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Prod. #: 16104
Multifocal intraocular lenses
Roberto Bellucci
Purpose of review
Multifocal intraocular lenses (IOLs) are growing in
popularity among patients and surgeons, and opened the
way to refractive lens exchange. Still they are not used
routinely in cataract surgery, for reasons probably
connected to the frequently observed reduction in contrast
sensitivity. Recent papers with clinical study outcomes can
help in understanding the advantages and the limits of
multifocal IOLs.
Recent findings
Emerging from every published study, both refractive and
diffractive multifocal IOLs usually provide good near visual
acuity with distance correction. As many multifocal IOLs are
distance-dominant, near vision can be improved by
correcting for near the distance focus. The near contrast
sensitivity thus obtained is similar to that of monofocal IOLs.
Multifocal IOLs have been employed with success in
complicated cataract surgery and in trauma cases, with the
same outcome as in normal cataract cases. Presbyopic
lens exchange remains controversial, with a high success
rate in original ametropic eyes, but limited success in
original emmetropic eyes. Secondary procedures to
improve the refractive outcome are usually of little efficacy
in improving patient satisfaction. A new anterior chamber
phakic multifocal IOL has been designed to correct
presbyopia and small refractive errors. The first clinical
results indicate high patient satisfaction, with 7.3%
explantation rate.
Summary
Multifocal IOLs can be more widely used after cataract
surgery, but should be used with caution in almost
emmetropic eyes with little or no cataract. Refractive lens
exchange with multifocal IOL is especially worthwhile in
hyperopic eyes. The new phakic multifocal IOL adds the
concept of reversibility to presbyopic lens exchange.
Keywords
multifocal intraocular lenses, patient satisfaction, refractive
lens exchange, presbyopic lens exchange, phakic
multifocal intraocular lenses
Curr Opin Ophthalmol 16:33–37. ª 2005 Lippincott Williams & Wilkins.
Director of the Ophthalmic Unit, Hospital and University of Verona, Italy
Correspondence to Roberto Bellucci, Director of the Ophthalmic Unit, Hospital and
University of Verona, Via degli Abeti 17 25087 Salo’ (BS) Italy
Tel: +39 045 807 3035; fax: +39 045 807 2289;
e-mail: roberto.bellucci@azosp.vr.it
Current Opinion in Ophthalmology 2005, 16:33–37
ª 2005 Lippincott Williams & Wilkins.
1040-8738
Introduction
The first multifocal intraocular lens (IOL) gaining some
diffusion in clinical practice had diffractive optics, with
the bifocal add designed as a Fresnel lens onto the poste-
rior optic surface [1]. Bifocal refractive IOLs, with differ-
ent optical zones devoted to distance and to near vision
appeared at the same time [2]. To date, the best studied
multifocal IOL is the silicone AMO Array, an intraocular
lens thought to provide some intermediate vision in addi-
tion to distance and to near vision [3]. After the positive
results in cataract patients, multifocal IOLs have been
employed in nearly emmetropic eyes to correct for presby-
opia [4]. Recently, phakic multifocal IOLs have been
designed and implanted [5••], and new foldable diffrac-
tive IOL with unique optics in acrylic material has been
produced and is entering clinical practice [4]. The sensa-
tion is that multifocal intraocular lenses are ready to be
more widely used in ophthalmic surgery.
Characters of multifocal intraocular lenses
Multifocal IOLs have two or more optical foci. This
means the presence of at least two co-axial dioptric
powers, usually separated by a 4 D interval to provide
a 3 D interval at the spectacle plane. On the retina, the
two dioptric powers will produce two superimposed im-
ages of any observed object. Under the best conditions,
one image will be in sharp focus, and the other image
will be blurred by a 3 D defocus aberration (Fig. 1). For
example, a black line on white paper will appear sur-
rounded by a narrow grey ribbon. This is the optical rea-
son for the reduction in modulation transfer function
observed with multifocal IOLs [6], unfortunately a reduc-
tion strictly connected to the presence of co-axial differ-
ent powers. This lower optical quality as compared with
monofocal IOLs emerges as lower contrast sensitivity in
implanted patients.
Many studies have been carried out to improve this draw-
back. One proposed solution is to direct different amounts
of the refracted light on the different foci, thus privileging
distance or near vision. Distance-dominant multifocal
IOLs provide higher contrast sensitivity for distance
focus, and lower contrast sensitivity for near focus, while
the contrary happens with near-dominant multifocal IOLs
[7]. A further approach is to get some help from the pupil,
driving different amounts of light on the different foci
depending on pupil dilation. As compared with monofocal
IOLs, the AMO Array refractive multifocal IOL directs
42% (miosis) to 73% (mydriasis) of light onto the distance
focus [8], whereas the Alcon SA60D3 diffractive multifocal
33
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34 Cataract surgery and lens implantation
Figure 1. Multifocal intraocular lens and dioptric powers
Every multifocal IOL provides at least two dioptric powers, with
two images of the same object forming on the retina. The defocused
image causes blurring of the focused image, reducing modulation.
IOL with apodized optics directs 42% to 85% of light on
the distance focus (Fig. 2)(Data on File, Alcon Laborato-
ries, Forth Worth, TX). Future clinical studies will define
the efficacy of this approach (Table 1).
Recent clinical studies
After previous demonstration of the efficacy of multifocal
intraocular lenses, recent clinical studies aimed at verify-
ing success rate more in terms of contrast sensitivity and
patient satisfaction than in terms of Snellen visual acuity.
Figure 2. Alcon SA60D3 multifocal intraocular lens
Distribution of light to the distance and far focus as a function of
pupil diameter with the Alcon SA60D3 multifocal IOL with
diffractive apodized optics.
Figs. 1,2 live 4/C
Table 1. Comparison between refractive AMO SI40N
and diffractive Alcon SA60D3
AMO SI40N Alcon SA60D3
IOL type Three-piece Single-piece
Multifocal type Refractive Diffractive, apodized
Multifocal add Anterior Anterior
Optic material Silicone Hydrophobic acrylic
Optic diameter 6 mm 6 mm
Square edge No Yes
Refractive index 1.46 1.55
Multifocal zone diameter 4.7 mm 3.6 mm
Light to distance focus
Miosis ~42% ~42%
Mydriasis ~73% ~85%
Haptic material PMMA Hydrophobic acrylic
Multifocal intraocular lenses versus monofocal
intraocular lenses
According to Leyland and Zinicola [9•], the key question
to be answered is whether the optical tradeoff inherent in
a multifocal IOL results in better or worse visual function
than a monofocal IOL. They selected 8 randomized con-
trolled trials published from 1992 to 2002, comparing mul-
tifocal IOLs with monofocal IOLs of similar design and
material. Diffractive and refractive IOLs have been sepa-
rately analyzed. This study could not find any difference
between multifocal and monofocal IOLs for uncorrected
distance visual acuity. Best corrected distance visual
acuity was also similar in the two groups, multifocal and
monofocal, but within the multifocal group the refractive
subgroup performed better than the diffractive. Unaided
near visual acuity was far better for multifocals, although
measurement heterogeneity made statistical analysis im-
possible. Multifocal patients had definitely lower specta-
cle dependence than monofocal patients. Glare and halos
were present with both types of multifocals. This review
could not find better patient satisfaction with multifocal
IOLs as compared with monofocal IOLs. Whether the im-
provement in the unaided near vision outweigh the reduc-
tion in contrast sensitivity and the presence of halos is
a matter to be decided by the individual patient.
A prospective nonrandomized study comparing multifocal
IOLs (AMO Array) with monofocal IOLs (AMO SI40NB)
has been published by Montés-Micò et al. [10••]. This
study examined contrast sensitivity in photopic (85 cd/m2),
mesopic (5 cd/m2), and low mesopic (2.5 cd/m2) lumi-
nance conditions. Contrast sensitivity was the same with
either IOL only in photopic conditions and for distance
vision, while it was reduced with the multifocal IOL in
most distance mesopic and near photopic and mesopic
conditions. In near vision, monofocal IOLs with near cor-
rection yielded better results than multifocal IOLs with
distance correction. However, differences were found only
at 12 and at 18 cycles/degree when the distance focus of the
multifocal IOL was near corrected. This is to say that mul-
tifocal implanted patients can improve their near vision
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by correcting for near the distance focus, the focus receiv-
ing most of the refracted light.
The improvement in patient’s ability to properly use mul-
tifocal IOLs has been examined by Montés-Micò and
Alio [11•], who studied 21 patients with multifocal IOLs
(AMO Array) and 21 patients with monofocal IOL (AMO
SI40NB) for 18 months. Near contrast sensitivity was
found reduced in the multifocal group in all testing con-
ditions up to three months after surgery. It improved
thereafter, with no eventual difference between multifo-
cal near corrected eyes and monofocal near corrected eyes.
The authors conclude that the optical blur caused by the
distance optical power (driving the most of the refracted
light) continues to affect the image produced by the near
optical power over time. On the contrary, after the first
weeks patients apparently learned to ignore the blur
caused by the near power on the image produced by
the distance power.
Comparison between multifocal intraocular lenses
Clinical studies comparing different types of multifocal
IOLs are rare. One of them has been performed by Perez
et al. [12], who compared diffractive and refractive IOLs in
99 patients, 47 of whom received the Pharmacia 811E
PMMA IOL, and 52 received the Ioltech MF4 hydrophilic
acrylic IOL. The two lenses had the same near add, +4 D.
The given results are better for the diffractive IOL in
terms of uncorrected and best corrected distance visual
acuity, and in terms of near visual acuity with distance
correction. However, follow-up length is only 6 months;
owing to the wide incision required to implant a 6-mm
PMMA IOL, longer observation would be preferred before
valid conclusions are made. As the objective of multifocal
IOLs is spectacle independence, the effect of any astig-
matism cannot be overemphasized.
Simultaneous bilateral implantation
There is some concern to implant patients bilaterally dur-
ing the same surgical session. With multifocal IOLs this
concern is increased because of the optical properties of
these IOLs, and because of the possible occurrence of bi-
lateral pseudophakic refractive errors. However, patients
frequently ask for bilateral simultaneous surgery, and
the analysis of patient satisfaction following such surgery
could be of great interest. Pineda-Fernández et al. [13•]
examined 35 patients implanted simultaneously in both
eyes with the AMO Array IOL: 7 of them were hyperopic
by more than 2 diopters and 28 had cataracts. The visual
and the refractive outcomes of those patients were com-
parable to the results of previous studies conducted after
sequential surgery [14,15]. Three months after surgery,
31% of patients never wore glasses, 63% wore them occa-
sionally, and 6% wore them always. Most patients (71%)
were very satisfied with their vision, 26% were satisfied,
and 1 patient (3%) was dissatisfied. Halos at night were
Multifocal intraocular lenses Bellucci 35
reported by 24% of patients, none of whom asked for
IOL exchange.
Complicated surgery
Multifocal intraocular lenses must be implanted bilaterally
for better patient satisfaction, and possibly in an intact
capsular bag to ensure optimal centration [16]. The prob-
lem arises when the second eye has a complication during
surgery, preventing IOL implantation in the capsular bag.
Aralikatti et al. [17••] identified 15 second eyes, where the
AMO Array multifocal IOL had to be implanted in the
ciliary sulcus because of surgical complications. One to
4.2 years after surgery, the IOL was centered in 11 eyes
(73%), and decentered by 1 mm in 4 eyes (27%). One
eye required IOL reposition because of pupil capture.
Two of the complicated eyes and none of the contralateral
uneventful eyes were found to have cystoid macular
edema. Visual results were as good as in the contralateral
uneventful eye, with the exception of the two eyes with
CME and two additional eyes with epiretinal membrane
and with amblyopia. The VF-14 questionnaire for patient
satisfaction gave scores similar to that of studies con-
ducted on uneventful eyes. Thus, sulcus implantation
of the Array multifocal IOL is an option in the case of
surgery complications.
Loss of accommodation is a common problem after
traumatic cataract surgery in young patients. Jacobi et al.
[18••] implanted 29 such patients with the AMO Array
multifocal IOL over a 5-year period, while 22 similar pa-
tients were implanted with a monofocal IOL. Most trau-
mas were due to corneal wound. Multifocal IOLs could be
implanted in the capsular bag in 9 eyes, they were capsule
supported in 15 eyes, and they were scleral-fixated in
5 eyes. Despite this variety in IOL location, leading to five
cases of decentration, refractive and visual results were as
good as in the monofocal group. Near visual acuity without
correction or with distance correction was better in the
multifocal group, with 17% being dependent on glasses
for near vision as compared with 81% in the monofocal
group. Percentages reporting glare and halos did not differ
between multifocal and monofocal patients in this study.
The conclusion is that multifocal IOLs can be employed
for the visual rehabilitation of young patients with unilat-
eral traumatic cataract even due to corneal wound, thus
improving near vision while not impairing distance vision
as compared with monofocal IOLs.
A case of implantation of a multifocal IOL in one eye after
refractive corneal surgery has been reported by Yip and
Claoué [19]. They sequentially implanted an Array IOL
in both eyes of one patient who had been previously op-
erated with photorefractive keratectomy and laser ther-
mokeratoplasty. The positive result of this case could
have been favored by the relative regularity of the corneal
surface.
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36 Cataract surgery and lens implantation

Presbyopic lens exchange Figure 3. The Baikoff multifocal anterior chamber phakic
intraocular lens
Multifocal IOLs could be the ideal solution for refractive
lens exchange in general, and for presbyopic lens exchange
in particular. The ability to focus on near and distant
objects, and also on intermediate distances in some cases,
is attracting more and more patients without cataracts to
surgery, especially if some refraction defect is present for
distance vision [20]. In addition, according to Hoffman
et al. [4] candidates for presbyopic lens exchange include
emmetropic patients, where presbyopia is the only refrac-
tive defect. Results of the procedure have been reported
to satisfy operated subjects, with excellent refractive and
visual outcome in published studies [15,21].

However, we cannot assume IOL power calculation to al-

ways be perfect, and astigmatism to always be negligible.
Intraocular lens exchange, IOL re-location in the ciliary
sulcus, piggyback IOL implantation, and refractive corneal
surgery are possible options in the case of postoperative
refractive surprise [4]. The efficacy of these secondary
procedures over visual and refractive results and over pa-
tient satisfaction has been investigated by Leccisotti
[22••]. He examined 52 patients aged 45 to 62 years This lens is to be implanted in the anterior chamber of phakic
who were originally emmetropic or hyperopic, and who eyes to correct presbyopia with and without distance refractive
had presbyopic lens exchange between 2001 and 2002. errors.
Professional drivers and patients with any disorder that
could affect the anatomic and visual outcome were ex-
cluded. The AMO Array SI40N was implanted in all eyes.
while the haptics are made of PMMA with hydrophilic
Patients were planned for bilateral sequential surgery with
acrylic footplates. The IOL optic has three optical zones:
a 3-week interval, but 8 (16%) canceled the second eye
one central 1.5-mm zone for distance vision, one 0.55-mm
surgery due to intolerable halos, even after laser refraction
ring zone for near vision, and one 1.45-mm outer ring zone
correction in 4 eyes. Of the 44 patients with bilateral sur-
for distance vision. The IOL can be injected through
gery, 33 reported good satisfaction, while 11 patients with
3.2-mm incisions. This approach to presbyopia correction
low uncorrected near visual acuity reported low to no sat-
could be reversible with only minor problems after IOL
isfaction. A total of 9 patients with bilateral implant (20%) removal. In the first published study 55 eyes of 33 patients
had important refractive errors in the postoperative period. have been implanted and followed for 2 to 83 weeks. Ex-
Six of them required PRK, with improvement in refrac- clusion criteria were shallow anterior chamber and low
tion, but limited improvement in uncorrected near visual endothelial cell count. Postoperatively, uncorrected near
acuity. IOL exchange to monofocal was performed in visual acuity was 2.3 ± 0.6 of the Parinaud scale, comparing
seven eyes after unilateral implant, because of intolerable favorable with the best corrected preoperative value of
visual disturbance due to halos. The procedure was un- 2.03 ± 0.1. However, patients experienced a mean one-line
complicated and halos resolved, but the patients’ dissat- loss in best corrected distance visual acuity, the occur-
isfaction remained. Overall, secondary procedures were rence of halos (24%), pupil ovalization (10%), and endothe-
performed in 37.5% of eyes who were originally emme- lial cell loss was 5% after 1 year. Four IOLs (7.27%) had to
tropic or less than 2 D hyperopic, and in 0% of eyes who be explanted because patients were not satisfied with the
were originally more than 2 D hyperopic. This finding results. Interestingly, the study of Leccisotti reported sim-
led the author to reconsider presbyopic lens exchange ilar explantation percentage (7.29%) in multifocal pseudo-
in nearly emmetropic eyes, and to favor refractive lens ex- phakic eyes after presbyopic lens exchange [22••].
change with a multifocal IOL in elderly hyperopic patients.

One major problem of presbyopic lens exchange is the lack Conclusion

of reversibility. Baikoff [5••] designed a refractive bifocal Every published study confirms that multifocal IOLs lead
IOL (Fig. 3), to be implanted in the anterior chamber of to good near visual acuity with distance correction, with
phakic eyes to correct presbyopia with and without dis- high patient satisfaction after both uncomplicated and
tance refractive errors. The optic is hydrophilic acrylic, complicated cataract surgery. It is clear that minor

Fig. 3 live 4/C

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decentration (up to 1 mm) does not cause visual prob-
lems. Improvements in IOL power calculation has almost
overcome the occurrence of refractive surprises, and it has
been demonstrated that refractive corneal surgery can be
employed to correct small pseudophakic refractive errors
in multifocal patients. The use of multifocal IOLs is
expanding to trauma cases, to special eyes with previous
corneal surgery, to presbyopic lens exchange. Still, they
fail to satisfy all the highly demanding patients, with
reported explantation rate up to 7%. The presence of
halos around image borders and around typed letters for
instance, could overcome the advantages of spectacle in-
dependence. As the strength of these halos depends on
the luminance of the defocused image, multifocal IOLs
can be distance-dominant or near-dominant, or even change
dominance with pupil diameter. In the future, patients
could therefore be selected for a particular lens design
based on their visual demands and activities, and taking
pupil diameter into account.
With modern cataract surgery, we cannot rely on myopic
astigmatism to increase the depth of focus with monofocal
IOLs, an additional reason for the interest in multifocal
intraocular lenses to grow. The recent development of
aspherical surfaces [23] will probably give rise to a number
of designs, with the purpose of addressing specific optical
needs including near vision. Accommodative IOLs, whether
one-piece or multi-piece, are another option aimed at the
dream of many patients and surgeons—spectacle inde-
pendence.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
• of special interest
•• of outstanding interest
1 Keates RH, Pearce JL, Schneider RT: Clinical results of the multifocal lens.
J Cataract Refract Surg 1987; 13:557–560.
2 Duffey RJ, Zabel RW, Lindstrom RL: Multifocal intraocular lenses. J Cataract
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3 Percival SP, Setty SS: Prospectively randomized trial comparing the pseu-
doaccommodation of the AMO ARRAY multifocal lens and a monofocal lens.
J Cataract Refract Surg 1993; 19:26–31.
4 Hoffman RS, Fine IH, Packer M: Refractive lens exchange with a multifocal
intraocular lens. Curr Opin Ophthalmol 2003; 14:24–30.
5 Baikoff G, Matach G, Fontaine A, et al. Correction of presbyopia with refrac-
••
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30:1454–1460.
This is the first published study about clinical results with the multifocal phakic
anterior chamber IOL. Patient satisfaction and explantation rate were similar to
the results after presbyopic lens exchange.
Multifocal intraocular lenses Bellucci 37
6 Holladay JT, Van Dijk H, Lang A, et al. Optical performance of multifocal
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• aract surgery. A systematic review. Ophthalmology 2003; 110:1789–1798.
This review confirmed the known advantages and limitations of multifocal intra-
ocular lenses. His patient satisfaction rate was counterbalanced by some loss
in contrast sensitivity and in best corrected visual acuity.
10 Montes-Mico R, Espana E, Bueno I, et al. Visual performance with multifocal
•• intraocular lenses: mesopic contrast sensitivity under distance and near
conditions. Ophthalmology 2004; 111:85–96.
This paper demonstrated better near contrast sensitivity and better bear visual
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A learning curve for implanted patients to get accustomed to multifocal IOLs has
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12 Perez LA, Munoz LA, Gimeno SJA, et al. Estudio clı́nico comparativo de los
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Esp Oftalmol 2003; 78:665–673.
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A further paper confirming the efficacy and the safety of simultaneous bilateral
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17 Aralikatti AK, Tu KL, Kamath GG, et al. Outcomes of sulcus implantation of
•• Array multifocal intraocular lenses in second-eye cataract surgery complicated
by vitreous loss. J Cataract Refract Surg 2004; 30:155–160.
A well-designed study indicating the feasibility of multifocal IOL implantation even
in the case of surgical complications.
18 Jacobi PC, Dietlein TS, Lueke C, Jacobi FK: Multifocal intraocular lens implan-
•• tation in patients with traumatic cataract. Ophthalmology 2003; 110:531–
538.
The first paper dealing with multifocal IOL implantation after traumatic cataract.
A control group with monofocal IOLs is also provided.
19 Yip JLY, Claoué C: Surgery for 4 refractive errors in 1 patient. J Cataract
Refract Surg 2004; 30:527–528.
20 Hoffman RS, Fine IH, Packer M: Refractive lens exchange as a refractive
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21 Dick HB, Gross S, Tehrani M, et al. Refractive lens exchange with an array
multifocal intraocular lens. J Refract Surg 2002; 18:509–518.
22 Leccisotti A: Secondary procedures after presbyopic lens exchange. J Cat-
•• aract Refract Surg 2004; 30:1461–1465.
Secondary procedures for refractive errors and for visual disturbances were
required by originally emmetropic patients, and not by patients originally hyperopic
by two or more diopters. Secondary procedures did not increase patient satisfac-
tion in this study.
23 Holladay JT, Piers PA, Koranyi G, et al. A new intraocular lens design to
reduce spherical aberration of pseudophakic eyes. J Refract Surg 2002;
18:683–691.