Would you implant a multifocal IOL in a patient with age-related macular degeneration?
Click here to read the Cover Story, "Retinal OCT before cataract surgery increasingly helps guide treatment choices."
Multifocal IOLs a great help
Patients with macular degeneration experience great frustration. They are losing their independence and their ability to read. Often they are no longer able to drive and to engage in activities they loved doing. Several articles have listed depression as something not uncommon among patients with AMD. Therefore, I am a believer that these patients should be helped as much as possible while maintaining realistic expectations so they do not become discouraged even more.
If somebody with AMD has a cataract that requires surgery, I work closely with the retina specialist. We plan the operation together and co-monitor the patient. Establishing a good dialogue between the retina specialist, the cataract surgeon and the patient is essential. Once the retina specialist says the macula is stable, I discuss the option of a multifocal or extended depth of focus lens with the patient. I generally prefer a multifocal to give patients the highest possible magnification so that they are able to read the best they possibly can with their underlying pathology. I tell my patients that they will need bright light for reading, that bright light is their friend and that they can still wear reading glasses on top of the built-in reading glasses they now carry inside their eyes. Often these are patients who do not drive anymore or do limited daytime driving just to the grocery store and back. Therefore, nighttime halos, glare or other light phenomena no longer are an issue.
Considering all these aspects, I do not see a downside of using multifocal IOLs in patients with AMD as long as realistic expectations are set for the patient and his/her family. Many of these eyes are treated with intravitreal injections, and the retina specialists I work with have become acquainted with performing the injection looking through multifocal IOL optics.
Cynthia A. Matossian, MD, FACS, is an OSN Cataract Surgery Board Member. Disclosure: Matossian reports she is a consultant for Johnson & Johnson and Alcon.
Multifocal IOLs exacerbate problems
In general, I would not use multifocal IOLs in patients with AMD. Certainly, there are varying degrees of AMD, ranging from mild pigmentary changes and drusen in the macula to the advanced stages of wet or atrophic AMD. Most people with early AMD are typically asymptomatic and do not even realize they have the disease. However, the concern is that, with aging and deterioration, multifocal lenses might become a further cause of visual problems, psychological distress and degradation of visual quality. The light-splitting multifocal optics, with alternating refractive power for distance and near, can increase the risk for dysphotopsias and reduce optical quality, ultimately compounding the visual deficits caused by the macular pathology. Ideally, we should use multifocal lenses only in healthy eyes with no comorbidities to achieve optimal results and satisfied patients. Extended depth of focus and low-add multifocal lenses could be carefully considered in particular patients with significant counseling and discussion. Given that there is an approximate 1:300 risk for persistent dysphotopsia after multifocal IOL requiring explantation in healthy eyes, patients must understand the risks.
With progression of disease, a decision to exchange the IOL may be necessary. It is typically preferred to perform a lens exchange in the early stages after cataract surgery, typically in the first few months before the capsular bag has fibrosed around the lens. A lens can be removed at a later time, even years after cataract surgery, but the risk for capsular damage, vitreous prolapse and retinal problems can occur. In an eye that has a preexisting macular condition, lens exchange could exacerbate the disease.
There are other alternatives to multifocal IOL that may work well. “Blended vision,” for example, with one eye targeted for distance and the second eye for slightly near vision (approximately –0.75 to –1), can be used successfully in many patients. True monovision (distance dominant eye for distance and nondominant eye for reading –1.75) is also an option for patients, but I would only consider it in patients who are successfully using monovision before cataract surgery in their day-to-day life, typically with contact lenses, as many patients cannot tolerate it. Other types of lenses, such as accommodating lenses, could also be considered. And as previously mentioned, in particular patients with mild or perifoveal disease, with careful consent you could consider a low-add multifocal or EDOF. These IOLs are not an absolute contraindication, but there has to be a lot of counseling, you have to find the right candidates, and they have to be well informed.
Kathryn M. Hatch, MD, is an OSN Technology Board Member. Disclosure: Hatch reports she is a consultant for Johnson & Johnson and Carl Zeiss Meditec.