Presbyopia / SPO - 3.2.2.3. Mix & Match with multifocal intraocular lenses for the treatment o

3.2.2.3. Mix & Match with multifocal intraocular lenses for the treatment of presbyopia

Sergio Kwitko

Hospital de Clínicas de Porto Alegre, Brasil OftalmoCentro, Porto Alegre, Brasil

INTRODUCTION

A current and effective alternative for the treatment of presbyopia is the extraction of the crystalline lens, opaque or not, and the implantation of multifocal intraocular lenses (MF IOLs), bifocals, trifocals and with extended focus. There are now a wide variety of options1-7.

As each lens has specific characteristics that do not always provide adequate focus at all distances, several technologies can be combined. This is called Mix & Match8-11.

Refractive lenses, primarily represented by Rayner's M-Flex, are truly multifocal and provide better vision for distance and intermediate distances than for near.

However, they generally lack the near vision. One can use the Far and Near strategy, i.e., implant an M-Flex with predominance of focus for far in the dominant eye (M-Flex Far) and an M-Flex with predominance of focus towards near in the non-dominant eye (M-Flex Near)3,9,16.

Bifocal diffractive lenses with addition of +4.00 D provide excellent vision for near and far, but they are not desirable for intermediate vision3,9,16.

Manufacturers then have in their portfolio diffractive bifocals with a minor addition (+2.50, +2.75, +3.00, +3.25 D), or extended focus IOL, to better cover intermediate vision.

However, these IOLs favor vision between 40 cm and 65 cm and fall short at close range over +4.00 D bifocal diffractive IOLs that have an excellent focus at 33 cm.

More recently, trifocal diffractive IOLs have been made available, in order to provide a more complete view at all distances. Indeed, trifocal IOLs are a more complete alternative to bifocals12,13.

However, these trifocal IOLs still favor intermediate vision a little more than near vision, as their closest focus is between 37 and 40 cm, which can satisfy long-vision patients or those who do not have intense close activity12,13.

For a longer reading, or a clearer vision between 33 and 35 cm, the trifocal IOLs are often not enough either and the patient may need to use complementary glasses12,13.

In order to provide a complete vision at all distances, an interesting option that has been used is the mixture of different IOLs (Mix & Match), in which the dominant eye is implanted with an IOL that gives vision for intermediate and distance (with addition around +3.00 D), and in the non-dominant an IOL that gives sharpness for near and far (addition of +4.00 D). This allows the patient to have a greater range of vision at all distances, without increasing complications8-11.

In the authors' experience, using Mix & Match in this way, 96% of patients are completely independent of the glasses at all distances8, which is demonstrated by the defocus curve in Figure 1 comparing several combinations of IOLs17:

Figure 1 - Defocus curves in bilaterally implanted patients: With refractive lenses (A); With diffractive lenses (B); With asymmetric rotary lenses with +3.00 D addition (C); Mix and Match with refractive and diffractive lenses (D); Mix and Match combining +1.50 D and +3.00 D addition on asymmetric rotary lenses (E); With Trifocal Lenses (F). Error bars represent ± 1 SD.

It should be noted that the Mix & Match defocus curve was similar to that of trifocal IOLs, however a bit better for near and slightly worse for intermediate17.

In the authors' experience, there is no increase in side effects such as halos and glare with Mix & Match compared to two similar IOLs in both eyes8,14,16.

The fundamental point for a good result is the understanding on the part of the patient in the operation and the limitation of the multifocal IOLs.

In addition, the surgery must be absolutely accurate, from accurate biometry and uncomplicated surgery with the IOL implant inside the capsular bag.

REFERENCES

Montés-Micó R, España E, Bueno I, Charman WN, Menezo JL. Visual performance with multifocal intraocular lenses: mesopic contrast sensitivity under distance and near conditions. Ophthalmology 2004; 111(1): 85-96.
Leyland M and Zinicola E. Multifocal versus monofocal intraocular lenses in cataract surgery: a systematic review. Ophthalmology 2003; 110(9): 1789-98.
Alió JL, Tavolato M, De la Hoz F, Claramonte P, Rodríguez-Prats JL, Galal A. Near vision restoration with refractive lens exchange and pseudoaccommodating and multifocal refractive and diffractive intraocular lenses: comparative clinical study. J Cataract Refract Surg 2004; 30(12): 2494-503.
Mester U, Hunold W, Wesendahl T, Kaymak H.. Functional outcomes after implantation of Tecnis ZM900 and Array SA40 multifocal intraocular lenses. J Cataract Refract Surg 2007; 33(6): 1033-40.
Pineda-Fernández A, Jaramillo J, Celis V, Vargas J, DiStacio M, Galíndez A, Del Valle M. Refractive outcomes after bilateral multifocal intraocular lens implantation. J Cataract Refract Surg 2004; 30(3): 685-8.
Javitt JC and Steinert RF. Cataract extraction with multifocal intraocular lens implantation: a multinational clinical trial evaluating clinical, functional, and quality-of-life outcomes. Ophthalmology 2000; 107(11): 2040-8.
Leyland MD, Langan L, Goolfee F, Lee N, Bloom PA. Prospective randomised double-masked trial of bilateral multifocal, bifocal or monofocal intraocular lenses. Eye (Lond) 2002; 16(4): 481-90.
Kwitko S. Como eu trato presbiopia com lentes intra-oculares multifocais. Oftalmologia em foco, 2011.
Goes FJ. Visual Results Following Implantation of a Refractive Multifocal IOL in One Eye and a Diffractive Multifocal IOL in the Contralateral Eye. J Refract Surg 2008; 24(3): 300-5.
Yoon Y, Song IS, Kim JY, Kim MJ, Tchah H. Bilateral mix-and-match versus unilateral multifocal intraocular lens implantation: Long-term comparison. J Cataract Refract Surg 39(11): 1682-90, 2013.
Lacmanović-Loncar V, Pavicić-Astalos J, Petric-Vicković I, Mandić ZMultifocal intraocular Mix and Match lenses. Acta Clin Crat 2008; 47(4): 217-2008.
Sheppard AL , Shah S, Bhatt U, Bhogal G, Wolffsohn JS. Visual outcomes and subjective experience after bilateral implantation of a new diffractive trifocal intraocular lens. J Cataract Refract Surg 2012; 39(3): 343-9.
Marques EF, Ferreira TB. Comparison of visual outcomes of 2 diffractive trifocal intraocular lenses. J Cataract Refract Surg 2015; 41(2): 354-63.
Pieh S, Weghaupt H, Skorpik C. Contrast sensitivity and glare disability with diffractive and refractive multifocal intraocular lenses. J Cataract Refract Surg 1998; 24(5): 659-62.
Pieh S , Lackner B, Hanselmayer G, Zöhrer R, Sticker M, Weghaupt H, Fercher A, Skorpik C. Halo size under distance and near conditions in refractive multifocal intraocular lenses. Br J Ophthalmol 2001; 85(7): 816-21
Schmitz S, Dick HB, Krummenauer F, Schwenn O, Krist R. Contrast sensitivity and glare disability by halogen light after monofocal and multifocal lens implantation. Br J Ophthalmol 2000; 84(10): 1109-12.
Wolffsohn JS, Jinabhai AN, Kingsnorth A, Sheppard AL, Naroo SA, Shah S, Buckhurst P, Hall LA, Young G.. Exploring the optimum step size for defocus curves. J Cataract Refract Surg 2013; 39(6): 873- 80.

Report abuse