Dissatisfied Multifocal IOL problems

[John C Hagan III, MD, FACS, FAAO]

Study finds most dissatisfied multifocal IOL patients can be treated effectively
Researchers retrospectively reviewed charts of 49 patients (76 eyes) dissatisfied with their vision after multifocal IOL implantation (mostly+4.00 D Restor IOL) and found that blurred vision, with or without photic phenomenon, occurred in 94.7 percent and photic phenomena, with or without blurred vision, occurred in 38.2 percent. Both symptoms were present in 32.9 percent. The most common reasons: residual ametropia and astigmatism, posterior capsule opacification, and a large pupil. While most patients were amenable to therapy (refractive surgery, spectacles, and laser capsulotomy), IOL exchange was performed in 4 percent. Journal of Cataract & Refractive Surgery, May 2011

[JohnHaganMD]

FOLLOW THIS LINK TO FURTHER DISCUSSION:  https://www.medhelp.org/posts/Eye-Care/Dissatisfied-Multifocal-IOL-problems/show/1523554

[concentrico]

I'll have my multifocal iols explanted soon. Can't wait to get rid of that nightmare of last 6 months. Absolutely dreadful lenses.

[JohnHaganMD]

Please share your experience on some of these other discussion threads.

[Colecard]

I am 55 and just had a multi-focal IOL implanted last week in my left eye, which is the dominant eye. My eye is still swollen, dilated and irritated, so I do not know what my final vision will turn out to be yet. I’m nervous because as I’ve described my blurry, milky and haloed vision to my surgeon he mentioned that I might need to have a laser poke through the capsule behind the new multifocal IOL. I was shown a video on how the laser works to fix the clouded capsule, but no discussion took place afterward. I’m supposed to have my other eye done in a week but cannot afford to have any period where I don’t have at least one good eye. Right now, I am scared to moved forward. I would appreciate hearing from anyone about resolutions that might make sense for me, including telling me not to worry that I will be fine in a few days. I’m just nervous and don’t know if my doctor and I have communicated as thoroughly as we need to. I’m not sure I know what to ask him nor understand what he is telling me sometimes. He is a great doctor, very nice and attentive. I’m still hoping this will be okay. Thoughts? Advice?

[JohnHaganMD]

Something that has worked great in our practice and in the eye forum.   Don't have surgery one the second eye till you are happy with the first eye!!!!  Know that multifocal IOLs are associated with a higher incidence of dissatisfaction, night vision problems, unexpected need for glasses and disturbing light reflexes (dysphotopsia) than monofocal or toric IOLs.   Also rates of ex plantation and exchange are much higher. Know also if you have a yag laser capsulotomy (put a hole in the membrane) it makes IOL exchange much more difficult and risky.   You have been warned but how would you like to be having these problems in BOTH EYES?  Consider waiting. See how thing check out. If a yag laser is recommended consider an independent second opinion.

[AustinDiver]

I would proceed with caution.   I just had Symfony lens implanted by a top notch surgeon.  I would have passed on multifocal lens.   You have the right to be picky with the surgeon.  
Do not hesitate to get a second opinion.   I investigated multiple surgeons in the Austin area.    One surgeon (who has multiple videos on the internet) gave me a tough time for asking a lot
of questions.  The dr did not introduce himself,   he came into the room and told me he did not want me to compare his opinions with other surgeons.  Somehow my layman questions offended him.   I May have set of alarm bells that I would not be a good patient for him.

One of this surgeons  videos  showed how wonderful his closeup vision was 10 minutes after he personally received a Symfony lens.   Looking back,  I think the video  is terribly misleading.  Some patients might  have great luck.   Cataract surgery is not open heart surgery, but recovery, from personal experience, takes time.  Dr's do not like writing prescriptions for a month or so.    I am two weeks post surgery and the distance vision is starting to settle in.   I am also having to manage some dry eye.  

I did not have laser cataract surgery.  I now think that was a good decision.   I was in my brothers car at the point that this surgeon was in his actual cataract surgery after the laser procedure.

I am sorry about the diatribe.  Do not hesitate to get a second opinion.   Getting on a Drs schedule for a second opinion can take time.   From a fellow patient, YAG laser at this point should not be rushed into.

[JohnHaganMD]

Agree

[LenaToronto]

My mom has the same problem. It's been over 7 month since the surgery and it is nightmare! She can see either very close or very far, but the rest (which is the vision you use every second !)  is glare, halo, starbursts, blurry, foggy...you name it !!!
Going to see different surgeon tomorrow, and most likely will be removing this multi focal lenses. The problem is, it's been 7-8 month after the surgery done and how difficult is the removal could be? What is the rick?
Awful experience!

P.S. the other patient, who did the same surgery (same multi-lenses) in the same day with my mom, has the same (even worst) result!

[KayakerNC]

The Calhoun LAL seems to be a game-changer in premium IOLs.  If the FDA doesn't get off its' dead butt, I'll seriously consider medical tourism.

[cassyjones]

I am reading these posts and wondering why I did not do that before my surgery.  I have the mufti focal tecnis IOL and I am hoping to get it removed soon.  I will choose the mono focal and gladly wear glasses if needed.  I have many problems including pain, burning, wavering vision, glare, star bursts and halos.  My vision is worse.   The first few weeks were miserable, and this has been going on for over 3 months.  Try putting a contact lens in your eye with the wrong prescription ; that severely limits your function on a day to day basis and that would give you "some" idea of my experience with this lens.  I think most people do not post negative results because they are so over whelmed with the bad experience,

[byzie]

I have had the cataract/Tecnis mutlifocal lens surgery on my left eye - exactly a month ago. I'm concerned that my reading vision is not good. I read for pleasure and was formerly an editor, so I was a professional reader. I have delayed having the second eye surgery, and I'm really torn about it. Difficulty reading would seriously affect my quality of life. I'm told that the second surgery will make a lot of difference, but I'm afraid to take the chance.
b

[ambamata]

Hi I'm looking for some hope and advice as what to do next. I had tecnis multifocal iol's implanted a year and a half ago (Sept 2010) along with an Astigmatic Keratotomy.  Then three months later (Jan 2011) I had further lasek to reduce my remaining astigmatism.  Prior to all ops my prescription was

Right eye:   Sph +5.75    Cyl -2.75    Axis 92.5
Left eye:     Sph +6.00    Cyl -2.50    Axis 90

After all ops my prescription is now:

Right eye:  Sph: - 0.50    Cyl -1.25    Axis 105
Left eye:    Sph :- 0.50    Cyl -1.00    Axis 100

When I was young I also had two squint operations on my left eye so my right eye has always been my stronger dominent eye.

I now feel that I just can't function properly.  I feel that I'm off balance sometimes and that I do not have the vision that I had with glasses/contact lenses.  My vision is sometimes blurred depending on how bright the day(light) is and I feel that I am wearing a pair of dirty glasses that I can't take off and clean.  

Would the remaining prescription I have left be causing this?  would further laser surgery correct this?  could I have them replaced with toric monofocal iols.

[cwatt1]

My comment regarding additional work/procedures could be extended to any type of lens implantation, but I intended it to be in the context of premium lenses that are designed to minimize a patient's dependence on corrective lenses.

The reason is that typically a patient's expectations are that they will spend most of their time free of corrective lenses.  In order to accomplish this, additional corrective procedures such as LASIK, PRK, or limbal relaxing incisions may be needed.  This is particularly true for a patient that has astigmatism, as premium lenses such as Crystalens (or Tecnis or ReSTOR, for that matter) tht are designed to provide effective vision at all distances will not correct astigmatism.

[John C Hagan III, MD, FACS, FAAO]

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[caren123]

My apoligies, I've introducted Crystalens into this discussion and it is not a "mnultifocal" lens -  but it is a premium lens.  As soon as I get my facts straight as to my case, I will ask Dr. Oyakawa what he thinks about the coments my doctors have made..  
I am interested to know regarding cwatt1's comment that "both surgeon and pt must be accepting of the fact that additional work/procedures may have to be done after implementation", is this additional work needed more often when premium IOL's are used, or is it common also when using standard lenses.

[curator19]

Reading between the lines of many postings, it seems that multifocal introocular lens implants are recommended in some cases where some measurement, technique or calculation ought to have been performed.  So where can we find what constitutes the standard of care" for an ophthalmologist who deals with patients who require cataract surgery and who may be recommended for implants?  Is there a recognized publication that spells out what measurements,what medical examinations, and what calculations should be made?

[John C Hagan III, MD, FACS, FAAO]

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[John C Hagan III, MD, FACS, FAAO]

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[JodieJ]

One other contraindication (although it's not really relevant to this thread):  Do not get a toric IOL if you have irregular astigmatism.  Per an article I've received from an unhappy toric patient, a conventional spherical IOL works best with irregular astigmatism.  Send me a private message with an email address to receive this article.

[cwatt1]

It seems there is a wide difference of opinion among ophthalmologists as to what sort of premium lens is preferable.  My own eye surgeon does not like Crystalens nearly as much as the multifocals -- it's his experience that sometimes these lenses accommodate pretty well and sometimes they don't.

One thing that seems to be pretty certain is that multifocal lenses such as ReSTOR are definitely contraindicated where someone has a retinal problem or whose eyes are otherwise not healthy.

I too am interested to hear Dr. Oyakawa's comments regarding Crystalens in light of caren123's comments.

[JodieJ]

Your experience should be valuable information for other people with retinal problems who are contemplating getting the Crystalens.  Dr. Oyakawa, who has had multiple surgeries for retinal detachment and ERM peeling, has reported on this forum that he has been pleased with his Crystalens despite the distortion he has due to retinal damage.  I'd be interested in reading his comments to your post.

I've read that some visual problems (such as mild retinal damage, higher order aberrations, and astigmatism) make vision with a multifocal IOL much worse than it would be with a monofocal IOL.  It seems that some cataract surgeons are unaware of the contraindications for a "premium" IOL.

[caren123]

From my experience with this lens, I would not choose Crystalens if there are retina problems.  I was screened out for Restore and was given the choice whether to have Crystalens or old fashioned lens, presented to me as a toss up--  risks the same and did I want to pay for a possible outcome of not wearing glasses  I decided - yes.  

The cataract surgeon made  no mention of the fact that my possible retina problems were a consideration.  Turned out, the retina specialist had reported that  an accurate condition of the retina could not be determined until the centrally located cataract was removed and he could see more clearly.  Hindsight--  I had possible retinal problems and moderate or  astigmatism but neither were mentioned as considerations when I was presented with making my own choice.  Perhaps they should have been.  The Crystalens was expensive and did  nothing to help the (still present) retina problems including distortion.  Also,more than one refractive surgeon I have complained to about the poor accommodation and range of vision I have with the Crystalens, has said the lens will  with not work as it is supposed to do if there is a problem with the retina.  I'm not sure exactly what they mean.  I have had surgery to improve retina - ERM peel- it did not solve all my problems, I still have distortion, but I really have not seen  any improvement in the operation of the Crystalens

[cwatt1]

You are probably right, Jodie.  There is certainly a limited population that are good candidates for multifocals.  I have no doubt that there are many patients who are disappointed with these lenses, and much of that disappointment is warranted. My only point here is that some folks may have been expecting better vision -- not perfect necessarily, but better than it actually turned out -- so it is incumbant on the eye surgeon to do a good job of ensuring that expectations are realistic as wll as a good job of screening prospective patients.

[JodieJ]

It's my belief that people who are unhappy with their vision usually have good reasons to feel that way.  They are not neurotic or perfectionistic.  Many middle-aged (and older) adults have more than one of the following characteristics:  astigmatism, large pupils, retinal conditions, corneal conditions, dry eyes, higher order aberrations.  (I have at least 4 of the above.)  We're probably poor candidates for multifocal IOLs, and I seriously doubt that a LASIK touch-up would turn us into happy multifocal patients.  My impression is that an accommodating IOL like the Crystalens might be a better choice for many people who aren't ideal candidates for multifocals but don't want monovision.  

[cwatt1]

I invite you to read my journal (actually journals) about my own experience with the implantation of ReSTOR lenses.  As you will see, my surgeon has done a great deal to ensure that my vision is of the best quality possible.  I do agree, in general, with Jodie that the best patients for multifocal IOL's are probably those with no or miminal astigmatism and smaller pupils -- at least those eyes whose angle kappa is narrow enough so that the innermost ring of the lens won't cause problems.

Jodie also has a point about friends of patients.  But sometimes friends or acquaintances can influence people in a negative way.  It's possible that reasonably satisified people can be influenced to feel that they should NOT have been satisfied because their vision isn't perfect.  I think, too, that although the literature suggests that patients should be informed at the outset that their vision is not going to be perfect, and that there are some tradeoffs between multifocal lenses and monofocals, some eye surgeons tend to minimize this.  The bottom line, then, is that (1) the patient has be be carefully screened, (2) the patient absolutely MUST be informed, and must accept the fact, that his/her vision is probably nto going to be perfect, (3) the surgeon should be experienced and comfortable with the type of lens being implanted, (4) the surgeon and patient must be accepting of the fact that additional work/procedures may have to be done after implantation.

[yarrow]

As you perhaps know, my own surgical outcome with the reStor D1 was so successful that it essentially gave me youthful, perfect vision.  

However, as I have mentioned, my surgeon is very careful to match his lenses to his patients, and he says he gives the reStor to only about 30% of his cataract patients, based on criteria that you list, including a 'short' eyeball (hyperopia), no astigmatism, retinal health, and certain other intraocular measurements.

I get the impression from reading posts by unhappy patients that this degree of selectiveness may be rare among eye surgeons, but who knows?  Happy patients are not posting here.   I also have the impression that multifocal IOLs may still be rather rare in the general population.  For example, I am an eye patient (obviously) and have several friends with fixed focus IOLs (two of them with unsuccessful outcomes, interestingly).  I have never met another person with a multifocal IOL, even though I am in an age group where you would expect to see some lens replacements.

My doctor is naturally conservative and neither pushes surgery nor promises miracles, but he has been in business here for decades and done thousands of eyes, and according to him, among his reStor patients, he has had only three truly unhappy patients.  He said that two of them finally got to 'happy,' and he's still working with the third.

[JodieJ]

Yes, there probably is a bias in satisfaction level among people who post on forums.  Yet a few of the unhappy multifocal patients have reported that none of their friends/associates who also have multifocal IOLs are very happy either.  I've never seen a study indicating the percentage of multifocal patients who are happy with their outcome, although this would be easy to determine by post-surgery interviews/questionnaires.  Are the happy patients a select group of people?

The criteria for a good outcome with ReStor seem to include:  healthy eyes, no astigmatism, small pupils, an experienced surgeon, and possibly the absence of higher order aberrations.  The above study suggests that some problems (e.g., residual astigmatism and ametropia) can be helped by refractive surgery,  glasses, and/or YAG.  But do these corrective treatments really change most of the dissatisfied patients into happy ones?  

[yarrow]

The majority of posters in medical forums write in precisely because they are having some kind of problem.  

By contrast, happy patients for whom things have gone well seldom post at medhelp or at any other medical forum.  Those who are reasonably content with their outcomes do not haunt these sites.  They don't need help, so we don't hear much from them.

Therefore, we see an inherent bias towards displeasure, when in fact the balance could be much different from what it appears.

By now, there must be some kind of good sized study out there which contains both positive and negative reactions to multifocal implants gleaned from a reasonably large patient database, but I have not found one.

[cwatt1]

Count me among the satisfied ones.  Although I have ReSTOR IQ +3. which I understand is an improvement over +4, mostly due to intermediate vision.