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Clinical Optometry

Clcal Optomtry 2010:2 13

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O R i g i n A L R e s e A R C h

A tudy of moofocal traocular l (Acrysof) m-moovo (MMV) ad prmummultfocal mplatato of RsTOR

M C1

Mdy C2

1Jo A Bur scool of Md c ,Uvrty of hawa, UsA; 2Uvrty

of Calfora, irv, UsA

Corrpodc: M C55 s. Kuku st. #c-109, hoolulu,hawa 96813emal [email protected]

Abstract: We compared the AcrySo monoocal intraocular lens (IOL) in mini-monovision

(MMV) (n = 20) with the ReSTOR multiocal IOL (n = 20) or glasses independence ater

cataract surgery. The ReSTOR IOL showed a signicantly higher proportion o postoperative

independence rom glasses. The MMV ormula monoocal AcrySo recipients with the same

pre-op selection criteria as the ReSTOR achieved 20/30 and J3 without glasses post cataractsurgery. AcrySo IOL can be a good alternative or those patients who cannot aord ReSTOR

IOL and yet desire some degree o independence rom glasses.

Keywords: cataract, cataract surgery, intraocular lens, AcrySo IOL, ReSTOR IOL, minimo-

novision, glasses independence

IntroductionModern cataract surgery has progressed to reractive cataract surgery. Myopia,

astigmatism, hyperopia and presbyopia can now all be corrected during cataract surgery.

Independence rom spectacle use has become a post-operative target ollowing cataract

surgery and can greatly enhance patients quality o lie.1 The ReSTOR (Alcon, Inc.)

multiocal intraocular lens (IOL) can achieve a high percentage (85%) o 20/20 distantvision and J1 reading vision without corrective glasses.2 However, the expense o these

ReSTOR IOLs and the expertise required to implant them (perection in phacoemulci-

cation and experience in multiocal IOLs) can be a limiting actor in their use. The pre-op

examinations o multiocal IOLs require topography, optical coherence tomography and

pachymetry beside routine ones. Surgeons need to be skillul in phacoemulcication,

IOL implantation and limbal relaxation incision. Additionally, these lenses may have

optical irregularities such as glare and decreased contrast sensitivity.3

We know that monovision can produce 20/20 vision or the dominant eye (Plano)

and J1 reading vision or the nondominant eye (-2.00 to -2.50). However, it may be di-

cult to tolerate or most patients because o the severity o anisometropia (more than 2

D dierence between 2 eyes). Alternative strategies to achieve spectacle independence

that can be well tolerated as suggested in the Cochrane systematic review3 are mini-

monovision (MMV) (nondominant eye -0.50 D to -1.25 D) and accommodative IOL.

This is the descriptive study o the MMV o AcrySo (Alcon, Inc.) SN60WF and

multiocal ReSTOR SN60D3. The MMV in monoocal IOLs yields a high percentage

o patient satisaction with 20/30 and J3 vision without glasses similar to older styles

o multiocal Array IOL.4 The MMV monoocal IOL is usually covered by insurance

and is relatively easy to implant even or inexperienced eye surgeons, and has less

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Clinical Optometry

1 April 2010
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Clcal Optomtry 2010:2

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optical disturbance (clear optics without rings) compared to

multiocal IOLs. In addition, since MMV IOLs recipients

can tolerate anisometropia better than true monovision,4 a

postoperative vision o 20/30 distant and J3 reading without

glasses may be satisactory or most patients5 who do not

need to drive or do extensive reading.

MethodsAll 40 patients included in the study were rom the Ming

Chen MD. Eye Clinic in Honolulu, Hawaii rom January 2007

to May 2009. Twenty subjects were chosen or each variable.

Those patients whose eyes showed major ocular pathology,

including leukoma cornea or maculopathy and a cylinder

over 0.75 D, were excluded (these are the criteria required

by ReSTOR IOL). Twenty patients randomly selected rom

the group o patients who met the criteria and also had the

MMV ormula reraction (the dominant eye o between

Plano and-0.50 spherical equivalents and-0.50 to -1.25 in

the nondominant eye) 3 months post-op were included in the

group o bilateral monoocal IOLs (AcrySo). Twenty patients

who met the criteria and had between plano and 0.75 reraction

3 months post-op were in the group o bilateral ReSTOR

IOLs. All 40 patients had bilateral uncomplicated cataract

surgery by a single surgeon at one surgical center.

Vision was checked binocularly without glasses using

a standard Snellen chart or distance and a near chart at

14 inches or near vision in the same illumination in the

same exam room by the same technician who was masked

or the study.

This study was approved by the Hawaii Pacic Health

Institutional Review Board.

ResultsAs shown in Figure 1, the postoperative vision o MMV mono-

ocal IOL and o ReSTOR IOL showed that all 40 patients

achieved 20/30 distance vision and J3 visual acuity without

glasses. There were no dierences in proportions o the

two groups in this comparison. However, a signicantly

higher proportion o the ReSTOR patients (19/20) 95%

achieved glasses independence compared to the MMV group

(7/20) 35% (Figure 2). In order to estimate the accuracy in

the normal population o these two independent proportions,

we calculated the standard error using the ormula below.

We are 95% condent that the true dierence in proportions

lies between 0.58 and 0.62 (condence intervals (CI)). Weconclude that the ReSTOR IOL recipients are signicantly

more glasses independent than the MMV recipients. In this

study, we consider the patient is glasses independent i the

patient declares independence rom glasses.

Formula to estimate standard error (SE):

SE p p p pN

p p

N( )

( ) ( )1 2

1 1

1

2 2

2

1 1- =

-

+

- P

1= 0.95P

2= 0.35N

1= 20N

2= 20, SE= 0.013

95% CI or true P (the estimate o the proportion) is

0.6+

or-

1.96

0.013 rom 0.58 to 0.62.

DiscussionWith the current high cost o premium multiocal IOLs and

a sagging economy, patients take into careul consideration

the cost o ophthalmic surgery with an expensive lens versus

Table Dcrptv caractrtc of 40 traocular l (iOL)

rcpt

Mini monovision IOL (%) ReSTOR IOL (%)

sx

Mal 10 (25) 10 (25)

Fmal 10 (25) 10 (25)

A

5060 3 (15) 3 (15)6170 7 (35) 9 (45)

70 10 (50) 8 (40)

0

5

10

15

20

20/30, J3

AcrySofReSTOR

Figure 20/30, J3 vo Acrysof ad RsTOR. Tr wr 20 patt ac

roup.

Figure gla dpdc.

0

2

4

6

8

1012

14

16

18

20

Glasses

ind.

AcrySof

ReSTOR
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Acrysof moofocal traocular lDovepress


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the value o having good visual acuity or the rest o their

lie. While some subjects enjoy a liestyle where glasses

independence via multiocal IOLs is a necessity, this study

suggests that monoocal IOLs are usually aordable and

consistently successul in restoring visual acuity o 20/30

and the ability to read J3 without glasses.4 Two years ago,4

we compared in the same setting MMV and Array multio-

cal (same price as MMV), which showed similar outcomes

in MMV and Array multiocal in glasses independence by

achieving 20/30, J3 vision without glasses. However, the

reported outcome o 19/20 glasses independence in ReSTOR

versus 7/20 in MMV AcrySo monoocal may be subject

to considerable bias as the patients who select (and could

aord) ReSTOR IOLs may have been more determined to

be independent o glasses.

Various barriers remain or ReSTOR IOLs. The cost is

higher and not covered by insurance,6 ophthalmologists with

the special training to implant multiocal IOLs are ewer,

and some patients are not candidates or ReSTOR IOLs

or various reasons. There were more complaints o halos,

glares and a decreased contrast sensitivity rom patients who

had ReSTOR IOLs implantation.7,8 With these limitations in

mind, the MMV ormula o monoocal IOL is a good alter-

native to ReSTOR IOL. However, the premium multiocal

IOL o N, TT. ReSTOR is signicantly more eective in

achieving glasses independence, as shown in this study.

This study has a signicant eect on the economic issues

o the aordability o ReSTOR IOLs. In particular in devel-

oping countries and in underprivileged peoples, the MMV

monoocal IOLs can provide suciently good vision (20/30

or driving, J3 or reading yellow pages) without glasses

and can be tolerated well (no subjects in this study reported

complaints).

Future studies in MVM IOL should ocus on the measure-

ment o the amplitude o accommodation as an objective test

instead o testing reading vision subjectively. In addition, it

will be interesting to determine whether there is a signicant

dierence among dierent monoocal IOLs (eg, one piece,

two piece, small optic) in MMV.

ConclusionThe MMV ormula monoocal AcrySo recipients with the

same pre-op selection criteria as or ReSTOR can achieve

20/30 and J3 without glasses post cataract surgery. It can

be a good alternative or those patients who cannot aord

ReSTOR IOL and yet desire some degree o reedom rom

glasses. However, the ReSTOR IOLs recipients had a signi-

cantly higher percentage o glasses independence compared

to MMV ormula AcrySo IOL recipients.

DisclosuresThe authors declare no conficts o interest.

References1. Javitt JC, Steinert RF. Cataract extraction with multiocal intraocular

lens implantation: a multinational clinical trial evaluating clini-cal, unctional, and quality-o-lie outcomes. Ophthalmology .

2000;107:20402048.

2. Chang DF. Prospective unctional and clinical comparison o bilateral

ReZoom and ReSTOR intraocular lenses in patients 70 years or

younger.J Cataract Refract Surg. 2008;34:934941.

3. Leyland M, Zinicola E. Multiocal versus monoocal intraocular

lenses in cataract surgery: a systematic review. Ophthalmology.

2003;110:17891798.

4. Chen M, Atebara N, Chen TT. A comparison o a monoocal AcrySo

IOL using the blended monovision ormula with the multio-

cal array IOL or glasses independence ater cataract surgery. Ann

Ophthalmol(Skokie). 2007;39:237240.

5. Ito M, Shimizu K. Reading ability with pseudophakic monovision

and with reractive multiocal intraocular lenses: Comparative study

J Cataract Refract Surg. 2009;35:15011504.

6. Department o Health and Human Service, Centers or Medicare &

Medicaid Service, United States o America. CMS Rulings No.

05-01(2005). URL: www.cms.hhs.gov/rulings.

7. Kamlesh, Dadeya S, Kaushik S. Contrast sensitivity and depth o ocus

with aspheric multiocal versus conventional monoocal intraocular

lens. Can J Ophthalmol. 2001;36:197201.

8. Ortiz D, Ali JL, Bernabu G, et al. Optical perormance o monoocal

and multiocal intraocular lenses in the human eye.J Cataract Refract

Surg. 2008;34:755762.
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