Multifocal intraocular lenses (MFIOL) enable good near and far vision after cataract surgery. Excellent results with
cataract patients encouraged ophthalmologists to implant MFIOL after clear lens extraction (CLE). There are two types
of MFIOL: diffractive and refractive. In our prospective study we compared clinical outcomes after CLE and bilateral implantation
of diffractive (Tecnis Multifocal), (N = 100 eyes, 50 patients) and refractive (ReZoom), (N = 100 eyes, 50 patients)
MFIOL to patients with presbyopia and hyperopia. Near and distant uncorrected visual acuity (UCVA), spectacle
dependency, subjective satisfaction and visual disturbances were measured and compared between two groups. Patients
achieved good near and distant UCVA in both groups. »Tecnis« group had better near UCVA (statistically not significant)
and less night time visual disturbances. »ReZoom« group reported less problems with intermediate vision. Diffractive
and refractive MFIOL enable high rate of spectacle independency to presbyopic hyperopic patients with low rate of
side-effects. Refractive MFIOL provide better intermediate vision and diffractive slightly better near vision and less haloes
and glare

Ante Barišić

Iva Dekaris

Maja Bohač

Nikica Gabrić

English

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Coll. Antropol. 32 (2008) Suppl. 2: 27–31Original scientific paperComparison of Diffractive and RefractiveMultifocal Intraocular Lenses in PresbyopiaTreatmentAnte Bari{i}, Iva Dekaris, Nikica Gabri}, Maja Boha~, Ivana Romac,Ivana Mravi~i} and Ratimir Lazi}Eye Clinic »Svjetlost«, Zagreb, CroatiaA B S T R A C TMultifocal intraocular lenses (MFIOL) enable good near and far vision after cataract surgery. Excellent results withcataract patients encouraged ophthalmologists to implant MFIOL after clear lens extraction (CLE). There are two typesof MFIOL: diffractive and refractive. In our prospective study we compared clinical outcomes after CLE and bilateral im-plantation of diffractive (Tecnis Multifocal), (N = 100 eyes, 50 patients) and refractive (ReZoom), (N = 100 eyes, 50 pa-tients) MFIOL to patients with presbyopia and hyperopia. Near and distant uncorrected visual acuity (UCVA), spectacledependency, subjective satisfaction and visual disturbances were measured and compared between two groups. Patientsachieved good near and distant UCVA in both groups. »Tecnis« group had better near UCVA (statistically not signifi-cant) and less night time visual disturbances. »ReZoom« group reported less problems with intermediate vision. Diffra-ctive and refractive MFIOL enable high rate of spectacle independency to presbyopic hyperopic patients with low rate ofside-effects. Refractive MFIOL provide better intermediate vision and diffractive slightly better near vision and less ha-loes and glare.Key words: presbyopia, hyperopia, multifocal, lenses, diffractive, refractive, phacoemulsification, pseudophakiaIntroductionPresbyopia and its treatment options are intensivelyinvestigated in modern ophthalmology. Although, thereare numerous discussions regarding causes and optimaltreatment of presbyopia, clear answers are still not avail-able. At the moment, glasses are mostly used for correc-tion of presbyopia but many patients dislike them. In ev-eryday practice we see that more and more people wantto become independent of glasses.»Monovision« principle, contact lenses, laser refrac-tive surgery and new accommodative intraocular lensesare current attempts for presbyopia treatment1. Thosemethods did not achieve completely satisfying outcomesand have many limits in patient selection.Multifocal intraocular lenses (MFIOL) have two ormore focuses and they enable good near and distant vi-sion after lens removal2,3. They can be implanted to cataactpatients and after clear lens extraction as refractive sur-gery procedure4. Cataract patients who received MFIOLhave well near and far uncorrected visual acuity(UNCVA), low spectacle dependency and they are highlysatisfied5. Thanks to the fact that MFIOL can producetwo images and excellent experience in cataract patients,we started to use them in refractive lens exchange (RLE)as presbyopia treatment.There are some side-effects of MFIOL implantationsuch as visual disturbances at night, halos and glare andproblems with intermediate vision (work at computer)6.Those problems are reduced three to twelve postopera-tive months, so most of patients do not have seriouscomplains7. Postoperative astigmatism is one of the mostimportant issues. It is the most common reason for wear-ing glasses after MFIOL implantation so we have toavoid patients with more than 1D of preoperative astig-matism.There are two types of MFIOL: diffractive and refrac-tive. Diffractive MFIOL use light diffraction at an inter-27Received for publication July 30, 2008ference grid to produce two different focal points8. In re-fractive MFIOL, refractive power changes from centre toperiphery of lens and produces many focuses9. TecnisMultifocal is diffractive MFIOL which has diffractiveposterior surface and prolate anterior surface that sup-presses spherical aberrations. It has +4.00 D addition forreading distance. Light distribution between two focusesis 50–50%. ReZoom is refractive MFIOL composed of 5optical zones with aspherical transition. Three zones, in-cluding central, are for far vision, other two for near.ReZoom distributes 10–11% of light to intermediate fo-cus. In our study we have investigated clinical outcomesof Tecnis and ReZoom implantation to presbyopic andhyperopic patients after clear lens extraction and com-pared obtained differences between two lenses.Patients and MethodsIn this prospective, randomized, comparative study,we divided patients in two groups. Clear lens extractionwas performed in both groups on the same PHACO ma-chine using the same operative technique by two experi-enced surgeons, followed by MFIOL implantation. Infirst group, Tecnis MFIOL were bilaterally implanted to50 patients (N = 100 eyes) and in second, ReZoomMFIOL also to 50 patients (N = 100 eyes). There were nosignificant differences between the two investigated groupsregarding age, gender and ocular pathology. Mean agewas 52 ± 3.7 years in »Tecnis« group and 54 ± 2.6 years inother one, 29 females and 21 males in both groups. In-cluding criteria were presbyopia and hyperopia morethan +1.00 D, need for a bilateral IOL implantation, pa-tients who dislike glasses and were highly motivated forsuch procedure. Patients with astigmatisms over 1.00 D,retinal or any other serious ocular pathology, profes-sional drivers, people with high professional visual needsor unrealistic expectations were excluded. Preoperativebest corrected visual acuity in all cases was 1.0. Follow upwas at least 6 months. Near and distant uncorrected vi-sual acuity (UCVA), spectacle dependency, subjective sat-isfaction and visual disturbances were measured andcompared in both groups.SPSS 11.0 for Windows was used for statistical analy-sis. Since there were two investigated groups with di-chotomous variables, statistical significance was deter-mined by c2 test at level of 5%.ResultsPatients achieved excellent distance and near uncor-rected visual acuity (UCVA) in both groups. UCVA betterthan 0.8 (20/25) was achieved in 89.00% eyes in »Tecnis«group and 86.00% in »ReZoom« group (Figure 1). Therewas no statistically significant differences between groups(c2 = 0.41; df = 1; p = 0.670) (Figure 2). Near UCVA wasalso good, 85.00% read J2 or better in »Tecnis« group and79.00% in »ReZoom group (Figure 3), without statisti-cally significant differences between lenses (c2 = 0.866;df = 1; p = 0.457) (Figure 4). 72.00% of patients neverwear glasses and 28.00% wear them sometimes whenthey read small letters or work at computer in »Tecnis«A. Bari{i} et al.: Comparison of Diffractive and Refractive MFIOL in Presbyopia Treatment, Coll. Antropol. 32 (2008) Suppl. 2: 27–31280102030405060701 0,9 0,8 0,7 0,6 0,5 0,4Distant UCVATecnis MultifocalReZoomNo.ofeyesFig. 1. Distance uncorrected visual acuity (UCVA) at six postop-erative months on eyes implanted with diffractive (Tecnis Multi-focal) and refractive multifocal intraocular lens (ReZoom).ReZoomTecnis Multifocal120100806040200<0.8>0.8NumberofeyesFig. 2. Statistical analysis of difference between distance uncor-rected visual acuity (UCVA) in Tecnis Multifocal and ReZoomgroup. c2 = 0.41; df = 1; p = 0.670.0No.ofeyes203040506070J1 J2 J3 J4 J5Near UCVATecnis MultifocalReZoom10Fig. 3. Near uncorrected visual acuity (UCVA) at six postopera-tive months on eyes implanted with diffractive (Tecnis Multifocal)and refractive multifocal intraocular lens (ReZoom).group. 8.00% of »ReZoom« patients have to wear glasseshalf time, 24.00% wear them sometimes and 68.00%never (Figure 5), also there was no statistically signifi-cant differences between groups (c2 = 0.190; df = 1; p =0.828) (Figure 6). Binocular UCVA was even better, 84.00%of patients read 1.0 and 72.00% J1. All »Tecnis« patientswould implant the same lens again (Figure 7) and aver-age satisfaction mark was 8.9 at 1–10 scale. In »ReZoom«group, 4 patients would not implant it again (Figure 7)and average mark was 7.8. 10 patients in »Tecnis« groupand 21 in »ReZoom« complained at mild to moderatenight driving visual disturbances. In »ReZoom« group wehad to explant 4 lenses (2 patients) due to severe haloesand secondary implanted monofocal IOL. In »Tecnis«group 7 patients had problems with work at computerand they have to use reading glasses (+ 0.75 dsph) whenthey work for a longer time. In »ReZoom« group 4 pa-tients had to wear glasses for computer occasionally.Three patients had decentration of IOL, we made suc-cessful reposition of IOL. Other intra-operative or post--operative complications were not reported.DiscussionHyperopic and presbyopic patients in this study, whounderwent refractive lens exchange followed by implan-tation of diffractive or refractive multifocal intraocularlens, were highly satisfied. They have good near and farvision in both groups, diffractive and refractive and theyare free of glasses most of time. ReZoom patients haveexcellent far vision in bright light because central zone isfor distant focus and it acts like monofocal lens, but theyhave very poor near vision in same light conditions. Pa-tients who received ReZoom reported less problems withintermediate vision and less need for small hyperopiccorrection (+0.75 dsph). Refractive lenses produce mul-tiple focuses and distribute 10–18% of light, depend onpupil size so they have better vision at 60–80 cm. Di-ffractive lenses are bifocal and light distribution is be-tween near and far focus (50–50%) so intermediate visionis poorer than refractive, but they are independent onpupil size10. Night time visual disturbances, haloes andglares were reported by patients in both groups andA. Bari{i} et al.: Comparison of Diffractive and Refractive MFIOL in Presbyopia Treatment, Coll. Antropol. 32 (2008) Suppl. 2: 27–3129<J2>J2ReZoomTecnis Multifocal120100806040200NumberofeyesFig. 4. Statistical analysis of difference between near uncorrectedvisual acuity (UCVA) in Tecnis Multifocal and ReZoom group. c2= 0.866; df = 1; p = 0.457.Near spectacle wearPatients(%)10%20%30%40%50%60%70%80%None Some Half Most AllPortion of timewearing glassesTecnisReZoomFig. 5. Portion of time patients wear reading glasses at six post-operative months after implantation of diffractive (Tecnis Multi-focal) and refractive multifocal intraocular lens (ReZoom).Wear glassesNeverwear glassesReZoomTecnis Multifocal120100806040200NumberofpatientsFig. 6. Statistical analysis of difference between portion of timepatients wear reading glasses in Tecnis Multifocal and ReZoomgroup. c2 = 0.190; df = 1; p = 0.828Would you have Tecnis/ReZoomIOL implanted again0%20%40%60%80%100%ReZoomYesNoPatients(%)TecnisFig. 7. Patient’s subjective satisfaction after diffractive (TecnisMultifocal) and refractive multifocal intraocular lens (ReZoom)implantation.those are side-effects of MFIOL because one image is al-ways blurred and this defocused light energy creates dis-turbances. ReZoom patients reported more severe prob-lems with halos and we had to explant four lenses in twopatients. Other patients who complained of night timevisual disturbances had these issues weakened and al-most disappeared in six months of follow up. Also, afterthat period, portion of time they wore reading glasseswas reduced. This is explained by the fact that time isnecessary for brain to adjust to new situation with twoimages. Optimal results are accomplished with bilateralimplantation and patients faster adapt themselves tolenses if we perform simultaneous implantation. Threepatients complained of blurred image due to IOL decen-tration so we performed reposition of IOL which was suc-cessful and complains disappeared. These emphases thatsurgeon’s skill and experience is important and this kindof lens must be very well centrated during surgery. Mostof patients who did not achieve UCVA 1.0 had postopera-tive astigmatism; although we excluded those with morethan 1.00 D preoperative astigmatism. For them, it ispossible to perform laser refractive surgery 3–6 monthsafter operation to correct this postoperative astigma-tism11. Satisfaction was high, especially in presbyopeswith higher hyperopia. Average mark in Tecnis groupwas 8.9 and 7.8 in ReZoom group. Patients in Tecnisgroup complained to mild halos, glare, longer period ofaccommodation, reading problems with very small let-ters and computer, but all patients would implant thesame lens again. Patients in ReZoom reported seriousproblems with halos and moderate with near reading.They needed longer period of adaptation. Four patientswould not implant this lens again.In our practice we meet patients who do not want towear glasses. Many of them are presbyopes and laser re-fractive surgery or Phacic IOL is not helpful for them.MFIOLs proved to be good choice for patients who arehighly motivated and have realistic expectations12,13,14.Patient selection is the key point for refractive lens ex-change because these patients have big expectations andrequest perfect vision; as good as they had before opera-tion. It is important to spend enough time with patientsbefore surgery and to explain them all advantages andsome potential disadvantages of this treatment. Patientswho ask for guaranties and can not accept possibility towear glasses sometimes when they work at computer arenot candidates for MFIOL.If we compare our results with recent studies (2008),we will see that F. J. Goes and S. Cillino in their studieshave similar results for distance UCVA, visual distur-bances and intermediate vision for both lenses, but be-tter near UCVA and spectacle independence for TecnisMultifocal and worse for ReZoom6,7.At the moment we do not have perfect solution for pa-tients with presbyopia and refractive lens exchange withimplantation of MFIOL is the optimal treatment forcarefully selected patients. Our study proved thatCLE+MFIOL highly reduce spectacle dependency andinsure patient’s satisfaction with minimal visual distur-bances. Attention should be made that those patientswhose professional or living style is not favorable forMFIOL are excluded from this treatment. People who of-ten drive in night and live active professional and privatelife are not perfect for refractive IOL. We have also con-cluded that patients with diffractive IOL who work morethan 4–5 hours at computer should accept possibility towear reading glasses sometimes.ConclusionDiffractive MFIOL enable excellent near and far vi-sion and have no restriction on pupil size and reducenight visual issues but intermediate vision is poor. Re-fractive lenses give excellent far vision, good near and in-termediate images but their disadvantages are problemswith halo and glare.R E F E R E N C E S1. SARAGOUSSI J, Ophtalmol, 30 (2007) 552. — 2. BELLUCCI R,Curr Opin Ophthalmol, 16 (2005) 33. — 3. LANE SS, MORRIS M,NORDAN L, PACKER M, TARANTINO N, WALLACE RB, OphthalmolClin North Am, 19 (2006) 89. — 4. FERNANDEZ-VEGA L, ALFONSO JF,RODRIGUEZ PP, MONTES-MICO R, Ophthalmology, 10 (2007) 37. — 5.DENOYER A, LE LEZ ML, MAJZOUB S, PISELLA PJ, J Cataract Re-fract Surg, 33 (2007) 210. — 6. CILLINO S, CASUCCIO A, DI PACE F,MORREALE R, PILLITTERI F, CILLINO G, LODATO G, Ophthalmol-ogy, 115 (2008) 1508. — 7. GOES FJ, J Refract Surg, 24 (2008) 243. — 8.DE VRIES NE, WEBERS CA, MONTÉS-MICÓ R, TAHZIB NG, CHENGYY, DE BRABANDER J, HENDRIKSE F, NUIJTS RM, J Cataract Re-fract Surg, 34 (2008)1476. — 9. AUFFARTH GU, RABSILBER TM, KO-HNEN T, HOLZER MP, Ophthalmologe, 105 (2008) 522. — 10. CHIAM PJ,CHAN JH, HAIDER SI, KARIA N, KASABY H, AGGARWAL RK, J Cata-ract Refract Surg, 33 (2007) 2057. — 11. JENDRITZA BB, KNORZ MC,MORTON S, J Refract Surg, 24 (2008) 274. — 12. ALIO JL, TAVOLATOM, DE LA HOZ F, CLARAMONTE P, RODRIGUEZ-PRATS JL, GALA A,J Cataract Refract Surg, 30 (2004) 2494. — 13. PACKER M, HOFFMANRS, FINE IH, DICK HB, Int Ophthalmol Clin, 46 (2006) 63. — 14. HOL-ZER MP, RABSILBERT M, AUFFART GU, Ophthalmologe, 103 (2006) 661.A. Bari{i}Eye Clinic »Svjetlost«, Zagreb, Croatiae-mail:antebarisic@yahoo.comA. Bari{i} et al.: Comparison of Diffractive and Refractive MFIOL in Presbyopia Treatment, Coll. Antropol. 32 (2008) Suppl. 2: 27–3130USPOREDBA DIFRAKTIVNIH I REFRAKTIVNIH MULTIFOKALNIHINTRAOKULARNIH LE]A U TERAPIJI PRESBIOPIJES A @ E T A KMultifokalne intraokularne le}e (MFIOL) omogu}uju dobar vid na blizinu i daljinu nakon operacije katarakte. Odli~nirezultati s bolesnicima kojima je operirana katarakta ohrabrila je oftalmologe na ugradnju MFIOL nakon odstranjenjabistre le}e (CLE). Postoje dvije vrste MFIOL: difraktivne i refraktivne. U na{oj prospektivnoj studiji uspore|ivali smoklini~ke rezultate nakon CLE i obostrane ugradnje difraktivne (Tecnis Multifocal), (N = 100 o~iju, 50 bolesnika) irefraktivne (ReZoom), (N = 100 o~iju, 50 bolesnika) MFIOL presbiopima i hipermetropima. Mjerili smo nekorigiranuvidnu o{trinu (UCVA) na blizinu i daljinu, ovisnost o nao~alama, subjektivno zadovoljstvo i vidne smetnje bolesnika iuspore|ivali ih izme|u dvije skupine. Bolesnici su ostvarili dobru UCVA na blizinu i daljinu u obje skupine. »Tecnis«skupina imala je ne{to bolju UCVA na blizinu (bez statisti~ke zna~ajnosti) i manje no}nih smetnji vida. »ReZoom«skupina prijavila je manje problema s intermedijarnim vidom. Difraktivne i refraktivne MFIOL omogu}uju visok stu-panj neovisnosti o nao~alama presbiopima hipermetropima uz mali broj nuspojava. Refraktivne MFIOL osiguravajubolji intermedijarni vid, a difraktivne ne{to bolji vid na blizinu i manje haloa i zablje{tenja.A. Bari{i} et al.: Comparison of Diffractive and Refractive MFIOL in Presbyopia Treatment, Coll. Antropol. 32 (2008) Suppl. 2: 27–3131

Comparison of Diffractive and Refractive Multifocal Intraocular Lenses in Presbyopia Treatment

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