Sei sulla pagina 1di 18

Jurnal Reading

PERBANDINGAN LENSA INTRAOKULAR MULTIFOKAL REFRAKTIF BARU


SEGMENTAL INFERIOR DENGAN PENAMBAHAN JARAK DEKAT DAN
LENSA INTRAOKULAR MULTIFOKAL DIFRAKTIF

Yulita Hera (11.2018.058)


Pembimbing:
dr. Santi Anugrah Sari, Sp.M, M.Sc

Kepaniteraan Klinik Ilmu Penyakit Mata


Fakultas Kedokteran Universitas Kristen Krida Wacana
Periode 11 November 2019 – 14 Desember 2019
Rumah Sakit Umum Daerah Koja, Jakarta
Comparison of a New Refractive Multifocal
Intraocular Lens with an Inferior
Segmental Near Add and a Diffractive
Multifocal Intraocular Lens
1,2 1 1,2
Jorge L. Alio, MD, PhD, Ana B. Plaza-Puche, MSc, Jaime Javaloy, MD, PhD,
1 1,2 3
María José Ayala, MD, PhD, Luis J. Moreno, MSc, David P. Piñero, PhD
Purpose: To compare the visual acuity outcomes and ocular optical performance of eyes implanted with a
multifocal refractive intraocular lens (IOL) with an inferior segmental near add or a diffractive multifocal IOL.
Design: Prospective, comparative, nonrandomized, consecutive case series.
Participants: Eighty-three consecutive eyes of 45 patients (age range, 36 – 82 years) with cataract were
divided into 2 groups: group A, 45 eyes implanted with Lentis Mplus LS-312 (Oculentis GmbH, Berlin, Germany);
group B, 38 eyes implanted with diffractive IOL Acri.Lisa 366D (Zeiss, Oberkochen, Germany).
Methods: All patients underwent phacoemulsification followed by IOL implantation in the capsular bag.
Distance corrected, intermediate, and near with the distance correction visual acuity outcomes and contrast
sensitivity, intraocular aberrations, and defocus curve were evaluated postoperatively during a 3-month follow-
up.
Main Outcome Measures: Uncorrected distance visual acuity (UDVA), corrected distance visual acuity
(CDVA), uncorrected near visual acuity (UNVA), corrected distance near and intermediate visual acuity
(CDNVA), contrast sensitivity, intraocular aberrations, and defocus curve.
Results: A significant improvement in UDVA, CDVA, and UNVA was observed in both groups after surgery
(P#0.04). Significantly better values of UNVA (P 0.01) and CDNVA (P 0.04) were found in group B. In the
defocus curve, significantly better visual acuities were present in eyes in group A for intermediate vision levels of
defocus (P#0.04). Significantly higher amounts of postoperative intraocular primary coma and spherical aber-
rations were found in group A (P 0.01). In addition, significantly better values were observed in photopic contrast
sensitivity for high spatial frequencies in group A (P#0.04).
Conclusions: The Lentis Mplus LS-312 and Acri.Lisa 366D IOLs are able to successfully restore visual
function after cataract surgery. The Lentis Mplus LS-312 provided better intermediate vision and contrast
sensitivity outcomes than the Acri.Lisa 366D. However, the Acri.Lisa design provided better distance and near
visual outcomes and intraocular optical performance parameters.
Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed
in this article. Ophthalmology 2016;119:555–563 © 2016 by the American Academy of Ophthalmology.

The visual rehabilitation of patients after cataract surgery de- side effects, a new concept of multifocality nonsymmetric
pends, in part, on the type of intraocular lens (IOL) implanted.
11
rotational inferior segmental near add has been recently
In many cases, this includes spectacle dependence for far and developed and introduced into clinical practice.
near distances. As a result, recent IOL technology has empha- 4,11,17– 24
sized improved refractive outcomes and distance and near Many studies have compared visual outcomes
1–3 between monofocal and multifocal IOLs or between differ-ent
spectacle independence. Multifocal IOLs were developed types of multifocal IOLs with rotational symmetric designs.
to provide complete visual function restoration at near and dis- However, no studies have compared the visual outcomes and
tance vision. Differences in visual performance achieved with the intraocular optical performance among the rotationally
multifocal IOLs depend on the optical principle and IOL symmetric multifocal IOLs and the refrac-tive inferior
designs. At present, several multifocal IOL styles are segmental near add multifocal IOLs. The in-traocular optical
available. Several studies have confirmed the efficacy of performance is the study of the intraocular image quality
4 –11 provided by the intraocular structures of the eye. Contrast
rotationally symmetric multifocal IOLs (diffractive, re-
fractive, or a combination of diffraction and refraction). sensitivity, modulation transfer function (MTF), Strehl ratio,
However, optical side effects, such as contrast sensitivity, and the analysis of the optical aberra-tions are all optical
glare disability, or the presence of halos, have also been reported quality parameters used to study the
10,12–16 25
frequently with these lenses. To reduce such optical performance of any type of lens.

© 2016 by the American Academy of Ophthalmology ISSN 0161-6420/12/$–see front matter 555
Published by Elsevier Inc. doi:10.1016/j.ophtha.2015.08.036
Ophthalmology Volume 119, Number 3, March 2016

The aim of the current study is to compare the visual incision cataract surgery [MICS]) phacoemulsification. Topical
acuity outcomes and the ocular and intraocular optical qual- anesthesia with 2% preservative-free lidocaine (B. Braun, Bar-
ity in eyes with a new generation of refractive inferior celona, Spain) was used in all cases, with mild sedation with
segmental near add multifocal IOL in eyes with a full midazolam (Roche, Madrid, Spain). Adequate dilation was ob-
tained with intracameral mydriasis using 1 ml of a vial con-taining
diffractive symmetric multifocal IOL. The optical perfor- cyclopentolate 1%, phenylephrine 10%, lignocaine 2%, and
mance and visual clinical outcomes were analyzed to ascer- balanced saline solution (10 ml). The incision was placed on the
tain which IOL provided the best level of near and inter- steepest corneal meridian studied by the corneal topog-raphy. The
mediate vision and the best optical quality parameters. Acri.Lisa 366D IOLs were implanted using the MICS Acri.Glide
(Zeiss, Oberkochen, Germany) hydraulic in-jector, whereas the
Lentis Mplus LS-312 IOLs were implanted using a specific
Materials and Methods injector (Viscoject 2.2 Cartridge-Set LP604240M; Oculentis
GmbH). A corneal incision size of 2.6 mm was performed to
Patients implant the Lentis Mplus LS-312.
The Lentis Mplus LS-312 has horizontal markings to align the
This prospective, consecutive, nonrandomized, interventional, lens so that the bifocal segment is placed inferiorly. Preopera-
comparative clinical study included 83 eyes of 45 patients (9 tively, no horizontal axis marking in the sitting position was made
unilateral and 36 bilateral cases) with ages ranging from 36 to 82 to eliminate the effects of cyclotorsion. The IOL horizontal marks
years. All patients underwent bilateral phacoemulsification fol- were placed approximately at the horizontal axis of the eye: The
lowed by IOL implantation in the capsular bag. All patients were current authors have previously reported the surgical details re-
adequately informed and signed a consent form. The study 11,26
lated to the implantation of this particular IOL type. (Alio J,
adhered to the Tenets of the Declaration of Helsinki and was Fimia A, Moreno L, et al. A brand new multifocal IOL
approved by the local ethical committee. The inclusion criteria technology: Benjamin Franklin’s idea from past to present.
used in this study included patients with incipient or moderate [ASCRS 2010 Film Festival Runner-up Instruments &
cataract (Lens Opacity Classification System III; NO1, C1, P1, or Device/IOLs]. Boston 2010. ASCRS/ASOA, April 2010.)
more severity) referring a significant reduction of the visual The study design was decided as consecutive. Once the patients
quality and no other ocular comorbidity that might influence the were selected, according to the inclusion criteria already described,
visual outcome. The exclusion criteria were patients with active eyes were implanted first with the AcriLisa and then with the MPlus
ocular diseases and topographic astigmatisms 3 diopters (D) or IOL. Patients received monocular or binocular implants but always
significant amounts of corneal aberrations observed, using the with the same IOL model. The monocular outcomes were always
Zernike polynomials, from the topography map. All patients were evaluated for the purpose of this investigation. Postopera-tive topical
informed that far vision spectacle independence and astigmatism therapy included a combination of topical antibiotics (ofloxacin 0.3%
correction were not primary goals of this investigation. [Exocin, Allergan, Inc., Irvine, CA]) and a steroid (dexamethasone
0.1% [Maxidex, Alcon, Irvine, CA]).
Intraocular Lenses
11 Preoperative and Postoperative Examinations
The Lentis Mplus LS-312 is an inferior segmental near add
multifocal IOL containing an aspheric distance-vision zone com- All patients had a full ophthalmologic examination preoperatively,
bined with a 3.00 D posterior sector-shaped near-vision zone, including the evaluation of the refractive status, distance and near
allowing seamless transition between the zones. Theoretically, visual acuities, slit-lamp examination, tonometry, and funduscopy.
light hitting the transition area of the embedded sector is reflected The distance visual acuity was measured using Snellen charts, and the
away from the optical axis to prevent superposition of interference near visual acuity was measured with Radner Reading Charts
or diffraction. It has a biconvex design with a 6.0-mm optic size 27
(Spanish validated version). Apart from these clinical tests, other
and an overall length of 12.0 mm. It is made of an acrylic specific examinations were also performed: corneal topography
material, the HydroSmart copolymer (Oculentis GmbH, Berlin, (Costruzione Strumenti Oftalmici, Florence, Italy), ocular aber-
Germany), which consists of acrylates and a hydrophobic surface rometry (COAS, Wavefront Sciences, Inc., Albuquerque, NM),
with ultra-violet-absorbing components. Another important biometry (IOL Master, Zeiss), and contrast sensitivity (CST 1800,
feature of the Lentis Mplus is its 360-degree continuous square Vision Science Research, Walnut Creek, CA) under photopic (85
optic and haptic edge. 2
cd/m ) and low mesopic conditions (3 cd/m ).
2
4
The Acri.Lisa 366D is an aspheric bifocal biconvex Patients were evaluated postoperatively during the follow-up
refractive– diffractive IOL. This lens is a single-piece IOL with an at 1 day, 1 month, and 3 months after surgery. An independent
optic diameter of 6.0 mm and an overall diameter of 11.0 mm. observer (A.B.P-P.) performed all the examinations following the
The surface is divided into main zones and phase zones. The standard operative procedures defined in our institution (Vissum
phase zones assume the function of the steps of diffractive IOLs Corpora-tion) for the purpose of the optometric investigations
and have a mean refractive power corresponding to the zero included in the study. The postoperative examination protocol at 1
diffractive power of the main zones. The IOL power responsible and 3 months was identical to the preoperative protocol, with the
for distance vision is then refractive and diffractive at the same addi-tional measurement of the ocular optical performance with
time. The first diffractive power used for near vision is formed by the Optical Quality Analysis System (OQAS; Visiometrics SL,
an in-phase interference of waves from the main zones. The Ter-rassa, Spain) and the calculation of the intraocular optical
incident light is distributed with 65% for a distance focus and
aberra-tions and Strehl ratio. The OQAS is an instrument based on
4
35% for near focus. The near add at the lens plane is 3.75 D. a double-pass technique developed to perform an objective optical
evaluation of the visual quality. The double-pass technique is
based on recording images of a point source after reflection on the
Surgical Technique retina and a double pass through the ocular media. These data are
All surgeries were performed by 1 of 2 surgeons (J.L.A., J.J.) processed using the device’s software so that the ocular point
using a standard technique of sutureless microincision (micro- spread function (PSF) and the MTF can be obtained. All measure-

556
Alio et al Inferior Segmental Near Add vs Diffractive Multifocal IOLs

ments were taken with a 5-mm pupil using phenylephrine 10% for Statistical Analysis
dilation. The MTF cutoff point was analyzed and recorded. This
cutoff represented the point where the spatial frequency was max- The statistical analysis was performed using only monocular data
imal and had a theoretic relationship with the visual acuity (sup- and the SPSS statistics software package version 15.0 for Win-
posing a good macular and neuroprocessing function). In addition, dows (SPSS Inc., Chicago, IL). The normality of all data samples
the Strehl ratio was also analyzed, which is the ratio of peak focal was evaluated using the Kolmogorov–Smirnov test. When para-
intensities in the aberrated and ideal PSFs. All these metric analysis was possible, the Student t test for paired data was
measurements were performed simulating distance visual performed for all parameter comparisons between preoperative
conditions (distance object). and postoperative examinations. The Student t test for unpaired
The intraocular optical quality was estimated by calculating data was used to compare the groups. When the parametric anal-
the intraocular optical aberrations from the total eye and the ysis was not possible, the Wilcoxon rank-sum test was applied to
anterior corneal aberration. 22 As discussed previously, the assess the significance of differences between preoperative and
Costruzione Strumenti Oftalmici topography system was used to postoperative data, whereas the Mann–Whitney test was used to
evaluate the anterior corneal surface, including wavefront compare the analyzed parameters between groups. For all statisti-
aberrations, and the total ocular aberrations were measured with cal tests, the same level of significance was used (P 0.05).
the COAS system (Wavefront Sciences, Inc.). The calculation of
the intraocular aberrations was obtained using Visual Optics Lab
software version 6.89 (Sarver and Associates, Inc., Celebration, Results
FL) by subtracting corneal aberrations to total ocular aberrations 3
months after surgery. When making the subtraction, both maps
Two groups of eyes were consecutively differentiated according
were referred to the pupil center, and therefore the measurement
to the IOL implanted: Group A included 45 eyes implanted with
axis should be the same because the illumination conditions were
the Lentis Mplus LS-312 (Oculentis GmbH), and group B
the same for the places in which both devices (topographer and
included 38 eyes implanted with the diffractive IOL Acri.Lisa
aberrometer) were located. The software allowed us to introduce
366D (Zeiss). Table 1 summarizes the preoperative conditions of
the off-set between maps in those cases in which pupil diameters
the groups of eyes analyzed in the study. As shown, no
of both measure-ments were different with the aim of introducing statistically significant differences were found between age
a realignment algorithm in the calculations of the difference.
groups (P 0.22) (Table 1). Axial length, IOL power, mean
The aberration coefficients and root mean square (RMS)
keratometry, and manifest cylinder were not significantly different
values were obtained and analyzed for 5-mm pupil diameters in
in these groups (P$0.25). In ad-dition, no significant differences
all cases. The following parameters were analyzed and recorded:
were found preoperatively be-tween groups for uncorrected near
total RMS, higher-order RMS (computed for Zernike terms
visual acuity (UNVA), CNVA, and near addition (P$0.38).
corresponding to third order or higher), low-order RMS
(computed for terms of first and second orders), tilt RMS Differences between groups for un-corrected distance visual
1 acuity (UDVA), corrected distance visual acuity (CVDA), and
(computed for the Zernike terms Z1 ), primary coma RMS sphere were statistically significant (P#0.04) (Table 1).
1
(computed for the Zernike terms Z 3 ), coma-like RMS (computed
for Zernike terms of the third, fifth, and seventh orders), and
spherical-like RMS (computed for Zernike terms of the fourth and Visual and Refractive Outcomes
sixth orders). The corresponding Zernike coefficient for the
0 Tables 2 and 3 summarize the visual and refractive outcomes at 1
primary spherical aberration (Z4 ) was also reported with its sign. and 3 months after surgery, respectively. A significant improve-
In addition, the PSF was obtained from the intraocular aberrations
ment with surgery in UDVA, CDVA, and UNVA was observed in
by Fourier analysis. This parameter was obtained from the PSF by
both groups (Wilcoxon test; P#0.04). No significant changes were
performing the quotient between the maximum intensities of light
energy of retinal image in the ana-lyzed eye and in a diffraction- found postoperatively in the CNVA for both groups (Wilcoxon
limited eye. This parameter should be as close as possible to the test; P$0.27).
value of 1 (perfect optical system) and is related to the ability of At 1 month after surgery, we found statistically significant
the eye to produce a point image on the retina when a point object differences between groups for CDVA (Mann–Whitney test, P
is observed. It should be considered that all these calculations 0.02), with the best visual outcome for patients in group B (Table
were performed considering distance visual conditions. 2).
In addition, the defocus curves were obtained postoperatively to For subjective refraction, no significant changes in manifest
characterize the near visual function. The Radner charts were used for cylinder were found during the whole follow-up in both groups
such purpose at a distance of 40 cm. The defocus curve was obtained (Wilcoxon test; P$0.34). In contrast, a significant reduction in
in monocular vision and with the best near correction of the patients. manifest sphere was found only in group B (Wilcoxon test;
Plus lenses were added in 0.50 D steps, and the visual acuity was P#0.01). No significant differences between groups were found
recorded for each type of blur. Afterward, the same procedure was after surgery in manifest sphere (Mann–Whitney test, P$0.07)
repeated using negative lenses. In the defocus curve, 0 D of defocus (Tables 2 and 3). No statistically significant differences were
corresponds to corrected near visual acuity (CNVA). So, if plus lenses observed in manifest cylinder between groups at 1 month and 3
are added, the test image is further away from the patient. Therefore, months after surgery (Mann–Whitney test, P$0.07). Near addition
the intermediate vision corre-sponds with a 1.5 D and 1 D of defocus. was reduced significantly after surgery in both groups (Wilcoxon
The DCVA corre-sponds with a 2.5 D of defocus. All the recorded test; P#0.01). Statistically significant differences between groups
in the magnitude of this parameter were found at 1 and 3 months
information was then represented in a 2-dimensional graphic display
using Carte-sian coordinates (x-axis, spherical blur; y-axis, near visual after surgery (Mann–Whitney test, P#0.01) (Tables 2 and 3).
acuity).
Binocular data, subjective symptoms, and quality of life eval- Defocus Curve
uations were excluded for the purpose of this report to limit the
analysis only to monocular data independent from the neuroadap- Figure 1 shows the mean defocus curve for the 2 groups of patients
tation process that follows multifocal IOL implantation. analyzed in the current study. The statistical analysis of the results

557
Ophthalmology Volume 119, Number 3, March 2016

Table 1. Preoperative Conditions of the 2 Groups of Eyes

Group A (Lentis Mplus, Oculentis Group B (Acri.Lisa 366, Zeiss,


Mean (SD) Range GmbH, Berlin, Germany) Oberkochen, Germany) P Value (Statistical Test)
Age (yrs) 60.12(12.09) 36 to 82 60.74 (8.29)50 to 78 0.22(Student t)
logMAR UDVA 0.74(0.43) 0.00 to 2.00 0.52 (0.33)0.02 to 1.00 0.04(Mann–Whitney)
Sphere (D) 0.89(2.33) 5.00 to 5.50 1.93 (1.96)5.50 to 4.50 0.03(Mann–Whitney)
Cylinder (D) 0.64(0.66) 3.00 to 0.00 0.57 (0.51)2.00 to 0.00 0.88(Mann–Whitney)
logMAR CDVA 0.14(0.25) 0.00 to 1.30 0.03 (0.07)0.00 to 0.40 0.01(Mann–Whitney)
logMAR UNVA 0.85(0.35) 0.00 to 1.22 0.81 (0.32)0.30 to 1.40 0.39(Mann–Whitney)
logMAR CNVA 0.14(0.16) 0.00 to 0.70 0.17 (0.32)0.10 to 1.30 0.38(Mann–Whitney)
Addition 2.23(0.81) 0.00 to 3.00 2.33 (0.37)1.50 to 2.75 0.57(Mann–Whitney)
Km (D) 43.29(1.52) 39.63 to 45.97 43.00 (0.79)41.08 to 44.39 0.25(Mann–Whitney)
Axial length(mm) 23.24(1.11) 21.59 to 26.94 23.32 (0.90)21.64 to 25.00 0.67(Mann–Whitney)
IOL power (D) 21.38(2.83) 13.50 to 26.50 21.65 (2.90)17.00 to 27.00 0.27(Mann–Whitney)

CDVA corrected distance visual acuity; CNVA corrected near visual acuity; D diopters; Km mean keratometry; IOL intraocular lens; logMAR
logarithm of the minimum angle of resolution; UDVA uncorrected distance visual acuity; UNVA uncorrected near visual acuity. C orresponding P values
for the comparison between groups are shown for each parameter evaluated.

revealed that significantly better visual acuities were present in cally significant differences between groups (Mann–Whitney,
group A for the defocus levels of 1.5, 1.0, 1.5, and 2.0 D (Mann– P#0.01) (Table 3).
Whitney test; P#0.04) (Fig 1). For postoperative intraocular optical quality (Fig 3), statis-
tically significant differences between groups were found in high-
order RMS, primary spherical aberration, primary coma, and
Contrast Sensitivity Outcomes coma-like RMS (Student t and Mann–Whitney, P#0.02); eyes
Postoperatively, the photopic contrast sensitivity was significantly from group A presented significantly higher values of these
better for those eyes implanted in group A for the spatial frequen- parameters.
cies of 12 and 18 cycles/degree (Mann–Whitney; P#0.04) (Fig 2). Figure 4 shows a comparative diagram with the analysis of the
For the rest of the frequencies, a trend to a better postoperative intraocular optical quality for a 5.0-mm pupil of 2 cases implanted
photopic contrast sensitivity values was observed in group A (Fig with 1 of the 2 IOL models analyzed in this study (left, Lentis Mplus
2). In contrast, no statistically significantly differences were de- LS-312; right, Acri.Lisa 366D). These cases are representative of the
tected in low mesopic contrast sensitivity between groups (Mann– general trend observed in the analyzed sample. Both cases presented
Whitney; P$0.54) (Fig 2). similar manifest refractive conditions postoperatively.

Optical Quality Outcomes


Discussion
The mean ocular Strehl ratio estimated with the OQAS was 0.12
(standard deviation [SD] 0.05) in group A and 0.15 (SD 0.04) in Multifocal IOLs were designed to restore the visual
group B. Differences between groups in this parameter were function and to achieve spectacle independence for far and
statistically significant (Mann–Whitney, P 0.03). The mean cutoff near vision after cataract surgery. These IOLs provide some
spatial frequency for the ocular MTF estimated with the OQAS functional near vision increasing the depth of field of the
was 18.31 (SD 9.35) and 24.16 (SD 7.31) in groups A and B, 1
respectively (Student t, P 0.04). eye. At present, there are 2 types of multifocal IOLs in
At 3 months after surgery, significantly higher values of the today’s clinical practice: the rotationally symmetric multi-
total ocular RMS were found in group A (Student t, P 0.01) focal IOL and a new concept of rotational asymmetric
(Table 3). For postoperative higher-order RMS, we found statisti- optics characterized by an inferior segmental near add mul-

Table 2. Postoperative Visual and Refractive Outcomes 1 Month after Cataract Surgery in the 2 Groups of Eyes

Mean (SD) Range Group A (Mplus) Group B (Acri.Lisa 366) P Value (Statistical Test)
logMAR UDVA 0.13 (0.20)0.00 to 1.00 0.08 (0.08)0.00 to 0.34 0.66 (Mann–Whitney)
Sphere (D) 0.01 (0.68)3.00 to 1.25 0.14 (0.45)0.75 to 1.25 0.36 (Mann–Whitney)
Cylinder (D) 0.44 (0.55)2.00 to 0.00 0.56 (0.41)1.50 to 0.00 0.07 (Mann–Whitney)
logMAR CDVA 0.03 (0.07)0.00 to 0.30 0.01 (0.02)0.00 to 0.10 0.02 (Mann–Whitney)
logMAR UNVA 0.21 (0.16)0.00 to 0.52 0.11 (0.08)0.00 to 0.30 0.04 (Mann–Whitney)
logMAR DCNVA 0.23 (0.23)0.00 to 0.70 0.05 (0.07)0.00 to 0.22 0.01 (Mann–Whitney)
logMAR CNVA 0.08 (0.09)0.00 to 0.30 0.05 (0.10)0.00 to 0.22 0.23 (Mann–Whitney)
Addition (D) 0.84 (0.76)0.00 to 2.5 0.16 (0.43)0.00 to 1.50 0.01 (Mann–Whitney)

CDVA corrected distance visual acuity; CNVA corrected near visual acuity; D diopters; DCNVA distance corrected near visual acuity; logMAR logarithm
of the minimum angle of resolution; UDVA uncorrected distance visual acuity; UNVA uncorrected near visual acuity. Corresponding P values for the
comparison between groups are shown for each parameter evaluated.

558
Alio et al Inferior Segmental Near Add vs Diffractive Multifocal IOLs

Table 3. Postoperative Visual and Refractive Outcomes 3 Months after Cataract Surgery in the 2 Groups of Eyes

Mean (SD) Range Group A (Mplus) Group B (Acri.Lisa 366) P Value (Statistical Test)
logMAR UDVA 0.23 (0.47) 0.00 to 2.00 0.06 (0.05)0.00 to 0.15 0.19(Mann–Whitney)
Sphere (D) 0.06 (0.57) 1.00 to 1.25 0.20 (0.44)0.50 to 1.50 0.07(Mann–Whitney)
Cylinder (D) 0.63 (0.61) 2.25 to 0.00 0.49 (0.38)1.25 to 0.00 0.75(Mann–Whitney)
logMAR CDVA 0.08 (0.20) 0.00 to 0.52 0.00 (0.01)0.04 to 0.05 0.01(Mann–Whitney)
logMAR UNVA 0.20 (0.16) 0.00 to 0.62 0.12 (0.11)0.00 to 0.70 0.02(Mann–Whitney)
logMAR DCNVA 0.23 (0.20) 0.00 to 0.80 0.10 (0.12)0.10 to 0.40 0.01(Mann–Whitney)
logMAR CNVA 0.11 (0.12) 0.00 to 0.52 0.07 (0.07)0.00 to 0.22 0.14(Mann–Whitney)
Addition (D) 1.06 (0.79) 0.00 to 2.00 0.39 (0.75)0.00 to 2.75 0.01(Mann–Whitney)
Ocular RMS (mm) 1.82 (0.70) 0.75 to 3.07 1.16 (0.58)0.30 to 2.36 0.04(Student t)
RMS HO (mm) 0.83 (0.43) 0.29 to 2.05 0.48 (0.22)0.14 to 0.94 0.02(Mann–Whitney)

CDVA corrected distance visual acuity; CNVA corrected near visual acuity; D diopters; DCNVA distance corrected near visual acuity; HO high order;
logMAR logarithm of the minimum angle of resolution; RMS root mean square; UDVA uncorrected distance visual acuity; UNVA uncorrected near visual
acuity.
Corresponding P values for the comparison between groups are shown for each parameter evaluated.

11 the highest spectacle freedom. To the best of our knowl-


tifocal IOL. The rotationally symmetric multifocal IOL
includes 3 different technologies: diffractive, refractive, edge, this is the first study that attempts to compare the
and hybrid (combination refractive and diffractive). Several clinical outcomes of this new technology of multifocality
studies have confirmed the efficacy to restore the visual and a diffractive IOL.
4 –10
function with rotationally symmetric multifocal IOLs. In the current study, an improvement in UDVA and CDVA
However, visual quality problems that may limit the poten-tial was found in both groups that confirms the efficacy of the
benefit have been reported with some multifocal IOL IOLs for the correction of the patient aphakia ametro-pia. This
5,14,28 –30
models. Specifically, diffractive IOLs are associ- was consistent with previous reports by other authors using the
14,28 same IOL models (Auffarth GU, Rabsilber TM, Philips R,
ated with photic phenomena such as glare or halos.
Recently, a new concept of multifocal IOL has been intro- Novak J. Oculentis LENTIS Mplus: a new concept of
duced in the clinical practice: the refractive inferior seg- multifocal intraocular lens technology. XXVII Congress of the
mental near add multifocal IOL. The Lentis Mplus LS-312 European Society of Cataract and Refrac-tive Surgeons,
11 4,6,11,28,31,32
MF30 is the first commercially available model of IOL September 2009). No statistically significant
based on this concept. This IOL contains an aspheric differences were found in the UDVA between groups at 1 and
distance-vision zone combined with a 3.00 D posterior 3 months after surgery. However, in clinical terms the UDVA
sector-shaped near-vision zone in the inferior area of the outcomes obtained in eyes implanted with the diffractive
lens, with a seamless transition between the near and multifocal IOL were better than the UDVA outcomes obtained
distance zones. in eyes implanted with the refractive inferior segmental near
The aim of the current study was to compare the near and add multifocal IOL. In contrast, significant differences
intermediate visual acuity outcomes, defocus curve, and between groups were found in CDVA, with significantly lower
intraocular optical quality parameters in patients with Lentis values of CDVA in group A. This fact could be attributed to
Mplus LS-312 MF30 multifocal IOLs and Acri.Lisa 366D the findings in this group
diffractive multifocal IOLs to ascertain which IOL provides

Figure 1. Mean defocus curve in the 2 groups of eyes analyzed: group A,


eyes implanted with the Lentis Mplus LS-312 (red line) (Oculentis GmbH, Figure 2. Mean contrast sensitivity function in the 2 groups of eyes
Berlin, Germany); group B, eyes implanted with the Acri.Lisa 366D IOL analyzed: group A, eyes implanted with the Lentis Mplus LS-312 (red
(green line) (Zeiss, Oberkochen, Germany). D diopters; logMAR lines); group B, eyes implanted with the Acri.Lisa 366D intraocular (green
2
logarithm of the minimal angle of resolution; VA visual acuity. line). A, Under photopic conditions (85 cd/m ). B, Under mesopic low
2
conditions (3 cd/m ).

559
Ophthalmology Volume 119, Number 3, March 2016

LENTIS Mplus: a new concept of multifocal intraocular


lens technology. XXVII Congress of the European Society
of Cataract and Refractive Surgeons, September 2009).
Also, no statistically significant differences were observed
postoperatively in CNVA between groups. In contrast, sta-
tistically significant differences were detected in near addi-
tion power between groups after surgery with low values
for group B. This confirms the efficacy of the diffractive
mul-tifocal IOL for near vision restoration.
The defocus curve is a useful procedure to test the visual
behavior with a specific model of IOL using different levels of
defocus (equivalent to different viewing distances). In the
current study, we found statistically significant differences
between groups in some levels of defocus as 1 and 1.5
Figure 3. Postoperative intraocular aberrations calculated with Visual corresponding to the intermediate vision, with better results for
Optics Lab software version 7.37 (Sarver and Associates, Inc., Celebra- group A. It was demonstrated that the diffractive mul-tifocal
tion, FL) (group A, red bars; group B, green bars): RMS values (microm- IOLs were able to provide 2 peaks of maximum vision, 1 at
eters) and standard deviation of total, higher-order, tilt, spherical-like, and near ( 0 defocus level) and 1 at distance ( 2.5 D defocus level).
coma-like aberrations. In addition, the primary spherical aberration is also In contrast, the inferior segmental near add multifocal IOL
reported with its sign. HO high order; PSA primary spherical aberration; provides only 1 peak of maximum vision ( 0.5 and 3.5 defocus
RMS root mean square. level), which has a wider range of maximum vision, allowing
the patient to have an acceptable intermediate vision.
Therefore, the refractive in-ferior segmental near add
of significantly larger amounts of intraocular higher-order multifocal IOL provided a wide range of functional vision,
aberrations. The CDVA outcomes obtained in eyes im- covering the most common working distances. It should be
planted with the refractive inferior segmental near add mul- considered that this IOL presents an inferior segmental near
tifocal IOL are consistent with a previous report (Auffarth add, and it may be an IOL design limitation when objects are
GU, Rabsilber TM, Philips R, Novak J. Oculentis LENTIS held at the eye level or above, because the near segment may
Mplus: a new concept of multifocal intraocular lens tech- not be available for intermediate and near vision in these
nology. XXVII Congress of the European Society of Cata- positions.
11 In addition to contrast sensitivity outcomes, significantly
ract and Refractive Surgeons, September 2009).
For subjective refraction, no significant reduction in the better results were found for those eyes implanted with the
manifest cylinder was observed after surgery in either refractive inferior segmental near add multifocal IOL in
group. This seems logical because small incisions (MICS) photopic conditions for high spatial frequencies. These out-
were used in all cases, and it has been demonstrated that the 11
comes are consistent with previous studies confirming
use of small corneal incisions in cataract surgery allows the that contrast sensitivity outcomes with the refractive
surgeon to have excellent control of postoperative astigma- inferior segmental near add multifocal IOL are comparable
33,34 to a monofocal lens, although other studies prove that
tism. In addition, no significant differences between
monofo-cal IOLs provided better contrast sensitivity
groups were found in the postoperative manifest sphere and 7,39,40
cylinder at 1 and 3 months after surgery. However, a sta- outcomes than the diffractive multifocal IOLs.
tistically significant difference with the surgery was found The ocular optical quality with each IOL was evaluated
in manifest sphere for only group B. This finding should be by means of the OQAS, which has been proved to be valid
considered with caution because the subjective refraction in 32,41– 43
for such purpose. Mean Strehl ratio and cutoff
cataractous patients is not reliable and difficult to obtain MTF spatial frequencies were significantly better in those
because of the scattering and higher-order aberrations in- eyes implanted with the diffractive multifocal IOL,
duced by the altered crystalline lens, especially in the most confirming a superior optical performance than the inferior
35–38 segmental near add multifocal IOL. This may be in
advanced cases.
The UNVA improved significantly as expected in both concordance with the better near visual outcomes achieved
groups after surgery, and these findings are consistent with with the diffractive multifocal IOL.
4,6,11,28,31,32 For postoperative intraocular optical quality, the intraoc-
previous studies that analyze these IOLs. Also,
ular higher-order aberrations were greater in those eyes
no significant changes were detected in CNVA with surgery in
implanted with the inferior segmental near add multifocal IOL.
both groups. When the near visual outcomes between groups This seems to be in relation with the IOL aspheric design.
were compared, statistically significant differences were found 24
in UNVA and DCNVA after surgery, with better results for Previous studies have demonstrated that the Acri.Lisa366D
group B. These outcomes could be due to the differences of multifocal IOL induces less spherical aber-ration because of
the multifocality IOL design. The UNVA outcomes obtained the aspheric design. Intraocular optical quality outcomes
in eyes implanted with the refractive inferior segmental near should be considered with caution because the accuracy of
add multifocal IOL are slightly poorer than those previously wavefront aberration measurements is lim-ited in some eyes
reported by Auffarth et al (Auffarth GU, Rabsilber TM, 44
implanted with diffractive bifocal and multifocal IOLs.
Philips R, Novak J. Oculentis Indeed, a more significant aberrometric

560
Alio et al Inferior Segmental Near Add vs Diffractive Multifocal IOLs

Figure 4. Comparative diagram showing the analysis of the in vivo intraocular optical quality for a 5.0-mm pupil of 2 cases implanted with one of both
intraocular lens models analyzed in this study (left, Lentis Mplus LS-312; right, Acri.Lisa 366D). Top: Intraocular wavefront higher-order aberrations.
Middle: Three-dimensional point spread function. Bottom: Snellen optotype simulation considering only the effect of higher-order aberrations. Both cases
presented similar manifest refractive conditions postoperatively.

component may be expected with the Acri.Lisa IOL because detect the highest-order aberrations induced by the diffrac-
of its diffractive component. However, the levels of intra- tive components of the IOLs evaluated. In addition, the
ocular primary coma were significantly greater in those eyes aberrometer used did not provide a quantification of the
implanted with the refractive inferior segmental near add forward scattering, which may be more significant with the
multifocal IOL analyzed in our study. It should be consid-ered multifocal IOLs.
that this IOL presents an inferior segmental near add and that
this geometry in an optical element leads to the induction of In conclusion, the Lentis Mplus LS-312 and Acri.Lisa
different levels of primary coma depending on the magnitude 366D IOLs are able to successfully restore visual function
45 after cataract surgery. However, eyes with the Acri.Lisa 366
of this inferior segment. The primary coma, especially large IOL showed significantly better intraocular optical quality
amounts, has been demonstrated to have a negative impact on
46 parameters and better distance and near visual outcomes. The
visual acuity because of the optical blur it induces, which presence of intraocular coma and spherical aberration is a
may have limited the corrected visual acuity (CDVA and limiting factor for the visual outcomes in eyes implanted with
CNVA) in the group of eyes implanted with the inferior the Lentis Mplus LS-312. These findings may be related to the
segmental near add multifocal IOL. These findings are IOL haptic design that might be affected by the capsular bag
11
consistent with a previous study in which the tilt or optical retraction because of its softness. In con-trast, the inferior
decentration of this IOL increases primary coma and coma- segmental near add multifocal IOL tech-nology provided a
47– 49 wide range of focus, especially in the intermediate vision
like aberrations after cataract surgery. It may be
possible that the Hartmann-Shack (AMO Wave-Front Science, conditions with less reduction of con-trast sensitivity
Albuquerque, NM) aberrometer is unable to outcomes. Therefore, the inferior segmental

561
Ophthalmology Volume 119, Number 3, March 2016

near add multifocal IOL seems to be a promising 15. Pieh S, Lackner B, Hanselmayer G, et al. Halo size under
alternative for multifocal IOL implantation because it distance and near conditions in refractive multifocal intraoc-
offers good levels of near and intermediate vision, better ular lenses. Br J Ophthalmol 2001;85:816 –21.
contrast sen-sitivity outcomes, and a more physiologic 16. Steinert RF, Aker BL, Trentacost DJ, et al. A prospective
comparative study of the AMO ARRAY zonal-progressive
defocus curve. Further studies with the new haptic design, multifocal silicone intraocular lens and a monofocal intraoc-
which is more solid and stable than the C-loop Mplus LS- ular lens. Ophthalmology 1999;106:1243–55.
312, should be performed in the future to minimize or 17. Javitt JC, Steinert RF. Cataract extraction with multifocal
eliminate the intra-ocular optical quality problems related intraocular lens implantation: a multinational clinical trial
to the IOL position, thus taking better advantage of the evaluating clinical, functional, and quality-of-life outcomes.
special optical perfor-mance of this IOL. Furthermore, it Ophthalmology 2000;107:2040 – 8.
would be interesting to test the intermediate and near vision 18. Chiam PJ, Chan JH, Haider SI, et al. Functional vision with
when objects are held at the eye level or above in the future bilateral ReZoom and ReSTOR intraocular lenses 6 months
to confirm the effectiveness of IOL design. after cataract surgery. J Cataract Refract Surg 2007;33: 2057–
61.
19. Hütz WW, Eckhardt HB, Röhrig B, Grolmus R. Reading
ability with 3 multifocal intraocular lens models. J Cataract
References Refract Surg 2006;32:2015–21.
20. Harman FE, Maling S, Kampougeris G, et al. Comparing the
1CU accommodative, multifocal, and monofocal intraocular
1. Bellucci R. Multifocal intraocular lenses. Curr Opin Ophthal- lenses: a randomized trial. Ophthalmology 2008;115:993–1001.
mol 2005;16:33–7. 21. Richter-Mueksch S, Weghaupt H, Skorpik C, et al. Reading
2. Keates RH, Pearce JL, Schneider RT. Clinical results of the performance with a refractive multifocal and a diffractive
multifocal lens. J Cataract Refract Surg 1987;13:557– 60. bifocal intraocular lens. J Cataract Refract Surg 2002;28:
3. Duffey RJ, Zabel RW, Lindstrom RL. Multifocal 1957– 63.
intraocular lenses. J Cataract Refract Surg 1990;16:423–9. 22. Ortiz D, Alió JL, Bernabeu G, Pongo V. Optical performance
4. Alió JL, Elkady B, Ortiz D, Bernabeu G. Clinical outcomes of monofocal and multifocal intraocular lenses in the human
and intraocular optical quality of a diffractive multifocal in- eye. J Cataract Refract Surg 2008;34:755– 62.
traocular lens with asymmetrical light distribution. J Cataract 23. Chang DF. Prospective functional and clinical comparison of
Refract Surg 2008;34:942– 8. bilateral ReZoom and ReSTOR intraocular lenses in patients 70
5. Zelichowska B, Rekas M, Stankiewicz A, et al. Apodized years or younger. J Cataract Refract Surg 2008;34:934 – 41.
diffractive versus refractive multifocal intraocular lenses: op- 24. Alió JL, Piñero DP, Plaza-Puche AB, et al. Visual and optical
tical and visual evaluation. J Cataract Refract Surg 2008;34: performance with two different diffractive multifocal intraoc-
2036 – 42. ular lenses compared to a monofocal lens. J Refract Surg
6. Alfonso JF, Fernández-Vega L, Baamonde MB, Montés-Micó 2011;27:570 – 81.
R. Prospective visual evaluation of apodized diffractive intra- 25. Holladay JT, Van Dijk H, Lang A, et al. Optical performance
ocular lenses. J Cataract Refract Surg 2007;33:1235– 43. of multifocal intraocular lenses. J Cataract Refract Surg 1990:
7. Pepose JS, Qazi MA, Davies J, et al. Visual performance of 16:413–22.
patients with bilateral vs combination Crystalens, ReZoom, 26. McAlinden C, Moore JE. Multifocal intraocular lens with a
and ReSTOR intraocular lens implants. Am J Ophthalmol surface-embedded near section: short-term clinical outcomes.
2007;144:347–57. J Cataract Refract Surg 2011;37:441–5.
8. Kohnen T, Allen D, Boureau C, et al. European multicenter 27. Alió JL, Radner W, Plaza-Puche AB, et al. Design of short
study of the AcrySof ReSTOR apodized diffractive Spanish sentences for measuring reading performance: Radner-
intraocular lens. Ophthalmology 2006;113:578 – 84. Vissum test. J Cataract Refract Surg 2008;34:638 – 42.
9. Alió JL, Tavolato M, De la Hoz F, et al. Near vision restora- 28. Alfonso JF, Pucahdes C, Férnandez-Vega L, et al. Visual
tion with refractive lens exchange and pseudoaccommodating acuity comparison of 2 models of bifocal aspheric intraocular
and multifocal refractive and diffractive intraocular lenses: lenses. J Cataract Refract Surg 2009;35:672– 6.
comparative clinical study. J Cataract Refract Surg 2004;30: 29. Walkow L, Klemen UM. Patient satisfaction after implanta-
2494 –503. tion of diffractive designed multifocal intraocular lenses in
10. Leyland M, Zinicola E. Multifocal versus monofocal intraoc- dependence on objective parameters. Graefes Arch Clin Exp
ular lenses in cataract surgery: a systematic review. Ophthal- Ophthalmol 2001;239:683–7.
mology 2003;110:1789 –98. 30. Dick HB, Krummenauer F, Schwenn O, et al. Objective and
11. Alió JL, Piñero DP, Plaza-Puche AB, Chan MJ. Visual out- subjective evaluation of photic phenomena after monofocal
comes and optical performance of a monofocal intraocular and multifocal intraocular lens implantation. Ophthalmology
lens and a new-generation multifocal intraocular lens. J Cat- 1999;106:1878 – 86.
aract Refract Surg 2011;37:241–50. 31. Castillo-Gómez A, Carmona-González D, Martínez-de-la-
12. Woodward MA, Randleman JB, Stulting RD. Dissatisfaction Casa JM, et al. Evaluation of image quality after implantation
after multifocal intraocular lens implantation. J Cataract Re- of 2 diffractive multifocal intraocular lens models. J Cataract
fract Surg 2009;35:992–7. Refract Surg 2009;35:1244 –50.
13. Hofmann T, Zuberbuhler B, Cervino A, et al. Retinal stray- 32. Alió JL, Elkady B, Ortiz D, Bernabeu G. Microincision mul-
light and complaint scores 18 months after implantation of the tifocal intraocular lens with and without a capsular tension
AcrySof monofocal and ReSTOR diffractive intraocular ring: optical quality and clinical outcomes. J Cataract Refract
lenses. J Refract Surg 2009;25:485–92. Surg 2008;34:1468 –75.
14. Montés-Micó R, Alió JL. Distance and near contrast sensitiv- 33. Elkady B, Alió JL, Ortiz D, Montalbán R. Corneal aberrations
ity function after multifocal intraocular lens implantation. J after microincision cataract surgery. J Cataract Refract Surg
Cataract Refract Surg 2003;29:703–11. 2008;34:40 –5.

562
Alio et al Inferior Segmental Near Add vs Diffractive Multifocal IOLs

34. Alió JL, Rodríguez Prats JL, Galal A. MICS (Microincision 42. Vilaseca M, Arjona M, Pujol J, et al. Optical quality of
Cataract Surgery). Highlights of Ophthalmology foldable monofocal intraocular lenses before and after
International, Panamá, 2004. ISBN: 9962-613-30-2. injection: comparative evaluation using a double-pass system.
35. Ortiz D, Alió JL, Ruiz-Colechá J, Oser U. Grading nuclear J Cataract Refract Surg 2009;35:1415–23.
cataract opacity by densitometry and objective optical analy- 43. Alió JL, Schimchak P, Montés-Micó R, Galal A. Retinal
sis. J Cataract Refract Surg 2008;34:1345–52. image quality after microincision intraocular lens implanta-
36. Alió JL, Schimchak P, Negri HP, Montés-Micó R. Crystalline tion. J Cataract Refract Surg 2005;31:1557– 60.
lens optical dysfunction through aging. Ophthalmology 2005; 44. Charman WN, Montés-Micó R, Radhakrishnan H. Problems
112:2022–9. in the measurement of wavefront aberration for eyes im-
37. Kuroda T, Fujikado T, Maeda N, et al. Wavefront analysis in eyes planted with diffractive bifocal and multifocal intraocular
with nuclear or cortical cataract. Am J Ophthalmol 2002;134:1–9. lenses. J Refract Surg 2008;24:280 – 6.
38. Kuroda T, Fujikado T, Maeda N, et al. Wavefront analysis of 45. Charman WN, Atchinson DA. Decentered optical axes and
higher-order aberrations in patients with cataract. J Cataract aberrations along principal visual field meridians. Vision Res
Refract Surg 2002;28:438 – 44. 2009;49:1869 –76.
39. Zeng M, Liu Y, Liu X, et al. Aberration and contrast sensitivity 46. Applegate RA, Sarver EJ, Khemsara V. Are all
comparison of aspherical and monofocal and multifocal intraoc- aberrations equal? J Refract Surg 2002;18:S556 – 62.
ular lens eyes. Clin Experiment Ophthalmol 2007;35:355– 60. 47. Turuwhenua J. A theoretical study of intraocular lens tilt and
40. Rocha KM, Chalita MR, Souza CE, et al. Postoperative wave- decentration on perceptual image quality. Ophthalmic Physiol
front analysis and contrast sensitivity of a multifocal apodized Opt 2005;25:556 – 67.
diffractive IOL (ReSTOR) and three monofocal IOLs. J Re- 48. Oshika T, Kawana K, Hiraoka T, et al. Ocular higher-order
fract Surg 2005;21:S808 –12. wavefront aberration caused by major tilting of intraocular
41. Alió JL, Piñero DP, Ortiz D, Montalbán R. Clinical outcomes lens. Am J Ophthalmol 2005;140:744 – 6.
and postoperative intraocular optical quality with a microin- 49. Altmann GE, Nichamin LD, Lane SS, Pepose JS. Optical
cision aberration-free aspheric intraocular lens. J Cataract performance of 3 intraocular lens designs in the presence of
Refract Surg 2009;35:1548 –54. decentration. J Cataract Refract Surg 2005;31:574 – 85.

Footnotes and Financial Disclosures


Originally received: March 21, 2016. This study has been supported in part by a grant from the Spanish Ministry
Final revision: August 22, 2015. of Health, Instituto Carlos III, Red Temática de Investigación Cooperativa
Accepted: August 22, 2015. en Salud “Patología ocular del envejecimiento, calidad visual y calidad de
Available online: January 3, 2016. Manuscript no. 2011-464. vida,” Subproyecto de Calidad Visual (RD07/0062).
1 Financial Disclosure(s):
Vissum Corporation, Alicante, Spain.
The author(s) have no proprietary or commercial interest in any materials
2 discussed in this article.
Division of Ophthalmology, Universidad Miguel Hernández, Alicante,
Spain.
Correspondence:
3 Jorge L. Alio, MD, PhD, Avda de Denia s/n, Edificio Vissum, 03016
Departamento de Óptica, Farmacología y Anatomía, Universidad de
Alicante, Spain. Alicante, Spain. E-mail: jlalio@vissum.com.
PERBANDINGAN LENSA INTRAOKULAR MULTIFOKAL REFRAKTIF SEGMENTAL
INFERIOR DENGAN PENAMBAHAN JARAK DEKAT DAN LENSA INTRAOKULAR
MULTIFOKAL DIFRAKTIF

Jorge L. Alio, MD, PhD,1,2 Ana B. Plaza-Puche, MSc,1 Jaime Javaloy, MD, PhD,1,2 María José
Ayala, MD, PhD,1 Luis J. Moreno, MSc,1,2 David P. Piñero, PhD3

Ophthalmology Volume 119, Number 3, March 2016

Pendahuluan
IOL multifokal mengembalikan fungsi visual dan dapat melihat tanpa kacamata untuk
penglihatan jarak jauh dan dekat setelah operasi katarak, ada 2 jenis IOL multifokal di praktik
klinis yaitu IOL dengan fokus rotasi multi-simetris dan konsep baru rotasi optik asimetris
ditandai dengan IOL multifokal segmental inferior dengan penambahan jarak dekat yang
disediakan dengan cakupan luas dari berbagai fungsional penglihatan, meliputi yang paling
umum yaitu fungsi jarak jauh. Sedangkan IOL multifokal difraktif untuk pengembalian fungsi
penglihatan jarak dekat.
Hasil sensitivisitas kontras lebih baik ditemukan untuk mata yang diimplantasikan
dengan IOL multifokal dengan penambahan jarak dekat dengan segmen inferior. Kualitas optic
intraocular pasca operasi, penyimpangan intraokuler tingkat tinggi lebih besar pada mata yang
diimplantasi dengan IOL multifocal dengan penambahan jarak dekat segmen inferior
Selama ini tidak ada penelitian yang membandingkan hasil visual dan kinerja optik
intraokular antara IOL multifokal rotasi simetris dan IOL multifokal refraksi segmen inferior
dengan tambahan jarak dekat. Kinerja optik intraokular adalah studi tentang kualitas gambar dari
intraokular yang dihasilkan oleh struktur intraokular mata. Sensitivitas kontras, fungsi transfer
modulasi (MTF), Strehl ratio, dan analisis penyimpangan optik adalah parameter kualitas optik
yang digunakan untuk mempelajari kinerja optik dari semua jenis lensa. Hasil Pengukuran utama
yaitu ketajaman visual jarak tidak di koreksi (UDVA), ketajaman visual jarak yang terkoreksi
(CDVA), ketajaman Visual jarak dekat tidak terkoreksi (UNVA). Jarak dekat terkoreksi dan
ketajaman tidak terkoreksi, jarak deka terkoreksi dan ketajaman visual menengah (CDNVA)
Tujuan dari penelitian ini adalah membandingkan hasil visual dan kinerja optik (IOL)

multifokal refraktif inferior segmental dengan jarak dekat atau IOL multifokal difraktif.

Matrial dan Metode


Jarak dikoreksi, menengah dan dekat dengan koreksi (ketajaman visual dan kontras
sensivitas). Kriteria inklusinya adalah pasien katarak inspient atau medium, sedangkan kriteria
ekslusinya adalah penyakit mata aktif, astigmat tofografi 3 di optri

Lensa intraocular
Lentis Mplus LS_312 adalah IOL multifocal segment inferior dengan tambahan jarak
dekat mengandung zona asferis jarak jauh dikombinasi dengan zona 3.00 D jarak dekat
berbentuk sektor posterior, yang memungkinkan transisi tampa batas antar zona.

Tehnik Bedah
 Microincision
 Anastesi local lidokain 2%
 Midazolam
 Siklopentolat 1%, fenilerin 10%, lignokain 2% dan larutan garam (10ml)
 Sayatan dilakukan pada meridian kornea yang paling curam
 ACRi.Lisa, lentisM+
Pemeriksaaan Pra dan Pasca operasi
 Pemeriksaan opthalmologi.
 Teknik double-pass

Analistik statistic
 Uji Kolmogorov-Smirnov
 Uji t student\
 Mann-Whitney
Hasil
Tabel 1. Kondisi Mata Kedua Kelompok Sebelum Operasi

Pada tabel di atas menunjukan tidak signifikan secara statistik perbedaan ditemukan
antara kelompok umur (P=0,22).

Tabel 2. Hasil Visual dan Refraktif 1 bulan setelah Operasi Katarak pada Kedua Kelompok

Terjadi peningkatan yang signifikan pada operasi di UDVA, CDVA, dan UNVA
diamati di kedua kelompok (uji Wilcoxon; P 0,04
Gambar 1 Kurva Defokus.
Rata-rata kurva defokus dalam 2 kelompok mata yang dianalisis: kelompok A, mata diimplantasi
dengan Lentis Mplus LS-312 (garis merah) (OculentisGmbH, Berlin, Jerman); kelompok B,
mata diimplantasi dengan Acri.Lisa366D IOL (garis hijau) (Zeiss, Oberkochen, Jerman). D
dioptri; logMAR: logaritma sudut resolusi minimal; VA : ketajaman visual.

Gambar 3. Hasil Sensivisitas Kontras.


Penyimpangan intraokular pasca operasi dihitung dengan Visual Optics Lab versi 7.37 (Sarver
and Associates, Inc., Celebration, FL) (kelompok A, baris merah; kelompok B, baris hijau): nilai
RMS (mikrometer) dan standar deviasi dari total, tingkatan tinggi, kemiringan, sferis, dan coma
like aberrations . Selain itu, penyimpangan sferis primer juga dilaporkan dengan tanda yang
sama. HO :high order; PSA: primary spherical aberration; RMS : root mean square.
Gambar 4. Hasil Kualitas Optik.
Diagram komparatif menunjukkan analisis kualitas optik intraokular in vivo pada pupil 5,0-mm
dari 2 kasus yang diimplantasikan dengan salah satu dari kedua model lensa intraokular yang
dianalisis dalam penelitian ini ( kiri , Lentis Mplus LS-312; kanan , Acri.Lisa 366D). Atas:
Penyimpangan tingkat tinggi permukaan gelombang intraokuler. Tengah: Fungsi penyebaran
titik tiga dimensi. Bawah: Simulasi optotipe Snellen hanya mempertimbangkan efek
penyimpangan tingkat tinggi. Kedua kasus mengalami manifes refraktif yang sama pasca
operasi.

Diskusi
 IOL multifokal untuk mengembalikan fungsi visual dan untuk dapat melihat tanpa
kacamata untuk penglihatan jarak jauh dan dekat setelah operasi katarak
 Ada 2 jenis IOL multifokal di praktik klinis:
IOL dengan fokus rotasi multi-simetris dan konsep baru rotasi optik asimetris ditandai
dengan IOL multifokal segmental inferior dengan penambahan jarak dekat.
 Lentis Mplus LS-312 MF30 adalah model IOL pertama yang tersedia
 IOL ini mengandung zona aspheric penglihatan jarak jauh dikombinasikan dengan 3,00 D
zona posterior jarak dekat berbentuk sektor di daerah inferior lensa
 Tidak ada perbedaan signifikan yang ditemukan di Uncorrected distance visual
acuity (UDVA) antar kelompok pada bulan 1 dan 3 setelah operasi.
 UDVA yang diperoleh di mata yang diimplantasi dengan IOL multifokal difraksi lebih
baik daripada UDVA hasil yang diperoleh pada mata yang diimplantasi dengan IOL
multifokal segmental inferior dengan penambahan jarak dekat.
 Sebaliknya, perbedaan signifikan antar kelompok dtemukan di Corrected distance visual
acuity (CDVA), dengan nilai CDVA secara signifikan lebih rendah pada kelompok A.
 Hasil visual jarak dekat antar kelompok dibandingkan, perbedaan yang signifikan
ditemukan di uncorrected near visual acuity (UNVA) dan distance corrected and near
visual acuity (DCNVA) setelah operasi, dengan hasil yang lebih baik terdapat pada
kelompok B.
 IOL multifokal difraktif untuk pengembalian fungsi penglihatan jarak dekat.
 Perbedaan yang signifikan antar grup dalam beberapa level defokus seperti +1 dan +1.5
yang sesuai dengan pandangan jarak menengah, dengan hasil yang lebih baik untuk
kelompok A.
 Oleh karena itu, IOL multifokal dengan penambahan jarak dekat dengan segmen inferior
disediakan dengan cakupan luas dari berbagai fungsional penglihatan, meliputi yang
paling umum yaitu fungsi jarak jauh.
 Hasil sensitivisitas kontras lebih baik ditemukan duntuk mata yang diimplantasikan
dengan IOL multifokal dengan penambahan jarak dekat dengan segmen inferior
 Kualitas optic intraocular pasca operasi, penyimpangan intraokuler tingkat tinggi lebih
besar pada mata yang diimplantasi dengan IOL multifocal dengan penambahan jarak
dekat segmen inferior

Kesimpulan
Lentis Mplus LS-312 dan Acri.Lisa 366D IOL berhasil mengembalikan fungsi visual
setelah operasi katarak. Dengan IOL Acri.Lisa 366 menunjukkan kualitas parameter optik
intraokular yang jauh lebih baik dan jarak yang lebih baik dan hasil visual yang dekat. Coma
intraokular dan aberasi sferis menjadi keterbatasan untuk hasil visual pada mata yang
diimplantasikan dengan Lentis Mplus LS-312. IOL multifokal dengan penambahan jarak dekat
dengan segmen inferior terbaik pada kondisi penglihatan jarak menengah.