Reduction in Mean Deviation Values in Automated
Perimetry in Eyes With Multifocal Compared to Monofocal
Intraocular Lens Implants
MARJAN FARID, GARRICK CHAK, SUMIT GARG, AND ROGER F. STEINERT

PURPOSE: To evaluate differences in mean deviation
values in automated perimetry in healthy eyes with multi-
focal compared to monofocal intraocular lens (IOL)
implants.

DESIGN: Prospective, age-matched, comparative anal-
ysis.

METHODS: SETTING: Single-center, tertiary referral
academic practice. PATIENT POPULATION: A total of 37
healthy eyes in 37 patients with bilateral multifocal
(n [ 22) or monofocal (n [ 15) IOL implants were stud-
ied. INTERVENTION/OBSERVATION PROCEDURE: Humphrey
Visual Field 10-2 testing was performed on all patients.
MAIN OUTCOME MEASURES: Mean deviation (MD) and
pattern standard deviation (PSD) numerical values were
evaluated and compared between groups.

RESULTS: The average MD was L2.84 dB (SD 2.32)
for the multifocal IOL group and L0.97 dB (SD 1.58)
for the monofocal IOL group (P [ .006). There was
no significant difference in PSD between the 2 groups
(P [ .99). Eyes that had the visual field 10-2 testing
‡6 months from time of IOL placement showed no
improvement in MD when compared to eyes that were
tested within 6 months from IOL placement.

CONCLUSION: Multifocal IOL implants cause signifi-
cant nonspecific reduction in MD values on Humphrey
Visual Field 10-2 testing that does not improve with
time or neuroadaptation. Multifocal IOL implants may
be inadvisable in patients where central visual field reduc-
tion may not be tolerated, such as macular degeneration,
retinal pigment epithelium changes, and glaucoma. (Am
J Ophthalmol 2014;158:227–231. Ó 2014 by Elsevier
Inc. All rights reserved.)
N mated Esterman binocular field test,26 and Humphrey
ONPATHOLOGIC VISUAL FIELD DEFECTS FROM
optical anomalies are frequently encountered
during automated perimetry in the office setting.
Clinical reasons for these relative visual field changes
include media opacities, uncorrected refractive errors,
Accepted for publication Apr 22, 2014.
From Gavin Herbert Eye Institute, University of California, Irvine,
Department of Ophthalmology, 850 Health Sciences Road, Irvine,
California.
Inquiries to Marjan Farid, Gavin Herbert Eye Institute, University of
California, Irvine, Department of Ophthalmology, 850 Health Sciences
Road, Irvine, CA 92697; e-mail: mfarid@uci.edu
0002-9394/$36.00 Ó 2014 BY ELSEVIER INC. ALL
http://dx.doi.org/10.1016/j.ajo.2014.04.017
lens rim artifacts, miosis, and lid or brow ptosis.1–5 With
alterations in incident light and contrast on the retina,
changes in automated perimetry numerical values of
mean deviation (MD) and pattern standard deviation
(PSD) can be studied.
Multifocal intraocular lenses (IOLs) produce simulta-
neous retinal images with different focal planes in order
to reduce spectacle dependency for distance and near visual
acuities. Along with potential benefits, however, is the
reality that the amount of light energy in focus at any given
focal distance is reduced, out-of-focus light is superim-
posed, and approximately 18% of transmitted light in
diffractive IOLs, which may vary depending on IOL design,
is lost to higher orders of diffraction that are not ever
focused on the retina.6,7 As a result, patients with
multifocal IOLs may experience glare and halos, as well
as reduced contrast sensitivity.8–15 Mesopic conditions
tend to exacerbate these deficiencies.16,17 Furthermore,
increased chromatic aberrations and light scattering
have also been reported.6,18–21 In light of these optical
disturbances, we evaluated the effect of diffractive
multifocal IOLs on a common clinical test, Humphrey
Visual Field Analyzer (Zeiss-Meditec, Dublin, California,
USA) 10-2, to determine the impact on performance in
patients with bilateral multifocal or monofocal IOL
implants.
Several studies have previously reported the effects of
intraocular lenses on visual field testing. Mutlu and associ-
ates demonstrated that monofocal IOLs may reduce MD in
Humphrey Visual Field 24-2 testing compared to healthy
phakic patients.22 Specifically, the effects of multifocal
IOLs on perimetry have been evaluated with Octopus
101 autoperimetry,23 Goldmann manual perimetry,24
frequency doubling technology matrix perimetry,25 auto-
Visual Field 30-2.27 With appreciation of the previous con-
tributions, this study is the first to use Humphrey Visual
Field 10-2 to compare and quantify the effects of multifocal
and monofocal IOL on the central 10 degrees of vision.
MATERIALS AND METHODS
INSTITUTIONAL REVIEW BOARD/ETHICS COMMITTEE
approval was obtained from the University of California,
RIGHTS RESERVED. 227
Irvine, prior to a prospective comparative analysis. All
patients reviewed and signed a detailed informed consent
form prior to participating in the study. A total of 37
healthy eyes in 37 patients were enrolled, all with either
bilateral multifocal IOLs (n ¼ 22) or monofocal IOLs
(n ¼ 15). Cataract surgeries had been previously performed
by 1 of 3 surgeons (M.F., R.F.S., S.G.). One eye was
selected at random from each patient for the study to
ensure independence of the variables. Inclusion criteria
were each eye having corrected distance visual acuity
(CDVA) > _20/25 with no other ocular pathology, including
retinal disease, glaucoma or optic neuropathy, ocular
hypertension, amblyopia, irregular corneal astigmatism,
corneal dystrophy, or significant capsular opacity. Dilated
examinations of the macula and optic nerve were
performed on all eyes to ensure no evidence of pathology
prior to testing. All eyes had normal intraocular pressures
on multiple visits. Patients with mild dry eye symptoms
and signs were not excluded from the study. All cataract
surgeries were uncomplicated, with clear corneas and
good centration of the IOL in the capsular bag. All multi-
focal IOLs had aspheric diffractive optics (no refractive
multifocal IOLs were included). Any patients with psycho-
logical or neurologic disorders, poor concentration, or poor
cooperation were excluded from the study. Patients were
also excluded if they had a history of prior refractive
corneal surgery. Patients with scotopic pupil diameters
smaller than 2.5 mm were excluded to avoid diffraction-
limited visual field artifacts. All manifest refractions were
within 1 diopter of goal in the monofocal IOL group and
within 0.5 diopter spherical equivalent in the multifocal
IOL group. All eyes had less than 0.5 diopters of refractive
astigmatism. No patients with monovision were included.
All refractive errors were lens corrected during Humphrey
Visual Field 10-2 testing.
All Humphrey Visual Field 10-2 automated perimetry
testing was measured with the Swedish Interactive
Threshold Algorithm (SITA) standard threshold test
algorithm, white stimulus, size III target, and standard
Humphrey background luminance of 31.5 apostilb. The
earliest visual field testing was measured at postoperative
month 1. Near vision refractions were done on every eye
prior to testing to ensure that the patient had the minimum
refractive add power necessary for comfortable 20/20 vision
at the testing distance. Most multifocal IOL eyes required
little or no add at this distance. Nevertheless, careful refrac-
tive measurements were performed at the testing distance
and if an add power was required, it was given by corrective
lenses. MD and PSD, as well as reliability indices including
fixation losses and false-positive and false-negative numeric
values, were recorded. Poor tests with high fixation losses or
false-positive/negative values were repeated for reliability.
Statistical analysis was performed comparing the multifocal
group to the monofocal group using a 2-tailed Student t test
under the assumption that the 2 groups had unequal vari-
ance (www.studentsttest.com).
228 AMERICAN JOURNAL OF OPHTHALMOLOGY
RESULTS
THIRTY-SEVEN PATIENTS WERE INCLUDED IN THE STUDY.
One eye from each patient was selected randomly for anal-
ysis: 22 eyes with multifocal IOLs and 15 eyes with mono-
focal IOLs. The multifocal IOLs included the 1-piece
Tecnis ZMB00 (n ¼ 11) and the 3-piece Tecnis ZMA00
(n ¼ 6) (Abbott Medical Optics, Santa Ana, California,
USA), as well as the Acrysof IQ ReSTOR SN6AD1
(n ¼ 5) (Alcon, Fort Worth, Texas, USA). The monofocal
IOLs included the 1-piece Tecnis ZCB00 (n ¼ 7) and the
3-piece Tecnis ZA9003 (n ¼ 6) (Abbott Medical Optics)
as well as the Acrysof IQ SN60WF (n ¼ 2) (Alcon). There
was no significant difference in age or sex between the
groups. The average age was 73 years in both groups, with
14 female patients in the multifocal group (14/22; 63.6%)
and 10 in the monofocal group (10/15; 66.7%).
The average mean deviation was 2.84 dB (SD 2.32) for
the multifocal IOL group and 0.97 dB (SD 1.58) for the
monofocal IOL group (P ¼ .006) (Figure 1). The average
pattern standard deviation was 1.41 dB (SD 0.94) and
1.41 dB (SD 0.37) for the multifocal and monofocal groups,
respectively (P ¼ .99) (Figure 2).
Time from cataract surgery to Humphrey Visual Field
10-2 testing was also evaluated to assess if neuroadaptation
over time may correlate with less reduction in MD. The
time between surgery and visual field testing averaged
12.5 months in the multifocal IOL group (range,
1–34 months) and 4.9 months in the monofocal IOL
group (range, 1–26 months). Six months was chosen as a
dividing line to assess neuroadaptation based on previous
reports.28–30 The MD values in multifocal IOL patients
with time to visual field testing less than 6 months (n ¼
7) compared to those with time to visual field testing
greater than 6 months (n ¼ 15) were 1.65 dB
and 2.98 dB, respectively, with no significant difference
between the two (P ¼ .15) (Figure 3).
DISCUSSION
THIS IS THE FIRST CASE-CONTROL STUDY TO EVALUATE AND
quantify differences in Humphrey Visual Field 10-2 testing
in healthy eyes with diffractive multifocal vs monofocal
IOLs. A significant depression in MD, by approximately 2
dB, is seen in the multifocal IOL group. This same degree
of MD reduction was seen in the study by Aychoua and
associates using Humphrey Visual Field 30-2 testing in the
multifocal vs monofocal IOL analysis.27 Patients with multi-
focal IOLs have been shown to have reduced contrast sensi-
tivity,12–15 particularly in mesopic conditions.16,17 Standard
automated perimetry, which measures differential light
sensitivity thresholds at various locations across the visual
field, is a reliable measure of this subclinical reduction
in visual sensitivity in diffractive multifocal IOL eyes.
AUGUST 2014
FIGURE 1. Mean deviation values on Humphrey Visual Field
10-2 testing in patients with multifocal and monofocal intraoc-
ular lens implants. Note that there is a significant difference
between the 2 groups (P [ .006).
FIGURE 2. Pattern standard deviation values on Humphrey
Visual Field 10-2 testing in patients with multifocal and mono-
focal intraocular lens implants. Note that there is no statistical
difference between the 2 groups (P [ .99).
The reduced MD on Humphrey Visual Field 10-2 testing in
our study is likely related to this reduction in differential
light sensitivity.31 If further studies confirm the 2 dB reduc-
tion in MD in multifocal normal eyes, a new baseline in
Humphrey Visual Field testing may be established in this
population.
Previous studies of visual field effects from multifocal
IOLs have been reported. A prospective nonrandomized
clinical study by Bi and associates used Octopus 101 auto-
perimetry to compare visual field results in patients who
had multifocal IOLs (AcrySof ReSTOR SA60D3) with
patients who had monofocal IOLs (AcrySof SN60AT)
and found no significant difference between the 2 groups.23
In another prospective comparative analysis, Kang and Lee
demonstrated that patients with multifocal IOLs (3M
diffractive bifocal IOL) have greater reduction in visual
field on Goldmann manual perimetry than patients with
monofocal IOL, and this was reflected across different
spot size and intensity.24 In another prospective compara-
tive analysis, Stanojcic and associates studied the effects
VOL. 158, NO. 2 VISUAL FIELD TESTING IN MULTIFOCAL INTRAOCULAR LENS EYES
FIGURE 3. Mean deviation values on Humphrey Visual Field
10-2 categorized by patients who had testing within 6 months
post multifocal intraocular lens implantation and patients who
had testing after 6 months post multifocal intraocular lens im-
plantation.
of multifocal IOL (Tecnis ZM900) vs monofocal IOL
adjusted for monovision on binocular visual fields, evalu-
ated by automated Esterman binocular field, and found
no statistically significant difference between the 2
groups.26 Whereas this study was intended to assess differ-
ences in binocular visual fields and visual disability for
driving evaluation in the United Kingdom, when it comes
to monocular central vision, the Esterman test inherently
screens for larger scotomas and does not evaluate subtle de-
pressions in central visual field.32 In another prospective
comparative study, Bojikian and associates demonstrated
no difference between an apodized diffractive multifocal
IOL (AcrySof ReSTOR) and a monofocal IOL (AcrySof
IQ) on results of frequency doubling technology perimetry,
which is used for early detection of glaucoma, as the perim-
eter predominantly stimulates the magnocellular ganglion
cell pathway and is less sensitive to optical blur as
compared to automated perimetry.25
The reduction of MD in static perimetry with multifocal
technology has been previously reported. Madrid-Costa and
associates showed statistically significant reduction in MD
but not PSD in patients who wore multifocal contact lenses
compared to those who wore monofocal contact lenses on
Humphrey Visual Field 24-2.33 Aychoua and associates
recently evaluated the effects of varying lens status
comparing multifocal IOL (Tecnis ZM900 silicone 3-piece
diffractive IOL and also Zeiss 809M acrylic 1-piece diffrac-
tive IOL), monofocal IOL, and also phakic controls on
Humphrey Visual Field 30-2 perimetry and demonstrated
reduced MD in multifocal IOL eyes.27 Similar to this study,
our study also included 2 different models of diffractive
multifocal IOLs: Tecnis ZMB00 or ZMA00 and AcrySof
IQ ReSTOR SN6AD1. Although our sample size was too
small for a definitive subgroup analysis, no outstanding
differences between these models were revealed, suggesting
that the reduced visual sensitivity is inherent to the diffrac-
tive multifocal optic and not specific to the brand.
229
 Neuroadaptation, which is believed to represent a
learning adaptation in the image processing centers of
the visual cortex, improves subjective complaints of glares
and halos that are commonly more pronounced in the first
few months after surgery.28–30 Neuroadaptation has been
defined as a phenomenon that involves a decrease in
perceived ocular aberrations and an improvement in
quality of vision over time.34 Some patients require more
time to neuroadapt after multifocal IOL implantation,
while some may need training regimens. One study evalu-
ated neuroadaptation by assessing the minimum amount of
time postoperatively to obtain better visual function results
in patients who had bilateral multifocal IOL surgery, with a
diffractive IOL in 1 eye and a refractive IOL in the other,
and concluded that at least 6 months was necessary.28 In
our study, there was no significant difference in Humphrey
Visual Field 10-2 performance between those that had
testing done in the first 6 months and those who had testing
done after postoperative month 6 in the multifocal IOL
group. The reduction in MD on central visual field testing,
regardless of evaluation time postoperatively, is presumably
from decreased contrast sensitivity that is inherent to the
multifocal optic and does not appear to decrease with
neuroadaptation. Interestingly, there appeared to be a
trend toward worsening MD with time, although this did
not reach statistical significance.
ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST.
Drs Farid, Garg, and Steinert are consultants for Abbott Medical Optics. Supported in part by a Department Developmental Grant from Research to
Prevent Blindness (RPB), New York, New York. Contributions of authors: design of the study (M.F.), conduct of the study (M.F., S.G., R.F.S.); manage-
ment, analysis, and interpretation of the data (G.C., M.F., S.G., R.F.S.); preparation, review, or approval of the manuscript (G.C., M.F., S.G., R.F.S.).
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 Biosketch
Dr Marjan Farid is the Director of Cornea, Cataract, and Refractive Surgery and Vice-Chair of Ophthalmic Faculty at the
Gavin Herbert Eye Institute (GHEI) at the Univeristy of California, Irvine. Dr Farid is also the founder of the Severe Ocular
Surface disease center at GHEI. Her work is published in numerous peer-reviewed journals and she has authored multiple
textbook chapters. She also serves on the editorial board of Ophthalmology.

231.e1 AMERICAN JOURNAL OF OPHTHALMOLOGY AUGUST 2014

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