found limited IOL movement and limited improvement in near acuity for most patients targeted for best distance acuity. Thus, many surgeons are utilizing a “mini-monovision” strategy when implanting the accommodating IOL, leaving the nondominant eye targeted for slight myopia (–0.50 to –0.75 D).
Hoffman RS, Fine IH, Packer M. Accommodating IOLs: current technology, limitations, and future designs. Current Insight. San Francisco: American Academy of Ophthalmology. Available at http://aao.org/current-insight/accommodating-iols-current-technology-limitations-.
Wallace BR III. Multifocal and accommodating lens implantation. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 2004, module 11.
Multifocal Intraocular Lenses
Multifocal IOLs have the ability to provide appropriate patients with functional vision at near, intermediate, and far distances in each eye. This ability is due to lens multifocality that causes light rays to be split such that different focal points are created where objects will be clearest. However, all multifocal IOLs have potential trade-offs in vision quality and adverse effects, especially at night, and careful patient selection and counseling are necessary to achieve optimal outcomes. These types of lenses and their outcomes are discussed further in Chapter 9.
Patient Selection
Patients likely to be successful with a multifocal IOL implant after lens surgery are adaptable, less visually demanding individuals who place a high value on reduced spectacle dependence at all distances postoperatively. They should have good potential vision without significant pathology at any other location along the visual axis. Specific preoperative evaluation of macular function and anatomy may be warranted to exclude patients with epiretinal membrane or other conditions leading to suboptimal retinal function. Careful attention should be paid to evaluation of the corneal endothelium, as patients with any sign of Fuchs dystrophy are not ideal candidates for multifocal IOLs. Patients with more than 0.75 D residual astigmatism after multifocal IOL implantation frequently have suboptimal vision quality, and if this result is expected, strategies to reduce postoperative astigmatism should be evaluated and discussed before IOL implantation. Evidence has shown that patients generally have better visual outcomes if multifocal IOLs are implanted bilaterally.
Surgical Technique
The surgical technique for multifocal IOL insertion is the same as that used in standard small-incision cataract surgery with a foldable acrylic IOL. Multifocal IOLs are much more sensitive than are monofocal IOLs to minor optic decentration. If the posterior capsule is not intact, IOL decentration is more likely to occur, and adequate fixation for a multifocal IOL should be determined before implantation.
Outcomes
Patients are most likely to achieve independence from glasses after bilateral implantation of multifocal IOLs. Recent meta-analyses found bilateral multifocal IOL implantation associated with significant improvement in both distance and near visual acuity with each type of implant studied.
As patients age, the pupillary diameter may decrease. If the pupillary diameter decreases to less than 2.0 mm, unaided reading ability may diminish. Gentle dilation with topical mydriatic drugs or laser photomydriasis may restore near acuity. Photomydriasis may be performed with an argon or