IMPORTANT ARTICLE ON MULTIFOCAL IOLS

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

There is a very important and very thorough article published just now on multifocal IOLs. It is a pretty fair assessment of the good, the bad and the ugly.  This is the reference. There may be a charge to access it. Perhaps a librarian might be "free' copy

"Maximizing satisfaction with presbyopia correcting intraocular lenses: the missing links.  Jay S. Pepose MD  American Journal of Ophthalmology  2008 November 146: 641-648

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

The first reports on Crysalens HD indicates that to address these near problems that with bilateral IOLs the distance eye is targeted at 0.00 and the reading eye at -0.37 to-.57 that boosts the reading power by about half a diopter and gets most people to near 20/20 at near.

JCH MD

[TW101]

As a recent recipient of the Crystalens HD, I want to express my great satisfaction with the lens and my terrific clear distance vision. However, at this point I need readers for reading and was told that I would upfront. I am also expecting my reading vision to improve overtime so that I may only need readers for very small print. What was not explained to me is that I would need to wear a contact lens in my non-operated eye. I was led to believe that my old glasses with a clear lens replacement would work. That has caused me a significant problem until today when after further examination, it was discovered I was wearing the wrong size contact lens … OOCH! Now corrected, it’s much better. Perhaps someday I’ll be forced to have cataract surgery on my other eye. If indeed the Crystalens HD I now have improves my reading ability over time, I may want to duplicate the process in my remaining eye. Only time will tell.

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

Anyone that even casually reads posts here will know that I am not a fan of today's generation of multifocal IOLs.

I do believe that this type of IOL will be used more and more and that the ultimate answer will be a accommodating type of IOL like the Crystalens.

We may be 5-10 years away from a technology that I would want put in my eye. Nevertheless there are many many happy multifocal IOL patients. Our forum is a magnet for unhappy patients with problems (that's what its for).

There are eye surgeons that put in multifocal IOLs that have had them put in their own eyes so they obviously demonstrate the ultimate test of believe in them.

JCH MD

[JodieJ]

It makes sense that a paid consultant for Bausch & Lomb (manufacturer of the Crystalens) would focus almost exclusively on the problems of their major competitor, Alcon's ReStor.  Thanks for the summary, Buttercup.

[BUTTERCUP109]

I read the article on multifocal lenses. It seemed to concentrate mostly on ReStor and problems with reduced contrast sensitivity, neural adaptation problems with multifocal vision, and photic phenomenon. There was surprisingly little mention of Crystalens. However, near the end.."Ultimately, accommodating lens designs will prevail because they offer superior vision quality...Long-term performance ...may be impacted by RESTRICTIVE POSTOPERATIVE FIBROTIC CAPSULAR CHANGES".  This was the only mention of this in the entire article. For a lens design that ultimately will prevail and has superior vision quality, I thought this odd. Dr. Pepose failed to mention that surgical technique is key in avoiding problems such as these fibrotic capsular changes. I'm the poster-child for this!

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

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[JodieJ]

And perhaps the subjects of the case studies were not as "delighted" with their vision as the authors would have you believe.

[walkietalkie]

Case studies could mean just ONE (good) case studies. That's nowhere near statistics. Nobody will write a bad case study in glossy journals b/c they will say not enough data is available.  

[JodieJ]

Actually, most of the articles about multifocal/accommodating IOLs written by the paid consultants are not experimental studies involving statistical analyses.  Instead, they are case studies of individual patients who received a particular IOL, invariably with excellent results.  Remarkably, even patients receiving bilateral ReZooms are reported to be delighted with their new vision.  By regularly skimming the contents of a couple of online journals, it became easy to associate authors' names with particular IOLs, which always seemed to produce excellent outcomes.  Almost nobody needed their readers anymore.  Meanwhile, this forum was filled with complaints about IOLs that didn't accommodate and debilitating problems with glare, halos, ghosting, waxy vision, etc.      

[walkietalkie]

yep. more lies.

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

Remember Mark Twain's quote:

There are three types of lies.

1. Ordinary lies
2. Extraordinary lies
and the worse lies of all  "statistics"

OR

If at first statistics don't prove what you want then you need more statistics.

JCH MD

[berrywoo]

Walkietalkie,you bring up a good point. Anyone who has taken the most basic of statistics courses will be in agreement. Many people seem to be under the impression that numbers are infallible and cannot be manipulated. Yet the truth is, anything, even numerical data, can and often times is spun to suit a particular agenda.

Thank you Dr. Hagan for posting the informations about the new article.

[BUTTERCUP109]

Dr. Hagen,
Can't wait to read the article you have sited. I have my own theory about the "accommodating" type, which is: that success is very, very dependent on the skill of the surgeon in leaving behind no debris in the capsular bag. Epithelial cells or cortex will "clog" everything so that the IOL cannot flex..also excessive Yag energy can cause the capsular bag to "shrink up" around the IOL, as well.  I'm in the process of proving this to be true in my case with a personal evaluation with B&L. I'm especially motivated because, while Crystalens failed me totally, in fact giving me worse near and intermediate vision than before surgery, my ordeal has been highly successful in giving me a chronic retina inflammation that has lingered now for almost 8 months.

[JodieJ]

From my grad school days, I also recall that the design of a study and the statistics used to analyze the data have a lot to do with the results obtained.

Based on some of the information posted on this forum, I've gotten the impression that some cataract surgeons are just as surprised by the poor results obtained with multifocal/accommodating IOLs as their unhappy patients.  The glowing reports about these IOLs written by paid consultants for the IOL manufacturers may be partially responsible for creating unrealistic expectations.      

[walkietalkie]

Data can be ‘massaged’. Outliers can be ignored if they don’t fit into the normal convention. When a paper or report is written, it can be suited to fit the occasion.

[JodieJ]

The abstract of the 2008 article (which is probably all that many readers see) begins by stating that "...overall satisfaction with the currently available presbyopia-correcting IOLs remains high..."  I believe that many people posting here might disagree.  Unfortunately, the author's financial incentives are not apparent in the abstracts.

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

In the financial statement the author Dr. Pepose says he is a paid consultant to B&L, Visiogen and Calhoun Vision.

JCH MD

[JodieJ]

The author of the above article also wrote a 2007 study comparing the Crystalens vs. ReStor vs. Rezoom.  According to the abstract, the Crystalens provided the best corrected vision at distance, intermediate and near, in addition to the best quality vision.  The ReStor provided the best uncorrected near vision.

It's unfortunate that patients can only access abstracts of the articles in this journal.  We can read entire articles online in Eye World and Cataract & Refractive Surgery Today.  However, many of these articles are written by paid consultants of the IOL manufacturer, and they seem to present a very favorable (and possibly distorted) view of the outcome.  This might contribute to unrealistic expectations for the patient and the surgeon.    

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

Today's technology has significant drawbacks that unless a person is fully aware of and accepts them (need for glasses some of time, night vision problems, dysphotopsia in its many forms) will lead to dissatisfaction.  Surgery will probably continue to move in that direction and future research will greatly help. For the present they don't live to to the promise and expectations of most people.

JCH MD

[walkietalkie]

Is it more of the good or the bad and the ugly? What's the gist of the story?