Eur J Ophthalmol 2011 ; 21 ( 6): 826-829 DOI: 10.5301/ejo.

5000005

CASE REPORT

Prevention of hyperopic surprise after LASIK

in patients with refractive multifocal intraocular lenses
César Albarrán-Diego1, Gonzalo Muñoz1, Teresa Ferrer-Blasco2, Santiago García-Lázaro2
1
Refractive Surgery Department, Marqués de Sotelo Ophthalmological Center and Hospital NISA Valencia al Mar,
Valencia - Spain
2
Optometry Research Group (G.I.O.), Department of Optics, University of Valencia, Valencia - Spain
Refractive Surgery Department, Marqués de Sotelo Ophthalmological Center and Hospital NISA Valencia al Mar, Valencia - Spain
Optometry Research Group (G.I.O.), Department of Optics, University of Valencia, Valencia - Spain

Purpose. Three cases of patients who developed a similar hyperopic defect in refraction following laser
in situ keratomileusis (LASIK) after multifocal intraocular lens (IOL) implantation are described.
Methods. Ophthalmologic evaluation including refractive status, corrected and uncorrected visual acu-
ity (both at far and near), and corneal topography in patients presenting similar hyperopic refractive
surprise in one eye as a result of LASIK refinement of residual ametropia after refractive multifocal IOL
implantation.
Results. Laser in situ keratomileusis enhancement for residual ametropia of –1.00 to –1.50 D in pa-
tients with a prior implantation of refractive multifocal IOL resulted in a refractive surprise of +2.25 to
+2.50 D. After excluding other possible sources of error, an explanation for such a refractive surprise
is suggested, and a simple method for avoiding this error is presented.
Conclusions. Proper knowledge of the defocus curve and the use of a systematic method for deter-
mining subjective refraction in patients implanted with refractive multifocal IOLs will reduce the pos-
sibility of refractive surprise after LASIK enhancement in a bioptics procedure.

Key Words. Defocus curve, LASIK, Refractive multifocal IOL, Refractive surprise
Accepted: May 12, 2011

INTRODUCTION
The Lentis Mplus IOL (Oculentis GmbH, Berlin) is a one-
piece refractive multifocal lens made of hydrosmart with an
Multifocal intraocular lenses (IOLs) are designed to reduce aspheric posterior surface. The multifocality is achieved by
dependence on eyeglasses after cataract surgery or clear implementing a distance part and a distinct near sector of
lens extraction. Refractive multifocal IOLs use surfaces of +3.0 D in the lower IOL segment, comparable to a bifocal
different optical power to provide multifocality. The Re- spectacle lens.
Zoom IOL (Abbott Medical Optics, Santa Ana, CA) uses In general, patients implanted with multifocal IOLs are less
5 concentric rings of varying optical power. The near ad- dependent on eyeglasses, but it is often necessary to com-
dition of the lens is +3.5 D at the lens plane which results bine multifocal IOL with other refractive techniques such as
in approximately +2.6 D at the glasses plane. The ReZoom laser in situ keratomileusis (LASIK) to achieve optimum re-
lens has been developed from the previous Array multifo- sults in the so-called bioptics approach (1). In bioptics, IOL
cal IOL providing better image quality particularly at distant implantation is followed by corneal refractive surgery so that
focus (6). The ReZoom lens has been widely used alone or the greatest amount of ametropia is corrected with the lens
in combination with diffractive multifocal IOLs in the mix and the residual refraction is treated on the cornea taking
and match technique. advantage of the precision of the excimer laser correction.

826 © 2011 Wichtig Editore - ISSN 1120-6721

Albarrán-Diego et al

In the present report, 3 patients who developed a hyper-
opic defect in refraction following LASIK in eyes containing
a ReZoom multifocal IOL (2 eyes) or a Lentis Mplus multifo-
cal IOL (1 eye) are described and discussed.
Case reports
corrected to 20/20 with +2.50 D. Uncorrected near visual
acuity (UCNVA) was very poor at 20/200 and best distance-
corrected near visual acuity (BDCNVA) was 20/30. Topog-
raphy showed a well-centered myopic ablation and mean
keratometry of 42.9 D. Refraction remained stable through
the following months.

Two patients presenting a hyperopic surprise after LASIK Case 2

in one eye were referred to the clinic for a second opinion.
A similar patient who presented consecutive hyperopia af-
ter LASIK for low residual myopia after clear lens extraction
with multifocal IOL implantation had been previously seen.
The 3 eyes shared the presence of a refractive multifocal
IOL: ReZoom IOL (2 eyes) and Lentis Mplus IOL (1 eye).
The characteristics of the 3 eyes involved in the present
report are summarized in Table I.
Case 1
A 56-year-old woman had LASIK in her right eye 1 month
after cataract surgery with a ReZoom multifocal IOL of
+27.0 D implanted. Before LASIK, corrected distance vi-
sual acuity (CDVA) was 20/25 with –1.25 –0.50 × 175º. Au-
tomated refraction was –0.75 –075 × 175º. Near vision was
not measured at that time. Topography was within normal
limits with a mean keratometry of 44.1 D and central ultra-
sonic pachymetry was 522 µm. Laser in situ keratomileu-
sis flap was created using an Amadeus II microkeratome
(Ziemer Ophthalmics Systems AG) with a nasally placed
hinge. Ablation was performed with the Visx S4 Star exci-
mer laser (Abbott Medical Optics). The procedure was un-
eventful, but 24 hours postoperatively the patient showed
an uncorrected distance visual acuity (UCDVA) of 20/60
A 53-year-old man had LASIK done in the right eye after
clear lens extraction with implantation of a Lentis Mplus
MIOL of 17.5 D. Before LASIK, CDVA was 20/25 with –1.00
D. Automated refraction was not reliable, offering values
that ranged between +0.50 and –1.50 D for the sphere
and variable cylinder both in magnitude and axis. No data
about near vision were available. Topography was normal
and showed a mean keratometry of 45.3 D. Central ultra-
sonic pachymetry was 589 µm. Laser in situ keratomileusis
flap was created with a Moria One microkeratome (Moria)
with a nasally placed hinge, and ablation was performed
with a Technolas 217z100 excimer laser (Bausch & Lomb).
One week postoperatively, the patient showed UCDVA of
20/30 corrected to 20/20 with +2.25 D, and refraction re-
mained stable since. Uncorrected near vision was 20/100
whereas BDCNVA achieved 20/25. Postoperative topog-
raphy showed a well-centered myopic ablation and mean
keratometry of 44.4 D.
Case 3
A 56-year-old woman had LASIK in her left eye after clear
lens extraction with a ReZoom MIOL of 28.0 D implanted.
Preoperative CDVA was 20/32 with –1.25 –0.25 × 90º. Au-

TABLE I - CHARACTERISTICS OF THE 3 EYES CONTAINING A REFRACTIVE MULTIFOCAL INTRAOCULAR LENS (IOL) THAT
PRESENTED A HYPEROPIC OUTCOME AFTER LASER IN SITU KERATOMILEUSIS (LASIK)

Case Age, y Eye Multifocal Preop K Preop Pre-LASIK Microkeratome/ Postop K Postop Post-LASIK
no. IOL (power) pachymetry subjective excimer laser pachymetry subjective
refraction refraction

1 56 R ReZoom 44.1 522 –1.25 –0.50 Amadeus II/Visx S4 Star 42.9 501 +2.50
(27.0) × 175º
2 53 R Lentis 45.3 589 –1 Moria One/Technolas 44.4 573 +2.25
Mplus (17.5) 217z100
3 56 L ReZoom 43.3 543 –1.25 –0.25 Carriazo-Barraquer/Visx 41.9 538 +2.25
(28.0) × 90º S2 Star

© 2011 Wichtig Editore - ISSN 1120-6721 827

Defocus curve analysis as a help in subjective refraction
Fig. 1 - Defocus curves for the two refractive bifocal intraocular lens-
es (solid line for the AMO ReZoom and dashed line for the Oculentis
M-Plus). A is the far focus and B is the near focus of the IOL. Refrac-
tion for far can be achieved using both foci of the lens. If B is used
for far vision, refraction will be -2.50 D more myopic than the real re-
fraction using A. If a corneal excimer procedure is performed based
on the refraction obtained with B, the patient will develop yatrogenic
secondary hyperopia. Units are in Snellen decimal notation for visual
acuity and diopters for defocus.
tomated refraction was –0.75 –075 × 90º. Near vision had
not been tested. Topography was normal with mean ker-
atometry of 43.3 D and central ultrasonic pachymetry was
543 µm. Laser in situ keratomileusis flap was created with
a Carriazo-Barraquer microkeratome (Moria) with a superior
hinge. Ablation was performed with the Visx S2 Star excimer
laser (Abbott Medical Optics). One week after the procedure,
the patient showed UCDVA of 20/50 corrected to 20/20 with
+2.25 D, UCNVA of 20/200, and BDCNVA of 20/30. Refrac-
tion remained stable throughout the following months.
DISCUSSION
Three cases of 3 patients who developed a hyperopic sur-
prise after LASIK in eyes implanted with a refractive multi-
focal IOL are reported. Subjective refraction before LASIK
ranged between –1.00 and –1.50 D spherical equivalent
achieving a CDVA ranging between 20/32 and 20/25. After
otherwise uneventful myopic LASIK, the 3 patients pre-
sented a hyperopic outcome ranging between +2.25 and
828 © 2011 Wichtig Editore - ISSN 1120-6721
+2.50 D achieving a CDVA of 20/20 in every case. Retro-
spective examination of ablation reports (and keratometric
change achieved with LASIK procedures) performed in the
3 cases excluded other possible sources of error.
The following explanation for the hyperopic outcome in the
3 cases described is proposed: subjective refraction for
CDVA was achieved using the near focus of the multifo-
cal IOL, so that the eyes were not really myopic of –1.00
to –1.50 D, but hyperopic of +1.00 to +1.50 D. Hence, the
myopic treatment resulted in a more hyperopic residual
defect. It must be kept in mind that in the presence of a
multifocal IOL far vision can be corrected by using the 2
principal foci of the IOL, but only if the far focus is in focus
for far vision will the near focus be useful for near vision. If
the near focus is in focus for far vision, obviously the near
focus does not provide useful near vision. The subjective
refraction value when using the near focus for far vision is
equal to the real refractive error minus the addition of the
IOL for near vision, which is between +2.25 and +2.50 D
at the spectacle plane depending upon the multifocal IOL
design and power (Fig. 1). For instance, for a patient with
a real –1.00 D of myopia after refractive multifocal IOL im-
plantation DCVA can be achieved using a –1.00 D (point A
in Figure 1: far focus in focus for far and near focus in focus
for near) or using a –3.25 D (point B in Figure 1: far focus
out focus for far and near focus in focus for far and out fo-
cus for near); for a patient with a real +1.00 D of hyperopia
after refractive multifocal IOL implantation DCVA can be
achieved using a +1.00 D (point A in Figure 1: far focus in
focus for far and near focus in focus for near) or using a
–1.25 D (point B in Figure 1: far focus out focus for far and
near focus in focus for far and out focus for near).
Subjective refraction remains the method of choice for de-
termining the refractive status after surgery with IOLs in-
cluding multifocal; however, it can be time consuming and
requires trained technicians. Automated refraction and re-
tinoscopy can be used to determine the start point for sub-
jective refraction (2, 3). In the general population retinos-
copy is superior to automated refraction (4) but it requires
experienced clinicians, while automated refraction does
not. It has been previously reported (5, 6) that automated
refraction in eyes with refractive multifocal IOLs shows
some kind of instrument myopia which is a false tenden-
cy towards more negative spherical values compared to
manifest refraction of approximately 1 D. Therefore great
caution should be exercised when autorefraction is carried
out in eyes implanted with refractive multifocal IOL.
Albarrán-Diego et al
In order to prevent this unwanted outcome after LASIK en-
hancement of a refractive multifocal IOL procedure, it is
necessary to be sure that the far focus of the multifocal
IOL is the one that the patient is using for distance vision
in subjective refraction. The following 3-step technique to
prevent this complication is proposed:
1) Once CDVA is achieved, near vision should always be
tested using the far refraction, which is BDCNVA. If BD-
CNVA is not within the expected values for the IOL, the
possibility of having used the near focus of the IOL for far
vision correction must be considered. However, in patients
implanted with refractive multifocal IOLs, UCNVA and BD-
CNVA improve over time by a neuroadaptation process in
which the brain reduces the noise-to-signal ratio produced
by multifocality (7). This means that poor distance-correct-
ed near vision does not always mean that refraction was
performed using the near focus for distance. This step may
be therefore not very practical sometimes, so the following
steps may be used.
2) Once CDVA is achieved, a +2.25 or +2.50 lens is placed
on top of it and distance vision tested again. If CDVA de-
creases to 20/100 or below, subjective refraction was
achieved using the far focus of the IOL and was correct. If
CDVA does not fall but remains similar or even increases,
CDVA was achieved with the near focus of the multifocal
IOL and was accordingly a wrong refraction for far vision.
3) Once CDVA is achieved, a –2.25 or –2.50 lens is placed
on top of it and distance vision tested again. If CDVA falls
to 20/100 or less, refraction was wrong and the patient was
using the near focus of the multifocal IOL for distance. If
CDVA remains similar or decreases 1–2 lines, refraction
was right and the patient was using the far focus of the
multifocal IOL for distance.
It is of utmost importance to be familiar with the defocus
curve of the multifocal IOL being used (Fig. 1). In the case
of refractive multifocal IOL the 2 peaks of maximum visual
acuity are separated by +2.25 to +2.50 D, while in the case of
diffractive multifocal IOLs both peaks are separated further
and hence addition of +2.75 to +3 D (or –2.75 to –3 D) should
be used in steps 2 and 3, respectively (or even 3.25 D).
© 2011 Wichtig Editore - ISSN 1120-6721
In summary, in the presence of a refractive multifocal IOL,
it is mandatory to test BDCNVA once subjective refraction
for far has finished. If near vision with distance refraction
is not within the expected values for the specific IOL, the
possibility of having used the near focus of the IOL to pro-
vide far vision should be ruled out.
This research was supported in part by Ministerio de Ciencia e Inno-
vación Research grants (SAF2008-01114 and SAF2009-13342).
The authors report no proprietary interest.
Address for correspondence:
César Albarrán-Diego
Centro Oftalmológico Marqués de Sotelo
Avda. Marqués de Sotelo 5, planta 2ª
46002 Valencia
Spain
cesar.albarran@gmail.com
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