She had always been highly myopic and first visited us worried about cataracts and glaucoma. Both eyes had advanced myopic nuclear cataracts of about grade 4, with extreme myopia exceeding −10 D. She did not have advanced medical care insurance but was interested in multifocal lenses, so we explained them, including candidacy. She did not particularly play sports or drive but wished to read paperbacks without glasses, so we offered as options the bifocal TECNIS Multifocal with a 4.0 D near add and the trifocal PanOptix with a 3.2 D add. Corneal wavefront analysis as a candidacy test showed mild corneal astigmatism of about 1.0 D, but it was oblique, so we recommended the toric PanOptix Toric.
The cataracts were hard, brown nuclear cataracts, but the surgery was completed without problems; the intraocular lens did not rotate afterwards, the astigmatism was corrected exactly, and uncorrected distance vision, 0.03 before surgery, improved greatly to 1.5. Uncorrected near vision was also good at 1.2, and she was very satisfied to be able to read paperbacks without glasses.
Many cases of dissatisfaction with multifocal lenses seem to be due to residual astigmatism. Astigmatism includes regular astigmatism, which can be corrected with an intraocular lens, and irregular astigmatism, which cannot; if there is a large irregular component, the eye is unsuited to multifocal lenses, so corneal topography is a very important test in judging multifocal candidacy.
Regular astigmatism, too, may blur vertically (with-the-rule), horizontally (against-the-rule) or obliquely (oblique); with-the-rule astigmatism has less effect on vision at the same power (we do not usually use toric lenses for about 1.0 D of with-the-rule astigmatism), but horizontal and oblique blur in particular greatly affect postoperative vision, so correcting them with a toric intraocular lens seems essential for satisfaction with multifocal lenses. Our clinic performs not only topography but also wavefront analysis as corneal shape analysis to diagnose the location and type of astigmatism, so if you are worried about astigmatism, please feel free to consult us.
Cataract Surgery Cases / Case
Multifocal IOL
Case #40: Woman in her 60s from Suginami (extreme myopia with nuclear cataract, toric trifocal intraocular lens: PanOptix Toric)
This is an English translation of the original Japanese case report. If the two differ, the Japanese version takes precedence. Visual acuity is shown in decimal notation (1.0 ≈ 20/20).
Change in visual acuity (decimal; corrected values in parentheses)
Right eye: pre-op → post-op
- Far
- 0.03(0.9p)→1.5p(1.5)
- Near
- —→1.2(n.c.)
Left eye: pre-op → post-op
- Far
- 0.03(0.9)→1.5(n.c.)
- Near
- —→1.2(n.c.)
2019.12.01
Patient questionnaire
Answers translated from Japanese.
- What was your condition before surgery?
My vision kept dropping; I remade my glasses and contacts two or three times, but letters looked double or triple.
- What led you to have surgery?
I suspected these symptoms might be cataracts.
If so, I wanted to consult the doctor early.
I wanted clear vision.- Which did you choose, a multifocal lens or a monofocal lens?
After many years with high myopia I wanted to be freed from glasses and contacts, so I chose multifocal lenses.