When neuroadaptation fails, do not give up multifocality but implant a different lens

Switching from one optic design to another is a successful strategy in most cases.

When neuroadaptation fails, exchanging a multifocal IOL without giving up multifocality is feasible and fulfills patients’ expectations for premium vision, according to a study.

The secret is using a different optic design because “the brain reacts differently to different types of multifocal optics,” Jorge L. Alió, MD, PhD, said in an interview with Ocular Surgery News.

Neuroadaptation failure is one of the main reasons of patient dissatisfaction with multifocal IOLs. The patient reports significant symptoms of poor visual performance, truncated vision and other distortions, dysphotopsia and poor image quality despite good Snellen acuity.

Jorge L. Alió, MD, PhD
Jorge L. Alió

“There is no way of objectively seeing and measuring the problem, and the diagnosis is made on the basis of symptoms that patients report in absence of any organic complication,” Alió said.

The only choice with neuroadaptation failure is to explant the lens. Usually surgeons replace it with a monofocal lens, which causes new problems because the patient paid out of pocket for a premium procedure and expects near and far visual performance. Losing the option of multifocality is a letdown, and patients are understandably dissatisfied and unhappy.

Subjective reactions to different optics

Four years ago, Alió and his group started addressing this issue by exchanging the IOL with a different multifocal optic technology. If a refractive optic was used, they implanted a diffractive lens, and vice versa.

“Lens exchange 1 month or more after the initial surgery is never easy, but as a precaution we always use a capsular tension ring when we do cataract surgery, which allows us to reopen the capsular bag up to 3 years after surgery and to implant the new lens safely and conveniently with adequate surgical experience,” Alió said.

The data of the first 26 eyes of 15 patients were included in a study, now awaiting publication. Following IOL exchange, visual acuity and refraction were measured. Patient satisfaction and quality of vision were assessed through validated questionnaires.

“Visual outcomes were good, and we can document that patients were happy, that the symptoms they previously experienced disappeared with the new lens, and new symptoms, if any, were not clinically significant. Satisfaction improved in over 82% of the cases,” Alió said.

These are important findings because they demonstrate that the brain behaves differently with different types of optical images and that the brain of each patient reacts to specific optic designs in different ways. Refractive lenses such as the Rayner M-flex or the Oculentis Lentis Mplus did not do well in some patients who neuroadapted well when reimplanted with a diffractive IOL such as the Zeiss At Lisa. Other patients had neuroadaptation failure with the diffractive Alcon ReSTOR or the Zeiss At Lisa and were reimplanted successfully with the Oculentis Lentis.

“The EDOF Mini Well (SIFI) did not work well in our hands. We reimplanted those patients with the Lisa, and they were happy. Tolerance is different in an unpredictable way,” Alió said.

Poor adaptation not a personality problem

Neuroadaptation failure is not something that can be foreseen and prevented, and personality-based selection criteria can be misleading, according to Alió.

“Over these years, we have seen patients classified as positive personalities reporting problems with multifocal IOLs while some of those classified as negative personalities were perfectly happy. To be true, we don’t know why. We still have problems with some patients in spite of good selection, in spite of excluding patients with dry eye, with problems that are potentially limiting vision, and in spite of good surgery. It is important to understand that poor adaptation is a neuroprocessing problem, not a personality problem,” Alió said.

Why one IOL is well tolerated by one person and not by another is unclear as much as the mechanisms that govern people’s attraction or the like or dislike of certain perfumes and colors.

“Here we are talking about patients with good vision and nothing withstanding to successful outcomes, and yet the brain cannot accept it and they are not satisfied. The brain tells you what is good for you and what is not, and we are far from understanding the formula that determines the choice and makes it predictable to us,” Alió said. – by Michela Cimberle

Disclosure: Alió reports he is a clinical investigator of Oculentis, medical director of Akkolens project and clinical investigator for Zeiss.

When neuroadaptation fails, exchanging a multifocal IOL without giving up multifocality is feasible and fulfills patients’ expectations for premium vision, according to a study.

The secret is using a different optic design because “the brain reacts differently to different types of multifocal optics,” Jorge L. Alió, MD, PhD, said in an interview with Ocular Surgery News.

Neuroadaptation failure is one of the main reasons of patient dissatisfaction with multifocal IOLs. The patient reports significant symptoms of poor visual performance, truncated vision and other distortions, dysphotopsia and poor image quality despite good Snellen acuity.

Jorge L. Alió, MD, PhD
Jorge L. Alió

“There is no way of objectively seeing and measuring the problem, and the diagnosis is made on the basis of symptoms that patients report in absence of any organic complication,” Alió said.

The only choice with neuroadaptation failure is to explant the lens. Usually surgeons replace it with a monofocal lens, which causes new problems because the patient paid out of pocket for a premium procedure and expects near and far visual performance. Losing the option of multifocality is a letdown, and patients are understandably dissatisfied and unhappy.

Subjective reactions to different optics

Four years ago, Alió and his group started addressing this issue by exchanging the IOL with a different multifocal optic technology. If a refractive optic was used, they implanted a diffractive lens, and vice versa.

“Lens exchange 1 month or more after the initial surgery is never easy, but as a precaution we always use a capsular tension ring when we do cataract surgery, which allows us to reopen the capsular bag up to 3 years after surgery and to implant the new lens safely and conveniently with adequate surgical experience,” Alió said.

The data of the first 26 eyes of 15 patients were included in a study, now awaiting publication. Following IOL exchange, visual acuity and refraction were measured. Patient satisfaction and quality of vision were assessed through validated questionnaires.

“Visual outcomes were good, and we can document that patients were happy, that the symptoms they previously experienced disappeared with the new lens, and new symptoms, if any, were not clinically significant. Satisfaction improved in over 82% of the cases,” Alió said.

These are important findings because they demonstrate that the brain behaves differently with different types of optical images and that the brain of each patient reacts to specific optic designs in different ways. Refractive lenses such as the Rayner M-flex or the Oculentis Lentis Mplus did not do well in some patients who neuroadapted well when reimplanted with a diffractive IOL such as the Zeiss At Lisa. Other patients had neuroadaptation failure with the diffractive Alcon ReSTOR or the Zeiss At Lisa and were reimplanted successfully with the Oculentis Lentis.

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“The EDOF Mini Well (SIFI) did not work well in our hands. We reimplanted those patients with the Lisa, and they were happy. Tolerance is different in an unpredictable way,” Alió said.

Poor adaptation not a personality problem

Neuroadaptation failure is not something that can be foreseen and prevented, and personality-based selection criteria can be misleading, according to Alió.

“Over these years, we have seen patients classified as positive personalities reporting problems with multifocal IOLs while some of those classified as negative personalities were perfectly happy. To be true, we don’t know why. We still have problems with some patients in spite of good selection, in spite of excluding patients with dry eye, with problems that are potentially limiting vision, and in spite of good surgery. It is important to understand that poor adaptation is a neuroprocessing problem, not a personality problem,” Alió said.

Why one IOL is well tolerated by one person and not by another is unclear as much as the mechanisms that govern people’s attraction or the like or dislike of certain perfumes and colors.

“Here we are talking about patients with good vision and nothing withstanding to successful outcomes, and yet the brain cannot accept it and they are not satisfied. The brain tells you what is good for you and what is not, and we are far from understanding the formula that determines the choice and makes it predictable to us,” Alió said. – by Michela Cimberle

Disclosure: Alió reports he is a clinical investigator of Oculentis, medical director of Akkolens project and clinical investigator for Zeiss.