Bad Optics Alert: multifocal IOLs

[Dr. Bill Stacy]

In my practice, I strongly recommend against multifocal IOLs for all my cataract patients who are contemplating surgery.

Unlike a spectacle multifocal, where a patient can adjust their head position to select whichever part of the lens they want to use, with multifocal IOLs (intraocular lenses) the patient has no such choice. He/she must always look through all parts of the lens that optically fills his/her pupil, no matter what the head position. The same is pretty much true of soft multifocal contact lenses, but at least those can be removed.

IOLs are a one shot permanent fix, so you don't want something in your eye that cannot be easily removed unless it will give you one optic and one only. And explanting a plastic IOL you don't like is not a cake walk. It's far more difficult and complicated than explanting a human lens.

Worst of all, as an optometrist, none of my skills will help an eye that has been permanently blurred due to at least half of the available light being out of focus at ANY viewing distance.

Don't talk to me about how wonderfully grandma did with her multifocal IOLs. Sure, anything would be better than what she had pre-op. And sure, she doesn't need glasses post-op because they won't help!! The truth is, grandma wouldn't have minded wearing some reading glasses post op if they would just give her a crisp 20/20.

[rbaker]

Are we out fishing for red herrings on a lazy Sunday morning? In as much as there are no Ophthalmologists here on OptiBoard this discussion has no place to go. However, I'll bet that it stirs up a hornets nest.

[Dr. Bill Stacy]

Call it a red herring if you like, but this is a real problem that I see all to often. As to why OMDs don't frequent these haunts, probably because they are not all that comfortable talking optics. Optics are not one of their main points of umm, focus. But maybe this thread will attract some. I would welcome that, for sure.

As to lazy days, none of that for me. I'm off to work. (my new mall location requires SOMEBODY to be there 7 days a week).

[Robert_S]

Call it a red herring if you like, but this is a real problem that I see all to often. As to why OMDs don't frequent these haunts, probably because they are not all that comfortable talking optics. Optics are not one of their main points of umm, focus. But maybe this thread will attract some. I would welcome that, for sure.

As to lazy days, none of that for me. I'm off to work. (my new mall location requires SOMEBODY to be there 7 days a week).

I agree completely with every point.

[Craig]

I always tell clients to ask the MD why they have glasses on? No MD get any elective eye surgery that can be cured with a pair of glasses or contacts.

I always wonder why the Ophthalmologist is the only cash hawking surgeon besides the tucks done by Plastic surgeons. Imagine your ability to earn money is a direct correlation to the amount of procedures you sell folks over 65 years old; welcome to the world of procedures that benefit the one who sells it and will not get it done themselves.

We wear our own glasses yet they do not have the same surgery they sell to the elderly of the US.

[SharonB]

From a dispenser's standpoint....I hated dealing with patients who brought in MD's Rxs for glasses to wear over the multi-focal IOLs - The patients are usually disappointed, no, make that angry - (they pay a lot extra for these, as medicare doesn't cover them completely), and the eyeglass-over-IOL solutions prescribed by the MDs never seemed to work. I had both eyes done almost 2 years ago with DV only IOLs. New Rx O.U. plano add +2.75.

[Chris Ryser]

I had both eyes done almost 2 years ago with DV only IOLs. New Rx O.U. plano add +2.75.

As another one like you, my both eyes done and I can wear again all my old glasses from years ago.

[Happylady]

I have a friend who is 61 and needs cataract surgery and where she is planning on going they do multifocals almost exclusively. She says it's going to be 6K and she doesn't have the money now.

My mom had Restor done back in 2005. Before she was nearsighted and could read without her progressives. Afterwards her distance was good except she had glare in low light but her reading wasn't great. If there was plenty of light(like outside in the daytime) she could read but she finally got new progressives with mostly reading in them.

At 81 it was quite an adjustment going from nearsighted to farsighted.

[Dr. Bill Stacy]

Tell your friend to run, don't walk away from that surgeon. He's doing it for the money, or he's completely hoodwinked by the manufacturers and doesn't understand optics. As for your mom, sorry for her, and one thing I demand from my surgeons, is target a little myopia post op. Why make them unclear at ALL distances without glasses? Dial in a little myopia on the first eye, then shoot for -.25 on the 2nd eye. That's what I got and love to shave in the morning without glasses. If I were an old gal and or for some reason decided to use eye makeup, I'd sure rather be a little nearsighted for putting on the makeup. My wife went all the way from +3 o.u. pre-op to -1 in one eye and -2 in the other, and her makeup always is straight and nice.

The worse thing medicare ever, ever did was allow multifocal and focusing IOL "upgrades" in the IOL market. Sick.

[Tallboy]

As another one like you, my both eyes done and I can wear again all my old glasses from years ago.

Are you quite happy you stayed away from the Multifocal IOLs Chris?

[Robert Martellaro]

"Basically, the trade-off for an increased chance of spectacle-independence is reduced visual quality and a 1 in 20 chance of a further operation with some morbidity attached..."

https://www.medscape.com/viewarticle/812387

http://www.aaojournal.org/article/S0...688-X/abstract

[uncut]

I have a friend who is 61 and needs cataract surgery and where she is planning on going they do multifocals almost exclusively. She says it's going to be 6K and she doesn't have the money now.

My mom had Restor done back in 2005. Before she was nearsighted and could read without her progressives. Afterwards her distance was good except she had glare in low light but her reading wasn't great. If there was plenty of light(like outside in the daytime) she could read but she finally got new progressives with mostly reading in them.

At 81 it was quite an adjustment going from nearsighted to farsighted.

Your last sentence makes me wonder why vision restoration is not the goal?

Plano distance Rxs are not necessarily happiness.

[Dr. Bill Stacy]

I think she meant "hyperopic" not "emmetropic". Surgeons who don't understand ophthalmic optics very well will target plano (emmetropia) at distance, but all the nomograms they use seem to put a hyperopic bias on their results. I consider ANY hyperopia in any meridian in either eye to be a miss, and since there's always some slop in their biometry, my routine recommendation is this:

For the first eye, target a myopia spherical equivalent of -0.75. If they wind up anywhere between Plano and -1.50 I'm happy. Then use what they learned from the first eye to target -.25 for the other eye. And remember, NO MULTIFOCAL IOLS, NO "FOCUSING" IOLS for sure !

If the surgeon fails to do any of my requests, it will be his/her last referral from me. Until they come crawling back with a promise never to do it again. (believe me, it has happened, and the surgeon no longer puts in those lenses; explantation was very nearly beyond his ability, and is not a pretty thing to watch).

To Robert, it's a bad tradeoff. A better one is my "modified monovision" approach that accomplishes the reduced dependency issue for many, with no need for explanting a plastic lens, which is always less than optimal for the patient's eye health. (Much larger incision, chopping up the plastic IOL with scissors, etc.)

You cannot phakoemulsify a plastic or silicone lens, but must use scissors.

[Chris Ryser]

Are you quite happy you stayed away from the Multifocal IOLs Chris?

Tallboy thanks for giving me the kick to tune in again.

When I checked into the hospital I was told that the cost for the implant was $ 200.00 (one eye at a time, spaced 2 month apart)

I went to a doc that was recommended to me for using the latest techniques
and because my name starts with an R, I was the last patient to get under the knive of about 12 others that morning.

I tried to follow all steps that were done without seeing too much and found it interesting.

The result was that an hour after the operation my wife picked me up and we walked to the parked car and tried to lift the bandage and everyhing looked to bright.

After the second eye was done the same way I could only make some visual judgements.

Distance was perfect without any correction, so I used some of my older saved glasses, having a ton of them saved over the years and had no problem whatsoever. The only problem I have encountered is that I wear light sunglasses on a cloudy day and found only a few month ago that I am most comfortable now with my BlueBlockers in bright sun light.

I was never asked what kind of implants I wanted so I had no choice, like you get what we have. Today I am glad it went this way I never even made some new glasses. I have never been a fanatic of progressives, and I have a few pairs. I prefer my ST35 glasses and they are just perfect on the computer.

So my full cost for both eyes was 2x $ 200.00 operation included by Canadian Medicare.

[Robert Martellaro]

To Robert, it's a bad tradeoff. A better one is my "modified monovision" approach that accomplishes the reduced dependency issue for many, with no need for explanting a plastic lens, which is always less than optimal for the patient's eye health. (Much larger incision, chopping up the plastic IOL with scissors, etc.)

You cannot phakoemulsify a plastic or silicone lens, but must use scissors.

Very bad. Hard to sleep at night when roughly 5% of your MIOLs have to be explanted due to poor vision that cannot be addressed with spectacle lenses and dry eye treatment.

I've seen a handful of good multifocal IOL outcomes when there was very strict screening along with high motivation, and a more significant number of positive outcomes for those who chose a mild/modified level of monovision.

But the benchmark for quality of vision and low risk is still monofocal IOLs with spectacle lenses over. If you go into surgery wearing eyeglasses full-time, this should be the default choice, and is the one that I will recommend for my age 89 mother.

[Dr. Bill Stacy]

Distance was perfect without any correction, so I used some of my older saved glasses, having a ton of them saved over the years and had no problem whatsoever. The only problem I have encountered is that I wear light sunglasses on a cloudy day and found only a few month ago that I am most comfortable now with my BlueBlockers in bright sun light.

I was never asked what kind of implants I wanted so I had no choice, like you get what we have. Today I am glad it went this way I never even made some new glasses. I have never been a fanatic of progressives, and I have a few pairs. I prefer my ST35 glasses and they are just perfect on the computer.

So my full cost for both eyes was 2x $ 200.00 operation included by Canadian Medicare.

Glad you had a good result and sounds like they were standard single vision IOLs. Not sure about Canada, but in the US the multifocal "upgrade" costs the patient another thousand bucks or so per eye. My wife got standard IOLs here in the US and with MediCare and our supplement, the total out of cost was $0.00 for both surgeries.

Again, I think that MediCare paying ANYTHING for a multifocal IOL is a travesty. And oh, I'm guessing they will even pay for the subsequent corrective explantation and implanting of a standard IOL so the doc is actually double dipping. That way he gets paid for 4 surgeries instead of 2, plus the 2 Grand ripoff from the patient that won't be refunded. Nice racket.

[Happylady]

Your last sentence makes me wonder why vision restoration is not the goal?

Plano distance Rxs are not necessarily happiness.

I went with my mom when she went to the cataract doctor and asked about leaving her a little nearsighted(in the -2.00 range) and they told me due to her astigmatism it wasn't doable.

[Dr. Bill Stacy]

I've seen a handful of good multifocal IOL outcomes when there was very strict screening along with high motivation, and a more significant number of positive outcomes for those who chose a mild/modified level of monovision.

Only if you define a good outcome as the patient doesn't have to wear glasses which wouldn't work anyway. Never mind these good outcomes were permanently denied the possibility of crisp, clear 20/20 vision under most lighting conditions, and will always have reduced contrast sensitivity. Yep, they are better off than they were before the surgery because they were improved from a very blurry 20/40 to a somewhat blurred 20/25. The "very strict screening" includes being successful in convincing them that eyeglasses are bad and their "high motivation" means "this one can afford a couple of Gs", and we can always explant them which will help keep the surgery center busy...

I've not yet seen a good outcome from multifocal IOLs

[Dr. Bill Stacy]

I went with my mom when she went to the cataract doctor and asked about leaving her a little nearsighted(in the -2.00 range) and they told me due to her astigmatism it wasn't doable.

Depending on how much astigmatism, she could upgrade to a toric single vision IOL and get the -2.00, although that's a bit more than a "little" nearsighted; ok if she plans on not needing glasses for near, but will need them at far for sure. If that cataract doctor can't figure out how much extra plus to put into a toric IOL to get to -1 or -2 residual, he/she hasn't been paying attention. (in all fairness to the OMDs it's not all that simple, as the IOL is suspended in water, so one has to know how much to adjust the powers in air to get the difference in water). It is doable, but the doc MUST pay attention to details. Even if she doesn't want to pay the extra for the toric, she could be left with her cyl in the minus as a residual that of course would be correctable with specs.

Here's some rough estimates

Her present Rx in one eye...... What most OMD's end up with.........................What you want her to end up with
+2.00 -2.00 x 180 ..............+.50 if toric iol; +1.00-2.00x180 if std IOL....... -.75 if toric iol; -.25 -2.00 x 180 if std IOL

[Happylady]

My moms cataract surgery was almost 10 years ago and she's gone now but it's interesting to read your opinions on multifocal implants. Generally the reviews of them on the Internet are good.

[fjpod]

I am anti multifocal iols as well, for all the same reasons Dr. Bill mentions.

Once that mf iol is in there, you can't fix stupid.

[Dr. Bill Stacy]

About the explanting fix, if anyone is unhappy enough, be sure to get it done ASAP, as after about 6 mos, the scar down makes it much harder, much riskier to pull off.

As for those good reports, most come from iol makers and surgeons, naturally. Their "satifaction surveys" always compare pre op vision to post op vision. Not post op vision compared to the best corrected vision they ever had in their life. Barring macular degeneration and other issues that may be present vision could and should be equal to the best corrected vision they ever had. But those numbers would not be so good for the multifocals.

[fjpod]

About the explanting fix, if anyone is unhappy enough, be sure to get it done ASAP, as after about 6 mos, the scar down makes it much harder, much riskier to pull off.

As for those good reports, most come from iol makers and surgeons, naturally. Their "satifaction surveys" always compare pre op vision to post op vision. Not post op vision compared to the best corrected vision they ever had in their life. Barring macular degeneration and other issues that may be present vision could and should be equal to the best corrected vision they ever had. But those numbers would not be so good for the multifocals.

Those surveys are designed such that they skew the questions to only get positive replies.

And doesn't explanting require incision through the sclera requiring stiches and much longer recoveries?

[Dr. Bill Stacy]

Not sure. That's one procedure I've never watched. But whatever the approach it has to be a larger incision through which they can manipulate scissors and pull chunks of plastic through. Has to take a lot more time with the eyeball being opened up considerably longer than the 12 min or so with normal cataract surgery. And yes, pretty sure stitches would be required. All in all pretty much a creep show.

[Robert Martellaro]

Intraocular Lens Exchange post YAG




Restor IOL exchange for monofocal +LRI