Dr H.

Razmjoo
Isfahan University of Medical
Sciences
Multifocal
Multifocal
IOLs

IOLs

Presbyopia IOL options

Monovision
Refractive
Diffractive
Accommodative

The Ideal Multifocal IOL

Patient

50s to the mid 60s

Cataract starting to compromise quality of vision
Active lifestyle
Concerned about their appearance & quality of life
Do not want to get old
Spending on lifestyle enhancing procedures
Realistic Expectations
Motivated
Asks lots of questions

Whos A Suitable Candidate?

Wants to be less dependent on glasses
Understands the limitations
Willing to accept several months to
adapt to their new visual system

Whos Not A Suitable

Candidate?
Significant dry eyes
Corneal scarring
Pupil size < 2.5 mm
Monofocal implant in first eye
Uncorrected post-op astigmatism > 0.5 D
Unstable capsular support
Someone who demands perfect vision

ReZoom Multifocal IOL

(AMO)
Refractive lens
Delivers good near, distance and
intermediate vision

Is The ReZoom
Perfect?
The most common concerns
Distance blur
Monocular diplopia
Object glow
Ghosting
Halos at night
These are the biggest post-op

The 3.5 D add

at the IOL
plane provides
for fairly good

Acrysof ReStor IOL

(Alcon)
Diffractive technology
Silicone material
Uses apodization to soften blur
and sharpen vision
Provides excellent VA at near,
distance and intermediate
ranges

Strengths of the AcrySof

ReSTOR IOL
High quality uncorrected near and
distance vision with 20/40 or better
intermediate vision without
movement of the IOL
80% Overall Spectacle Freedom
Nearly 94% of patients would have
the lens again

 The ReSTOR IOL is an IOL that

provides significant magnification.
Many patients spend 10 to 15 years
gradually holding reading materials
farther away. By the time a patient is
55 years old, with 55 to 60 years
being the typical age range for
presbyopic IOL exchange, the patient
is holding reading materials at 14 to
20 inches away from his or her eyes.

 After ReSTOR IOL

implantation set at +0.25
D to +0.5 D, a patient has
near vision of 9 to 10
inches.
However, the ReSTOR IOL
does not provide a
significant increase in

Do We currently have any

aspheric multifocal IOLs?

Tecnis multifocal
(AMO)
Sofport AO (Bausch &
Lomb)

 Haloes and glaare at night are

common- these diminish with time
Longer adaptation period may take
weeks or months for patients to
accept their new visual system
Near vision may be fuzzy to myopes
May need reading specs for
prolonged nearpoint work

 In the United States, a new category

of intraocular lenses was opened
with the approval by the Food and
Drug Administration in 2003 of
multifocal and accommodating
lenses.
The aim of the procedure is to allow
the eye to focus on near as well as
distant objects without regular need
to use glasses. These lenses have
areas of different refractive powers
and allow both near and distant

events
problems with
intermediate vision
reduced contrast
sensitivity
halos
glare
Vaseline vision / waxy
vision

 Clinicians wishing to undertake

implantation of multifocal (nonaccommodative) IOLs during
cataract surgery should ensure
that patients understand the
risks of the procedure, including
the possibilities of halo and
glare, and reduced contrast
sensitivity. Patients should also
be made aware that the lenses
may be difficult to remove or

 To incorporate the strengths

of each type of IOL, some eye
surgeons recommend using a
multifocal IOL in one eye to
emphasize close reading
vision and an accommodating
IOL in the other eye for
further midrange vision. This
is called "mix and match."
Distance vision is not

The TECNIS
Multifocal IOL

Spherical aberration
correction to essentially zero
chromatic aberration
reduction
A pupil-independent, fulldiffractive posterior surface
High-quality vision in all
28

TECNIS Multifocal Acrylic IOL

13.0 mm
overall
diameter

TECNIS
IOL
wavefrontdesigned
aspheric
surface

Frosted,
continuous
360 posterior
square edge
Posterior
diffractive
surface
6.0 mm
optic
diameter

29

Anterior side

Haptics
offset for 3
points of
fixation
Posterior side

TECNIS Multifocal 1-Piece IOL

Specifications
Full diffractive posterior
surface
Pupil-independent
Wavefront-designed aspheric
anterior surface
Light distribution 50/50
Optical power add +4.0 D
To optimize acuity at
preferred
reading distance of 33 cm

30

Important Safety
Information

31

Under low-contrast
conditions, contrast
sensitivity is reduced with
a multifocal lens compared
to a monofocal lens.
Therefore, patients with
multifocal lenses should
exercise caution when
driving at night or in poor

Important Safety
Information

33

Precautions: The central one

millimeter area of the lens creates a
far image focus, therefore patients
with abnormally small pupils (~1 mm)
should achieve, at a minimum, the
prescribed distance vision under
photopic conditions; however, because
this multifocal design has not been
tested in patients with abnormally
small pupils, it is unclear whether such
patients will derive any near vision

Manual Refraction
Autorefractors may not provide optimal
postoperative refraction of multifocal
patients; manual refraction is strongly
recommended.

Emmetropia should be
targeted as this lens is
designed for optimum visual
performance when
emmetropia is achieved. Care
should be taken to achieve
centration.

Spherical Aberration
Correction

Correcting spherical aberration (SA) to zero

results in sharper focus of light and therefore
sharper vision at both near and distance.

TECNIS Multifocal
IOL

36

*In the average cataract patient

ReSTOR +3.0 IOL

37

Spherical Aberration
Correction
There is a measurable
difference
An IOL that fully corrects
spherical aberration can
provide a 13% increase
in contrast over an IOL
that leaves +0.1 residual
spherical aberration

Combining Spherical and

Chromatic Aberration
Correction

38

Several studies have

shown the correction of
chromatic aberration and
spherical aberration
together is more
beneficial than the sum of

Full Diffractive vs. Apodized

Diffractive
Effect in Low Light Conditions
As the pupil widens in mesopic conditions:
TECNIS Multifocal IOL is pupil-independent so light is
still distributed equally to near and distance focal points,
retaining high-quality near vision
The apodized design functions as a monofocal lens on the
outer perimeter, therefore distributing more light to
distance and degrading the quality of near vision

TECNIS Multifocal
IOL
39

ReSTOR +3.0 IOL

Rayner Intraocular
Lenses Ltd

The Rayner M-flex

Multifocal IOL

The Rayner M-flex (630F)

Multifocal IOL

M-flex

M-flex is a multi-zoned,
refractive, aspheric
multifocal intraocular
lens (MIOL) indicated for
those patients requiring a
degree of

M-flex
M-flex is a single-piece,
hydrophilic acrylic
injectable MIOLwhich can
be considered to be the
multifocal analogue of
Superflex, having an

Good Optic
Design
M-flex is based on multi-zoned refractive aspheric
optics with either 4 or 5 refractive zones
(depending on base power), providing an additional
+3.0D of refractive power in the IOL plane, which is
equivalent to +2.25D in the spectacle plane
The refractive zones around the central (1.75mm)
distance zone are
annular and alternate between distance and near
focus
with a 60:40 split (Distance:Near)

AVH Technology
10.5mm

10.0mm

9.5mm

The outer haptics begin to take up the

compression due to capsular contraction

Progressive resistance to the compression

forces is generated as the outer and inner
haptics engage
1) The outer and inner haptics lock together
2) The IOL assumes an oval configuration
3) The haptic dynamics change, increasing
haptic rigidity and providing superior
capsular stability

Note the perfectly

symmetrical haptic
compression

Enhanced Square
Edge

Anteri
or
surfac

Posterior
surface

Power options
M-flex (630F)
Sphere
+ 14.0D to + 25.0D in 1.0D
increments
+ 18.0D to + 24.0D in 0.5D
increments
Power addition
+3.0D

Patient Selection for

Multifocal IOLs:
No contraindications
e.g., recurrent severe
inflammation or uveitis
Bilateral implantation
Postoperative astigmatism <0.75 D
Postoperative emmetropia or max.
<0.75 D hyperopia
Patient motivation (e.g., high
diopter glasses, hyperopia,
spectacle independence)
Visual expectations of the patient
52

Exclusion
Criteria

Macular pathologies, glaucoma with

severe visual
field loss
Monofocal IOL already in one eye
(relative exclusion)
Unrealistic visual expectations
Happy with reading glasses
Surgical complications, such as
capsulorhexis tear, capsular folds,
fixation in sulcus
Patient is at risk for developing PCO
53