Ординатура / Офтальмология / Английские материалы / Modern Cataract Surgery_Kohnen_2002

far vision, distorted far vision, depth perception, double vision (one eye), double vision (both eyes), or color distortion. There were no significant between-group differences for 8 of the visual symptoms. Subjects with the multifocal implant reported significantly more difficulty with haloes, glare/flare, and blurred far vision (p 0.014). The percentages of multifocal vs. monofocal subjects who reported ‘severe difficulty’ with these phenomena were low: 15 vs. 6% for haloes, 11 vs. 1% for glare/flare, and 4 vs. 1% for blurred far vision. These generally low values combined with high subject satisfaction scores suggest that their occasional experience of these phenomena was an acceptable tradeoff for the benefits of multifocal vision.

Javitt and Steinert [12] asked subjects in both IOL groups to rate glare disability (limitation in activities of daily living), degree of bother due to double or distorted vision, and degree of bother due to glare, haloes, or rings around lights. The rating scale was 0 (no limitation or bother) to 4 (extreme limitation or bother). No significant between-group differences were seen in glare disability or double or distorted vision. Subjects implanted with multifocal IOLs had significantly more bother with glare, haloes, or rings around lights than those implanted with monofocal IOLs (p 0.0001). In a separate study, Javitt et al. [11] found that subjects implanted with the multifocal IOL experienced more nightflare and haloes than those with the monofocal IOL. However, Lesueur et al. [18] reported similar rates of haloes and glare in the two groups: 8% with the P359 lens and 9% with the Array.

Dick et al. [8] compared multifocal and monofocal IOLs with respect to occurrence of photic phenomena (halo, flicker or forward-scattered light, glare). No differences were found between multifocal and monofocal IOLs for objective measures of these phenomena. Subjects also subjectively evaluated these symptoms by filling out a questionnaire. Nine of 28 multifocal and 3 of 27 monofocal subjects noticed light sensations (mainly haloes) that had not been present before surgery. However, the majority of subjects were not bothered by these sensations.

Stereoacuity and aniseikonia following unilateral or bilateral implantation of the Array lens was evaluated by Häring et al. [26]. The unilateral and bilateral groups had similar stereoacuity, but distance and near aniseikonia were significantly less in the bilateral than the unilateral group. However, the authors concluded that the Array multifocal IOL allowed good binocular vision despite the simultaneous formation of multiple retinal images. Arens et al. [6] tested best visual acuity in three bright light conditions (comparable to: bright overhead commercial lighting, partly cloudy day, direct overhead sunlight) in 21 patients with bilateral Array multifocal IOLs and 15 patients with bilateral monofocal IOLs. For binocular vision, multifocal subjects had slightly better visual acuity in all three light conditions than the monofocal patients, but the differences were

not statistically significant. For monocular vision, there were almost no differences between the multifocal and monofocal eyes. Therefore, no disadvantages were found for multifocal IOLs at any glare level tested with this method.

Vaquero-Ruano et al. [7] found that the occurrence of ghost images and glare was similar in the Array multifocal (n 50) and monofocal IOL subjects (n 50). At 18 months after surgery, ghost images were reported by 6% of multifocal and by 2% of monofocal subjects; glare reported by 4 and 2%, respectively. However, all subjects found these visual symptoms were tolerable and none wished to have the IOL removed.

In summary, certain visual symptoms such as glare, haloes, blurred vision, or ghosting may occur occasionally in subjects implanted with multifocal IOLs. These symptoms, however, appear to mild enough so as not to detract from overall subject satisfaction. Many subjects with monofocal IOLs implanted also note haloes and glare. Much of the skill in using multifocal IOLs is ensuring that subjects are reassured that ‘haloes’ are a ‘symptom’ that the IOL is ‘working properly’! If presented to the subject in this fashion, there is usually an immediate reduction of subject anxiety and a rapid adaptation to pseudo-accommodation.

Driving Ability

The effect of multifocal IOLs on driving ability at night and in other low contrast situations has been studied because of concern over the reduced visual acuity at low contrast levels and occurrence of glare symptoms reported in multifocal subjects.

Featherstone et al. [9] conducted a novel driving study using the Iowa Driving Simulator in subjects with bilateral Array multifocal IOLs (n 33) or bilateral monofocal IOLs (n 33). Under three poor visibility conditions (clear weather at night with or without a glare source, fog), 30 different measures of driving performance were made. In 26 of the 30 (87%) comparisons, the Array multifocal and monofocal subjects had similar performances. In the 4 comparisons in which the Array multifocal group was lower than the monofocal group, the subjects with multifocal IOLs still performed, on average, within safety guidelines. The authors concluded that there were no consistent differences in driving performance and safety, but that multifocal subjects may have more difficulty in recognizing certain traffic signs while driving during the night or poor visibility conditions.

Grosskopf et al. [10] prospectively assessed visual acuity under various contrast and glare levels in order to determine nighttime driving ability in subjects with beginning cataracts (n 41), Array multifocal IOLs (n 50), and monofocal IOLs (n 85). According to the criteria of the German Ophthalmological Society, which are generally considered to be rather strict, only 38% of the multifocal subjects and 41% of the monofocal subjects met the standards

Fig. 4. Subjects able to function without spectacles (from Steinert et al. [3]).

for nighttime driving ability. The authors concluded that elderly pseudophakic subjects and those with beginning cataracts should be informed that their nighttime driving ability may be impaired, even if their visual acuity is sufficient.

Independence from Spectacles

In the Array safety and efficacy study by Steinert et al. [3] the percent of subjects with bilateral multifocal IOLs who could function comfortably without spectacles were 93% for distance, 93% for intermediate, and 81% for near vision (fig. 4). These percentages were generally greater for subjects who had received bilateral Arrays. For near vision, a significantly higher percentage of subjects with bilateral multifocal IOLs could function comfortably without eyeglasses (81% (96 of 118)), compared to 56% (93 of 165; p 0.001) of multifocal/monofocal subjects, or to 58% (56 of 97; p 0.001) with unilateral monofocals. Thus, the full advantages of multifocality are more likely gained with bilateral implantation. If a subject requires cataract surgery and aspires to be spectacle-independent, then only implantation of multifocal IOLs can achieve this with preservation of stereopsis.

Patient Satisfaction and Quality of Life

Patient satisfaction at 1 year postsurgery in the study by Steinert et al. [3] was very high. More than 90% of subjects were moderately or very satisfied, and more than 90% of them would choose the same IOL again.

Subjects in the multifocal IOL groups in the studies by Javitt and Steinert [12] and Javitt et al. [11] rated their vision without glasses better overall, at near, and at intermediate distances than subjects in the monofocal IOL groups (p 0.05). Subjects with the Array demonstrated better visual function for near tasks and social activities and less spectacle dependency that subjects implanted with traditional monofocal IOLs.

All 50 subjects with implanted Array IOLs in the study by Vaquero-Ruano et al. [7] were satisfied with the lens and their increased range of functional vision, even if they were not fully independent of spectacles. Brydon et al. [27] also found that subjects with bilateral Array IOLs were significantly more pleased with their improved vision than subjects with bilateral monofocals, based upon mean scores on the VF-14 index of visual function (p 0.003).

In subjects with unilateral implantation of the CeeOn 811E diffractive bifocal [19], 31% (11 of 35) were dissatisfied with their uncorrected distance and near vision; the authors suggest that this high dissatisfaction rate is related to the unilateral implantation. Of the other subjects, 43% (15 of 35) were satisfied and 26% (9 of 35) were highly satisfied. After best distance correction, 57% (20 of 35) were satisfied, 37% (13 of 35) were highly satisfied, and only 6% (2 of 35) were dissatisfied. Eighty-nine percent (31/35) of subjects said they would choose the same IOL for their fellow eye.

Conclusion

Multifocal IOLs more closely replicate the near to far vision of the prepresbyopic crystalline lens than monofocal IOLs and may well offer definite advantages over monofocal IOLs. Refractive multifocal IOLs, refractive bifocal IOLs and diffractive bifocal IOLs all showed distance vision comparable to monofocal IOLs. The Array refractive multifocal IOL provided significantly better near visual acuity and significantly greater depth of focus than monofocal IOLs. The Domilens Progress 1 refractive multifocal IOL provided intermediate and near visual acuity comparable to monofocal IOLs. The True Vista refractive bifocal IOL provided better uncorrected near vision and distance-corrected near vision than monofocal IOLs. The diffractive bifocal IOLs – CeeOn 811E, Pharmacia 808X, 3M 825X and 3M 815LE – provided good distance and near visual acuities. The diffractive optics, however, do not use all available light and this appears to have a negative impact on low contrast sensitivity.

As for the future, we would hope for an injectable accommodative implant which would virtually mimic the physiological behavior of the lens – although this is clearly a distant wish at present.

References

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Charles Claoué, MD, DBCG, PO Box 12650, London SE3 9ZZ (UK)

Tel. 44 020 8852 8522, Fax 44 020 8852 8522, E-Mail eyes@dbcg.co.uk

Author Index

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Subject Index

239