**4.7 Retinal disease**

*Current Cataract Surgical Techniques*

parameters [41] (**Figure 7**).

*Pupil size, angle kappa and angle alpha.*

**4.6 Glaucoma**

**Figure 7.**

the central optical zone. The limitation of k value is different according to the different multifocal IOLs——ReSTOR(Alcon) 0.4 mm, Tecnis multifocal IOL (Abbott

Angle alpha is defined by the radial distance between the center of the limbus and the visual axis, which was found to predict the tilt of the IOL in respect to the visual axis. Wang had demonstrated that angle alpha was relatively stable whereas angle kappa changes from pre- to postoperative situation [45]. Angle alpha seems to be a better predictor for photic phenomena and patient satisfaction with multifocal IOLs [46]. But there still was different aspects on the predictive capacity of angle α on the outcome with multifocal IOLs. Piracha had concluded the angle alpha distance is larger than 0.5 mm, the eye is not suitable for multifocal IOL implantation [47], while Fu found there was no statistically significant correlation between angle alpha and the objective visual quality

Glaucoma patients often presented with the visual field damage, contrast sensitivity loss, small pupils and capsular and zonular issues, to affect vision outcomes

Previous generation multifocal IOLs (Restor, Alcon; ReZoom, Abbott Medical Optics) were reported to significantly reduce the contrast sensitivity, especially in refractive multifocal IOL implantation. New advanced technology multifocal IOL or EDOF IOLs seem to mitigate the loss of contrast sensitivity [48]. And multifocal IOL also affect the visual field test and oct scan in the glaucoma patients' follow-up. But because of a lack of scientific evidence in the form of large trials on the impact of multifocal IOLs in glaucoma, decisions regarding the implantation in a glaucoma patient should be tailored according to the patient' s motivation and the rate of glaucoma progression. The patient who is glaucoma suspect, ocular hypertensive, early stage with controlled and stable visual field damage is the candidate for diffractive multifocal IOLs and EDOF IOLs. The patients with severe, advanced, progressive glaucoma, or with high risk of pupil or zonular changes like chronic miotics, pseudoexfoliation, pigment dispersion will not benefit of

must be taken into account when choosing a premium IOL.

Medical Optics) 0.5 mm, FineVision POD F IOL(PhysIOL) 0.6 mm [44].

**142**

multifocality [49].

It is a controversial topic of premium IOLs application in retinal disease patients because there are varying degrees of macular lesion, ranging from drusen without visual damage to the late stages of atrophic AMD. Multifocal IOLs are strictly not recommend in retinitis pigmentosa and Stargardt's disease, while diabetic retinopathy, age-related macular degeneration, and epiretinal membranes are relative contraindications [50]. Beside the different character of retinal diseases, the progression is an important issue to consider for premium IOLs solution [17].

For the mild or stable disease, multifocal IOLs is option for patient with careful and thoroughly consent about the prognosis including the issue of lower contrast sensitivity and long-term results with the disease progressing. Many studies had demonstrated the contrast sensitivity decreased in multifocal IOLs. Due to loss of contrast sensitivity at lower spatial frequencies is also presented even in mild forms of AMD, the EDOF IOLs is preferred in these cases. Multifocal IOLs generally are disadvised for patients with severe AMD because pre-existing pathologic features are a contraindication.

The presence of an epiretinal membrane (ERM) can lead to more unpredictability with the spherical power of the IOL selection and its refractive outcome. Multifocal IOLs in ERM patients will face to the loss of contrast sensitivity, increased risk for postoperative cystoid macular edema [51].

There are few studies addressing the multifocal IOLs and retinal disease, which report a significant improvement in visual-related outcomes than the monofocal implantation. Nevertheless, more research is needed to address the aforementioned concerns and to optimize the use of MIOLs in eyes with retinal disease.
