**3. Patients selection**

Even the IOLs technique progress offers patients the possibility of spectacle independence, the selection of presbyopia correction candidates is the most important issue which can lead to a successful surgery [16]. The right patients are the cataract or presbyopia patients who seek an intraocular IOLs solution to spectacle

**137**

*Successful Premium Multifocal IOL Surgery: Key Issues and Pearls*

IOLs to patient, that can establish their realistic expectation [17].

independence. The surgeon should understand patient's expectations about visual task. A detailed discussion should be held to explain the limitations of premium

The characteristics of lifestyle or work is also an important selection criterion for premium IOL procedure. Ophthalmologists choose the correct type multifocal IOLs depending on what they do or where they live. Different cultures expressed different visual requirement on lifestyle and work. There may be a lot of timeconsuming on near work with the computer, tablet, mobile phone, and on near life with book reading in Asian people, while there are more of an outdoor life in western populations. Especially, Chinese text may be very small and intricate comparing to English character, and hence a full reading add is usually needed. Furthermore, Asian people are generally shorter figure and shorter arms which cause the shorter distance between the face and the book, the mobile phone and other materials. Low add multifocal IOLs or normal monovision strategies may not be able to cope with the demands of reading in Asian people. The near vision satisfaction will be gain better in western population than Asian people. When such near vision is a high priority, high add multifocal IOLs or full-range multifo-

Age also plays an important role in patient selection. Several conditions become

Patients' current visual acuity and refractive error and should be considered. Hyperopes who have significant cataracts will gain the most from presbyopia correcting IOLs, with uncorrected vision improvement at all distances. Mild myopes who have transparent crystalline lens may be dissatisfied with the result, because they often rely on their near vision for specific tasks and may have something to lose

Before choosing the presbyopia correcting IOLs, the surgeon should spend a lot of time in counseling with patients to access the personality, occupation and lifestyle of patients. In some clinics, a questionnaire is also helpful for evaluating patient's needs and ranking patient's personality from "easygoing" to "perfectionist" (**Figure 4**). It is important to rule out those patients who have unreasonable expectations about perfect visual needs or who have anxiety, doubt, nervousness characteristics. Those patients are more likely to be dissatisfied with presbyopia correcting IOLs. A visual behavior monitor that patients can wear on their spectacles to track their visual behavior and environment, now provides a lifestyle match index to help ophthalmologist convert that data into useful clinical information to select the best

Some patients who need the specific vision requirement in their daily work and life also should be excluded out of the candidate, such as airline pilots, truck drivers, taxi drivers and anyone whose job requires activity at night or low-light conditions. The patients who often mention halos and glare disturb their jobs also should

more prevalent with age, such as optic neuropathy, macular degeneration and ocular surface disease, that may compound the loss of contrast sensitivity seen in multifocal IOLs. The examination of ocular disease using OCT, visual field, visual electrophysiology will provide some information about the post-operative visual quality results. These age-related diseases will be discussion in below. Multifocal IOLs implantation in pediatric cataract case is the subject of much controversy [18]. Amblyopia is common in these patients especially in unilateral pediatric cataract patients, while multifocal IOLs will reduce the contrast sensitivity and exacerbate amblyopia. Another issue is the ongoing growing of the child resulting in the question of how to calculate the power of the implanted lens, because the target refractive status depend on the age of the patient and the visual demands. There are just a few publications on this subject, we also did not have any experiences of multifocal

*DOI: http://dx.doi.org/10.5772/intechopen.96182*

cal IOL is the better solution.

IOLs in children [19–21].

IOL for a given patient [22].

postoperatively.

#### *Successful Premium Multifocal IOL Surgery: Key Issues and Pearls DOI: http://dx.doi.org/10.5772/intechopen.96182*

*Current Cataract Surgical Techniques*

Tecnis ZKB, ZLB, ZMB

Mplus Lentis MF 20/30(X)

Comfort Lentis MF 15 (Oculentis)

Mini Well Ready (Sifi

Meditec)

**Table 1.**

(AMO)

(Oculentis)

**136**

distance [13, 14] (**Table 1**).

**3. Patients selection**

statement for EDOF IOL. These should have an extended far focus area which reaches the intermediate distance, providing excellent intermediate vision. Depth of focus should be at least 0.5 D wider than monofocal IOL for distance visual acuity of 0.03 logMAR [12]. Nevertheless, in practice, EDOF lenses provide excellent intermediate vision, but inadequate quality of vision for near

IC-8 (AcuFocus) EDOF Masked, Pin-hole EDOF

**Premium IOL Principle Optical design Focality Interm/**

Crystalens (Bausch & Lomb) Accommodative Single-Optics Accommodating >0.4 1CU (Human Optics) Accommodative Single-Optics Accommodating 1.36 ~ 2.25

Synchrony IOLs (AMO) Accommodative Duel-Optics Accommodating 1 Array (AMO) Refractive Zonal, progressive 2 0/3.5 ReZoom (AMO) Refractive Zonal,progressive 2 0/3.5

Diffractive Symmetric,

Refractive Asymmetric.

AT Lisa Tri (Zeiss) Diffractive Diffractive, Zone 3 1.67/3.3

EDOF Progressive,

Apodized

Constant

Constant

Segmental

Segmental

Constant

Diffractive

achromate

Spherical aberration

EDOF Refractive 2 1.5/0

Restor (+4,+3,+2.5) (Alcon) Diffractive Symmetric,

AT Lisa 809MP (Zeiss) Diffractive Symmetric,

SBL 2 and 3 (Lenstec INC) Refractive Asymmetric.

PanOptix AcrySof (Alcon) Diffractive Diffractive,

FineVision (PhysIOL) Diffractive Apodized

Symfony Tecnis (AMO) EDOF Diffractive,

*Properties of popular premium intraocular lenses (IOLs) [10, 11].*

**Near Add(D)**

[15]

0/3.0 0/2.5

0/3.25, 0/4.0

0/3

0/3

2 0/4.0

2 0/2.75,

2 0/3.75

2 0/2,

2 0/2,

3 2.17/3.25

3 1.75/3.5

EDOF 1.75/0

EDOF 0/3

Even the IOLs technique progress offers patients the possibility of spectacle independence, the selection of presbyopia correction candidates is the most important issue which can lead to a successful surgery [16]. The right patients are the cataract or presbyopia patients who seek an intraocular IOLs solution to spectacle

independence. The surgeon should understand patient's expectations about visual task. A detailed discussion should be held to explain the limitations of premium IOLs to patient, that can establish their realistic expectation [17].

The characteristics of lifestyle or work is also an important selection criterion for premium IOL procedure. Ophthalmologists choose the correct type multifocal IOLs depending on what they do or where they live. Different cultures expressed different visual requirement on lifestyle and work. There may be a lot of timeconsuming on near work with the computer, tablet, mobile phone, and on near life with book reading in Asian people, while there are more of an outdoor life in western populations. Especially, Chinese text may be very small and intricate comparing to English character, and hence a full reading add is usually needed. Furthermore, Asian people are generally shorter figure and shorter arms which cause the shorter distance between the face and the book, the mobile phone and other materials. Low add multifocal IOLs or normal monovision strategies may not be able to cope with the demands of reading in Asian people. The near vision satisfaction will be gain better in western population than Asian people. When such near vision is a high priority, high add multifocal IOLs or full-range multifocal IOL is the better solution.

Age also plays an important role in patient selection. Several conditions become more prevalent with age, such as optic neuropathy, macular degeneration and ocular surface disease, that may compound the loss of contrast sensitivity seen in multifocal IOLs. The examination of ocular disease using OCT, visual field, visual electrophysiology will provide some information about the post-operative visual quality results. These age-related diseases will be discussion in below. Multifocal IOLs implantation in pediatric cataract case is the subject of much controversy [18]. Amblyopia is common in these patients especially in unilateral pediatric cataract patients, while multifocal IOLs will reduce the contrast sensitivity and exacerbate amblyopia. Another issue is the ongoing growing of the child resulting in the question of how to calculate the power of the implanted lens, because the target refractive status depend on the age of the patient and the visual demands. There are just a few publications on this subject, we also did not have any experiences of multifocal IOLs in children [19–21].

Patients' current visual acuity and refractive error and should be considered. Hyperopes who have significant cataracts will gain the most from presbyopia correcting IOLs, with uncorrected vision improvement at all distances. Mild myopes who have transparent crystalline lens may be dissatisfied with the result, because they often rely on their near vision for specific tasks and may have something to lose postoperatively.

Before choosing the presbyopia correcting IOLs, the surgeon should spend a lot of time in counseling with patients to access the personality, occupation and lifestyle of patients. In some clinics, a questionnaire is also helpful for evaluating patient's needs and ranking patient's personality from "easygoing" to "perfectionist" (**Figure 4**). It is important to rule out those patients who have unreasonable expectations about perfect visual needs or who have anxiety, doubt, nervousness characteristics. Those patients are more likely to be dissatisfied with presbyopia correcting IOLs. A visual behavior monitor that patients can wear on their spectacles to track their visual behavior and environment, now provides a lifestyle match index to help ophthalmologist convert that data into useful clinical information to select the best IOL for a given patient [22].

Some patients who need the specific vision requirement in their daily work and life also should be excluded out of the candidate, such as airline pilots, truck drivers, taxi drivers and anyone whose job requires activity at night or low-light conditions. The patients who often mention halos and glare disturb their jobs also should


**Figure 4.** *Preoperative questionnaire (courtesy of dr. Takashi).*

be rule out of the candidates. The diffractive or refractive multifocal IOLs will increased the photic phenomena in dim environment, while the accommodation IOL or monovision based on the monofocal IOLs should be better choice.
