**3. A case of trifocal intraocular lens implantation for high myopia complicated with cataract after LASIK operation**

A 51-year-old male patient underwent LASIK surgery 23 years ago due to high myopia in both eyes. According to the patient's recollection, the best postoperative visual acuity in his eyes was 0.5 in the right eye and 0.6 in the left eye. On May 20, 2019, the patient presented with high myopia and cataract in both eyes, binocular visions: right eye 0.08, left eye 0.12; optometry: right eye −14.50DS = 0.3, left eye −13.50DS/−0.75 DC\*50° = 0.3. The fundus photos and OCT scanning of both eyes showed high myopic retinal changes (**Figure 4**).

The corneal topography examination showed obvious decentered ablation (**Figure 5**), and the right eye's total corneal astigmatism was 1.3 D, total corneal spherical aberration (SA) was 0.532 μm, total corneal irregular astigmatism was 1.615 μm, and angle kappa was 0.79 mm. The left eye's total corneal astigmatism was 2.4 D, total corneal SA was 1.259 μm, and total corneal irregular astigmatism was 1.373 μm. The above indicators were significantly beyond the scope of application of the trifocal IOL recommended by the Expert Consensus on The Clinical Application of Multifocal IOLs in China (2019): estimated postoperative total corneal astigmatism ≤ 0.75 D, preoperative total corneal spherical aberration (SA) ≤ 0.3 μm, total corneal irregular astigmatism ≤ 0.3 to 0.5 μm, angle kappa ≤ 0.5 mm, or less than half of the diameter of the central refractive optical zone of the IOL.

Given the actual situation of the patient, we conducted in-depth communication with the patient and recommended that the patient should receive an implant of a single-focus IOL to avoid evident symptoms of visual discomfort after the operation. However, the patient had a strong willing of not wearing eyeglasses after surgry; therefore, he still wanted to apply trifocal IOL to achieve full range of vision after surgery. Even in the event of maladaptation, he was willing to replace the IOL with another operation.

Finally, it was decided to perform phacoemulsification combined with trifocal IOL implantation on the right eye, which had relatively good corneal conditions.

**61**

**Figure 4.**

*Special Cases in Cataract Surgery*

*DOI: http://dx.doi.org/10.5772/intechopen.98260*

In this case, a multi-formula average method from the American Society of Cataract and Refractive Surgery (ASCRS) website was used for IOL power calculation to improve the accuracy. Because the patient's right eye corneal astigmatism was 1.3D, we used a 3.0-mm symmetrical and clear corneal incision on the 101.9° meridian of the steep axis of the cornea to partially correct the corneal astigmatism. Subsequently, continuous circular capsulorhexis with a diameter of approximately 5.5 mm was performed during the operation, and the phacoemulsification was completed using the Stellaris (Bausch +Lomb Laboratories, USA) system. After aspirating cortex, the anterior and posterior capsules were thoroughly polished, and +10.0 D (IOL degrees of both eyes are selected according to the ASCRS IOL Calculator for Eyes with Prior Myopic LASIK/PRK online calculation formula) Zeiss trifocal IOL (AT LISA tri839MP) was implanted; no complications occurred during the operation. Visual acuity on the second day of right eye was as follows: far vision 0.4, medium vision 0.63, near vision 0.63; optometry showed that the far vision was −0.5 DS/−0.75 DC\*105°=0.5 and intraocular pressure was 15 mmHg; slit-lamp examination showed that the cornea was transparent and clear, and the clear corneal incision was well closed; the pupil was sensitive to light, and the IOL was well-centered (**Figure 6**). The Pentacam examination of the right eye showed that the corneal incision was well closed, and the patient was highly satisfied and did not

*Fundus photography and OCT examination showing high myopic changes in the fundus of both eyes.*

Given the more obvious decentered ablation of the left cornea, greater corneal astigmatism, and greater total corneal SA and total corneal irregular astigmatism (**Figure 5**), we communicated with the patient repeatedly to inform about the possible obvious visual disturbance and discomfort after surgery. After the patient's approval to use the ZEISS trifocal IOL, we used the same method to perform left eye phacoemulsification combined with +9.5 D Zeiss trifocal IOL implantation for the patient on May 28, 2019. There were no complications during the operation.

On May 29, 2019, a re-examination showed that the right eye had a far vision of 0.5, medium vision of 0.63, and near vision of 0.63, and the left eye had a far vision of 0.5, medium vision of 0.5, and near vision of 0.5. Optometry showed that the

complain of any visual disturbance or discomfort.

*Current Cataract Surgical Techniques*

for trifocal IOL surgery.

the pros and cons according to the specific situation. If the trifocal IOL could not be stably implanted in the capsular bag or if there was a large amount of vitreous overflow, then we would choose to implant a single focal three-piece IOL in the ciliary sulcus, and the optical part was captured in the anterior capsulorhexis opening of less than 6 mm, which could prevent the eccentricity and tilt of the IOL that might occur after surgery and keep its stability [10]. The surgeon assessed that although the posterior capsular capsulorhexis dehiscence occurred during the intraoperative trifocal IOL implantation in this patient, the anterior vitreous membrane was well protected in the early stage and there was no vitreous overflow; therefore, the long axis of trifocal IOL was rotated to the direction perpendicular to the direction of dehiscence, which reduced further pulling of the IOL on the capsulorhexis opening

of dehiscence and allowed it to be stable and centered in the capsular bag.

**3. A case of trifocal intraocular lens implantation for high myopia** 

A 51-year-old male patient underwent LASIK surgery 23 years ago due to high myopia in both eyes. According to the patient's recollection, the best postoperative visual acuity in his eyes was 0.5 in the right eye and 0.6 in the left eye. On May 20, 2019, the patient presented with high myopia and cataract in both eyes, binocular visions: right eye 0.08, left eye 0.12; optometry: right eye −14.50DS = 0.3, left eye −13.50DS/−0.75 DC\*50° = 0.3. The fundus photos and OCT scanning of both eyes

The corneal topography examination showed obvious decentered ablation (**Figure 5**), and the right eye's total corneal astigmatism was 1.3 D, total corneal spherical aberration (SA) was 0.532 μm, total corneal irregular astigmatism was 1.615 μm, and angle kappa was 0.79 mm. The left eye's total corneal astigmatism was 2.4 D, total corneal SA was 1.259 μm, and total corneal irregular astigmatism was 1.373 μm. The above indicators were significantly beyond the scope of application of the trifocal IOL recommended by the Expert Consensus on The Clinical Application of Multifocal IOLs in China (2019): estimated postoperative total corneal astigmatism ≤ 0.75 D, preoperative total corneal spherical aberration (SA) ≤ 0.3 μm, total corneal irregular astigmatism ≤ 0.3 to 0.5 μm, angle kappa ≤ 0.5 mm, or less than half of the diameter of the central refractive optical zone of the IOL. Given the actual situation of the patient, we conducted in-depth communication with the patient and recommended that the patient should receive an implant of a single-focus IOL to avoid evident symptoms of visual discomfort after the operation. However, the patient had a strong willing of not wearing eyeglasses after surgry; therefore, he still wanted to apply trifocal IOL to achieve full range of vision after surgery. Even in the event of maladaptation, he was willing to replace the IOL

Finally, it was decided to perform phacoemulsification combined with trifocal IOL implantation on the right eye, which had relatively good corneal conditions.

**complicated with cataract after LASIK operation**

showed high myopic retinal changes (**Figure 4**).

Although this study did not involve a follow-up for 1 year or longer after surgery, the long-term stability of the trifocal IOL remained to be observed; however, this study emphasizes that for posterior capsular continuous circular capsulorhexis in posterior polar cataract surgery or a small range of posterior capsular rupture in common cataract surgery followed by posterior capsular continuous circular capsulorhexis, in circumstances where there is no vitreous overflow, the surgeon can evaluate whether it is feasible to implant the trifocal IOL in the capsular bag according to the actual intraoperative situation and expand the relative indications

**60**

with another operation.

In this case, a multi-formula average method from the American Society of Cataract and Refractive Surgery (ASCRS) website was used for IOL power calculation to improve the accuracy. Because the patient's right eye corneal astigmatism was 1.3D, we used a 3.0-mm symmetrical and clear corneal incision on the 101.9° meridian of the steep axis of the cornea to partially correct the corneal astigmatism. Subsequently, continuous circular capsulorhexis with a diameter of approximately 5.5 mm was performed during the operation, and the phacoemulsification was completed using the Stellaris (Bausch +Lomb Laboratories, USA) system. After aspirating cortex, the anterior and posterior capsules were thoroughly polished, and +10.0 D (IOL degrees of both eyes are selected according to the ASCRS IOL Calculator for Eyes with Prior Myopic LASIK/PRK online calculation formula) Zeiss trifocal IOL (AT LISA tri839MP) was implanted; no complications occurred during the operation.

Visual acuity on the second day of right eye was as follows: far vision 0.4, medium vision 0.63, near vision 0.63; optometry showed that the far vision was −0.5 DS/−0.75 DC\*105°=0.5 and intraocular pressure was 15 mmHg; slit-lamp examination showed that the cornea was transparent and clear, and the clear corneal incision was well closed; the pupil was sensitive to light, and the IOL was well-centered (**Figure 6**). The Pentacam examination of the right eye showed that the corneal incision was well closed, and the patient was highly satisfied and did not complain of any visual disturbance or discomfort.

Given the more obvious decentered ablation of the left cornea, greater corneal astigmatism, and greater total corneal SA and total corneal irregular astigmatism (**Figure 5**), we communicated with the patient repeatedly to inform about the possible obvious visual disturbance and discomfort after surgery. After the patient's approval to use the ZEISS trifocal IOL, we used the same method to perform left eye phacoemulsification combined with +9.5 D Zeiss trifocal IOL implantation for the patient on May 28, 2019. There were no complications during the operation.

On May 29, 2019, a re-examination showed that the right eye had a far vision of 0.5, medium vision of 0.63, and near vision of 0.63, and the left eye had a far vision of 0.5, medium vision of 0.5, and near vision of 0.5. Optometry showed that the

#### **Figure 5.**

*Binocular Pentacam examination showing decentered ablation in both eyes.*

right eye had −0.75 DC\*107°=0.5 and the left eye had −0.25 DS/−0.5 DC\*135°=0.5. The intraocular pressure was 14 mmHg in the right eye and 16 mmHg in the left eye. Slit-lamp examination showed that the cornea of both eyes was transparent and clear, the clear corneal incision was well closed, the pupils were sensitive to light, and the IOL was well-centered (**Figure 7**). On June 05, 2019, the results of Pentacam examination performed again on both eyes showed that the corneal incision was well closed, the corneal astigmatism in both eyes was reduced compared with that before the operation, and the total corneal SA and total corneal irregular astigmatism were both reduced compared with those before the operation. The patient was highly satisfied, which was a completely unexpected outcome (**Figure 8**).

**63**

**3.1 Discussion**

**Figure 7.**

**Figure 6.**

Since 1990s, corneal refractive surgery has been widely performed for refractive correction in millions of younger patients. As they grew older for cataract surgery, they are still willing to acquire better visual quality and freedom from glasses [11]. Some of previous studies have demonstrated that multifocal IOL implantation could be a safe and efficient way for patients with previous corneal refractive surgery [12–15]. However, due to the uncertainty in IOL power calculation and the potential side effects such as glare, halo or other visual acuity problems, premium IOL surgical plans for patients post-corneal refractive surgery are still facing many challenges. AT LISA tri839MP used in this study, as a monolithic diffractive trifocal IOL, is able to split the incoming light at near, intermediate, and distant focus, respectively. It has been shown to provide good outcomes of visual acuity at a near, intermediate, and far distance and a high postoperative satisfaction [16, 17]. Moreover, two previous studies also demonstrated that it can provide a good visual outcome at both near

*A binocular slit-lamp photograph taken on May 29, 2019, showing that the trifocal intraocular lens (IOL) is* 

*well centered, and the center of the diffraction ring is quite close to the center of the pupil.*

*A right-eye slit-lamp photograph taken on May 24, 2019, showing the trifocal intraocular lens (IOL) is well centered, and the center of the diffraction ring is quite close to the center of the pupil (Panel A). Simultaneously, Pentacam in the right eye shows that the corneal incision is well closed (red arrow in Panel B).*

Although the patient's corneal astigmatism, irregular astigmatism, and SA in both eyes exceeded the scope of application of the Zeiss trifocal IOL, the patient had a strong willingness of not wearing eyeglasses after the operation. Therefore,

and distance vision for post-myopic LASIK cases [18, 19].

*Special Cases in Cataract Surgery*

*DOI: http://dx.doi.org/10.5772/intechopen.98260*

#### **Figure 6.**

*Current Cataract Surgical Techniques*

**62**

**Figure 5.**

right eye had −0.75 DC\*107°=0.5 and the left eye had −0.25 DS/−0.5 DC\*135°=0.5. The intraocular pressure was 14 mmHg in the right eye and 16 mmHg in the left eye. Slit-lamp examination showed that the cornea of both eyes was transparent and clear, the clear corneal incision was well closed, the pupils were sensitive to light, and the IOL was well-centered (**Figure 7**). On June 05, 2019, the results of Pentacam examination performed again on both eyes showed that the corneal incision was well closed, the corneal astigmatism in both eyes was reduced compared with that before the operation, and the total corneal SA and total corneal irregular astigmatism were both reduced compared with those before the operation. The patient was

*Binocular Pentacam examination showing decentered ablation in both eyes.*

highly satisfied, which was a completely unexpected outcome (**Figure 8**).

*A right-eye slit-lamp photograph taken on May 24, 2019, showing the trifocal intraocular lens (IOL) is well centered, and the center of the diffraction ring is quite close to the center of the pupil (Panel A). Simultaneously, Pentacam in the right eye shows that the corneal incision is well closed (red arrow in Panel B).*

#### **Figure 7.**

*A binocular slit-lamp photograph taken on May 29, 2019, showing that the trifocal intraocular lens (IOL) is well centered, and the center of the diffraction ring is quite close to the center of the pupil.*

#### **3.1 Discussion**

Since 1990s, corneal refractive surgery has been widely performed for refractive correction in millions of younger patients. As they grew older for cataract surgery, they are still willing to acquire better visual quality and freedom from glasses [11]. Some of previous studies have demonstrated that multifocal IOL implantation could be a safe and efficient way for patients with previous corneal refractive surgery [12–15]. However, due to the uncertainty in IOL power calculation and the potential side effects such as glare, halo or other visual acuity problems, premium IOL surgical plans for patients post-corneal refractive surgery are still facing many challenges.

AT LISA tri839MP used in this study, as a monolithic diffractive trifocal IOL, is able to split the incoming light at near, intermediate, and distant focus, respectively. It has been shown to provide good outcomes of visual acuity at a near, intermediate, and far distance and a high postoperative satisfaction [16, 17]. Moreover, two previous studies also demonstrated that it can provide a good visual outcome at both near and distance vision for post-myopic LASIK cases [18, 19].

Although the patient's corneal astigmatism, irregular astigmatism, and SA in both eyes exceeded the scope of application of the Zeiss trifocal IOL, the patient had a strong willingness of not wearing eyeglasses after the operation. Therefore,

#### **Figure 8.**

*A binocular Pentacam image taken on June 05, 2019, showing that corneal astigmatism, total corneal spherical aberration (SA), and total corneal irregular astigmatism are all reduced compared with those before surgery.*

after a comprehensive preoperative evaluation, a symmetric clear corneal incision on a steep axis was used to correct corneal astigmatism. Pentacam examination after surgery showed that corneal astigmatism was corrected to a certain extent, and corneal irregular astigmatism and SA were reduced. This played a certain role in improving the visual quality of patients after surgery. The absence of evident symptoms of visual disturbance and discomfort after surgery in the patient may be related to the neurological adaptability of the brain for many years. Therefore, when the phacoemulsification cataract surgery removed the effects of cataract-induced refractive interstitial opacity and myopia and reduced astigmatism, irregularities, and SA, the patient had improved vision without the occurrence of any additional symptoms of visual disturbance and discomfort. For the calculation of IOL power,

**65**

**Figure 9.**

*Special Cases in Cataract Surgery*

refractive surgery.

*DOI: http://dx.doi.org/10.5772/intechopen.98260*

relatively accurate target refraction after the operation.

**retinitis pigmentosa and high myopia eyes**

there was obvious posterior subcapsular opacity (**Figure 9**).

we used the formula for the calculation of IOL after myopic refractive surgery on the ASCRS website, took the average power as the final IOL power, and obtained a

Through the analysis of this case, we can provide certain experience references for more patients who had undergone early myopia refractive surgery, particularly for some patients who desired to receive an implant of trifocal IOL but had decentered ablation, irregular corneal astigmatism, and large SA caused by early

**4. A case of early capsular shrinkage syndrome after cataract surgery for** 

On March 5, 2018, a patient with binocular retinitis pigmentosa and high myopia complicated with cataract was admitted to hospital. The visual acuity was hand motion in both eyes; intraocular pressure was 15 mmHg in the right eye and 20 mmHg in the left eye; there was alternating exotropia and nystagmus in both eyes. The lens cortex of the right eye had localized opacity, and the nucleus was opaque and dark brown; the left lens nucleus was opaque and brown-yellow, and

The patient underwent small incision cataract extraction in the right eye and phacoemulsification cataract surgery in the left eye on March 8, 2018, and April 3, 2018, respectively. The author knew that both retinitis pigmentosa and high myopia are risk factors for capsular contraction syndrome (CCS), small incision cataract extraction in the right eye was performed gently and the continuous curvilinear capsulorhexis (CCC) diameter was larger than 6 mm; the patient's lens suspensory

*The state of binocular lens opacity (the upper row is the right eye, and the lower row is the left eye).*

#### *Special Cases in Cataract Surgery DOI: http://dx.doi.org/10.5772/intechopen.98260*

*Current Cataract Surgical Techniques*

**64**

**Figure 8.**

after a comprehensive preoperative evaluation, a symmetric clear corneal incision on a steep axis was used to correct corneal astigmatism. Pentacam examination after surgery showed that corneal astigmatism was corrected to a certain extent, and corneal irregular astigmatism and SA were reduced. This played a certain role in improving the visual quality of patients after surgery. The absence of evident symptoms of visual disturbance and discomfort after surgery in the patient may be related to the neurological adaptability of the brain for many years. Therefore, when the phacoemulsification cataract surgery removed the effects of cataract-induced refractive interstitial opacity and myopia and reduced astigmatism, irregularities, and SA, the patient had improved vision without the occurrence of any additional symptoms of visual disturbance and discomfort. For the calculation of IOL power,

*A binocular Pentacam image taken on June 05, 2019, showing that corneal astigmatism, total corneal spherical aberration (SA), and total corneal irregular astigmatism are all reduced compared with those before surgery.*

we used the formula for the calculation of IOL after myopic refractive surgery on the ASCRS website, took the average power as the final IOL power, and obtained a relatively accurate target refraction after the operation.

Through the analysis of this case, we can provide certain experience references for more patients who had undergone early myopia refractive surgery, particularly for some patients who desired to receive an implant of trifocal IOL but had decentered ablation, irregular corneal astigmatism, and large SA caused by early refractive surgery.
