Monofocal IOLs will never help cataract and refractive surgeons provide patients with good distance and near vision—without the need for spectacle correction, that is. Increasingly, though, this is exactly what patients expect. They are not interested in the sudden need for spectacles and contact lenses when they have never required them in the past.

The arrival of a new generation of multifocal IOLs may help answer this dilemma in cataract surgery and refractive lens exchange, because these lenses are designed to achieve spectacle independence. A drawback of these lenses, however, is that any residual astigmatic or refractive error may degrade the quality of postoperative vision, leading to unhappy patients. For this reason, my colleagues and I undertook a clinical study investigating bioptics in patients with high levels of myopia and hyperopia. We implanted a Tecnis Aspheric Multifocal IOL (Advanced Medical Optics, Santa Ana, California) (Figure 1) and combined it with flap creation (Intralase, Irvine, California) in eyes with more than 1.00 D of preoperative astigmatism (n=65).

The Tecnis Aspheric Multifocal lens has a prolate anterior surface that is designed to compensate for the spherical aberration of the cornea. The posterior surface of the IOL is a diffractive design with a near add of 4.00 D, which is equivalent to a spectacle add of about 3.20 D. Independent of pupil size, the light distribution of far and near focus is 50%.

The flap, 120 µm and 9 mm in diameter, was created prior to surgery, and it was not lifted. Implantation occurred following cataract removal or refractive lens exchange. If the patient had postoperative ametropia, I lifted the flap and performed a wavefront-guided ablation with the Visx Star IR Excimer Laser (Advanced Medical Optics). This was done as early as 1 week following IOL implantation.

Including eyes enhanced with the excimer laser (n=16), the average uncorrected binocular distance visual acuity was 20/28 ±0.13 (range, 20/40 to 20/15), and the average near binocular UCVA was J2 (range, J1 to J4). Residual sphere was 0.12 D ±0.42 D (range, -0.50 D to 1.00 D); residual cylinder was 0.23 D ±0.26 D (range, 0 to 0.50 D); and BSCVA was 20/25 ±0.11 (range, 20/30 to 20/15).

Patients reported excellent near visual acuity, and no one required reading spectacles following surgery. All patients had some halos at night, but effects were severe in only one patient. Additionally, all patients reported that they were happy with their visual results and would undergo implantation with the Tecnis Aspheric Multifocal IOL again.

With increasing emphasis on providing our cataract patients with a visual result free from spectacles—as well as a growing interest in refractive lens exchange—it is important to provide patients with a visual result that maintains both near and distance vision. The Tecnis Aspheric Multifocal provides excellent near and distance vision without the need for spectacles. When combined with a precut femtosecond laser flap, we have the ability to quickly reduce astigmatism with an early enhancement using an excimer laser. In this study, virtually all patients achieved good distance and near vision without the need for spectacles. In our clinic, bioptics procedures using this approach are increasingly becoming the standard of care.

Michael C. Knorz, MD, is professor of ophthalmology at the University of Heidelberg, Medical Faculty. in Mannheim, Germany, and medical director of the Freevis LASIK Center, in Mannheim. Professor Knorz states that he is a consultant for Advanced Medical Optics and Intralase. He may be reached at knorz@eyes.de.