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Cover Focus | Jun 2016

Multifocality in a Complicated Case

Domestic abuse and anxiety contributed to the complexity.

Getting to Know the Patient

A 49-year-old woman with a history of domestic violence and anxiety disorder presented to our outpatient department in September 2015. Ocular findings showed a distance BCVA of 0.2 logMAR in her better right eye and 0.5 logMAR in her left. She described a progressive loss of vision for the past 3 years in both eyes after having experienced several head injuries due to domestic violence 3 years ago. Since then, she had been treated for her anxiety disorder and seen by three different ophthalmologists. To date, the only ophthalmic treatments she had received were ocular surface lubricants.

Slit-lamp examination showed a nuclear lens opacification in her right eye and an anterior cortical opacification in her left, with normal findings in the posterior segment of each eye. Anterior segment OCT of the left eye showed a separation of the anterior lens capsule in the midperiphery of the lens and scarring of the cortical lens tissue to the lens capsule.

After I explained the situation to the patient, she asked about the possibility to be spectacle-free after cataract surgery. She explained her current situation, which included being treated for her anxiety disorder as an inpatient and outpatient over the past 3 years, resulting in her inability to reenter the work force. Psychologically, she had begun to feel better in recent weeks, and she had expressed the desire to go back to work as a beautician. She had never needed spectacles before, and she felt that, after all that had happened to her, she would not be able to get back to her full strength if she needed spectacles after surgery. Because of the demands of her old job, she also expressed the desire to achieve good uncorrected vision for distance, intermediate, and near after surgery.

The patient’s request to be spectacle independent for all distances meant that there was a limited selection of IOLs that could address her needs, and it also meant that monocular or binocular trifocality might be called for. Regardless, I felt it was my duty to do everything I could for this patient to achieve spectacle independence postoperatively.


After extensive counseling of the patient, especially regarding the risk of capsular rupture in her left eye, we discussed lens options.

Option No. 1: Diffractive IOL. One option would be a diffractive trifocal IOL like the AT LISA tri 839MP (Carl Zeiss Meditec) or the FineVision (PhysIOL). Another option would be a diffractive bifocal IOL, like the Tecnis low-add ZKB00 or Tecnis Symfony IOL (both Abbott Medical Optics), with micro- or mini-monovision.

The problem with either of these choices, however, was that it was unclear whether a perfect capsulorrhexis could be performed, meaning there was a high risk of intra- or postoperative decentration of the implant. For this reason, we explained to the patient that we did not want to use a diffractive multifocal IOL for her.

Option No. 2: Rotationally asymmetric multifocal IOL. Another option with which we had seen good results in the past was binocular trifocality with implantation of a rotationally asymmetric multifocal IOL (Lentis Comfort; Oculentis) following the Düsseldorf formula.1 When I explained to the patient that, with this solution, binocular function could be achieved only at one distance, she declined this option.

Case Recap


49-year-old woman with progressive loss of vision binocularly, nuclear lens opacification in her right eye and anterior cortical opacification in her left, a normal posterior segment, separation of the anterior lens capsule in the midperiphery of the lens, and scarring of the cortical lens tissue to the capsule


A desire for spectacle independence at all distances, limiting IOL choice to diffractive, rotationally asymmetric multifocal, or progressive multifocal lenses


Progressive multifocal IOLs were implanted; patient was happy with postoperative outcomes

Option No. 3: Progressive multifocal IOL. The last option for IOL selection was a new progressive multifocal IOL based on different aspheric zones (Mini Well Ready; Sifi). I told the patient that, if the Mini Well Ready is implanted in the capsular bag, a decentration could result in loss of its multifocal function, but the lens could still offer clear vision without the disadvantage of loss of contrast sensitivity, as would be the case with a diffractive multifocal IOL.

If surgery was uneventful and a stable IOL position was achieved, binocular function could be achieved for all distances.

Decision. The patient agreed to option No. 3. She was carefully counseled about the inability to perform multifocal IOL implantation in the event of capsular rupture, and afterward she signed the informed consent for surgery. Because the patient had an anxiety disorder, she also negated the use of general anesthesia; she agreed to undergo surgery with retrobulbar anesthesia with a 30-second propofol anesthesia during the retrobulbar injection.


Due to the scarring of the anterior cortex to the lens capsule and the detected capsular defect in the patient’s left eye, we decided not to use laser-assisted cataract surgery in order to prevent the creation of capsular tags.

Surgery was performed with the use of trypan blue dye to stain the lens capsule. The anterior chamber was filled with a highly cohesive OVD (Healon5; Abbott Medical Optics), and then the capsule was carefully punctured with an angled 1.1-mm microvitreoretinal blade close to the scarred area. An approximately 5.5-mm diameter circular capsulorrhexis was performed, starting at the scarred area and ending at the other side of the scarred tissue. The capsule opening then was completed with 23-gauge curved vitrectomy scissors.

We performed only hydrodelineation, skipping hydrodissection to avoid possible further capsular rupture. The nucleus was removed with a stop-and-chop technique, followed by bimanual cortex removal. In the area of the scarring, the remaining cortical opacification with strong adherence to the anterior capsule was left in place, and the IOL was implanted under saline irrigation into the capsular bag without the use of OVD.

The IOL centered itself nicely, so we decided to refill the anterior chamber with a cohesive OVD, perform a radial cut beside the scarred tissue of the anterior lens capsule, and enlarge the capsulorrhexis to approximately 6 mm. During bimanual OVD removal, the IOL stayed well centered in the bag.

The first day after surgery, the patient’s visual acuity was already 0.1 logMAR for distance and near UCVA and 0.2 logMAR for intermediate UCVA. Surgery in the other eye was performed without complications the following day.

At 1 week postoperative, monocular distance UCVA was 0.0 logMAR, and intermediate and near UCVA were both 0.1 logMAR. Three months after surgery, both IOLs were well centered on the optical axis, and monocular UCVA was 0.0 logMAR for distance, 0.1 logMAR for intermediate, and 0.2 logMAR for near. Binocular UCVA was -0.1 logMAR for distance, 0.1 logMAR for intermediate, and 0.0 logMAR for near. The patient told us she was finally happy and that she went back to work 1 month after her surgeries.


From our point of view, the Mini Well Ready was the right choice of IOL for this patient. Still, in this case, anything could have happened during surgery, and the outcome was not clear from the beginning. In our interpretation, the counseling of the patient was the main key for success. Offering the patient adequate time and being responsive to her feelings and thoughts gave her faith in the surgery.

1. Breyer D. Comfort blended vision: The Düsseldorf formula. Paper presented at: Oculentis Satellite Meeting of European Society of Cataract and Refractive Surgeons Annual Meeting; September 5, 2015; Barcelona, Spain.

Florian T.A. Kretz, MD, FEBO
• Lead surgeon, Eyeclininc Ahaus-Raesfeld-Rheine, Dr. Gerl & Collegues, Ahaus, Germany
• Consultant and Research Coordinator, International Vision Correction Research Centre Network (IVCRC.net), Department of Ophthalmology, University of Heidelberg, Germany
• Financial disclosure: Consultant (Carl Zeiss Meditec, Oculentis)