The patient himself told us, "There's so little information about young people that I struggled, so please publish my case," so here is the case of a man in his early 40s who works as a TV production director.
*Note that because juvenile cataracts often involve complications, our clinic usually refers such patients to a university hospital; thank you for your understanding.
A well-known eye hospital in Tokyo had pointed out cataracts, and he then visited another clinic too; he came to us as a kind of second opinion, wanting surgery if he was a candidate. Both eyes had characteristic cataracts, mainly anterior capsule fibrosis and stellate anterior subcapsular opacity covering the pupillary area, as shown below.
Right eye Left eye
On questioning, he had no history of trauma but had had atopic dermatitis as a child, and given his age, atopic cataract rather than age-related cataract was suspected.
He works as a TV production director and said the monitors looked hazy and hard to see, so, if surgery would improve his vision, he wished for surgery with LENTIS Comfort, which he had researched himself.
His work involves looking at computer screens and monitors for long hours in dark rooms, so LENTIS Comfort, which rarely causes halos and glare, seemed a good choice; when we explained that he would need reading glasses for near, he said he already used near glasses and did not mind. However, in the preoperative questionnaire he gave top priority to intermediate distances of about 50 cm to 1 m, followed by near at 30–40 cm, so we recommended a power setting that slightly sacrificed distance.
He first wished for surgery only on the right eye, where the cataract was more advanced, so we operated with the target refraction set slightly myopic, at about −0.27 to −0.58 D.
In atopic cataracts the nucleus is usually close to zero hardness, so the opacity can be removed with almost no ultrasound; but because the anterior capsule is fibrotic and zonules are often weak, the anterior capsulotomy is the most difficult step of the surgery. A capsulotomy usually opens about 5.5 mm of anterior capsule, so the risk is lower if fibrosis has not spread beyond the central 5.5 mm. Unlike senile cataracts, atopic cataracts can spread month by month once they begin to progress, so for him we operated early, one month after his first visit, before the risk increased.
Fortunately, in the right eye the capsulotomy and zonules caused no problems and the surgery was completed safely; although we had aimed slightly toward near, uncorrected vision was 1.5 distance / 1.2p near, better than the lens's specifications at both distances, and he was very satisfied.
Day after surgery
Even the right eye surgery alone greatly improved his work efficiency, and since he was busy he put the left eye surgery on hold for the time being, but two months later he wished to have the left eye done after all. Personally I thought the right eye's near vision was sufficient, but he wanted the left eye set more toward near, so we set an even nearer target of about −0.62 to −0.98 D.
The left eye surgery was also completed safely, and he was very satisfied with good uncorrected vision of 1.2 distance / 1.2 near, without sacrificing distance. It does not show in the acuity numbers, but objective refraction was 0.5 D more toward near in the left eye, consistent with his feeling that the left eye saw near better.
Not only with LENTIS Comfort, but younger patients, perhaps because they adapt more easily through neural adaptation (getting used to it) and have good pupil movement, tend to achieve better vision than the lens's specifications. Conversely, in older patients, multifocal candidacy should be approached with caution. For reference, with LENTIS Comfort set exactly for distance (target refraction 0.00 D), near vision of at least about 0.4 is achieved.
Being segmental, LENTIS Comfort has a low add but is characterized by few photic phenomena such as halos and glare; however, around one month after right eye surgery he said he sometimes saw a ghosting phenomenon above and below. This can occur with segmental lenses and MiniWELL, but he said he no longer noticed it after both eyes were done, so this too seems a matter of neural adaptation (getting used to it).
Despite its low add of +1.5 D, LENTIS Comfort is at present the only multifocal (bifocal) lens covered by insurance, and it struck me that this patient too wrote in his postoperative survey, "I think LENTIS Comfort is great value for money!" Johnson & Johnson's TECNIS Eyhance, with an add of about +0.5 D, is due to be released under insurance (treated as monofocal), and Alcon's non-diffractive (few halos and glare) AcrySof IQ Vivity with a +1.5 D add also seems to be coming, so choosing a lens suited to each patient will become even more important.
2021.06.23