Multifocal IOL Implantation: OK After Prior Refractive Surgery?

Sumit (Sam) Garg, MD


January 05, 2018

Multifocal Intraocular Lens Implantation After Previous Corneal Refractive Laser Surgery for Myopia

Vrijman V, van der Linden JW, van der Meulen IJ, Mourits MP, Lapid-Gortzak R
J Cataract Refract Surg. 2017;43:909-914

High Expectations of Visual Function

Corneal refractive surgery has been performed on millions of patients to decrease their spectacle dependence. Most of these patients have high expectations of visual function—but as these patients age, they develop cataracts like the rest of the population, and yet their expectations for visual function remain.

Presbyopia-correcting intraocular lenses (PC-IOLs) offer patients an opportunity to decrease spectacle dependence. Although these IOLs can work well, there is no perfect technology. Each type of PC-IOL has its strong points and drawbacks. There are also patient selection and surgical considerations. Adding prior refractive surgery to the mix complicates the picture even more.

Study Summary

Vrijman and colleagues reported their outcomes in post-myopic refractive surgery patients undergoing implantation of an apodized multifocal IOL. The majority of patients were undergoing refractive lens exchange, with 38% having visually significant cataracts.

Overall, good refractive outcomes were shown in these patients, with 57% within ± 0.5 diopter (D) of emmetropia and 86% within ± 1 D of emmetropia.

In addition, the investigators noted that predictability of their results was less in patients who had >6 D of myopia correction.


Anecdotally, I found that the results of this study mirror my own clinical experience.

Many patients who have had prior refractive surgery and present with cataracts are excited about the possibility of a PC-IOL. However, implantation of this class of IOL in these patients requires a thorough and frank discussion about the uncertainty of refractive outcomes given their previous refractive surgery, now combined with a lens that splits light to provide distance and near vision.

Add into the fold the effect of centration of their refractive surgery, centration of the multifocal IOL, spherical and other aberrations, and the unknown, and the decision becomes even more complex. Even with all of these cautions, many patients still opt for a multifocal IOL.

Although this is neither the largest nor most comprehensive study on this topic, the results are interesting. The investigators report a relatively long study period of 7 years—during which they note that their predictability of outcomes improved as updates were made to the American Society of Cataract and Refractive Surgery postrefractive calculator.

In addition, the investigators did not use intraoperative aberrometry, a technology I find to be extremely helpful in post-refractive cataract surgery patients.

An interesting finding was that refractive accuracy was less in patients who had > 6 D of myopia correction. This finding requires further study but may help us further counsel patients who have had larger myopic corrections.

"Although this study shows good refractive outcomes, we do not know how 'happy' the patients were."

A major limitation of this study was that patient satisfaction was not addressed. As surgeons, we try to achieve our refractive goals in all patients. Even when we "nail" the outcome, some patients are not "happy." This can be for many reasons, some of which are not related to the refractive outcome. However, in patients with previous refractive surgery, the bar is often raised. Although this study shows good refractive outcomes, we do not know how "happy" the patients were.

We must continue to explore the outcomes of post-refractive cataract surgery patients to gain a better understanding of predictability of outcomes using the various types of PC-IOLs and, equally important, patient outcomes and satisfaction.


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