Unilateral Multifocal Lens Implantation in Patients With A Contralateral Monofocal or Phakic Eye Is A Viable Presbyopic Correction Option

Unilateral multifocal lens implantation
in patients with
a contralateral monofocal or phakic eye
is a viable presbyopic correction option
Robert J. Cionni, MD
Cincinnati Eye Institute, Cincinnati, OH
This study was supported by a research grant from Alcon Laboratories, Inc.
The author is a consultant for Alcon but has no direct financial interest in any product mentioned.
Purpose
To report visual outcome data and patient-reported
measures on 52 patients unilaterally implanted with an
aspheric apodized diffractive lens
Many presbyopic patients require only one lens implantation
for cataract correction1
No documented studies show whether unilateral patients
might avoid some halo or glare experienced by some bilateral patients
will benefit from a ReSTOR multifocal intraocular lens (IOL),
though results from other multifocal IOLs are supportive2-3
1. Williams A, et al. Arch Ophthalmol 2006;124:1308-1314. 2. Shoji N, Shimizu K. J Cataract Refract Surg 2002;28:1012-1017.
3. Haring G, et al. J Cataract Refract Surg 1999;25:1151-1156. 4. Steinert RF, et al. Ophthalmology 1999;106:1243-1255.
Methods:
Patient Enrollment
During a six-month window, enrolled 67 patients under age 71 without
ocular comorbidities and with 1 D astigmatism
any eligible patient with 1
previous ReSTOR IOL
was recruited: yield n = 15
Implant each
1 ReSTOR
bilateral multifocal
group
Monofocal IOLs (any

model) were present in
one eye of 20 patients
Implant each
1 ReSTOR
multifocal/monofocal
group
32 patients had no
previous cataract surgery
and needed an IOL in
only one eye
Implant each
1 ReSTOR
recruited for unilateral

group until each group
reached at least 20
patients
multifocal/phakic
group
multifocal/
mixed
supergroup
Methods:
Surgical Technique
Clear corneal incision (2.8 mm) at a location based on
reducing any preexisting corneal astigmatism
Complete hydrodissection
Circular capsulorhexis (5.5 mm)
Lens removed via bimanual phacoemulsification
Posterior lens capsule polished
SN60D3 ReSTOR IOL (Alcon Laboratories, Inc.)
implanted via Monarch II injector system
No posterior lens capsule breakage or outward vitreous flow
Patients received standard postoperative medications and a
routine 1day postoperative exam
Methods:
Testing and Analysis
All examinations were conducted six months (30 days) postoperatively
Visual acuity
Best corrected and uncorrected visual acuity at 31 cm, 50 cm, and 4 m
assessed using ETDRS charts
Contrast sensitivity tested using a CSV-1000 (VectorVision), under
photopic (81 cd/m2), mesopic (3 cd/m2), and mesopic + glare conditions
Stereopsis assessed with the Titmus Fly stereo ring test
Lifestyle vision
Patients completed a 28-question survey assessing the lifestyle impact of the
apodized diffractive lens, including questions about
visual difficulty of performing everyday tasks, such as reading a newspaper, driving,
playing board games, watching television, playing sports, cooking
visual disturbances (such as halos and glare)
night vision
patient satisfaction
spectacle freedom
ETDRS = Early Treatment of Diabetic Retinopathy Study
Results:
Uncorrected Visual Acuity
No statistical differences between the two unilateral subgroups
Bilateral group significantly better than the unilateral supergroup
at 31 cm
0.2
Multifocal/
Phakic,
n = 32
logMAR acuity
0.15
Multifocal/
Monofocal,
n = 20
0.1
0.05
Multifocal/
Mixed,
n = 52
0
-0.05
Bilateral
Multifocal,
n = 15
31 cm
50 cm
Distance
*P < 0.05
4m
Results:
Contrast Sensitivity & Stereopsis
Few significant differences or trends in contrast sensitivity
Mesopic
**
1.5
Mesopic with glare
log units
log units
log units
Photopic
1.5
1
0.5
1
3
12
Multifocal/Phakic,
n = 32
12
18
cycles per degree
cycles per degree
1.5
1
*
0.5
3
18
Multifocal/Monofocal,
n = 20
Multifocal/Mixed,
n = 52
12
cycles per degree

Bilateral Multifocal,
n = 15
Stereopsis
similar between the two unilateral subgroups
significantly different,
bilateral group (60 30 seconds of arc, test score 7.9 1.6) versus
unilateral supergroup (100 80 seconds of arc, test score 5.9 2.0).
*P < 0.05, multifocal/phakic versus multifocal/monofocal
**P < 0.05, multifocal bilateral versus multifocal/mixed
18
Results:
Patient Survey of Everyday Tasks
Difficulty of far-distance tasks without spectacles:
no significant differences among any groups
Difficulty of intermediate/near tasks without spectacles
Unilateral versus bilateral multifocal
6 tasks similar between groups: reading a book or newspaper, reading
large print, recognizing people, using a computer, cooking, playing board
games or card games
4 tasks significantly different: performing fine handwork, writing checks or
paying bills, reading small print, reading a restaurant menu in dim light
(all easier for the bilateral group than for the unilateral group)
Unilateral multifocal subgroups: phakic versus monofocal
results for 8 questions were similar between groups
two significant differences
favored phakic group for using a computer
favored monofocal group for reading large print
Results:
Visual Disturbances
Halos were reported by a smaller proportion of unilateral patients (57%)
than bilateral patients (77%), but difference was not significant
Problems with glare were reported by a larger percentage of
multifocal/phakic patients than multifocal/monofocal patients, likely
due to early cataractous changes in the phakic group
Report halo
Halo rating
Report glare
Glare rating
Multifocal/
Phakic
(n = 32)
Multifocal/
Monofocal
(n = 20)
Multifocal/
Mixed
(n = 52)
Bilateral
Multifocal
(n = 15)
58%
55%
0.83
57%
77%
0.19
1.3
1.3
0.73
1.3
1.4
0.20
69%
30%
0.006*
54%
39%
0.32
2.1
2.0
0.33
2.1
2.4
0.46
*Significant at P < 0.05
Halo/glare scale: 1 (not bothersome), 2 (mildly bothersome), 3 (moderately bothersome), 4 (severely bothersome)
Results:
Patient Satisfaction
A majority of all patients achieved spectacle independence
(60% unilateral, 77% bilateral, no statistical difference)
Almost all patients (>91% in any group) would choose
to have the procedure again
Average rating of satisfaction with vision was higher
in the bilateral group than in the unilateral group
Multifocal/
Phakic
(n = 32)
Multifocal/
Monofocal
(n = 20)
Multifocal/
Mixed
(n = 52)
Bilateral
Multifocal
(n = 15)
Spectacle
freedom
56%
65%
0.53
60%
77%
0.25
Would have
procedure again
91%
95%
0.56
92%
92%
1.00
Satisfaction
with vision
7.6
6.9
0.24
7.3
8.9
0.001*
*Significant at P < 0.05
Satisfaction scale: 1 (completely unsatisfied) to 10 (completely satisfied)
Results:
Distribution of Satisfaction Scores
A majority of patients in all groups (75% to 92%)
were satisfied with their vision (score 7 out of 10)
Percent of patients
More bilateral than unilateral patients

rated their vision 8 or 9
100%
NS
80%
Multifocal/
Phakic, n = 32
60%
Multifocal/
Monofocal, n = 20
40%
Multifocal/
Mixed, n = 52
20%
Bilateral
Multifocal, n = 13
0%
9 or 10
8
Satisfaction rating
Statistically similar proportions of unilateral and bilateral patients

(P = 0.27) rated satisfaction 7 or higher
*P < 0.05, unilateral vs bilateral
NS = not statistically different, unilateral vs bilateral
Conclusions
The unilateral implantation of an aspheric apodized diffractive
multifocal IOL provided patients in this population with
functional near, intermediate, and distance vision

contrast sensitivity that was similar to bilateral ReSTOR patients
spectacle freedom in 60% of cases
vision that 75% of patients rated at satisfaction of 7 or higher (out of 10)
Unilateral multifocal lens implantation

in patients with
a contralateral monofocal or phakic eye
is a viable presbyopia correction option

Unilateral Multifocal Lens Implantation in Patients With A Contralateral Monofocal or Phakic Eye Is A Viable Presbyopic Correction Option

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Unilateral Multifocal Lens Implantation in Patients With A Contralateral Monofocal or Phakic Eye Is A Viable Presbyopic Correction Option

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Unilateral multifocal lens implantation

Monofocal IOLs (any

recruited for unilateral

Mesopic with glare

cycles per degree

cycles per degree

cycles per degree

*Significant at P < 0.05

*Significant at P < 0.05

Satisfaction scale: 1 (completely unsatisfied) to 10 (completely satisfied)

More bilateral than unilateral patients

Statistically similar proportions of unilateral and bilateral patients

functional near, intermediate, and distance vision

Unilateral multifocal lens implantation

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