Can I Mix Different Multifocal Intraocular Lenses or Multifocal With Monofocal Intraocular Lenses? (2024)

Multifocal intraocular lenses and accommodating intraocular lenses can be paired with a normal crystalline lens in the opposite eye, a monofocal implant in the opposite eye, or a different multifocal or accommodating lens in the opposite eye. Combining complementary intraocular lenses provides a superior outcome to that achieved utilizing the same implant in both eyes.

The concept of using different optical systems that are complementary in each of a patient’s eyes is not new. The most common example of this, familiar to all ophthalmologists, is monovision in which 1 eye is set for distance and the other for near. If the difference between the 2 eyes is greater than 1.50 D, I call that monovision and if it is less than 1.5 D, I call it blended vision. In blended vision, some stereopsis and fusion are retained and a relative amblyopia for distance is less likely.

In the case of multifocal and accommodating lenses, there are at least 10 potential options that can be utilized:

1. An accommodating lens can be implanted into 1 eye and a normal crystalline lens in the opposite eye.

2. A multifocal lens can be implanted into 1 eye and a normal crystalline lens in the other eye.

3. Bilateral accommodating intraocular lenses can be utilized with a symmetrical refractive outcome target.

4. Bilateral accommodating intraocular lens can be utilized with a blended vision outcome (eg, targeting –0.25 D in 1 eye and –1.00 D in the alternate eye).

5. Bilateral multifocal implants with the same optical configuration can be implanted in both eyes with a symmetrical refractive outcome target.

6. Bilateral multifocal implants with the same optical configuration can be utilized with a blended vision outcome (eg, targeting plano in 1 eye and –0.50 D in the alternate eye).

7. An accommodating intraocular lens can be implanted in 1 eye and a monofocal implant in the opposite eye.

8. A multifocal intraocular lens can be implanted in 1 eye and the monofocal lens in the opposite eye.

9. An accommodating intraocular lens can be implanted in 1 eye and a multifocal lens in the opposite eye.

10 Complementary multifocal intraocular lenses can be implanted in the alternate eyes (eg, a zonal aspheric intraocular multifocal intraocular lens [ReZoom, Advanced Medical Optics, Santa Ana, Calif] in 1 eye and an apodized diffractive/refractive multifocal intraocular lens in the opposite eye [ReSTOR, Alcon, Fort Worth, Tex]). This has become known as “mixing and matching” presbyopia-correcting intraocular lenses.

In order to best use complementary intraocular lenses, it is important that the ophthalmologist understand the strengths and weaknesses of each intraocular lens.

The standard monofocal intraocular lens is the best economic value. It gives excellent distance, fair intermediate, and poor near vision (eg, 20/20+, J4, J7 at the 3 distances, respectively). The pseudoaccommodative amplitude is approximately 2 D, which means it has about 1 D of pseudoaccommodative amplitude to the minus side. This means that if the patient is targeted for a –1.50 refractive outcome, he or she will be able to read as though he or she had a +2.00 to +2.50 reader. The lens has positive spherical aberration of approximately +0.10 µm, somewhat dependent on optic power and optic design. This type of spherical aberration is best in patients who have negative spherical aberrations in the cornea such as those posthyperopic laser in situ keratomileusis (LASIK), with keratoconus, or with a cornea with naturally occurring negative spherical aberration (10% to 20%).

Second, we have aspheric monofocal intraocular lenses, including those with no spherical aberration (Bausch & Lomb’s Advanced Optic, Rochester, NY) and those with negative spherical aberration (Advanced Medical Optics’ TECNIS, Santa Ana, Calif and Alcon IQ, Fort Worth, Tex). The intraocular lens with no spherical aberration is most forgiving of decentration and tilt and might be selected in patients where decentration might occur such as in pseudoexfoliation, a capsular tear, or where an ideal capsulorrhexis is not available.

The implants with negative spherical aberration give better quality of vision, especially under mesopic conditions, in the patient with a typical cornea with positive corneal spherical aberration. They also provide superior performance in the patient that has undergone myopic keratorefractive surgery.

The Eyeonics’ Crystalens (Aliso Viejo, Calif) is an accommodating intraocular lens that gives excellent distance and intermediate vision. Typically, one can achieve 20/20+ and J1 at distance and intermediate, respectively. It provides good near acuity with a typical outcome being J3 or better. This lens produces the least night vision symptoms, the least loss of contrast sensitivity, and the least color distortion of all currently available presbyopia-correcting intraocular lenses. It is also pupil-size independent in its optical function and is excellent for blended vision.

The ReZoom, a zonal aspheric multifocal intraocular lens manufactured by AMO, provides good distance acuity, good intermediate acuity, and good near acuity. Typical outcomes are 20/20 distance, J2 intermediate, and J2 at near. There are some night vision symptoms, some loss of contrast sensitivity, and some color distortion with this IOL. The refractive performance of this lens is pupil-size dependent.

The AMO Multifocal TECNIS, an aspheric diffractive multifocal intraocular lens, provides good distance acuity, fair intermediate, and excellent near acuity. Typical outcomes to be expected are 20/20- at distance, J4 at intermediate, and J1 at near. It also has the potential for night vision symptoms, decreased contrast sensitivity, and some color distortion. The decreased contrast sensitivity usually associated with a multifocal implant is reduced by the aspheric nature of the optic. The refractive performance of this lens is not pupil-size dependent.

The Alcon ReSTOR, an apodized diffractive/refractive multifocal intraocular lens, provides good distance acuity, fair intermediate, and excellent near. Distance acuity might be expected to be 20/20-, intermediate J4, and near J1. This lens also potentially generates night vision symptoms, decreased contrast sensitivity, and color distortion. Its refractive performance is also pupil-size dependent because the lens becomes more distance dominant as the pupil dilates.

The author and other members of his practice (Minnesota Eye Consultants, PA) have utilized all of the above combinations of implants with good success. Multifocal intraocular lenses have been used in a mix-and-match approach for approximately 20 years, beginning in 1985. Our experience has been that almost all patients adapt well over time to the use of complementary optics in their alternate eyes.

Neuroadaptation is a concept that is receiving increased attention as ophthalmologists use more and more optical systems that are dissimilar to the natural crystalline lens. It appears that there is both an early stage and late stage neuroadaptation. Approximately 80% of patients seem to adapt easily to complementary optics whereas 20% may struggle for a few months to a year or more. Late neuroadaptation appears to occur at near 100% and the author’s personal experience is that there are no patients in his practice with over 2 years follow-up with dissimilar optics who have not adapted well to their optical system.

Recent clinical series of “mixing and matching” some multifocal and accommodating intraocular lenses provide insight into the outcomes that might be obtained. Leonardo Akaishi, MD and Pedro Paulo Fabri, from Sao Paulo, Brazil have performed a comparative series of ReZoom/ReZoom, ReSTOR/ReSTOR, ReZoom/ReSTOR, and TECNIS Diffractive/ReZoom. Their outcomes are summarized in Table 46-1. The best outcomes were obtained with ReZoom/ReSTOR and ReZoom/TECNIS diffractive intraocular lens combinations.

Rick Milne, MD from Columbia, SC has also performed a comparative series looking at patient satisfaction, spectacle independence, and daytime and nighttime halo. His outcomes are summarized in Table 46-2. Again, the ReZoom/ReSTOR outcomes generated higher patient satisfaction than the ReSTOR/ReSTOR outcomes in this series.

Frank A. Bucci, Jr, MD from Wilkes-Barre, Penn has also completed a series comparing ReSTOR/ReSTOR to ReZoom/ReZoom. His outcomes are summarized in Table 46-3. Of note is that his intermediate vision outcomes are significantly better with ReZoom/ReSTOR than with ReSTOR/ReSTOR and that his patient satisfaction is also higher.

Finally, Trevor Woodhams, MD from Atlanta, Ga has a series of patients with Crystalens/ReSTOR use in alternate eyes (Table 46-4). Again, he found excellent distance, intermediate, and near vision with high patient satisfaction.

Conclusion

The human visual system can neuroadapt to dissimilar optics in alternate eyes. Patients should be given at least 1 year to neuroadapt to their new optical system before explant/exchange is considered. Multifocal or accommodating intraocular lenses can be used successfully with a monofocal intraocular lens in the opposite eye. Multifocal or accommodating intraocular lenses can also be used successfully with a natural crystalline lens in the opposite eye. Of great importance is the observation that complementary multifocal and accommodating intraocular lenses may provide superior outcomes for many patients compared to symmetrical implantation of the same intraocular lens in both eyes. This is particularly true for function at intermediate distance. Further clinical study is ongoing, but the current evidence supports the use of complementary presbyopia-correcting intraocular lenses in the alternate eyes of select patients.

Bibliography

Davis EA, Hardten DH, Lindstrom RL. Presbyopic Lens Surgery: A Clinical Guide to Current Technology. Thorofare, NJ: SLACK Incorporated; 2007.

Lindstrom RL. Foreword. In: Holladay JT, ed. Quality of Vision: Essential Optics for the Cataract and Refractive Surgeon. Thorofare, NJ: SLACK Incorporated; 2006.