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Cover page of the Journal of Health Sciences


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 145-154

The visual outcome after cataract surgery with multifocal intraocular lenses and monofocal intraocular lenses at tertiary care hospital: A prospective observational study


Department of Ophthalmology, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India

Date of Web Publication30-May-2017

Correspondence Address:
Anjal M Shah
Department of Ophthalmology, Jawaharlal Nehru Medical College, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.ijhs_451_16

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  Abstract 

Background: The crystalline lens is part of the optical system of the eye that focuses rays of light on the retina. Apart from contributing to the optical power of the eye as a whole, the crystalline lens can dynamically change the optical power of the system by the process of accommodation for younger eyes. During life the ability of the crystalline lens to change in shape decreases, leading to presbyopia. For optimal visual performance, crystalline lens should be transparent. Cataract describes the pathological opacification of the crystalline lens. Removal of the crystalline lens followed by implantation of an artificial intraocular lens (IOL) in the capsular bag of the eye, as practiced in cataract surgery, offers an opportunity to address refractive anomalies in patients who are ametropic due to the removal of cataract. Implantation of an IOL with a fixed focal point (monofocal IOL) will render a patient at best emmetropic for a single fixed working distance only, leading to a postoperative result comparable to presbyopia in an emmetropic subject; pseudoaccommodation can play a role in increasing the depth of field but spectacle independence for a range of working distances is not be expected after implantation of a monofocal IOL. To restore the missing accommodation, we can implant multifocal IOLs. Multifocal IOLs, on the other hand, are designed to have two or more fixed focal points, thus, facilitating a sharp retinal image of objects at multiple working distances resulting in increased spectacle independence, but these lenses can cause a reduction in contrast sensitivity and higher incidence of photic phenomena such as halos, flare, and glare.
Aim of The Study: The study was carried out with the aim of comparing the visual outcome after cataract surgery with multifocal IOLs and monofocal IOLs in respect to distant visual acuity, near visual acuity, contrast sensitivity, subjective symptoms, and to assess functional status and quality of life.
Materials and Methods: A prospective observational study was conducted in the Department of Ophthalmology, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi on patients undergoing cataract surgery during January 1, 2015–December 31, 2015. The study was approved by the Ethical and Research Committee of Jawaharlal Nehru Medical College, Belagavi. Forty eyes of forty patients who undergone phacoemulsification surgery with IOL implantation under LA. Choice of IOL inserted given according to their desire for spectacle independency. Monofocal group was taken as control. Both groups were evaluated postoperatively after 3 weeks and 6 weeks for distant vision, near vision, contrast sensitivity for distance, subjective satisfaction by standard questionnaire method and subjective symptoms such as glare and halos and difficulty in night driving. Data were analyzed by Chi-square test (P < 0.05%).
Results: Distant visual acuity was 6/6–6/9 in 80% and 75% of the patients of multifocal and monofocal groups, respectively, remaining patients had 6/12–6/18 vision. 85% of multifocal group had N6–N8 vision (P < 0.0001). High contrast sensitivity for distance was almost similar in both groups, but low contrast was significantly reduced in multifocal group as compared to monofocal group (P = 0.0023). Fifteen percent of multifocal group had complained of glare and halos compared to monofocal group who never had these visual sensations. About 5% of patients in multifocal group had difficulty with nighttime driving. Nearly, 80% of patients in multifocal group and 40% of patients in monofocal group had become spectacles independent.
Interpretation and Conclusion: Multifocal IOL group experienced reduced spectacle dependency for near vision and a high level of patient satisfaction despite some reports of halos, glare, and difficulty in night driving. Monofocal IOL group experienced spectacle dependency for near vision. Overall, multifocal IOLs offer best near vision acuity, good distance visual acuity, less limitation in visual function in selected and motivated individuals.

Keywords: Contrast sensitivity, glare and halo, monofocal intraocular lens, multifocal intraocular lens, near vision, phacoemulsification


How to cite this article:
Shah AM, Harakuni UU. The visual outcome after cataract surgery with multifocal intraocular lenses and monofocal intraocular lenses at tertiary care hospital: A prospective observational study. Indian J Health Sci Biomed Res 2017;10:145-54

How to cite this URL:
Shah AM, Harakuni UU. The visual outcome after cataract surgery with multifocal intraocular lenses and monofocal intraocular lenses at tertiary care hospital: A prospective observational study. Indian J Health Sci Biomed Res [serial online] 2017 [cited 2022 Dec 4];10:145-54. Available from: https://www.ijournalhs.org/text.asp?2017/10/2/145/207262


  Introduction Top


The crystalline lens is part of the optical system of the eye that focuses rays of light on the retina. In subjects with an emmetropic refractive state, parallel rays emerging from a distant object are focused on the fovea with the different parts of the optical system in their natural state. In ametropic subjects, the power of the optical system needs to be adjusted (with spectacles, contact lenses, or refractive surgery) to reach this desired situation. Apart from contributing to the optical power of the eye as a whole, the crystalline lens can dynamically change the optical power of the system by the process of accommodation for younger eyes. Light rays emerging from objects at near distance rather than at infinity are entering the eye at an angle rather than parallel. The optical power of the lens must, therefore, be increased to let the light rays converge at the retina. According to the theory pioneered by Helmholtz, contraction of the ciliary muscle decreases tension on the zonular fibers, resulting in a change in shape and therefore optical power of the crystalline lens. The dynamic optical power of the system contributes to the ability of the subject to visualize objects at a range of distances. During life the ability of the crystalline lens to change in shape decreases, leading to presbyopia.[1]

For optimal visual performance, crystalline lens should be transparent. Cataract describes the pathological opacification of the crystalline lens.[2]

Cataract surgery has evolved through many phases from the olden days of intracapsular cataract extraction to extracapsular cataract extraction, followed by manual small incision cataract surgery to finally standard phacoemulsification and recent advance is femtosecond laser-assisted phacoemulsification.

Removal of the crystalline lens followed by implantation of an artificial intraocular lens (IOL) in the capsular bag of the eye, as practiced in cataract surgery, offers an opportunity to address refractive anomalies in patients who are ametropic due to the removal of cataract. Advances in preoperative calculations of the optical power of the IOL necessary for a desired refractive result, smaller incision sizes at the time of cataract surgery, and the introduction of IOLs with a wide range of spherical and cylindrical optical powers in small increments have contributed to the current state where cataract surgery is not just a treatment for a vision-threatening disease, but should additionally be considered as a refractive surgery procedure.

Despite these advances, implantation of an IOL with a fixed focal point (Monofocal IOL) will theoretically render a patient at best emmetropic for a single fixed working distance only, leading to a postoperative result comparable to presbyopia in an emmetropic subject. Although more complex optical phenomena such as certain higher order aberrations, corneal shape, and pseudoaccommodation can play a role in increasing the depth of field, spectacle independence for a range of working distances is not be expected after implantation of a monofocal IOL.

Compensating this lack of accommodation is one of the most important challenges in ophthalmologic research. Despite extensive investigations, the problem has not been fully solved. To restore the missing accommodation, we can implant multifocal IOLs. Multifocal IOLs, on the other hand, are designed to have two or more fixed focal points, thus facilitating a sharp retinal image of objects at multiple working distances resulting in increased spectacle independence, but these lenses can cause a reduction in contrast sensitivity and higher incidence of photic phenomena such as halos, flare, and glare.[1]

Hence, this study was done to compare and assess the effect of multifocal and monofocal IOL with reference to visual acuity both distant and near, contrast sensitivity, spectacle independence, complaints of glare and halos, and patient's visual satisfaction.

Aims and objectives

  • Primary objective: To compare the visual outcome after cataract surgery with multifocal IOLs and monofocal IOLs
  • Secondary objective: Assessment of functional status and quality of life with multifocal IOLs and monofocal IOLs.



  Materials and Methods Top


A study was conducted at KLES Dr. Prabhakar Kore Hospital and MRC, Belagavi on patients undergoing cataract surgery. Forty eyes of forty patients underwent phacoemulsification surgery with IOL implantation under LA. Monofocal group was taken as control. Both groups were evaluated postoperatively after 3 and 6 weeks. Data were analyzed by Chi-square test (P < 0.05%).


  Results Top


Study inclusion data

A total number of patients were 40, out of which 20 were in monofocal IOL group and 20 in Multifocal IOL group [Table 1].
Table 1: Study inclusion data

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Age distribution

Out of the forty patients included in this study, 20 cases were allocated to each of the two groups according to their desire for type of IOL. The mean age of the patients was 60.55 ± 7.06 years in the monofocal group and 61.15 ± 7.75 years in multifocal group as shown in [Table 2] and [Graph 1].
Table 2: Age distribution

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Gender distribution

In this study, out of twenty patients in monofocal group, 11 were male and 9 were female; out of twenty patients in multifocal group, 13 were male and 7 were female [Table 3] and [Graph 2].
Table 3: Gender distribution

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Preoperative distant vision acuity

Preoperative distant vision acuity was almost similar in both groups (P = 0.1371) [Table 4] and [Graph 3].
Table 4: Preoperative distant vision acuity

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Preoperative near vision acuity

Preoperatively, all the patients were spectacles dependent for near work activities. Fifty percent of patients of monofocal group and 35% of patients of multifocal group had preoperative near vision N12–N18. This difference of preoperative near vision acuity does not make any significance for postoperative visual outcome (P < 0.05) [Table 5] and [Graph 4].
Table 5: Preoperative near vision acuity

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Third week distant vision acuity

Distant vision acuity found to be almost similar in both groups by the end of the 3rd week. About 30% of patients with monofocal group had 6/6–6/9 vision compared to 25% of patients in multifocal group had 6/6–6/9 vision and remaining patients in both groups had slightly reduced vision in Snellen's vision chart as shown in [Table 6] and [Graph 5] (P = 0.9381).
Table 6: Third week distant vision acuity

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Third week near vision acuity

Multifocal group had better uncorrected near vision acuity by the end of 3rd week of the study. About 65% of the patients in multifocal had N6–N8 vision. Remaining 35% in multifocal and 100% in monofocal had reduced vision in Snellen's near vision chart (P < 0.005) as shown in [Table 7] and [Graph 6].
Table 7: Third week near vision acuity

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Third week contrast sensitivity – high (CSH) and contrast sensitivity – low (CSL) scores

In ETDRS contrast sensitivity chart mean contrast sensitivity at low contrast level was significantly reduced in multifocal group patients (P < 0.001) [Table 8] and [Graph 7].
Table 8: Third week CSH and CSL scores

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Third-week glare and halos

One patient in monofocal group and five patients in multifocal group had complained of glare and halos in 3 weeks postoperative follow-up period [Table 9] and [Graph 8].
Table 9: Third week glare and halos

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Third week difficulty in night driving (DND)

None of the patients in monofocal group had difficulty in nighttime driving whereas one patient in multifocal group found difficulty in nighttime driving which is statistically insignificant [Table 10] and [Graph 9].
Table 10: Third week DND

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Sixth week distant vision acuity

Distant vision acuity found to be almost same in both groups by the end of 6th week. Seventy-five percent of patients had 6/6–6/9 vision and remaining 25% had 6/12–6/18 vision in monofocal group. Eighty percent of patients had 6/6–6/9 vision and remaining 20% had 6/12–6/18 vision in multifocal group in Snellen's test chart as shown in [Table 11] and [Graph 10].
Table 11: Sixth week distant vision acuity

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Sixth week near vision acuity

Multifocal group had better uncorrected near vision acuity by the end of 6 weeks of the study. Nearly, 85% of the patients in multifocal had N6–N8 vision (P < 0.05). Remaining 15% in multifocal and 100% in monofocal had reduced vision in Roman near vision chart as shown in [Table 12] and [Graph 11].
Table 12: Sixth week near vision acuity

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Sixth week CSH and CSL scores

Even though the initial postoperative follow-up in multifocal group showed reduced contrast sensitivity but by the end of the 6th week showed almost similar to monofocal group at high contrast level but low contrast sensitivity was significantly reduced in multifocal group in ETDRS contrast sensitivity chart [Table 13] and [Graph 12].
Table 13: Sixth week CSH and CSL scores

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Sixth-week glare and halos

Three patients in multifocal group had complained of mild to moderate experiences of photic phenomena as shown in [Table 14] and [Graph 13].
Table 14: Sixth week glare and halos

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Sixth week DND

Only one patient of multifocal group had difficulty in nighttime driving in throughout the study period compared to monofocal group none had difficulty in nighttime driving [Table 15] and [Graph 14].
Table 15: Sixth week DND

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Status of spectacles independence

Patients were asked how often they wore glasses. Possible responses were: always, occasionally, and never. Patients with multifocal IOLs wore glasses less often than patients who had received monofocal IOLs, with 80% of patients who had received multifocal IOLs (16/20) and 40% of patients who had received monofocal IOLs (8/20) never wearing glasses. This difference was statistically significant (P = 0.0102) [Table 16], [Graph 15].
Table 16: Status of spectacles independence

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Status of satisfaction

All forty patients completed the questionnaire on visual symptoms and satisfaction. Despite the superiority of the multifocal IOL in primary outcome measures and spectacle dependence, overall patient satisfaction using the fulfillment theory (subtraction of preoperative expectations from postoperative evaluations) was similar in the 2 groups, and the number of patients who were satisfied with the outcome of their surgery did not differ among groups. Perceived quality of vision showed high ratings (approximately, 95% satisfied about aided near and distance vision in both groups) [Graph 16].



Patient satisfaction is predicted by aided quality of near vision. [Table 17] indicates that patients do not mind wearing reading glasses as long as near vision is good according to their own standards.
Table 17: Status of satisfaction

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  Discussion Top


Accommodation is the eye's ability to change its refractive power by altering its focal length. The ability to focus over a range of distances is essential in humans although this facility to accommodate reduces with increasing age and the amount of ciliary muscle contraction or accommodative effort unchanged. Once cataract develops transparency of lens is lost and it hardens.[3]

Age-related cataracts represent the most common cause of blindness in the world.[4]

Currently, the goal of cataract surgery is to provide fast and complete visual rehabilitation without surgical complications with minimal postoperative refractive errors. The available treatment option is surgical extraction of cataract and implantation of IOL to replace the focusing power of the natural lens. IOLs used in cataract surgery are either monofocal or multifocal. The former can be used to give clear point of focus for distance or near but can choose only one point of focus. Spectacles provide extra lens power, which enables focusing at other points whereas multifocal IOL can correct both distant and near vision, which eliminates near vision addition.

Hence, this study was conducted to compare the visual outcome after cataract surgery with multifocal IOLs and monofocal IOLs and also to assess functional status and quality of life.

The study is a prospective observational study. It was conducted on 40 patients with cataract, meeting the inclusion criteria, who presented to the Ophthalmology Department of KLES Dr. Prabhakar Kore Hospital and Medical Research Centre between January 20151, and December 31, 2015.

In this study, all the forty patients underwent clear corneal phacoemulsification cataract surgery with IOL implantation under local anesthesia. Choice of the lens inserted was given to the patients according to their willingness.

In the present study, the mean age was 60.55 ± 7.06 and 61.15 ± 7.75 years in monofocal and multifocal group, respectively. All of the patients were in the range of 40–70 years as cataract is more common in this age group. We included younger age group because this age demands good near vision. So according to their willingness for spectacle independence, they underwent multifocal or monofocal lens implantation. In older age group as even the other eye might have almost lost accommodation because of loss of elasticity of lens due to the aging process or cataractous changes. As an alternative to this lost accommodation after cataract surgery, either multifocal lens or monofocal lens with near addition spectacles was used according to their desire.

The difference in age group is statistically insignificant (P = 0.7922) in both groups. This indicates both groups have age matching.

In this study, 55% and 65% patients were male, whereas 45% and 35% patients were female, in monofocal group and multifocal group, respectively. We tried to match the gender distribution in both the IOL groups. This difference in the gender distribution of both groups has no statistical significance (P = 0.5191). Gender distribution difference does not make any significance on the postoperative visual outcome.

Similarly, Kumare et al. in their study found no significant difference between the two groups in term of age and gender distribution.[5]

Yamauch et al. in 2013 in their study also found that there is no statistically significance in the difference in terms of age and sex distribution (P = 0.7442).[6]

In the present study, the majority of the patients that is 55% had preoperative distant visual acuity in the range of 6/36 to CF 3 m, followed by 28% patients with preoperative visual acuity in the range of CF 2 m to hand movement close to face in both groups. About 30% of patients who had preoperative visual acuity in the range of 6/18–6/24 opted multifocal lens suggested that these patients would be more conscious of their visual outcome. The difference in preoperative distant visual acuity of both groups is statistically not significant (P = 0.1371).

Our study data showed that preoperatively majority of the patients were spectacles dependent for near work activities. Fifty percent of patients of monofocal group and 35% of patients of multifocal group had preoperative near vision N12–N18. 10% of patients of monofocal group and 25% of patients of multifocal group had preoperative near vision N8– N10 indicated that these patients were more dependent on spectacles for distant vision preoperatively. The difference of preoperative near vision acuity in both groups is not significant (P = 0.4102).

The study done by Sun et al. in 2012 and Yamauch et al. in 2013 also stated that the difference in preoperative distant and near vision is statistically insignificant.[6],[7]

All the patients under the study were examined postoperatively at 3 weeks and 6 weeks.

In every follow-up, we had examined uncorrected distant visual acuity (UDVA), uncorrected near visual acuity (UNVA), contrast sensitivity high and low, wound healing, corneal clarity, IOL position, and fundus visibility.

In the present study, UDVA was found to be almost similar in both groups by the end of 3 weeks. Thirty percent of patients with monofocal group had 6/6–6/9 vision compared to 25% of patients in multifocal group had 6/6–6/9 vision and remaining patients in both groups had slightly reduced vision in Snellen's vision chart. There was no difference in gaining distant visual acuity in patients of both groups (P = 0.9381).

Javitt J et al. had concluded that there was no statistical significant difference between two groups in mean uncorrected binocular distance visual acuity. Mean uncorrected binocular distance visual acuity was 1.0 (20/21) in the multifocal group and 0.9 (20/22) in the monofocal group (P = 0.446).[8]

Uncorrected near visual acuity was better in multifocal group by the end of 3rd week of the study. Almost 65% of the patients in multifocal group had N6–N8 vision. Remaining 35% in multifocal and 100% in monofocal had reduced vision in Roman near vision chart. Thus, there is a highly significant difference between the two groups in terms of the uncorrected near visual acuity (P < 0.0001). Two patients of monofocal group had developed near vision up to N10. On examination, these patients found to be more myopic than others, having an axial length of 24.53 mm and 24.10 mm, respectively. Hence, we concluded that being myopic, these patients gained slightly better near vision acuity than others.

Kumare et al. in 2015 in their study found that the postoperative uncorrected near visual acuity in the multifocal IOL versus monofocal IOL is 75% and 0%, respectively, for N6 near vision (P = 0.0000). Hence, postoperative near vision result of this study is highly supporting to our study.[5]

Vaggu and Kodepaka in their recent study in 2016 concluded that 15 (60%) patients had uncorrected near visual acuity (UCNVA) ≥ N12 (mean 0.2 LogMAR) in the monofocal IOL group and 25 (100%) patients had UCNVA ≥ N12 (mean 0.01 LogMAR) in multifocal group postoperatively, which was statistically significant P< 0.001.[9]

Cilino et al. stated that mean UCNVA in monofocal and multifocal groups were 0.61 and 0.7 decimal, respectively. The difference was statistically significant, and they concluded that multifocal IOLs are better capable of correcting NVA.[10]

At 6 weeks UDVA analysis in our study showed almost 80% of the patients in both the IOL groups, that is monofocal as well as multifocal group achieved 6/6–6/9 vision and remaining 20% of the patients achieved 6/12–6/18 vision 6 weeks postoperatively. In a period of 6 weeks, the distant vision was improved in both groups which states that factors such as corneal wound healing, postoperative corneal edema, postoperative mydriasis and cycloplegia are responsible for reduced distant vision in the immediate postoperative period.

In multifocal group, the mean monocular UDVA result which is similar to the values reported by Voskresenskaya et al. (mean UDVA 0.13 LogMAR) where predominantly multifocal IOL is implanted monocularly.[11]

Furthermore, in this study, visual acuity outcomes are comparable to those achieved with several bifocal-design diffractive IOLs. However, in our study, mean UDVA in multifocal group is lower than reported by Lesieur (mean 0.00 ± 0.01). It is likely that this difference is due to the older population examined in the present study (61.15 ± 7.75 years). The optical performance of the human eye is known to decline with age, with a resultant reduction in visual acuity for both elderly phakic and pseudophakic individuals.[12]

At the end of the 6 weeks, uncorrected near visual acuity in multifocal group had N6–N8 vision in 85% (P < 0.0001). Remaining 15% in multifocal and 100% in monofocal had reduced vision in Roman near vision chart.

The visual cortex contains no prewired circuitry that allows it to digest information from multifocal lenses; the brain requires a period of adjustment known as neuroadaptation that involves suppressing near vision when gazing at distant objects and restricting distance vision when focusing up close. Hence, the improvement in near vision acuity is due to neural adaptation that patients developed in this period of 6 weeks.

The study done by Hashemi and Nikbin showed that at 3 months after surgery the UCNVA in monofocal and multifocal groups were mean 0.22 LogMAR and mean 0.14 LogMAR respectively after correction of DVA and the intergroup difference was statistically significant. Findings in other studies support our result, and they agree that multifocal IOLs improve UCNVA.[13]

Gimbel et al. in his study, he compared the results of implantation of monofocal IOL versus multifocal IOL and found that 91% of patients in multifocal group achieved good near vision compared to 35% of patients of monofocal IOL group.[14]

Steinert et al. in their study showed that uncorrected distance visual acuity was similar between the multifocal and monofocal implants in the subset with 85% and 91% of eyes achieving 20/40 or better visual acuity. About 86% eyes developed better uncorrected near vision for multifocal lens compared to 49% of monofocal eyes achieving J3 or better.[15]

Brydon et al. in their study found that multifocal group had better visual acuity than the monofocal group at near with distance correction in place (70% vs. 43% achieved J3 or better). The multifocal group also had significantly better depth of focus. Subjectively, both groups indicated high levels of satisfaction during the day, at night, and overall without spectacles in multifocal groups.[16]

In the present study, 20% of patients in multifocal group and 60% of patients in monofocal group require spectacles for their near work activities. With correction near vision acuity was similar in both groups. This 20% of patients in multifocal group had near vision N10 in Roman near vision chart. Less near vision in these patients is due to postoperative astigmatism and mostly due to these patients require more time neuroadaptation to develop. Because multifocal lenses require greater adaptation, the amount of adjustment the brain needs to make between images can be pushed to the limit of its capability.

In the report by Chiam et al., mean UCNVA were 0.34 and 0.7 decimal in their monofocal and multifocal groups, respectively. The evidence on NVA was in favor of multifocal IOLs. In our study, CNVA was similar in both monofocal and multifocal IOL groups. Other similar studies have demonstrated that there are no significant differences between these groups in relation to CNVA.[17]


  Conclusion Top


This present study was done for postoperative analysis of differences in distant vision, near vision and contrast sensitivity, and also about subjective symptoms such as halos, glare, and difficulty in night-time driving encountered over 6 weeks follow-up in phacoemulsification with monofocal posterior chamber IOL (PC IOL) and phacoemulsification with multifocal PC IOL groups.

A successful refractive outcome can be obtained with proper patient selection, motivation and expectation; accurate preoperative biometry, IOL power calculation; and also good surgical technique.

Overall, the patients in our study were satisfied with their distant and near vision and with surgery, although 15% of patients reported mild to moderate halos, glare, and difficulty in night driving postoperatively. Good evidence exists that use of multifocal IOLs improves near vision in 85% of patients without any major adverse effects on distant vision.

Our study results also showed that patients were pleased with their IOL performance, and most would have multifocal IOLs implanted again. The frequency of spectacle wear was greatly reduced for both distance and near vision, with 80% of patients having rated their vision without spectacles to be noticeably better after each successive surgery. These findings suggest that multifocal IOLs can improve the quality of life in active patients who wish to reduce their dependence on glasses. This technology offers surgeons a feasible way of meeting patient's expectations of an improved lifestyle as the result of reduced spectacle dependence compared with the standard practice of monofocal IOL implantation.

In this context, multifocal IOL's are obviously better option in most of the cases except professional drivers, commercial airline pilots, architects, etc. Multifocal IOLs provide higher subjective satisfaction which overshadowed the minor side effects such as glare and halos seen in our patients. Careful patient selection is the determining factor to achieve better proper functional visual outcome and patient satisfaction. The use of multifocal IOLs in cataract surgery also resulted in a significant reduction in costs for patient's postoperative spectacles.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
de Vries NE, Nuijts RM. Multifocal intraocular lenses in cataract surgery: Literature review of benefits and side effects. J Cataract Refract Surg 2013;39:268-78.  Back to cited text no. 1
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Berrow E, Wolffsohn J, Bilkhu P, Dhallu S, Naroo S, Shah S. Visual performance of a new bi-aspheric, segmented, asymmetric multifocal IOL. J Refract Surg 2014;30:584-8.  Back to cited text no. 2
    
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Kumare D, Benurwar C, Tumram NK. Comparative study of multifocal versus monofocal lenses after cataract extraction surgery. Scholars J Appl Med Sci 2015;3:1159-62.  Back to cited text no. 5
    
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Yamauchi T, Tabuchi H, Takase K, Ohsugi H, Ohara Z, Kiuchi Y. Comparison of visual performance of multifocal intraocular lenses with same material monofocal intraocular lenses. PLoS One 2013;8:e68236.  Back to cited text no. 6
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Sun Y, Zheng D, Ling S, Song T, Liu Y. Comparison on visual function after implantation of an apodized diffractive aspheric multifocal or monofocal intraocular lens. Eye Sci 2012;27:5-12.  Back to cited text no. 7
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Javitt J, Brauweiler HP, Jacobi KW, Klemen U, Kohnen S, Quentin CD, et al. Cataract extraction with multifocal intraocular lens implantation: Clinical, functional, and quality-of-life outcomes. Multicenter clinical trial in Germany and Austria. J Cataract Refract Surg 2000;26:1356-66.  Back to cited text no. 8
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Vaggu SK, Kodepaka PN. A comparative study on visual outcome between multifocal and monofocal intraocular lenses. J Evid Based Med Healthc 2016;3:2979-83.  Back to cited text no. 9
    
10.
Cillino S, Casuccio A, Di Pace F, Morreale R, Pillitteri F, Cillino G, et al. One-year outcomes with new-generation multifocal intraocular lenses. Ophthalmology 2008;115:1508-16.  Back to cited text no. 10
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Voskresenskaya A, Pozdeyeva N, Pashtaev N, Batkov Y, Treushnicov V, Cherednik V. Initial results of trifocal diffractive IOL implantation. Graefes Arch Clin Exp Ophthalmol 2010;248:1299-306.  Back to cited text no. 11
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Lesieur G. Outcomes after implantation of a trifocal diffractive IOL. J Fr Ophtalmol 2012;35:338-42.  Back to cited text no. 12
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13.
Hashemi H, Nikbin HR. AcrySof ReSTOR multifocal versus AcrySof SA60AT monofocal intraocular lenses: Comparison of visual acuity and contrast sensitivity. Iran J Ophthalmol 2009;21:25-31.  Back to cited text no. 13
    
14.
Gimbel HV, Sanders DR, Raanan MG. Visual and refractive results of multifocal intraocular lenses. Ophthalmology 1991;98:881-7.  Back to cited text no. 14
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Steinert RF, Aker BL, Trentacost DJ, Smith PJ, Tarantino N. A prospective comparative study of the AMO ARRAY zonal-progressive multifocal silicone intraocular lens and a monofocal intraocular lens. Ophthalmology 1999;106:1243-55.  Back to cited text no. 15
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Brydon KW, Tokarewicz AC, Nichols BD. AMO array multifocal lens versus monofocal correction in cataract surgery. J Cataract Refract Surg 2000;26:96-100.  Back to cited text no. 16
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Chiam PJ, Chan JH, Haider SI, Karia N, Kasaby H, Aggarwal RK. Functional vision with bilateral ReZoom and ReSTOR intraocular lenses 6 months after cataract surgery. J Cataract Refract Surg 2007;33:2057-61.  Back to cited text no. 17
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17]



 

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  In this article
   Abstract
  Introduction
   Materials and Me...
  Results
  Discussion
  Conclusion
   References
   Article Tables

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