR SN6AD3), +3.75 D add (Acri.LISA 366D), or +3.00 D add (AcrySof ReSTOR SN6AD1). Six months postoperatively, binocular measurement of corrected distance visual acuity (CDVA) at 4 m, corrected near visual acuity (CNVA) at 40 cm, and corrected intermediate visual acuity (CIVA) at 50, 60, 70, and 80 cm were performed; the defocus curve was also measured.  Each IOL model was implanted in 20 eyes (10 patients). All IOL models resulted in good distance vision, with no statistically significant differences between models. Patients with the +3.00 aspheric IOL had statistically better binocular CIVA at 50, 60, and 70 cm (P<.0001) and binocular CNVA at 40 cm (P = 3 × 10−3) than patients with the other IOL models.  Patients with bilateral multifocal aspheric IOLs with a lower add had better intermediate and distance near visual acuity than patients with bilateral multifocal spherical IOLs or bilateral aspheric IOLs with a higher add. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

title: Refractive versus diffractive multifocal intraocular lenses in cataract surgery: a meta-analysis of randomized controlled trials.
abstract: Data sources, including PubMed, Medline, Embase, and the Cochrane Controlled Trials Register, were used to identify potentially relevant randomized controlled trials. Eight qualified studies incorporating 1,242 eyes of 621 patients were analyzed using Rev- Manager version 5.2 software (The Cochrane Collaboration, Oxford, England). The primary measures included uncorrected distance, intermediate, and near visual acuity. Reading ability, spectacle independence, and occurrence of photic phenomena were also addressed.



The refractive MIOL group exhibited better uncorrected distance visual acuity than the diffractive MIOL group (weighted mean difference [WMD] = -0.04, 95% confidence interval [CI]: -0.06 to -0.02, P < .01). However, the diffractive MIOL group performed better than the refractive MIOL group in uncorrected near visual acuity, reading acuity, reading speed, smallest print size, spectacle independence, halo, and glare rate (WMD = 0.13, 95% CI: 0.10 to 0.17, P < .01; WMD = 0.14, 95% CI: 0.08 to 0.19, P < .01; WMD = -24.14, 95% CI: -43.56 to -4.72, P = .01; WMD = 0.56, 95% CI: 0.43 to 0.69, P < .01; WMD = 0.56, 95% CI: 0.45 to 0.70, P < .01; WMD = 1.50, 95% CI: 1.16 to 1.93, P = .002; WMD = 1.39, 95% CI: 1.10 to 1.75, P = .006, respectively). There was no significant difference between the two groups in uncorrected intermediate visual acuity (WMD = -0.04, 95% CI: -0.09 to 0.00, P = .05).



Refractive MIOLs can provide better distance vision, whereas diffractive MIOLs provide better near vision, reading ability, and equivalent intermediate vision, reduce unwanted photic phenomena, and allow greater spectacle independence.

title: Functional vision with bilateral ReZoom and ReSTOR intraocular lenses 6 months after cataract surgery
abstract: To compare the visual outcomes in patients with bilateral implantation of AcrySof ReSTOR multifocal intraocular lenses (IOLs) (Alcon Laboratories) or ReZoom multifocal IOLs (Advanced Medical Optics) 6 months after cataract surgery.  Orsett and Southend Hospital, Essex, United Kingdom.  This study comprised patients who had uneventful bilateral cataract extraction with implantation of ReZoom (n = 50) or ReSTOR (n = 50) multifocal IOLs. Parameters analyzed included binocular uncorrected distance, intermediate, and near acuities; spectacle independence; subjective visual symptoms; and patient satisfaction. All parameters were evaluated 6 months after second‐eye surgery.  All patients had binocular uncorrected distance visual acuity of 20/32 or better; there was no statistically significant difference between the 2 groups. The mean binocular uncorrected near acuity was 20/26 (J1.22) in the ReSTOR group and 20/34 (J2.34) in the ReZoom group (P<.0001). The mean binocular uncorrected intermediate visual acuity was 20/42 and 20/34, respectively (P = .003). Patients in the ReZoom group reported greater satisfaction with intermediate vision (P = .04). No statistically significant difference was found in satisfaction with near vision. Eighty‐six percent of ReSTOR patients and 70% of ReZoom patients did not wear glasses for daily activities; the overall satisfaction was not statistically significantly different between groups. There was no significant difference between groups in photic phenomena.  The ReSTOR IOL provided better near vision and the ReZoom IOL better intermediate vision. Both multifocal IOLs gave excellent distance vision. Photic phenomena were comparable and clinically acceptable. ReSTOR patients had greater spectacle independence for near vision and ReZoom patients for intermediate vision. Overall spectacle independence was not statistically significantly different.

title: Comparison of visual outcomes and subjective visual quality after bilateral implantation of a diffractive trifocal intraocular lens and blended implantation of apodized diffractive bifocal intraocular lenses
abstract: To compare the visual acuity (VA) and quality of vision between bilateral implantation of a trifocal intraocular lens (IOL) and blended bifocal IOLs with an intermediate add in the dominant eye and a near add in the nondominant eye.  Patients with either trifocal or blended bifocal IOLs implanted were recruited after surgery. Subjects returned for a single diagnostic visit between 3 and 24 months after surgery. VA was tested at various distances, including low-contrast acuity and acuity at their preferred reading distance. A binocular defocus curve was obtained, and subjective visual function and quality of vision were evaluated.  Twenty-five trifocal subjects and 30 blended bifocal subjects were enrolled. There were no significant differences in low-contrast acuity, preferred reading distance, or acuity at that reading distance. Binocular vision at 4 m, 60 cm, and 40 cm was not statistically significantly different. The trifocal provided statistically significantly better visual acuity (P<0.05) at vergences from −0.5 to −1.5 D (from 2 m to 67 cm viewing distance, P<0.05). There was no statistically significant difference in the near vision subscale scores of the 39-question National Eye Institute Visual Function Questionnaire or the overall scores of the Quality of Vision questionnaire, though significantly more trifocal subjects reported that the observed visual disturbances were “bothersome” (P<0.05).  Both lens modalities provided subjects with excellent binocular near and distance vision, with similar low rates of visual disturbances and good reported functional vision. The trifocal IOL provided significantly better intermediate VA in the viewing distance range of 2 m to 67 cm, corresponding to viewing things such as a car dashboard or grocery shelf. VA was similar between groups at viewing distances from 60 to 40 cm, corresponding to computer or reading distance.

title: Comparative analysis of the visual performance after cataract surgery with implantation of a bifocal or trifocal diffractive IOL.
abstract: To evaluate and compare the visual, refractive, contrast sensitivity, and aberrometric outcomes with a diffractive bifocal and trifocal intraocular lens (IOL) of the same material and haptic design.



Sixty eyes of 30 patients undergoing bilateral cataract surgery were enrolled and randomly assigned to one of two groups: the bifocal group, including 30 eyes implanted with the bifocal diffractive IOL AT LISA 801 (Carl Zeiss Meditec, Jena, Germany), and the trifocal group, including eyes implanted with the trifocal diffractive IOL AT LISA tri 839 MP (Carl Zeiss Meditec). Analysis of visual and refractive outcomes, contrast sensitivity, ocular aberrations (OPD-Scan III; Nidek, Inc., Gagamori, Japan), and defocus curve were performed during a 3-month follow-up period.



No statistically significant differences between groups were found in 3-month postoperative uncorrected and corrected distance visual acuity (P ≥ .21). However, uncorrected, corrected, and distance-corrected near and intermediate visual acuities were significantly better in the trifocal group (P < .01). No significant differences between groups were found in postoperative spherical equivalent (P = .22). In the binocular defocus curve, the visual acuity was significantly better for defocus of -0.50 to -1.50 diopters in the trifocal group (P ≤ .04) and -3.50 to -4.00 diopters in the bifocal group (P ≤ .03). No statistically significant differences were found between groups in most of the postoperative corneal, internal, and ocular aberrations (P ≤ .31), and in contrast sensitivity for most frequencies analyzed (P ≤ .15).



Trifocal diffractive IOLs provide significantly better intermediate vision over bifocal IOLs, with equivalent postoperative levels of visual and ocular optical quality.

title: Analysis of Defocus Curves of Different Modern Multifocal Intraocular Lenses
abstract: To compare the visual performance in patients implanted with different modern multifocal intraocular lens (mfIOL) models using defocus curves.  This prospective, interventional, comparative, nonrandomized consecutive series of cases included 60 patients (45-87 years) who underwent binocular cataract surgery. Patients were divided into 4 groups depending on the intraocular lens (IOL) implanted after cataract surgery: group A, 15 patients with AT LISA tri 839MP IOL (Carl Zeiss Meditec); group B, 15 patients with FineVision trifocal IOL (PhysIOL); group C, 15 patients with ReSTOR SN6AD1 bifocal IOL (Alcon); and group D, 15 patients with Acri. Smart 48S monofocal IOL (Carl Zeiss Meditec). Distance and near visual acuity outcomes and defocus curve of each one of the mfIOLs were evaluated postoperatively during a 3-month follow-up.  Statistically significant differences in distance and near vision were found among groups (p<0.01). Statistically significant differences were found among groups (p<0.01) for defocus levels ranging from −4.00 D to +0.50 D. Statistically significant differences were found between trifocal IOL groups for defocus levels ranging from −2.00 to +1.00 D (p<0.01), with better values of visual acuity for group A. Statistically significant differences were detected between groups A and C for defocus levels of −1.50 and −1.00 D with better visual acuity for group A.  Multifocal IOLs provide good distance, near, and intermediate visual acuity. The AT LISA tri MP839 showed better outcomes for intermediate vision than the FineVision and AcrySof ReSTOR SN6AD1 IOLs. By knowing the defocus curve profile of each lens, the surgeon can select the best IOL.

title: Comparison of a trifocal intraocular lens with a +3.0 D bifocal IOL: Results of a prospective randomized clinical trial
abstract: To compare visual outcomes in patients with cataract surgery and bilateral implantation of a trifocal or bifocal intraocular lens (IOL).  University Eye Clinic Maastricht, the Netherlands.  Prospective randomized clinical trial.  Eyes with cataract and less than 1.0 diopter (D) of corneal astigmatism were randomized to receive bilateral implantation of Finevision Micro F trifocal IOLs or Acrysof IQ Restor +3.0 bifocal IOLs. Outcome measures were monocular and binocular uncorrected distance (UDVA), uncorrected intermediate (UIVA), and uncorrected near (UNVA) visual acuities; refractive outcomes; binocular defocus curve; contrast sensitivity; reading speed; patient satisfaction; and spectacle independence.  Six months postoperatively, the mean binocular UDVA, UIVA, and UNVA in 56 eyes of 28 patients were 0.01 logMAR ± 0.11 (SD), 0.32 ± 0.15 logMAR, and 0.15 ± 0.13 logMAR in the trifocal group (n = 15) and 0.00 ± 0.09 logMAR, 0.28 ± 0.08 logMAR, and 0.12 ± 0.08 logMAR in the bifocal group (n = 13), respectively. The trifocal group showed a more continuous defocus curve and better results at −1.0 D of defocus (P < .01). The mean mesopic contrast sensitivity was higher in the bifocal group (P = .02). Complete spectacle independence was reported by 80% of trifocal patients and 50% of bifocal patients. There were no significant differences in refractive outcomes, reading speed, or patient satisfaction.  This study showed noninferiority of visual outcomes with the trifocal IOL compared with the bifocal IOL, although the defocus curve was better at an intermediate distance with the trifocal IOL. Financial Disclosure Dr. Bauer received study grants from Alcon Laboratories, Inc., Carl Zeiss Meditec AG, and Physiol S.A. and a lecture fee from Alcon Surgical, Inc. Dr. Nuijts is a consultant to Alcon Surgical, Inc., Théa Pharma GmbH, and ASICO LLC; he has received study grants from Acufocus, Inc., Alcon Surgical, Inc., Carl Zeiss Meditec AG, Ophtec BV, and Physiol S.A. No other author has a financial or proprietary interest in any material or method mentioned.

title: Comparison of clinical performance between trifocal and bifocal intraocular lenses: A meta-analysis
abstract: To compare the clinical performance between trifocal and bifocal intraocular lenses in bilateral cataract and/or refractive lens exchange (RLE) surgery.  A comprehensive literature search of PubMed, EMBASE, Cochrane Controlled Trials Register and Web of Science was performed through October 2016 to identify randomized, controlled trials (RCTs) and comparative cohort studies. The primary outcomes were uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), uncorrected near visual acuity (UNVA), defocus curve, spectacle independence, patient satisfaction and contrast sensitivity. The secondary outcomes were residual sphere, spherical equivalent (SE), cylinder and complications.  Six RCTs and 2 cohort studies including 568 eyes (278 in the trifocal group and 290 in the bifocal group) were identified. There was a statically significant difference between the two groups in UDVA (WMD: -0.03, 95% CI: -0.05 to -0.01, P = 0.005), but the difference (0.03 log MAR) is not clinically significant. Intermediate visual acuity was better in the trifocal IOL group judging from UIVA and defocus curves. There was a statically significant difference between the two groups in residual cylinder (WMD: 0.11, 95% CI: 0.02 to 0.20, P = 0.02), and subgroup AT Lisa tri 839MP trifocal also showed significant better UNVA than bifocal IOLs (WMD: -0.13, 95% CI: -0.17 to -0.08, P<0.00001). However, no significant differences were observed in UNVA (WMD: -0.04, 95% CI: -0.11 to 0.02, P = 0.19), spectacle independence (WMD: 1.27, 95% CI: 0.89 to 18.15, P = 0.07), patient satisfaction (WMD: 4.01, 95% CI: 0.07 to 22.72, P = 0.87), residual sphere (WMD: -0.03, 95% CI: -0.18 to 0.13, P = 0.74), SE (WMD: 0.04, 95% CI: -0.09 to 0.16, P = 0.55) or complications (WMD: 2.08, 95% CI: 0.35 to 12.43, P = 0.42).  Trifocal IOL technology (especially AT Lisa trifocal 839M trifocal) had a clear advantage over bifocal IOLs in intermediate visual acuity, while both trifocal IOLs and bifocal IOLs showed excellent performance in distance visual acuity. AT Lisa trifocal 839M trifocal could provide better uncorrected near visual acuity than bifocal IOLs. However, more evidence is needed to compare their spectacle independence, higher satisfaction rate, and photic phenomena.

title: Prospective Clinical Comparison of Patient Outcomes Following Implantation of Trifocal or Bifocal Intraocular Lenses.
abstract: To compare the visual results and patient satisfaction after bilateral implantation between a bifocal and a trifocal intraocular lens (IOL).



This study is a prospective, randomized, controlled study involving bilateral implantation of one of two multifocal IOLs. Patients were assessed for uncorrected and distance-corrected near (33 cm), intermediate (66 cm), and distance visual acuity. Distance contrast sensitivity under photopic (85 cd/m2) conditions with and without glare was also measured. Using a subjective questionnaire, patient satisfaction, spectacle independence, and the perception of glare and halo phenomena were evaluated at the final follow-up; a defocus curve analysis was conducted.



Fifteen patients (30 eyes) were implanted with the FineVision IOL (PhysIOL, Liége, Belgium) and 12 patients (24 eyes) received the Tecnis ZMB00 IOL (Abbott Medical Optics, Santa Ana, CA). The average follow-up was 6 months. The mean binocular uncorrected visual acuity was 0.02 ± 0.04 logMAR in the FineVision group and 0.04 ± 0.05 logMAR in the Tecnis group and the mean binocular uncorrected near visual acuity was 0.01 ± 0.00 logMAR in both groups. In the intermediate range of the defocus curve, there was a statistically significant difference between the two IOLs (P < .05). Contrast sensitivity was within normal limits under photopic conditions in both groups.



Both the Tecnis and FineVision IOLs provide a satisfactory range of vision, including a high level of uncorrected distance, intermediate, and near acuity and improved contrast sensitivity under photopic conditions.

title: Visual Outcomes Following Bilateral lmplantation of Two Diffractive Trifocal Intraocular Lenses in 10 084 Eyes.
abstract: To investigate refractive and visual acuity outcomes, patient satisfaction, and spectacle independence at 3 months of 2 diffractive (non-toric) trifocal intraocular lenses (IOLs) in a large series of patients.



Multicenter, retrospective, nonrandomized clinical study.



Patients underwent lens phacoemulsification and were implanted bilaterally with a diffractive trifocal IOL: FineVision Micro F (PhysIOL SA, Liège, Belgium) or AT Lisa tri 839MP (Carl Zeiss AG, Jena, Germany). Surgeries were performed between 2011 and 2015 with at least 3 months of follow-up. Visual and refractive performance, patient satisfaction, and spectacle independence were evaluated.



A total of 10 084 trifocal IOLs were bilaterally implanted (5802 FineVision in 2901 patients and 4282 AT Lisa in 2141 patients). Three-month mean (± standard deviation) acuity: AT Lisa, binocular uncorrected distance visual acuity (UDVA), -0.01 logMAR ± 0.06; monocular distance corrected visual acuity (CDVA), 0.02 logMAR ± 0.06; binocular uncorrected near visual acuity (UNVA) at 40 cm, 0.05 logMAR ± 0.08; binocular uncorrected intermediate visual acuity (UIVA) at 80 cm, -0.05 logMAR ± 0.14; postoperative spherical equivalent, 0.26 D ± 0.47; cylinder -0.34 D ± 0.38; FineVision Micro F, binocular UDVA, 0.01 logMAR ± 0.05; monocular CDVA, 0.03 logMAR ± 0.06; binocular UNVA, 0.05 logMAR ± 0.08; binocular UIVA, -0.05 logMAR ± 0.12; spherical equivalent, 0.34 D ± 0.50; cylinder -0.39 D ± 0.40. The IOLs were equivalent in achieving spectacle independence; 98% were "satisfied" to "very satisfied" with their IOL performance.



In this retrospective study with over 5000 patients, implantation of both trifocal IOL models provided good functional distance, intermediate, and near visual acuity, resulting in high levels of both spectacle independence and patient satisfaction.

title: Clinical outcomes of a new extended range of vision intraocular lens: International Multicenter Concerto Study
abstract: To analyze the clinical outcomes after implantation of an extended range of vision intraocular lens (IOL), the Tecnis Symfony, in a routine clinical setting.  Forty clinical sites in Finland, France, Germany, Norway, Spain, Sweden, and the United Kingdom.   The study comprised 411 patients who had bilateral implantation of the extended range of vision IOL, with intended micro‐monovision in 1 group (monovision group) and intended emmetropia in the other group (non‐monovision group). Visual acuity, spectacle independence, patient and surgeon satisfaction, and photic phenomena were analyzed during the 4‐ to 6‐month follow‐up.  The monovision group comprised 112 patients and the non‐monovision group, 299 patients. The mean decimal uncorrected distance (UDVA), intermediate (UIVA), and near (UNVA) visual acuities were 0.95, 0.81, and 0.69, respectively, 4 to 6 months postoperatively. Significantly better UIVA (P = .003) and UNVA (P = .011) were found in the monovision group than in the non‐monovision group. Spectacle independence was high, with 14.4% of eyes requiring reading spectacles frequently. More than 90% of patients reported no or mild halos, glare, starbursts, or other photic phenomena. Patient satisfaction scores (median) for distance, intermediate, and near vision were 9.0, 10.0, and 8.0, respectively. The satisfaction score for near vision increased to 9.0 in the monovision group. More than 91% of patients said they would recommend the same procedure to their friends and family.  The extended range of vision IOL provided successful visual restoration across all distances after cataract surgery, with a minimal level of disturbing photic phenomena and high levels of patient satisfaction. Financial Disclosure Dr. Cochener is a clinical investigator for Revision Optics, Inc., Horus Vision LLC, Alcon Laboratories, Inc., Abbott Medical Optics, Inc., Théa Pharma GmbH, and Santen, Inc.; she is also a consultant to Alcon Laboratories, Inc., Abbott Medical Optics, Inc., Théa Pharma GmbH, and Santen, Inc.

title: Clinical outcomes with a trifocal intraocular lens: a multicenter study.
abstract: To evaluate the clinical results and safety obtained with a new type of multifocal intraocular lens (IOL) using a trifocal design to achieve pseudoaccommodation.



A pilot observational study of patients with a trifocal IOL (FineVision; PhysIOL, Liege, Belgium) implanted by 1 of 12 surgeons between March and December 2010. Visual outcomes that were assessed postoperatively included uncorrected and corrected distance, intermediate, and near visual acuity.



One hundred ninety-eight eyes of 99 patients were analyzed. Patients were observed for an average of 6.44 ± 4.67 months (range: 0.2 to 17 months). Preoperative corrected distance visual acuity was 0.22 ± 0.26 logMAR. At the final follow-up visit, corrected distance visual acuity was 0.01 ± 0.10 logMAR, uncorrected distance visual acuity was 0.01 ± 0.06 logMAR, uncorrected intermediate visual acuity was 0.08 ± 0.10 logMAR, and mean uncorrected near visual acuity was 0.00 ± 0.04 logMAR. Postoperative binocular uncorrected distance visual acuity was 0.01 ± 0.07 logMAR, uncorrected intermediate visual acuity was 0.06 ± 0.08 logMAR, and uncorrected near visual acuity was -0.03 ± 0.04 logMAR. Postopeative mean residual sphere was 0.21 ± 0.48 diopters (D), with a residual cylinder of -0.24 ± 0.31 D. Postoperative spherical equivalent was 0.11 ± 0.36 D.



The results demonstrated that the trifocal FineVision IOL is able to restore near, intermediate, and distance visual function.

title: Visual acuity comparison of 2 models of bifocal aspheric intraocular lenses
abstract: To compare visual acuity after bilateral implantation of 2 models of multifocal aspheric intraocular lenses (IOLs).  Fernández‐Vega Ophthalmological Institute, Oviedo, and University of Valencia, Valencia, Spain.  Prospective study of patients who had bilateral implantation of an AcrySof ReSTOR SN6AD3 IOL (Group 1) or an Acri.LISA 366D IOL (Group 2). Six months postoperatively, binocular uncorrected and best corrected distance visual acuity, uncorrected‐distance and best distance‐corrected near visual acuity, best corrected intermediate visual acuity, and the defocus curve were measured in both IOL groups.  Group 1 comprised 36 eyes (18 patients) and Group 2, 40 eyes (20 patients). The mean binocular values in Group 1 and Group 2, respectively, were as follows: best corrected distance acuity, −0.05 ± 0.09 logMAR and −0.08 ± 0.08 logMAR (both approximately 20/20); best distance‐corrected near acuity, −0.01 ± 0.16 logMAR and −0.05 ± 0.07 logMAR; best corrected intermediate acuity at 80 cm, 0.20 ± 0.18 logMAR (approximately 20/32) and 0.16 ± 0.13 logMAR (approximately 20/25) and at 60 cm, 0.16 ± 0.16 logMAR (approximately 20/25) and 0.18 ± 0.13 logMAR (approximately 20/25). There were no statistically significant between‐group differences in visual acuity at any distance (P>.3). Defocus curves were similar between groups (2.00 to −5.00 diopters) (P>.26).  The 2 multifocal aspheric IOL models gave similar and good high‐contrast visual acuity at distance and near. Intermediate visual acuity, also comparable between IOL models, was better than published results of a spherical IOL model.

title: Trifocal Intraocular Lens Implantation to Treat Visual Demands in Various Distances Following Lens Removal.
abstract: To evaluate visual and refractive outcomes after implantation of a trifocal intraocular lens (IOL).



Prospective, nonrandomized noncomparative case series.



setting: Department of Ophthalmology, Goethe University, Frankfurt/Germany. patient or study population: Twenty-seven patients (54 eyes) who had bilateral implantation of the AT LISA trifocal IOL (AT LISA tri839MP; Carl Zeiss Meditec, Jena, Germany) pre-enrollment. Exclusion criteria were previous ocular surgeries excluding cataract surgery and refractive lens exchange, irregular corneal astigmatism of >1.5 diopter, and ocular pathologies or corneal abnormalities. Intervention or Observation Procedure(s): Postoperative examination at 1 and 3 months included manifest refraction; monocular and binocular uncorrected (UCVA) and distance-corrected (DCVA) visual acuity in 4 m, 80 cm, and 40 cm; slit-lamp examination; and tomography. At 3 months defocus testing, binocular contrast sensitivity (CS) under photopic and mesopic conditions, and a questionnaire on subjective quality of vision, optical phenomena, and spectacle independence were performed.



Three-months-postoperative monocular and binocular UCVA and DCVA in 4 m, 80 cm, and 40 cm (logMAR); defocus curve; CS; and quality-of-vision questionnaire results.



Mean spherical equivalent was 0.05 ± 0.32 D 3 months postoperatively. Binocular UCVA at distance, intermediate, and near was -0.1 ± 0.1 logMAR, 0.0 ± 0.1 logMAR, and 0.0 ± 0.1 logMAR, respectively. Despite some optical phenomena, 92% of patients would choose the same IOL again.



Evaluation of a trifocal IOL showed good VA (0.1 logMAR or better) at far, intermediate, and near distance; high patient satisfaction despite some optical phenomena; and high spectacle independence 3 months postoperatively.

title: Comparative Analysis of the Clinical Outcomes With a Monofocal and an Extended Range of Vision Intraocular Lens.
abstract: To evaluate and compare the clinical outcomes with an aspheric monofocal intraocular lens (IOL) and an extended range of vision (ERV) IOL based on achromatic diffractive technology.



This was a prospective comparative study including 80 eyes undergoing cataract surgery with implantation of the monofocal Tecnis ZCB00 IOL (Abbott Medical Optics Inc., Santa Ana, CA) (monofocal group: 30 eyes of 15 patients) or the ERV Tecnis Symfony IOL (Abbott Medical Optics, Inc.) (ERV group: 50 eyes of 25 patients). Visual, refractive, contrast sensitivity, defocus curve, ocular optical quality (Optical Quality Analysis System; Visiometrics SL, Terrassa, Spain), and quality of life (National Eye Institute Refractive Error Quality of Life Instrument 42 Questionnaire) outcomes were evaluated during a 3-month follow-up.



Significantly better postoperative uncorrected monocular and binocular distance (UDVA), intermediate (UIVA), and near (UNVA) visual acuities were found in the ERV group (P ≥ .013). Postoperative spherical equivalent was within ±1.00 diopters in 94% and 100% of eyes in the ERV and the monofocal groups, respectively. Binocular UIVA and UNVA of 0.20 or better (Snellen 20/30) were observed in all cases in the ERV group and in 13.3% and 6.7% of eyes of the monofocal group, respectively. No significant differences among groups were observed in contrast sensitivity (P ≥ .156) or ocular optical quality parameters (P ≥ .084). In the monocular defocus curve, all visual acuities were better in the ERV group (P ≤ .002), except for the +0.50-diopter defocus level (P = .367). Significantly better scores were obtained for dependence on correction (P = .003) and suboptimal correction (P = .038) subscales in the ERV group.



The extended range of vision IOL provides better distance, intermediate, and near visual acuity than the aspheric monofocal IOL, while maintaining the same level of visual quality.

title: Evaluation of Different Power of Near Addition in Two Different Multifocal Intraocular Lenses
abstract: To compare near, intermediate, and distance vision and quality of vision, when refractive rotational multifocal intraocular lenses with 3.0 diopters or diffractive multifocal intraocular lenses with 2.5 diopters near addition are implanted.  41 eyes of 41 patients in whom rotational +3.0 diopters near addition IOLs were implanted and 30 eyes of 30 patients in whom diffractive +2.5 diopters near addition IOLs were implanted after cataract surgery were reviewed. Uncorrected and corrected distance visual acuity, intermediate visual acuity, near visual acuity, and patient satisfaction were evaluated 6 months later.  The corrected and uncorrected distance visual acuity were the same between both groups (p = 0.50 and p = 0.509, resp.). The uncorrected intermediate and corrected intermediate and near vision acuities were better in the +2.5 near vision added intraocular lens implanted group (p = 0.049, p = 0.005, and p = 0.001, resp.) and the uncorrected near vision acuity was better in the +3.0 near vision added intraocular lens implanted group (p = 0.001). The patient satisfactions of both groups were similar.  The +2.5 diopters near addition could be a better choice in younger patients with more distance and intermediate visual requirements (driving, outdoor activities), whereas the + 3.0 diopters should be considered for patients with more near vision correction (reading).

title: Visual performance of an apodized diffractive multifocal intraocular lens with +3.00-d addition: 1-year follow-up.
abstract: To determine whether implantation of a multifocal intraocular lens (IOL) with a lower addition (+3.00 diopters [D]) at the lens plane results in better intermediate visual acuity 1 year after surgery compared with a multifocal IOL with higher addition (+4.00 D).



This prospective, randomized, double-masked study included 80 eyes from 40 patients. Twenty patients were implanted bilaterally with the ReSTOR +3.00-D add IOL and 20 patients were implanted bilaterally with the ReSTOR +4.00-D add IOL. Primary outcome measures were distance, intermediate, and near visual acuity. Secondary outcomes were defocus curves, best reading distance, mesopic and photopic contrast sensitivity, quality of life, and spectacle independence. Monocular and binocular visual acuity were measured as uncorrected and corrected distance visual acuity at 4 m, uncorrected near and distance-corrected near visual acuity at 40 cm, and uncorrected intermediate visual acuity and distance-corrected intermediate visual acuity at 50, 60, and 70 cm.



Twelve months postoperatively, no statistically significant difference between groups in distance and near visual acuity was noted. The ReSTOR +3.00-D add group performed better than the ReSTOR +4.00-D add group at all intermediate distances studied. The ReSTOR +4.00-D group chose a reading distance 8 cm closer than the +3.00-D group. Both groups performed similarly with respect to contrast sensitivity, quality of life, and spectacle independence rates.



Patients implanted with a multifocal IOL with lower addition (ReSTOR +3.00 D) had better performance at intermediate distances compared with the ReSTOR +4.00-D add IOL with similar performance for distance and near visual acuity, contrast sensitivity, and quality of life.

title: Comparison of Far and near Contrast Sensitivity in Patients Symmetrically Implanted with Multifocal and Monofocal Iols
abstract: A prospective, randomized, double-masked, clinical trial was designed to evaluate distance and near contrast sensitivity (CS) in patients symmetrically, and randomly, implanted with 4 different multifocal intraocular lens (MIOL) designs (ReSTOR SN6AD1, ReSTOR SN60D3, ReZoom NXG, and Tecnis ZMA00) and a monofocal control group (Tecnis ZA9003), 6 months after cataract intervention.  Photopic, mesopic, and mesopic with glare distance CS, as well as photopic near CS, was evaluated with the CSV-1000 CS test and the Vistech VCTS 6000 system, respectively, in a group of 180 patients attending the ophthalmology department of Sant Pau Hospital, Barcelona, for cataract intervention and lens implantation.  Statistically and clinically significant differences were found between the monofocal and multifocal lens groups at all spatial frequencies and illumination conditions, both during distance and near CS evaluation (all p<0.05), with the monofocal lens offering the best performance in all cases. Contrast sensitivity was similarly compromised in all MIOL models at distance, although MIOLs with diffractive optics and aspheric profiles showed a non–statistically significant trend to perform better in mesopic conditions. Near CS was lower for refractive, distance dominant lens designs, particularly at medium to high spatial frequencies.  The present results, which reflect intraocular lens (IOL) characteristics in optics, profile, and add power, may contribute to help surgeons decide on the type of IOL most suitable for each patient by taking into consideration the individual needs for critical distance and near vision, both in terms of visual acuity and contrast sensitivity.

title: Contrast sensitivity comparison between AcrySof ReSTOR and Acri.LISA aspheric intraocular lenses.
abstract: To evaluate distance contrast sensitivity under photopic, mesopic, and mesopic with glare conditions after implantation of the AcrySof ReSTOR (Alcon Laboratories Inc) and Acri.LISA (Carl Zeiss Meditec) intraocular lenses (IOLs).



Binocular contrast sensitivity function was measured with the Optec 6500 FACT contrast sensitivity chart at distance and at three lighting conditions (85 cd/m2 and 3 cd/m2 with and without glare) in 36 eyes of 18 patients implanted with the AcrySof ReSTOR aspheric SN6AD3 IOL and 40 eyes of 20 patients implanted with the Acri.LISA 366D IOL. Results after implantation were compared between lenses at 1 and 6 months.



Our results revealed that both IOLs provided good best spectacle-corrected visual acuities at distance and near vision (approximately 20/20), and no statistically significant differences were noted between models at different time points after surgery. Both IOLs provided contrast sensitivity within the normal range in photopic conditions. Under low lighting conditions, a reduction in contrast sensitivity for both lenses, particularly at higher spatial frequencies, was noted. No significant differences were observed between both IOLs at any lighting condition.



The AcrySof ReSTOR SN6AD3 and Acri.LISA aspheric IOLs provided contrast sensitivity within normal range under photopic conditions and a reduction in contrast sensitivity under mesopic conditions, with no significant differences between the two brands.

title: Measuring contrast sensitivity in normal subjects with OPTEC® 6500: influence of age and glare
abstract: BackgroundThe purpose of this study was to develop age-related curves for contrast sensitivity (CS) in normal subjects under day and night conditions with and without glare.MethodsSixty-one healthy eyes from 61 subjects were measured with the OPTEC® 6500 P under day and night conditions (luminance levels: 85 cd/m2 and 3.0 cd/m2 with and without glare; spatial frequencies: 1.5, 3, 6, 12 and 18 cycles/degree). A reliability analysis with five repeated measurements of six persons on 4 days was performed to examine the repeatability. The influence of age on contrast sensitivity, forward and backward scatter was examined by means of linear regression.ResultsContrast sensitivity was significantly reduced under night conditions with glare, whereas glare had less influence under daylight illumination. Mean reliability coefficients are 0.87 (day), 0.77 (day with glare), 0.69 (night) and 0.81 (night with glare), which suggests sufficient retest reliability of the device. Regression analyses showed a highly significant influence of age, but the variance of the measurement values is not explained by age alone. The coefficients of determination for the regression of area under the log contrast sensitivity function (AULCSF) on age are 0.33 (photopic), 0.34 (photopic with glare), 0.29 (mesopic) and 0.36 (mesopic with glare, p < 0.0001 in all cases).ConclusionA significant relationship between age, CS and scatter was confirmed in our study. The results provide baseline values for the examination of patients with different diseases in which contrast sensitivity is impaired (such as glaucoma, cataracts and amblyopia) and might be useful in studies of roadworthiness or in investigation of the impact of intraocular lenses.

title: Differences in contrast sensitivity between monofocal, multifocal and accommodating intraocular lenses: long‐term results
abstract: To evaluate long‐term contrast sensitivity (CS) and visual acuity following implantation of monofocal, accommodating, refractive and diffractive multifocal intraocular lenses (IOLs) in patients with unilateral cataract

title: Visual function with bilateral implantation of monofocal and multifocal intraocular lenses: a prospective, randomized, controlled clinical trial.
abstract: To evaluate visual function of three types of multifocal intraocular lenses (IOLs) and one monofocal IOL (as the control group) after cataract surgery.  One hundred fourteen patients participated in a prospective, randomized, controlled clinical study and received monofocal Tecnis Z9000 (AMO) (n = 24, 48 eyes); symmetric diffractive multifocal Tecnis ZM900 (AMO) (n = 26, 52 eyes); zonal refractive multifocal ReZoom (AMO) (n = 32, 64 eyes); and asymmetric diffractive multifocal TwinSet (Acri.Tec) (n = 32, 64 eyes) IOLs.  Mean binocular distance best spectacle-corrected visual acuity (BSCVA) (logMAR) was 0.05 for controls, 0.08 for ZM900, 0.07 for ReZoom, and 0.11 for TwinSet, with mean binocular distance BSCVA at near of 0.49, 0.06, 0.22, and 0.11, respectively. Mean contrast sensitivity was better for the monofocal IOL group than for the multifocal IOLs. Patients assigned to TwinSet had less favorable contrast sensitivity scores. Patients with monofocal IOLs had more frequently recommended near addition (74%) than those with multifocal IOLs. Patients with refractive ReZoom had also recommended near addition more frequently than the two diffractive groups. The percentage of dysphotopsia phenomena was 81% in patients with diffractive multifocal ZM900 compared with 48% in patients with monofocal IOLs, 53% with refractive ReZoom, and 47% with diffractive TwinSet.  The monofocal IOL showed better visual function and lesser photic phenomena than multifocal IOLs but patients were spectacle dependent. ReZoom provided better distance BSCVA than the TwinSet diffractive model. Patients with Tecnis and TwinSet diffractive multifocal IOLs were more spectacle independent than patients with ReZoom. Patients with TwinSet had the worst visual function. Patients implanted with the Tecnis diffractive ZM900 were those reporting more photic phenomena.