Dr. Goes

"On the condition that patients are properly selected, mixing and matching multifocal IOLs provides excellent outcomes," said Frank J. Goes, MD, during the annual meeting of the American Society of Cataract and Refractive Surgery. "Although halos remain an inherent problem of multifocal IOLs, we found few patients had important complaints, whereas nearly all of our patients were spectacle free and very satisfied.

"These results are consistent with findings from other investigators who have reported high patient satisfaction, strong spectacle independence, and minimal problems with photic phenomena when mixing and matching multifocal IOLs with different optical principles," said Dr. Goes, director and senior eye surgeon, Goes Eye Centre, Antwerp, Belgium. "The collective experience indicates mixing and matching of multifocal IOLs is a valuable option for personalized multifocal vision."

The Tecnis ZM900 multifocal IOL is a silicone IOL with a near add of 4 D that distributes light 50:50 to distance and near. It gives very good, pupil-independent near and distance vision, although it is associated with limited intermediate vision, Dr. Goes said. The Tecnis ZMA00 is based on the same platform but is manufactured from a proven hydrophobic acrylic material that is free of glistening and has low chromatic dispersion, he said.

The refractive IOL also is constructed of a hydrophobic acrylic. It has a near add of +3.5 D. Based on a multizonal refractive principle, it gives very good distance vision and good intermediate vision, although patients may find that they need glasses when reading small print or for prolonged periods, Dr. Goes said.

A total of 213 patients underwent surgery. The protocol recommended implanting the refractive IOL in the distance-dominant eye, and that operation was performed in 94% of patients. The enrolled patients had a median age of 63 years and were a heterogeneous group, including patients undergoing both refractive lens exchange and cataract surgery and who had preoperative monocular distance best-corrected visual acuity (BCVA) ranging from 0.1 to 1.25 (mean, 0.7).

Emmetropia was the refractive target in 97% of patients. Mean incision size was 3 mm; the capsulorhexis had a mean size of 5.3 mm and was circular in 88% of eyes and centered in 98%. IOL positioning was excellent. Only two IOLs were slightly decentered (≤0.25 mm) and showed mild tilt.

Two keys to success

According to Dr. Goes, careful patient selection and thorough biometry are key to successful refractive lens surgery.

"Patients need to have a strong wish for spectacle independence and a clear picture of realistic visual expectations. Surgery needs to be on the highest technical level, including the proper choice of ophthalmic viscosurgical device, phaco technology, and IOL," he said.

Functional results 'excellent'

Uncorrected visual acuity (UCVA) results from the postoperative visits showed that distance and near vision were excellent and improved with time, and intermediate vision was favorable and stable. At the last visit, mean distance, intermediate, and near UCVA were 1.00, 0.60, and 1.00, respectively. Mean distance BCVA had improved to 1.0.

Reading speed and acuity were evaluated in mesopic and photopic conditions. Outcomes from the 6-month visit for a subgroup of 24 patients showed that mean reading acuity was 0.3 logRAD in mesopic conditions and 0.1 logRAD in photopic conditions. Patients read an average of 185 words per minute in mesopic conditions and 198 words per minute in photopic conditions.

"These functional results are excellent," Dr. Goes said. "The reading acuity outcomes are identical to those reported by Huetz et al. in 2006 in a study evaluating reading performance in patients with the Tecnis ZM001 and two other multifocal IOLs implanted, and the reading speeds are even better."

Reflecting the excellent visual acuity outcomes, spectacle independence was achieved in 88.6% of patients. Of the 17 patients who were prescribed glasses, six wore them for distance, seven for near, two had bifocals, and in two patients the type of glasses was not specified.

Forty-five patients reported halos, but only one patient had severe complaints, and in 33 patients, halos were described as mild. Complaints of night glare increased slightly from preoperatively, but overall, only eight patients reported night glare, and it was described as either mild (five patients) or moderate (three).

Results from a satisfaction questionnaire showed that 99% of patients would undergo the same procedure again, and 93% said that they would recommend the surgery to friends.