Joseph Pikkel

Multifocal intraocular lenses: An overview

Multifocal intraocular lenses are increasingly used in the management of pseudophakic presbyopia. After multifocal intraocular lens implantation, most patients do not need spectacles or contact lenses and are pleased with the result. Complications, however, may affect the patients quality of life and level of satisfaction. Common problems with multifocal lenses are blurred vision and photic phenomena associated with residual ametropia, posterior capsule opacification, large pupil size, wavefront anomalies, dry eye, and lens decentration. The main reasons for these are failure to neuroadapt, lens dislocation, residual refractive error, and lens opacification. To avoid patient dissatisfaction after multifocal intraocular lens implantation, it is important to consider preoperatively the patients lifestyle; perform an exhaustive examination including biometry, topography, and pupil reactivity; and explain the visual expectations and possible postoperative complications.

Multifocal Intraocular Lenses: Neuroadaptation

Neuroadaptation is a learning process in which our brain reacts to a previously inexistent sensory input and its ability to adapt to it by ignoring it or using it properly. Neuroadaptation is a major concern while implanting multifocal intraocular lenses since these lenses, in order to achieve multifocality, reduce contrast sensitivity and make at least one of the foci foggy. Knowing the patient’s needs, the lens’ qualities, and its advantages and disadvantages might help in choosing the most suitable lens for the individual patient. Explaining the phenomena to patients and, if needed, training them after surgery might be of great help and eventually lead to patients’ satisfaction. When implanting an intraocular lens, the aberrations of the cornea change due to the surgical incisions and the lens’ aberrations change as well. Multifocal intraocular lenses, due to their design, induce a further change since at least one focus (intermediate vision or near vision) is blurred, thus creating a more complex challenge for the brain to adapt to the new image on the retina. Neuroadaptation is the mechanism in which the brain “adapts” to the new image, uses it, and includes it in its neurosensorial performance to produce the new (postoperative) image. After the neuroadaptation to the new image profile is completed, the perceived image will be similar to the real-world image. This is a time-consuming process and it is dependent on individual factors, some of which, such as age, are predictable while others are unknown.

Multifocal Intraocular Lenses: Preoperative Considerations

Planning ahead cataract surgery with multifocal intraocular lens implant is of great importance and has a huge impact on the surgical result. Multifocal intraocular lenses can obtain multifocality in different ways and can be designed as diffractive, refractive, or as a combination of designs. No multifocal intraocular lens is ideal for all distances, and while choosing a multifocal lens, the surgeon should take into consideration the various factors that influence the surgical technique and the lens performance. Among these factors are dominance of far focus, adequate disparity between foci, aspheric design, availability of toricity, pupil independence, optical performance at the optical bench and “in vivo,” capsular bag stability, posterior capsular opacity rate, compatibility to microincisional surgery, and good far, intermediate, and near visual outcomes. Of great importance are patient selection and patient’s needs and preferences; their personality should also be considered in choosing the right lens for the right patient. Multifocal intraocular lens power calculations should be done carefully and as accurate as possible since the aim of these surgeries is to free patients from needing glasses or contact lenses. Corneal topography should be done prior to surgery in order to plan the cuts to prevent postsurgical astigmatism, and last but not least one should measure the kappa angle in order to prevent postoperative glare and halos.

Correlation between CHA2DS2-VASc Score and Glaucoma Treatment and Prognosis

Purpose To find if CHA2DS2-VASc scale can accurately predict the treatment, prognosis, and outcome for primary open-angle glaucoma (POAG). Patients and methods A survey of 250,000 patient years was taken, using the records of the Ophthalmology Department at Ziv Medical Center. Data was collected regarding the retinal nerve fiber layer (RNFL), visual field (VF), line of treatment (LOT) of glaucoma, and all the data needed to accurately calculate CHA2DS2-VASc score for each patient. Results Sixty-seven patients were included in the statistical analysis. The mean age was 72.5 years. The mean CHA2DS2-VASc score was 3.27 + −1.7. Positive Pearsons correlation coefficients were found for LOT and CHA2DS2-VASc score, 0.35, and for RNFL grade and CHA2DS2-VASc score, 0.37. The correlation was negative for RNFL width and CHA2DS2-VASc score, −0.35. Conclusions CHA2DS2-VASc score was shown to be correlated with glaucoma. This correlation was manifested positively by the LOT needed to stop glaucoma progression, with higher CHA2DS2-VASc scores correlated with more aggressive treatment. Since glaucoma is a disease with a progressing nature, it is important to treat patients aggressively on one hand, while offering the most benign treatment as possible on the other hand. Modification of the CHA2DS2-VASc score could achieve an even higher correlation.

Delivering Bad News: Can We Do Better?

Bad news in the context of health care has been broadly defined as significant information that negatively alters people’s perceptions of the present or future. Effectively delivering bad news requires excellent communication skills. Evidence shows that bad news is frequently given inadequately (Chumpitazi et al., Cureus 8:e595, 2016).

Summary of eight years 'Glaucoma Day' screening.

Y.Y. Pikkel , I. Epstein , A. Nov-Sharabi , I. Beiran , J. Pikkel b,f a Tzameret Medical Track, Hebrew University, Jerusalem, Israel b Department of Ophthalmology, Ziv Medical Center, Safed, Israel c Research Wing, Ziv Medical Center, Safed, Israel d Tel-Hai Academic College, Israel e Department of Ophthalmology, Rambam Medical Center, Haifa, Israel f The Faculty of Medicine, Bar Ilan University, Safed, Israel

Multifocal Intraocular Lenses in Special Cases

Though the use of multifocal intraocular lenses is rapidly increasing, in some cases special considerations about the efficacy, safeness, and patient’s well-being should be taken into account. Using these lenses in children can be of benefit because of the possibility for rapid rehabilitation of far, intermediate, and near vision; improved chance of binocularity; reduced risk of amblyopia; no need for bifocals; and a better self-estimation of the child. On the other hand, implanting multifocal intraocular lenses, we might reduce contrast sensitivity and intermediate vision and exacerbate amblyopia. Another special case is when treating glaucoma patients. Glaucoma patients, with no or slight visual field damage and controlled intraocular tension, may be also considered today as candidates for multifocal intraocular lens implant. However, patients with advanced glaucoma, significant visual field defects, or uncontrolled intraocular tension as well as patients with a glaucomatous damage in the other eye are not adequate candidates for this operation. As with glaucoma patients, patients that suffer from maculopathy should be carefully selected and preoperative assessed for multifocal intraocular lens implant. Some of these patients, dependent on their retinal status, will benefit from multifocal intraocular lenses. In patients that suffer from amblyopia, implanting multifocal intraocular lenses does not exacerbate amblyopia though there is a reduction in contrast sensitivity. Another situation to consider is the ocular surface health and integrity as well as the function of the lacrimal system and all its components. A healthy ocular surface is a key factor in achieving a successful result in multifocal intraocular lenses implant. Since the corneal tear film is actually the first refractive plane of the eye, its healthiness and integrity is important in reaching the aim of having the light rays uninterrupted focusing on the retina. Dry eye and ocular surface problems should be diagnosed and treated preoperatively but should not prevent multifocal intraocular lens implant and the patients to benefit from it. In treating unilateral cataract, some difficulties may arise, though bilateral multifocal intraocular lenses implant is favorable; in cases of unilateral cataract, patients gain more from these lenses compared to monofocal lenses, overcoming the reduction in contrast sensitivity. Though neuroadaptation might be more difficult or take longer even in unilateral cases, multifocal intraocular lenses implant is favorable.

Multifocal Intraocular Lenses: Critical Analysis of Results

There are numerous multifocal intraocular lenses available on the market. The surgeon may be totally confused and with no clear criteria about which multifocal lens to choose for a specific patient. In this chapter we have collected all the available information published on most of the lenses in the market today in order to form some kind of data banking of multifocal lenses. The data is presented in three ways – a description of every lens and its qualities, recent publications, and the most important experience of the authors when using these lenses. A second way of comparing the different lenses is by using the table provided in this chapter that enables a quick comparison between the various lenses.

Multifocal Intraocular Lenses and Corneal Refractive Surgery

The number of patients needing cataract surgery after having previously refractive surgery on the cornea is on the rise and will continue to increase in the future. At the same time, more and more patients that either had refractive laser enhancement or cataract surgery with multifocal intraocular lens implant have high expectations for good vision free of the need to use any other visual aid like spectacles or contact lenses. This leads to the need to combine the various laser refractive surgeries with cataract extraction and multifocal intraocular lens implant. There are two possible clinical conditions – multifocal intraocular lens implant after refractive laser treatment or refractive laser enhancement after multifocal intraocular lens implant.

Multifocal Intraocular Lenses: The Challenges

Modern lifestyles and quality of life are constantly improving. Cataract surgery and intraocular lens (IOL) implantation have evolved over the last decade, and the improvement of the quality of vision of patients utilizing these advances is therefore one of the main aims of today’s cataract surgeons. The increase in life expectancy and the fact that nowadays we operate on younger patients with cataract emphasize the need to provide good vision at all distances without the use of spectacles or contact lenses.