Mini-monovision Versus Multifocal Intraocular Lens

Implantation

Journal Reading

PRESENTER : OLLY CONGGA

ADVISOR: Dr. dr. ACHMAD AFIFUDIN, Sp.M(K), M.Kes

Prospective randomized trial

PURPOSE

SETTING

DESIGN

To compare the effect of monovision correction and multifocal intraocular lens (IOL) implantation on patient satisfaction, spectacle dependence, visual acuity, and dysphotopsia incataract patients.

University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandrou-polis, Greece.

Patients with a diagnosis of senile cataract with stage 2 nuclear opalescence were randomly assigned to 2 groups: monovision & multifocal IOL implantation. Uncorrected (UDVA) & corrected (CDVA) distance visual acuity, Visual Function Index-14 (VF-14) scores, & spectacle dependence were assessed prior to surgery & 6 months postoperatively

METHODS

The monovision group comprised 38 patients and the multifocal IOL implantation group, 37 patients. Both techniques provided excellent refractive outcomes in UDVA and VF-14 scores(all P < .01). No significant intergroup differences were detected in VF-14 scores at the final post-operative examination. The monovision group patients presented significantly more spectacle dependence for near vision but less glare.

Monovision and multifocal IOL implantation provided excellent refractive outcomes for distance vision. Multifocal IOL insertion was associated with less dependence on glasses overall but significantly more dysphotopsia

RESULTS

CONCLUSIONS

Journal Theory

1. Correction of postoperative loss of accomodation remains a challenge → various approaches to the correction of induced iatrogenic presbyopia → premium IOLs (accomodating & multifocal) & pseudophakic monovision techniques

2. Multifocal IOLs : refractive, diffractive, or hybrid diffractive–refractive

3. Diffractive multifocal IOLs use light diffraction to produce 2 focal points, one for distance vision and one for near vision.

Refractive multifocal IOLs, refractive power changes from the center to the periphery of the IOL → many focal points.

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4. multifocal IOLs → good results for near and distance vision → spectacle independence → frequently associated a number of visual adverse effects → dysphotopsia, visual disturbances at night, halos, and glare, mainly due to changes in pupil diameter → visual discomfort

5. pseudophakic monovision: 1 eye (dominant) is usually corrected to emmetropia for distance vision and the other (nondominant) is corrected for near vision.

6. Depending on the technique, target refraction of the nondominant eye ranges from 1.00 to 2.50 diopters (D) of myopia

7. Monovision has been widely used in presbyopic refractive surgery candidates, in association with contact lens fitting, providing excellent satisfaction rates

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Introduction

Various approaches of correcting postoperative loss of accomodation:1. Premium intraocular lenses (IOLs) → accomodating & multifocal2. Pseudophakic monovision techniques → monofocal IOL implantation → little evidence of satisfaction outcomes

However, the ultimate target :Spectacle independence for near and distance activities without compromising the patients' visual function and visual performance.

Primary objective of this study: To assess and compare the clinical

outcomes and the satisfaction rates of pseudophakic mini-monovision versus bilateral implantation of refractive multifocal IOLs in a sample of cataract patients.

Introduction

Eligibility criteria: Grade 2 nuclear opalescence according LOCS III, divided into 2 groups monovision & multifocal IOL

Exclusion criteria:1. manifest astigmatism > 1.00 D2. headaches and/or eyestrain with visual activities, 3. positive pathologic ocular cover test (near and distance), and/or the Mallett disparity test (near and distance) and the double Maddox rod test, 4. endothelial cell count less than 1900 cells/mm2 5. glaucoma, 6. intraocular pressure-lowering medications, 7. former incisional surgery, 8. former diagnosis of corneal disease, 9. former diagnosis of fundus disease, 10. diabetes, autoimmune or mental diseases.

Patients & Methods

Data collection:

1. Dysphotopsia → subjective perception of glare & unwanted shadows, spectacle dependence → Two direct 4-scale Likert-type questions → (always, most of the times, sometimes, never)

2. Functional impairment → VF-14 questionnaire → 1 day prior to surgery and 6 months after the second-eye operation

3. binocular UDVA → Greek Version ETDRS

4. binocular UNVA → Titmus stereo acuity at a distance of 40 cm under photopic conditions (85 cd/m2)

5. Contrast sensitivity → Pelli-Robson chart

Patients & Methods

Results

Results

Results

1. Dominant eye (-0.50 D), nondominant eye (-1.25 D) → mini-monovision corrections → slightly better outcomes in terms of spectacle ndependence, 31.4% of the monovision patients → spectacle free for distance and near activities.

2. Bilateral myopic defocus acts beneficially for near visual acuity without affecting distance vision;

The strict inclusion criteria for the monovision group, which excluded any patient with suspicion for heterophoria intolerance;

The actual mini-monovision correction unlikely to interrupt fusion → monovision was well tolerated; stereopsis and contrast sensitivity were not compromised by the myopic defocus

DiscussionMonovision Group

1. Refractive IOL implanted bilaterally -> emmetropia both eyes.

2. In our study, the multifocal IOL provided excellent outcomes in distance and near vision → 65.7% of the patients totally spectacle independent.

3. The lower independence rates -> principal difference between the 2 types of multifocal IOLs (refractive and diffractive) -> refractive IOLs produce multiple focuses and distribute light depending on pupil size to have better intermediate vision (60 to 80cm), diffractive IOLs producing 2 focuses, 1 for distance and 1 for near -> better near vision while being independent of pupil size

4. refractive IOLs -> more visual disturbances than diffractive and monofocal IOLs

5. multifocal arm -> more dysphotopsia phenomena than monofocal arm

DiscussionMultifocal Group

1. both methods have viable approaches for the postoperative loss of accommodation following cataract extraction

2. multifocal arm presented better near vision and significantly higher spectacle independence rates, whereas the monovision arm reported fewer postoperative visual disturbances with acceptable overall spectacle independence

3. modern multifocal IOLs provide the best outcomes with minimal dysphotopic side effects

Conclusions

Thank You