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Prevention of Hyperopic Surprise
Prevention of Hyperopic Surprise
5000005
CASE REPORT
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.
In the present report, 3 patients who developed a hyper- corrected to 20/20 with +2.50 D. Uncorrected near visual
opic defect in refraction following LASIK in eyes containing acuity (UCNVA) was very poor at 20/200 and best distance-
a ReZoom multifocal IOL (2 eyes) or a Lentis Mplus multifo- corrected near visual acuity (BDCNVA) was 20/30. Topog-
cal IOL (1 eye) are described and discussed. raphy showed a well-centered myopic ablation and mean
keratometry of 42.9 D. Refraction remained stable through
Case reports the following months.
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
In order to prevent this unwanted outcome after LASIK en- In summary, in the presence of a refractive multifocal IOL,
hancement of a refractive multifocal IOL procedure, it is it is mandatory to test BDCNVA once subjective refraction
necessary to be sure that the far focus of the multifocal for far has finished. If near vision with distance refraction
IOL is the one that the patient is using for distance vision is not within the expected values for the specific IOL, the
in subjective refraction. The following 3-step technique to possibility of having used the near focus of the IOL to pro-
prevent this complication is proposed: vide far vision should be ruled out.
1) Once CDVA is achieved, near vision should always be
tested using the far refraction, which is BDCNVA. If BD- This research was supported in part by Ministerio de Ciencia e Inno-
vación Research grants (SAF2008-01114 and SAF2009-13342).
CNVA is not within the expected values for the IOL, the
possibility of having used the near focus of the IOL for far The authors report no proprietary interest.
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 Address for correspondence:
César Albarrán-Diego
which the brain reduces the noise-to-signal ratio produced Centro Oftalmológico Marqués de Sotelo
by multifocality (7). This means that poor distance-correct- Avda. Marqués de Sotelo 5, planta 2ª
ed near vision does not always mean that refraction was 46002 Valencia
Spain
performed using the near focus for distance. This step may cesar.albarran@gmail.com
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- REFERENCES
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