UPDATE/REVIEW
Multifocal IOLs with apodized diffractive
central zone and refractive periphery: optical
performance and clinical outcomes
Javier Tomás-Juan, OD, MSc1,2
ABSTRACT: The apodized diffractive multifocal intraocular lens is one of the intraocular
lens types currently available for the correction of presbyopia. The design of apodized
diffractive multifocal intraocular lenses improves on the visual outcomes obtained with the
full optic diffractive and refractive intraocular lenses. In addition to the visual improvements,
apodized diffractive multifocal intraocular lenses, using a combination of diffractive and
refractive technologies and gradually decreasing diffractive steps from the center to the
periphery of the intraocular lens, reduce or eliminate the visual phenomena produced
mainly in night conditions when the pupil size increases.
J Emmetropia 2014; 5: 155-166
Nowadays, diffractive multifocal intraocular lenses
(IOLs) are considered a good alternative for the correction
of presbyopia1. The working principle of the full optic
diffractive multifocal IOLs is based on the creation of two
focal points, by using diffraction orders (order 0 and order
1)1. The power corresponding to the 0-order diffraction
is used to image distant objects, whereas the power
corresponding to the 1-order is used for near vision1. In
diffractive multifocal IOLs, the image is divided into two
focal points, one for distant vision and the other one for
near vision, so one of the images will always be sharp
whereas the other one will be barely perceived or blurred.
The blurred image is usually said to be located in the
blur circle2. Nevertheless, full optic diffractive multifocal
Submitted: 01/21/2014
Revised: 03/17/2014
Accepted: 04/24/2014
Vallmedic Vision Andorra.
1
School of Health Sciences. La Salle University, Bogotá, Colombia.
2
Financial disclosure: The author has no proprietary or commercial
interest in the medical supplies discussed in this manuscript.
Acknowledgements: To Manuel Alejandro Amaya Alcaraz and Ane
Murueta-Goyena Larrañaga for their collaboration in the review of
this manuscript.
Corresponding Author: Javier Tomás-Juan
Department of Visual Science. Vallmedic Vision Andorra.
Avinguda Nacions Unides 17. AD700
Escaldes-Ergordany, Andorra
E-mail: javier.tomas@vallmedicvision.com
© 2014 SECOIR
Sociedad Española de Cirugía Ocular Implanto-Refractiva
IOLs have the disadvantage that the image formed by
one of the foci in the retina will have the defocused image
from the other focus superimposed along the optical
axis. This can cause side effects, such as glares and halos,
mainly in mesopic and scotopic conditions when the
pupil diameter is increased1,3-14. Furthermore, due to the
design of the diffractive multifocal IOLs, patients who
have been implanted may have lower contrast sensitivity
(CS) values3,4,6,11-16, mainly due to forward dispersion
and the higher-order aberrations (HOA)2,17. It is very
important to consider the visual effects of the multifocal
diffractive IOLs, such as night vision disturbances18,
and dissuade people with nighttime visual needs, for
example, professional drivers, from undergoing this
surgery13. To reduce the visual effects mainly produced in
night vision with full optic diffractive multifocal IOLs,
IOLs combining refractive technology with diffractive
technology have been introduced2,13,19.
OPTICAL PERFORMANCE
The apodized diffractive IOLs consist of a peripheral
refractive zone and a central apodized diffractive zone
for achieving appropriate power in distant vision and
in near vision12,20,21. One of the main characteristics
of this type of IOL is the apodization of the central
diffractive zone, which, by gradually reducing the
number of diffractive steps in width and height,
produces a gradual transition from the center to the
periphery of the lens, in order to create a smooth
transition between the far, intermediate and near focal
points7,14,20,21. With apodization, the percentage of light
ISSN: 2171-4703
155
156
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
reaching the near focus and the distant focus depending
on the patient’s pupil size can be modified, so in bright
light conditions, when the patient’s pupil size is small,
the IOL distributes the energy similarly between the
distant focus and the near focus. Nevertheless, in
limited light conditions, when the patient’s pupil size
increases, less light will be directed to the near focus
and the refractive area will direct the light to the distant
focus8,17,21. This design prevents the light from reaching
both focal points with the same fixed percentage, and
the distribution of light will depend on the patient’s
pupil size, as occurs with the full-optic diffractive
IOLs. Visual results will differ, depending on the type
of apodized diffractive multifocal IOLs implanted and
the refraction and diffraction surface, benefitting or
deteriorating intermediate vision2.
CLINICAL OUTCOMES
Degree of satisfaction
The degree of satisfaction among patients receiving an
apodized diffractive multifocal IOL is high2,10,11,14,16,17,2224
. Knorz et al., in a study performed after implanting the
AcrySof® ReSTOR® 3.0 D multifocal toric IOL (Models
SND1T3, SND1T4 or SND1T5; Alcon Laboratories,
Inc., Fort Worth, TX, USA) in 49 patients, evaluated the
degree of satisfaction 6 months after the intervention.
They used a subjective questionnaire with a scale ranging
from 1 (the worst) to 10 (the best). The average score
reported by the patients regarding their uncorrected
vision was 7.9 ± 1.9, six months after implantation of the
AcrySof® ReSTOR® 3.0 D multifocal toric IOL (n = 37),
Table 1. Comparison of binocular visual acuity (LogMAR scale) of the different randomized studies
(mean ± standard deviation)
Study
Cillino et al. (2014)36
Rasp et al. (2012)41
Peng et al. (2012)17
Alió et al. (2011)60
Alió et al. (2011)12
IOL
EYES
AcrySof® SN6AD3
40
AcrySof® SN6AD1
42
TECNIS® ZMA00
MONTHS
UDVA
CDVA
0.010 ± 0.08
−0.09 ± 0.10
0.008 ± 0.05
−0.12 ± 0.05
44
0.006 ± 0.08
−0.11 ± 0.03
Acri.Smart 48S
58
0.08 ± 0.11
0.03 ± 0.11
AcrySof® SN6AD3
56
0.17 ± 0.12
0.11 ± 0.11
AT LISA®366D
60
0.16 ± 0.12
0.05 ± 0.07
TECNIS® ZMA00
52
0.10 ± 0.07
0.05 ± 0.07
ReZoom®
60
0.11 ± 0.11
0.07 ± 0.10
AcrySof® SN6AD1
100
0.03 ± 0.14
−0.02 ± 0.06
AcrySof® IQSN60WF
102
0.08 ± 0.15
−0.04 ± 0.08
Acri.Smart 48S
72
0.09 ± 0.15
0.04 ± 0.08
AcrySof® SN6AD3
78
0.15 ± 0.12
0.06 ± 0.08
Acri.LISA® 366D
84
0.12 ± 0.11
0.06 ± 0.10
ReZoom®
70
0.12 ± 0.13
0.06 ± 0.11
Acri.Smart 48S
26
0.03 ± 0.06d
0.02 ± 0.04d
AcrySof® SN6AD3
38
0.05 ± 0.08d
0.02 ± 0.03d
Acri.LISA® 366D
42
0.05 ± 0.10d
0.00 ± 0.03d
12 months
12 months
6 months
6 months
3 months
UDVA: Uncorrected Distance Visual Acuity; CDVA: Corrected Distance Visual Acuity; UIVA: Uncorrected Intermediate
Visual Acuity; DCIVA: Distance Corrected Intermediate Visual Acuity; UNVA: Uncorrected Near Visual Acuity; CNVA:
Corrected Near Visual Acuity.
a
In photopic conditions; bAt 80 cm; cAt 70 cm; dLogRAD scale.
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
compared to preoperative values of 3.6 ± 2.0 (n = 38)25.
Van der Linden et al. assessed the degree of satisfaction
between the LENTIS® Mplus LS-312 (Oculentis
GmbH, Berlin, Germany) sectorial addition multifocal
IOL and the AcrySof® ReSTOR® SN6AD1 apodized
diffractive multifocal IOL. At three months, patients
who received the AcrySof® ReSTOR® SN6AD1 apodized
diffractive multifocal IOL were more satisfied with their
vision (p < 0.001)11.
Apodized diffractive multifocal IOLs provide
independence from the use of spectacles after the
intervention10,14,16,22,24,26-31. Peng et al. found that the
vast majority of patients who were implanted with the
AcrySof® ReSTOR® IOL did not require spectacles after
the intervention, increasing the independence from
spectacles in near vision tasks by approximately 78%17.
UIVA
DCIVA
UNVA
CNVA
0.16 ± 0.12a,b
0.15 ± 0.07a,b 0.05 ± 0.08a
0.04 ± 0.05a
0.09 ± 0.12a,b
0.07 ± 0.05a,b 0.02 ± 0.04a
0.01 ± 0.05a
0.11 ± 0.04a,b
0.10 ± 0.04a,b 0.05 ± 0.06a 0.035 ±0.05a
0.18 ± 0.10c
0.18 ± 0.11c
0.07 ± 0.07
0.03 ± 0.11
0.17 ± 0.11c
0.19 ± 0.15c
0.64 ± 0.21
0.65 ± 0.34
0.47 ± 0.22d
0.24 ± 0.19d
0.28 ± 0.04d
0.21 ± 0.14d
0.19 ± 0.08d
0.15 ± 0.01d
157
These authors also found that the results obtained with the
AcrySof® ReSTOR® 3.0 D IOLs are better with bilateral
implantation17. However, Kohnen et al. found 88%
independence from spectacles after the intervention, when
the AcrySof® ReSTOR® SN6AD1 3.0 D was implanted
bilaterally30. Ferreira et al. found that independence from
spectacles with the new AcrySof® ReSTOR® 3.0 D was
100% at the three-month follow-up32.
Visual acuity
Apodized diffractive multifocal IOL implantation
is a safe and effective procedure for the correction of
presbyopia that provides good visual outcomes in distance
and near vision13,20,33-40. In recent years, randomized
studies that demonstrate the visual performance of
apodized diffractive multifocal IOLs have been conducted
(Table 1). Furthermore, good outcomes have been
observed in other non-randomized studies. Apodized
diffractive multifocal IOLs provide better results in
near vision than monofocal IOLs9,14,41,42. Zhao et al., in
a study performed in 161 eyes, implanted the AcrySof®
ReSTOR® multifocal IOL in 72 eyes, and the AcrySof®
SA60AT monofocal IOL in 89 eyes. Six months after the
intervention, they found that patients who had received
the AcrySof® ReSTOR® multifocal IOL had better
Uncorrected Near Visual Acuity (UNVA) than patients
who had received the AcrySof® SA60AT IOL (p <
0.05)14. Furthermore, 6 months after the intervention,
multifocal IOL group showed better Corrected Near
Visual Acuity (CNVA) than the monofocal IOL group (p
< 0.05)14. As a result, the apodized diffractive multifocal
IOL is considered a safe and effective procedure for the
correction of refractive errors after clear lens extraction23,43.
Sun et al. performed a non-randomized prospective
study comparing the results of the SN6AD1 apodized
diffractive multifocal IOL with the SN60WF monofocal
IOL. Three months after the intervention, they found
that the SN6AD1 provided better visual outcomes for
UNVA, Corrected Distance Visual Acuity (CDVA)
and Uncorrected Intermediate Visual Acuity (UIVA) in
conditions of high contrast (p < 0.05)23. However, they
found that UNVA, CDVA and the low contrast UIVA
did not differ between both groups for the distances
of 63 cm and 100 cm (p > 0.05), with better UIVA in
mild emmetropic and myopic patients than in hyperopic
patients23. In addition, Distance Visual Acuity (DVA)
and Near Visual Acuity (NVA) depend significantly on
the patient’s pupil size. Alfonso et al. found that large
pupil diameters were correlated with better DVA, and
poorer NVA8.
The addition of apodized diffractive multifocal IOLs
may vary according to the patient’s need, proving that,
although these have a similar performance in CS, quality
of life, distant vision and near vision, they may differ in
intermediate vision8,44. The AcrySof® ReSTOR® 4.0 D
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
158
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
(Model SN60AD3) apodized diffractive multifocal IOL
provides good visual outcomes in distant vision and in
near vision14,15, especially the lower the power of the
IOL13. Moreno et al. found that the Uncorrected Distance
Visual Acuity (UDVA) and Distance Corrected Near
Visual Acuity (DCNVA) deteriorated with increasing
lens powers13. Increased HOA underlie the flawed visual
outcomes of higher power lenses13. The Alcon Company
has improved the AcrySof® ReSTOR® 4.0 D with the aim
of improving intermediate vision, reducing the number
of diffractive steps from 12 to 9, but maintaining the
same diffractive zone size to provide a lower addition
with the AcrySof® ReSTOR® 3.0 D (Figure 1)10,17,36.
Figure 1. AcrySof® ReSTOR® 3.0 D (Model SN6AD1) consisting
of 9 diffractive apodized rings in the central zone, with apodized
diffractive zone of 3.6 mm and refractive periphery zone. A gradual
transition in the number of diffractive steps from the center to the
periphery is observed (with permission from Alcon).
This new model results in good visual outcomes at
intermediate distances, without compromising near
vision17,45. Santhiago et al. evaluated the behavior of the
AcrySof® ReSTOR® 3.0 D apodized diffractive multifocal
IOL comparing it with the AcrySof® ReSTOR® 4.0
D, which has greater power. Twelve months after the
intervention, they found that the AcrySof® ReSTOR® 3.0
D shows better results at all distances than the AcrySof®
ReSTOR® 4.0 D. Due to the increased addition of
AcrySof® ReSTOR® 4.0 D, implanted patients preferred
a reading distance of 8 cm closer than the patients
who received the AcrySof® ReSTOR® 3.0 D44. These
outcomes agree with those obtained by Sun et al. who
found that the AcrySof® ReSTOR® SN60AD1 IOL
provides better visual acuity outcomes in intermediate
vision compared with patients implanted with
AcrySof® ReSTOR® SN6AD3 IOL46. For patients who
have disturbances with the AcrySof® ReSTOR® 3.0 D, or
for those who are not good candidates for implantation,
AcrySof® ReSTOR® 2.5 D has been designed as an
alternative45. The AcrySof® ReSTOR® 2.5 D provides
excellent visual results in intermediate and near vision45.
The apodized diffractive multifocal IOL, besides
providing excellent outcomes in UNVA, provides
good results in UDVA in photopic conditions9,31,47.
Alió et al. compared the visual outcomes of the
rotationally asymmetric multifocal LENTIS® Mplus
LS-312 IOL, and the apodized diffractive multifocal
IOL (AcrySof® ReSTOR® SN6AD3) in 74 eyes of 40
cataract patients. They found that UNVA and DCNVA
were better in the apodized diffractive multifocal IOL
group than in the rotationally asymmetric multifocal
IOL group (p = 0.01)48. Nevertheless, they found that
intermediate visual acuity was better in the rotationally
asymmetric IOL group (p = 0.01) than in the apodized
diffractive multifocal IOL group48. These outcomes
agree with those obtained by Van der Linden et al. who
showed that the rotationally asymmetric multifocal
IOL (LENTIS® Mplus LS-312 IOL) provided worse
visual outcomes than the apodized diffractive multifocal
IOL (AcrySof® ReSTOR® SN6AD3) at reading
distances between 30 cm (0.15 ± 0.08 logMAR versus
0.05 ± 0.14 logMAR) and 40 cm (0.16 ± 0.21 logMAR
versus 0.05 ± 0.14 logMAR; p < 0.01 and p < 0.03,
respectively)11. Subsequently, Van der Linden et al.
performed a study to compare the visual outcomes
obtained with the SeeLens MF IOL (Hanita Lenses,
Hanita, Israel) in 48 eyes and the SN60AD1 in 37 eyes.
Three months after the intervention, the UNVA
between the SeeLens MF group (0.02 ± 0.07 logMAR)
and the SN60AD1 group (0.04 ± 0.09 logMAR) was
not statistically significant. Better CDVA results were
obtained with the SeeLens MF (−0.04 ± 0.05 logMAR)
than with the SN60AD1 IOL (−0.01 ± 0.04 logMAR,
p < 0.019), although the difference was not statistically
significant2. At visual distances between 30 cm and 40 cm
no statistically significant differences were obtained in
UNVA for both implanted lenses (0.09 ± 0.12 logMAR
vs 0.08 ± 0.09 logMAR). However, at distances between
50 cm and 60 cm (p < 0.03, p < 0.07 respectively),
the UNVA differed, with better visual outcomes being
obtained with the SeeLens MF2.
Besides studying the outcomes of monofocal and
multifocal apodized diffractive IOLs, single-optic
accommodating IOLs have also been analyzed49. Ang et
al. found that the AcrySof® ReSTOR® 3.0 D multifocal
IOL (Model SN6AD1) provides similar UDVA and
UNVA outcomes as the Crystalens® (Bausch & Lomb
Inc., North Bridgewater, NJ, USA). Nevertheless,
they found that the Crystalens® IOL provides better
intermediate vision outcomes49.
Apodized diffractive multifocal toric IOLs can also
be implanted in patients who have previously undergone
Laser In Situ Keratomileusis (LASIK)50-52. Furthermore,
patients with residual refractive error after implantation
of apodized diffractive multifocal IOL may also require
LASIK. Good visual results are obtained if the apodized
diffractive multifocal IOL is implanted before or after
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
LASIK31,51,53-55. Muftuoglu et al. implanted apodized
diffractive multifocal IOLs after myopic LASIK in 49
eyes. They found that, in the postoperative visit at six
months, 36 of the 49 eyes had a UDVA of 20/25 or
better. In addition, they found that UNVA was Jaeger
1 or better in the last follow-up visit50. Alfonso et al.
found that the AcrySof® ReSTOR® SN60D3 implanted
in eyes which had previously undergone hyperopic
LASIK, provides good visual outcomes at all distances,
similar to those obtained in phakic eyes under
photopic conditions. Nevertheless, they found that
the visual quality was especially limited under mesopic
conditions51. However, Muftuoglu et al. showed that in
the presence of residual astigmatism after implantation
of the apodized diffractive multifocal IOL, with or
without subsequent LASIK, limbal relaxing incisions
were effective in reducing corneal astigmatism and
improving visual outcomes56.
Recently, the toric diffractive multifocal IOL
3.0 D, based on a modification of the apodized
diffractive multifocal IOL, has been introduced.
The AcrySof® ReSTOR® 3.0 D allows correction of
up to 2.5 D of corneal astigmatism57. It consists of a
diffractive central optic of 3.6 mm, and it is comprised
of 9 concentric steps, with refractive periphery, and a
toric component on the posterior surface of the IOL.
The aspheric apodized diffractive multifocal toric
IOLs, in addition to providing good visual acuity at all
distances, reduces corneal astigmatism greatly, showing
good performance in terms of rotation32,57. Alfonso et
al., in a study performed in 49 patients implanted with
AcrySof® ReSTOR® 3.0 D multifocal toric IOL, found
that the cylinder average decreased from 1.07 ± 0.71 D
to 0.33 ± 0.44 D and reported an IOL rotation average
of 2.20 ± 4.34 degrees57.
Contrast sensitivity
Apodized diffractive multifocal IOLs do not
produce significant variations in long-term CS17,37.
Cionni et al. found that CS is similar when an apodized
diffractive multifocal IOL (AcrySof® ReSTOR®) is
implanted binocularly and monocularly16. Yoshino et
al. implanted an apodized diffractive multifocal IOL in
21 patients (42 eyes). They found that, after a follow-up
period of five years, the value of the CS was normal for
all the spatial frequencies37. No significant long-term
variations were produced in CS. However, changes in
light levels can reduce CS, mainly at high frequencies8.
CS has been compared between multifocal IOLs
implantations5,12,47,48. Alfonso et al. evaluated CS
between apodized diffractive central zone and refractive
periphery lenses (AcrySof® ReSTOR® SN6AD3), and
IOLs that intercalate the refractive and diffractive
technology from the center to the periphery (Acri.LISA®,
Carl Zeiss Meditec, Dublin, CA, USA; aspheric)57.
159
They found that both lenses produce a normal CS
range under photopic conditions and reduced CS
under mesopic conditions57. Alió et al. compared
the outcomes of CS after the implantation of the
AcrySof® ReSTOR® SN6AD3 apodized diffractive
multifocal IOL and the LENTIS® Mplus LS-312
rotationally asymmetric multifocal IOL. They
found that, three months after the intervention,
CS was significantly higher in patients with the
LENTIS® Mplus LS-312 rotationally asymmetric
multifocal IOL than in patients with the
AcrySof® ReSTOR® SN6AD3 apodized diffractive
multifocal IOL (p = 0.04)48. Later, Rosa et al. assessed
CS between the LENTIS® Mplus Mplus LS-312 IOL
and the AcrySof® ReSTOR® SN6AD1 IOL, finding
that CS under photopic and mesopic conditions was
better in the AcrySof® ReSTOR® SN6AD1 group5. Rosa
et al. found that the CS was higher for the high spatial
frequencies (7.1 cycles per degree [cpd] vs 23.6 cpd,
respectively), and for the intermediate spatial
frequencies (2.2 cpd versus 3.4 cpd, respectively)
which is important for intermediate vision5.
In addition to investigating CS between multifocal
IOLs, comparisons have also been performed between
multifocal IOLs and monofocal IOLs. Zhao et al. found
that patients who had been implanted with the singlepiece AcrySof® SA60AT IOL had significantly better CS
than patients who had been implanted with the AcrySof®
ReSTOR® SA60D3 apodized diffractive multifocal IOL
(both p < 0.05)14. Vingolo et al. studied CS between
the AcrySof® ReSTOR® apodized diffractive multifocal
IOL and the AcrySof® SA60AT monofocal, obtaining
lower CS values for the AcrySof® SA60AT monofocal
IOL22. Nevertheless, Bissen-Miyajima et al. compared
the AcrySof® ReSTOR® SA60D3 apodized diffractive
multifocal IOL and the AcrySof® SA60AT monofocal
IOL finding that CS was similar between both groups
for all spatial frequencies58.
CS has also been compared with the single-optic
accommodating IOL. Ang et al. compared CS between
the Crystalens®, the TECNIS® (Abbott Medical
Optics, Illinois, USA ) and the AcrySof® ReSTOR®49.
They found that the Crystalens® IOL provides better
CS than the AcrySof® ReSTOR® under mesopic
conditions without glare at 3.0 cpd (p = 0.046).
However, they found that the AcrySof® ReSTOR®
provides better visual outcomes than the TECNIS® at
1.5 cpd (p = 0.010)49.
Depth of focus
Although apodized diffractive IOLs increase
depth-of-focus, Zheleznyak et al. found that, when
an astigmatism of 0.75 D or more is maintained
without correction, the depth-of-focus decreases
considerably59.
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
160
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
Anterior Chamber Depth (ACD)
It is well known that the contraction of the ciliary
muscle can produce an IOL shift. Monofocal IOL
movement has been documented in a variety of studies.
However, there are few studies evaluating shift in
apodized diffractive multifocal IOLs. Tsorbatzoglou et
al. analyzed apodized diffractive multifocal IOL shift
(AcrySof® ReSTOR® SA60D3) with partial coherence
interferometry after pharmacologically induced ciliary
muscle relaxation and confirmed that apodized diffractive
multifocal IOL shift was similar to monofocal IOL shift34.
Visual fields
Apodized diffractive IOLs can alter the results
obtained with the FDT Perimetry, so the influence of
the apodized diffractive IOLs on the results obtained
with the FDT Perimetry must be carefully analyzed20.
Bojikian et al. performed a study with 37 eyes of
22 patients aged between 41 and 79 years (70.78 ± 9.83
years). The AcrySof® ReSTOR® Natural was implanted in
17 eyes and the yellow counterpart (Natural IQ), in 20
eyes. Three months after the intervention, FDT Matrix
Perimetry was performed in all cases. The mean deviation
obtained in the Natural IQ group was −1.83 ± 3.46 dB,
whereas in the AcrySof® ReSTOR® Natural group it was
−1.77 ± 3.94 dB (p = 0.28). The standard deviation in
the Natural IQ group was 3.49 ± 0.79 dB, whereas in the
AcrySof® ReSTOR® Natural group it was 3.20 ± 0.86 dB
(p = 0.27). The authors concluded that there were no
differences between eyes implanted with the AcrySof®
ReSTOR® Natural and the Natural IQ20.
Reading speed
The effectiveness of apodized multifocal IOLs in
patients’ visual quality is very important. Visual acuity
tests are not considered a good indicator of the patient’s
visual quality because it measures the visual quality in
static conditions. In the clinical practice, reading speed
tests assessing visual capacity in dynamic conditions are
increasingly common. Reading speed tests, in addition to
assessing the ability to read sentences, rather than isolated
letters as in the static visual acuity tests, provide quantitative
and qualitative measurements about various components
of reading ability. Reading speed studies performed in
apodized diffractive multifocal IOLs show that this type
of IOL increases reading speed41,57,60. Some reading speed
parameters have been studied by various groups (Table
2). Alió et al. compared reading speed parameters after
apodized diffractive multifocal IOL (AcrySof® ReSTOR®
SN6AD3 and Acri.LISA® 366D; Carl Zeiss Meditec,
Dublin, CA, USA) implantation with monofocal (Acri.
Table 2. Comparison of reading speed parameters among the different randomized studies
Study
Cillino et al.
(2014)36
Rasp et al.
(2012)41
Alió et al.
(2011)60
IOL
EYES
MONTHS
URS (wpm)
CRS (wpm)
URD (cm)
AcrySof® SN6AD3
40
AcrySof® SN6AD1
42
TECNIS® ZMA00
44
253 ± 28a
Acri.Smart 48S
58
148 ± 40
160 ± 41
38.9 ± 8.4
AcrySof® SN6AD3
56
147 ± 35
151 ± 35
31.8 ± 5.6
AT LISA® 366D
60
178 ± 50
166 ± 41
31.6 ± 4.5
TECNIS® ZMA00
52
139 ± 32
140 ± 28
32.1 ± 5.4
ReZoom®
60
152 ± 40
156 ± 40
37.1 ± 7.3
Acri.Smart 48S
72
117 ± 26
112 ± 30
38.9 ± 6.5
AcrySof® SN6AD3
78
110 ± 30
114 ± 30
29.2 ± 4.1
Acri.LISA® 366D
84
114 ± 28
119 ± 23
30.1 ± 3.7
ReZoom®
70
107 ± 25
120 ± 24
35.3 ± 7.1
248 ± 24a
12 months
12 months
6 months
263 ± 26a
wpm: words per minute; cm: centimeters; mm: millimeters; URS: Uncorrected Reading Speed; CRS: Corrected Reading Speed;
URD: Uncorrected Reading Distance; CRD: Corrected Reading Distance; USPZ: Uncorrected Smallest Print Size;
CSPZ: Corrected Smallest Print Size. aIn photopic conditions.
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
Smart 48S; Carl Zeiss Meditec, Dublin, CA, USA) and
refractive (ReZoom®; Abbott Medical Optics, Illinois,
USA) multifocal IOLs. They found that the apodized
diffractive multifocal IOL group had better reading acuity
than the rest of the groups at one and six months after
surgery (p < 0.01)60. Subsequently, in another study, Rasp et
al. compared reading speed parameters after Acri.Smart, AT
LISA® (Carl Zeiss Meditec, Dublin, CA, USA), AcrySof®
ReSTOR®, ReZoom® and TECNIS® MF implantation.
They found that apodized diffractive IOLs provided better
reading speed outcomes than multifocal refractive IOLs and
monofocal IOLs41. Furthermore, reading speed parameters
with the apodized multifocal diffractive toric IOL have
also been evaluated, showing good results. Alfonso et al.
evaluated visual outcomes after bilateral implantation in
49 patients with AcrySof® ReSTOR® 3.0 D diffractive
multifocal toric IOL57. Six months after the intervention,
mean corrected reading speed increased from 125.4 ± 33.6
words per minute (wpm) to 132.7 ± 23.7 wpm57.
Visual effects
Apodized diffractive IOLs have been specifically
designed with the aim of minimizing the presence of halos
and glares in low light conditions1. Since the apodized
diffractive multifocal IOL is diffractive at the center and
refractive at the periphery, it tends to reduce visual alterations
CRD (cm)
USPZ
CSPZ (mm)
0.35 ± 0.2a
0.35 ± 0.2a
0.34 ± 0.1a
36.7 ± 6.0
1.76 ± 0.61
0.72 ± 0.16
31.4 ± 4.7
0.87 ± 0.34
0.84 ± 0.24
31.3 ± 4.2
0.74 ± 0.19
0.67 ± 0.17
30.8 ± 3.8
0.87 ± 0.39
0.72 ± 0.19
35.5 ± 5.3
1.38 ± 0.53
0.74 ± 0.26
161
such as halos and glares where the pupil diameter increases,
especially in night conditions17. Cristóbal et al. implanted
apodized diffractive multifocal IOLs (AcrySof® ReSTOR®
SN60D3) in five children between four and six years of age
with unilateral cataract. Disturbances like glare and halos
were absent in the 21-month follow-up61. More recently,
Ram et al. implanted the apodized diffractive multifocal
IOL in children above the age of 5. They determined that
two patients complained of mild glare6. However, it is
worth pointing out the added difficulty of making accurate
measurements and carrying out subjective questionnaires
properly in children.
Nevertheless, patients who have received an apodized
diffractive multifocal IOL, despite reporting better quality
vision, sometimes tend to have visual alterations, such as
halos and glares, which are related to the IOL design7,23,31.
The incidence of halos varies depending on if the IOLs are
implanted monocularly or binocularly. Cionni et al. found
that the incidence of halos in patients with monocular
implantation of the AcrySof® ReSTOR® diffractive
multifocal IOL (57%) was lower than in patients who
had received the same lens binocularly (77%), although
no statistically significant differences were found16.
Kohnen et al. found that after bilateral implantation of
the AcrySof® ReSTOR® SN6AD1 3.0 D, patients reported
few visual disturbances30. De Vries et al. found that
patients implanted with the AcrySof® ReSTOR® SA60D3
diffractive multifocal IOL had less glare and halo than
patients who had been implanted with AcrySof® SA60AT
monofocal IOL62. Nevertheless, Van der Linden et al.
found that approximately 18% of patients who received
the AcrySof® ReSTOR® SN6AD1 apodized diffractive
multifocal IOL had dysphotopsia11. Yoshino et al.
implanted the apodized diffractive multifocal IOL in 21
patients (42 eyes). Five years after the intervention, no
patient complained of glare or halo37.
The new material (Benz26) and the design of the
SeeLens MF apodized diffractive multifocal IOL
(Figure 2), allow a greater amount of light to reach the
35.4 ± 4.8
28.4 ± 5.3
29.2 ± 4.0
33.3 ± 4.9
Figure 2. SeeLens MF Intraocular Lens consisting of 12 diffractive
apodized rings in the central zone, with apodized diffractive zone
of 4 mm. A gradual transition in the number of diffractive steps
from the center to the periphery is observed (with permission from
Hanita Lenses).
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
162
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
retina, decreasing forward scattering and eliminating
reflections2. Van der Linden et al. implanted the
SeeLens MF in 48 eyes and the AcrySof® ReSTOR®
SN60AD1 in 37 eyes. They found that three months
after the intervention, the patients implanted with
the SeeLens MF presented a significant decrease in
light diffusion (p < 0.0001) and less glare (p < 0.002),
compared to those who had received the SN60AD1
IOL2.
However, although multifocal apodized diffractive
IOLs show a lower incidence of halos, Ang et al.
found a lower incidence of halo and starbursts both
monocularly and binocularly with the accommodative
IOL Crystalens® than with the AcrySof® ReSTOR® 3.0 D
(Model SN6AD1)49.
Intraocular straylight
Laboratory studies have shown that spherical
multifocal IOLs and monofocal IOLs are associated with
light scattering37,63. Although the increase of straylight
levels in the monofocal IOLs does not affect the patient’s
quality of vision, it may affect CS37. In pseudophakic
eyes with the apodized diffractive multifocal IOL,
intraocular straylight increases with pupil diameter,
mainly if the capsulorhexis is small17. Besides the
increase in forward scattering with diffractive multifocal
IOLs, patient age, pupil diameter and corneal surface
quality are also thought to be important17. Some studies
have been conducted to determine how the levels of
straylight affect visual function. Peng et al. conducted a
randomized prospective study of 204 eyes (102 patients)
with bilateral AcrySof® ReSTOR® SN6AD1 3.0 D
diffractive multifocal aspheric IOL implantation to
determine the adverse effects produced in comparison
to the AcrySof® SN60WF monofocal aspheric IOL17.
Medium levels of straylight were analyzed through the
C-Quant, and no statistically significant differences
were found in the AcrySof® ReSTOR® SN6AD1
compared to the AcrySof® SN60WF monofocal IOL
group17. These outcomes coincide with those obtained
by Bissen-Miyajima et al. who found that six years
after the intervention, previous surface light scattering
increased similarly in the apodized diffractive
multifocal AcrySof® ReSTOR® SA60D3 and in the
monofocal IOL AcrySof® SA60AT58. Nevertheless,
de Vries et al. observed that, six months after the
intervention, the average intraocular straylight level
was higher in patients with the AcrySof® ReSTOR®
SA60D3 multifocal IOL than in patients who received
the AcrySof® SA60AT monofocal IOL (p = 0.026)62.
Yoshino et al. found after a period of five years that
the CS and visual acuity of the apodized diffractive
multifocal IOL were not affected by straylight
increases37.
Ocular aberrations
It is well known that IOLs with spherical profile
increase spherical aberration28,64. In order to reduce
that HOA, IOLs with aspheric profiles have been
designed26. At present, there is a great interest in
determining the benefits that could be offered by an
aspherical multifocal IOL, because some studies have
demonstrated that the IOLs with aspheric profile
provide no benefits in patients with small pupils1.
However, other studies have showed that diffractive
multifocal IOLs with aspheric profiles produce
fewer ocular aberrations than diffractive multifocal
IOLs with spherical profiles63. Diffractive multifocal
IOLs with an aspherical profile induce less spherical
aberration than diffractive multifocal IOLs with a
spherical profile. Toto et al., in a six-month prospective
study, found that AcrySof® ReSTOR® SN6AD3 4.0 D
and AcrySof® ReSTOR® SN6AD1 3.0 D aspheric
IOLs induce less spherical aberration than the
AcrySof® ReSTOR® SN60D3 4.0 D spherical IOL38.
Furthermore, Ferreira et al. found that HOA with
AcrySof® ReSTOR® 3.0 D, measured with OPD-III
scanning system, were similar to those obtained with
AcrySof® ReSTOR® monofocal toric32.
Gradually decreasing the apodization of multifocal
IOLs from the center to the periphery allows a decrease
in ocular aberrations, mainly of a spherical nature17,65.
In addition, the refractive zone of the IOL minimizes
disturbances, such as halos and glare17. Zelichowska et al.
evaluated ocular aberrations after the implantation of the
AcrySof® ReSTOR® SN60D3 diffractive multifocal IOL
compared to the ReZoom® refractive multifocal IOL,
finding more HOAs (coma and spherical aberration)
with the ReZoom® IOL (p < 0.001)9. Peng et al. found
that in 204 eyes (102 patients) with bilateral implantation
with the AcrySof® ReSTOR® SN6AD1 aspheric
diffractive multifocal IOL, the spherical aberration was
0.05 ± 0.06 µm17. There were no statistically significant
differences in coma aberration six months after the
intervention. These outcomes also coincide with those
obtained by de Vries et al., in which the spherical
aberration was 0.03 ± 0.0663. Alió et al. also found
a decrease in ocular aberrations in patients who had
received an apodized diffractive multifocal IOL (AcrySof®
ReSTOR® SN6AD3) in comparison with patients who
had received a rotationally asymmetric multifocal IOL
(LENTIS® Mplus LS-312 IOL, p = 0.02)48.
Optical quality
Point Spread Function (PSF) in apodized diffractive
multifocal IOLs has been studied. Moreno et al. measured
the PSF of the AcrySof® ReSTOR® SN6AD3 multifocal
IOL in 38 eyes of 19 patients with the double-pass
system. They found that there was a correlation between
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
the power of the apodized diffractive multifocal IOL
and the PSF width at 50% (p = 0.017). Furthermore,
these authors also found a correlation between the
power of the apodized diffractive multifocal IOL and
the PSF width at 10% (p = 0.017)13. This demonstrates
that optical quality is worse in eyes with high power
apodized diffractive multifocal IOLs13.
The Modulation Transfer Function (MTF) describes
how all spatial frequencies are transmitted by an optical
system66. Compared to CS, MTF is considered an
objective average, barely affected by the nerve pathways
of the retina that provides more precise data on the
quality of vision17. The image quality of the apodized
diffractive IOL provided by the manufacturer is based
on ex vivo models (in water or in air)3. However, more
studies are required to investigate the optical quality
of the apodized diffractive multifocal IOL, in order to
determine its performance. Ortiz et al. compared in
vivo optical quality of apodized diffractive multifocal
AcrySof® ReSTOR® and refractive ReZoom®, in
terms of the MTF of the monofocal AcrySof® MA60
IOL. They found that in vivo MTF was better in the
AcrySof® ReSTOR® group3. Artigas et al. analyzed the
performance of apodized multifocal IOLs in vitro,
with the aim of determining quality of vision. They
found that monofocal IOLs provided better image
quality than apodized diffractive multifocal IOLs for
distance focal points with small pupils66. However, they
concurrently found that apodized diffractive multifocal
IOLs had better image quality in near focus with all
pupil sizes66. Subsequently, MTF with different power
lenses was studied. Moreno et al. measured the MTF
of the AcrySof® ReSTOR® SN6AD3 multifocal IOL in
38 eyes of 19 patients with the double-pass system. They
found a correlation between the power of the apodized
diffractive multifocal IOL and the MTF (p = 0.05)13. It
is well known that a tilt in the IOL can affect the optical
quality of the patient. More recently, Soda and Yaguchi
evaluated the validity of the MTF with decentration.
They found that near MTF of the apodized diffractive
multifocal IOL (AcrySof® ReSTOR® SA60D3) decreased
with increasing decentrations, while MTF improved in
distance vision with same changes in decentration67.
They concluded that decentration above 0.75 mm was
associated with visual effects67.
In order to improve intermediate vision, apodized
diffractive multifocal IOLs with three focal points have
been introduced. Some studies have verified how the
distribution of the light in trifocal apodized diffractive
multifocal IOLs affects optical quality, particularly in
intermediate focusing21. Apodized diffractive IOLs
with two main focal points provide a better MTF
for the near focal points than IOLs with three focal
points. Nevertheless, trifocal IOLs provide better
resolution at intermediate visual distances than bifocal
163
lenses21,68. Montés-Micó et al. found that apodized
diffractive multifocal IOLs with two main focal points
(AcrySof® ReSTOR® 3.0 D) provides a wider range of
vision from far to near than the diffractive multifocal
IOLs with three main focal points (Finevision
multifocal IOL)21. They found that for the 0.0 D and
−2.5 D focal points, the AcrySof® ReSTOR® 3.0 D
provides better MTF values than Finevision multifocal
IOL. Nevertheless, for the intermediate focal point
(−1.5 D and −3.5 D), diffractive multifocal IOLs with
three main focuses (trifocal IOL) are thought to provide
a better optical quality21. These outcomes agree with
those obtained by Madrid-Costa et al. who found that
IOL with three focal points (AT LISA® 839MP) provide
better optical quality in the −1.5 D focal point than
the AcrySof® ReSTOR® SN6AD169. Madrid-Costa et al.
found that the optical quality of the AT LISA® trifocal
lens for focal points of −2.5 D was significantly lower
than in the bifocal lenses69. Peng et al. found some
statistically significant differences between patients
implanted with the AcrySof® ReSTOR® SN6AD1
aspheric diffractive multifocal IOL at 5 and 10 cpd with
pupil diameters of 3 mm17. Nevertheless, they found that
the MTF was lower in the AcrySof® ReSTOR® SN6AD1
aspheric diffractive multifocal IOL group than in the
AcrySof® SN60WF IOL group in pupil diameters from
3 mm to 5 and 10 cpd17.
Furthermore, MTF outcomes between apodized
diffractive IOLs and IOLs with the nonrotational
symmetric IOL have been studied70. Montés-Micó
et al. found that the AcrySof® SN6AD1 provides better
values for all frequencies than the LENTIS® Mplus
LS-312. They found that the MTF of the apodized
diffractive IOL decreased considerably when the IOL
was decentered or tilted. However, they found that the
PSF was worse for the apodized diffractive IOL70.
POSTERIOR CAPSULAR OPACIFICATION
Posterior capsule opacification (PCO) is one of the
main complications which often occurs after cataract
surgery, greatly affecting the visual quality of the patient.
Due to the design and the biocompatibility of the
material, the implantation of the diffractive multifocal
IOLs often produces lower levels of PCO2,24. Yoshino et
al. implanted an apodized diffractive multifocal IOL in
21 patients (42 eyes). Five years after the intervention,
they found that only 14.3% of operated eyes (6 eyes)
required of Nd:YAG laser capsulotomy for the
elimination of PCO37.
Patients who receive an apodized diffractive
multifocal IOL requiring Nd:YAG laser capsulotomy
usually achieve good visual outcomes. Vrijman et al.
performed a retrospective study in 75 pseudophakic
eyes (50 patients) which had been implanted with an
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
164
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
apodized diffractive multifocal IOL that subsequently
needed of Nd:YAG laser capsulotomy for the elimination
of PCO71. After Nd:YAG laser capsulotomy, there was a
statistically significant improvement in CDVA and in
UDVA (p < 0.001), with no changes in astigmatic power
vectors J(0) and J(45)71. These authors found that in the
vast majority of the patients who underwent Nd:YAG
laser capsulotomy, there was no variation in refraction,
while only 7% of patients experienced a significant
variation in subjective refraction, resulting in a variation
of approximately 0.5 D in the spherical equivalent for
subjective refraction71.
CONCLUSIONS
The new designs of apodized diffractive multifocal
IOLs provide good visual outcomes in distant vision,
intermediate vision and near vision, regardless of the
use of spectacles in the majority of cases. The gradual
transition which is produced in the number of diffractive
steps from the center to the periphery avoids variations
in CS and produces fewer aberrations and fewer glares
and halos, mainly in night conditions, when the pupil
size increases.
REFERENCES
1. Vega F, Alba-Bueno F, Millán MS. Energy distribution
between distance and near images in apodized diffractive
multifocal intraocular lenses. Invest Ophthalmol Vis Sci.
2011; 52:5695-701.
2. van der Linden JW, van der Meulen IJ, Mourits MP, LapidGortzak R. Comparison of a hydrophilic and a hydrophobic
apodized diffractive multifocal intraocular lens. Int
Ophthalmol. 2013; 33:493-500.
3. Ortiz D, Alió JL, Bernabéu G, Pongo V. Optical performance
of monofocal and multifocal intraocular lenses in the human
eye. J Cataract Refract Surg. 2008; 34:755-62.
4. Friedrich R. Intraocular lens multifocality combined with
the compensation for corneal spherical aberration: a new
concept of presbyopia-correcting intraocular lens. Case Rep
Ophthalmol. 2012; 3:375-83.
5. Rosa AM, Loureiro-Silva MF, Lobo C, et al. Comparison
of visual function after bilateral implantation of inferior
sector-shaped near-addition and diffractive-refractive
multifocal IOLs. J Cataract Refract Surg. 2013; 39:1653-9.
6. Ram J, Agarwal A, Kumar J, Gupta A. Bilateral implantation
of multifocal versus monofocal intraocular lens in children
above 5 years of age. Graefes Arch Clin Exp Ophthalmol.
2014; 252:441-7.
7. Davison JA, Simpson MJ. History and development of the
apodized diffractive intraocular lens. J Cataract Refract
Surg. 2006; 32:849-58.
8. Alfonso JF, Fernández-Vega L, Baamonde MB, MontésMicó R. Correlation of pupil size with visual acuity and
contrast sensitivity after implantation of an apodized
diffractive intraocular lens. J Cataract Refract Surg. 2007;
33:430-8.
9. Zelichowska B, Rekas M, Stankiewicz A, Cerviño A,
Montés-Micó R. Apodized diffractive versus refractive
multifocal intraocular lenses: optical and visual evaluation.
J Cataract Refract Surg. 2008; 34:2036-42.
10. Maxwell WA, Cionni RJ, Lehmann RP, Modi SS. Functional
outcomes after bilateral implantation of apodized diffractive
aspheric acrylic intraocular lenses with a +3.0 or +4.0
diopter addition power Randomized multicenter clinical
study. J Cataract Refract Surg. 2009; 35:2054-61.
11. van der Linden JW, van Velthoven M, van der Meulen I,
Nieuwendaal C, Mourits M, Lapid-Gortzak R. Comparison
of a new-generation sectorial addition multifocal intraocular
lens and a diffractive apodized multifocal intraocular lens. J
Cataract Refract Surg. 2012; 38:68-73.
12. Alió JL, Plaza-Puche AB, Piñero DP, Amparo F, RodríguezPrats JL, Ayala MJ. Quality of life evaluation after
implantation of 2 multifocal intraocular lens models and a
monofocal model. J Cataract Refract Surg. 2011; 37:63848.
13. Moreno LJ, Piñero DP, Alió JL, Fimia A, Plaza AB.
Double-pass system analysis of the visual outcomes and
optical performance of an apodized diffractive multifocal
intraocular lens. J Cataract Refract Surg. 2010; 36:2048-55.
14. Zhao G, Zhang J, Zhou Y, Hu L, Che C, Jiang N. Visual
function after monocular implantation of apodized
diffractive multifocal or single-piece monofocal intraocular
lens Randomized prospective comparison. J Cataract
Refract Surg. 2010; 36:282-5.
15. Ferrer-Blasco T, García-Lázaro S, Albarrán-Diego C, BeldaSalmerón L, Montés-Micó R. Refractive lens exchange with
a multifocal diffractive aspheric intraocular lens. Arq Bras
Oftalmol. 2012; 75:192-6.
16. Cionni RJ, Osher RH, Snyder ME, Nordlund ML.
Visual outcome comparison of unilateral versus bilateral
implantation of apodized diffractive multifocal intraocular
lenses after cataract extraction: prospective 6-month study.
J Cataract Refract Surg. 2009; 35:1033-9.
17. Peng C, Zhao J, Ma L, Qu B, Sun Q, Zhang J. Optical
performance after bilateral implantation of apodized
aspheric diffractive multifocal intraocular lenses with +3.00D addition power. Acta Ophthalmol. 2012; 90:e586-93.
18. Choi J, Schwiegerling J. Optical performance measurement
and night driving simulation of ReSTOR, ReZoom, and
Tecnis multifocal intraocular lenses in a model eye. J Refract
Surg. 2008; 24:218-22.
19. Maxwell WA, Waycaster CR, D’Souza AO, Meissner BL,
Hileman K. A United States cost-benefit comparison of
an apodized, diffractive, presbyopia-correcting, multifocal
intraocular lens and a conventional monofocal lens. J
Cataract Refract Surg. 2008; 34:1855-61.
20. Bojikian KD, Vita JB, Dal Forno CP, Tranjan-Neto A,
Moura CR. Does the apodized diffractive intraocular lens
Acrysof ReSTOR Natural interfere with FDT Matrix
perimetry results? Arq Bras Oftalmol. 2009; 72:755-9.
21. Montés-Micó R, Madrid-Costa D, Ruiz-Alcocer J, FerrerBlasco T, Pons AM. In vitro optical quality differences
between multifocal apodized diffractive intraocular lenses.
J Cataract Refract Surg. 2013; 39:928-36.
22. Vingolo EM, Grenga P, Iacobelli L, Grenga R. Visual
acuity and contrast sensitivity: AcrySof ReSTOR apodized
diffractive versus AcrySof SA60AT monofocal intraocular
lenses. J Cataract Refract Surg. 2007; 33:1244-7.
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
23. Sun Y, Zheng D, Ling S, Song T, Liu Y. Comparison on
visual function after implantation of an apodized diffractive
aspheric multifocal or monofocal intraocular lens. Eye Sci.
2012; 27:5-12.
24. de Vries NE, Webers CA, Montés-Micó R, et al. Long-term
follow-up of a multifocal apodized diffractive intraocular
lens after cataract surgery. J Cataract Refract Surg. 2008;
34:1476-82.
25. Knorz MC, Rincón JL, Suarez E, et al. Subjective outcomes
after bilateral implantation of an apodized diffractive +3.0 D
multifocal toric IOL in a prospective clinical study. J Refract
Surg. 2013; 29:762-7.
26. de Vries NE, Nuijts RM. Multifocal intraocular lenses in
cataract surgery: literature review of benefits and side effects.
J Cataract Refract Surg. 2013; 39:268-78.
27. Kohnen T, Allen D, Boureau C, et al. European multicenter
study of the AcrySof ReSTOR apodized diffractive intraocular
lens. Ophthalmology. 2006; 113:584.e1.
28. Souza CE, Muccioli C, Soriano ES, et al. Visual performance
of AcrySof ReSTOR apodized diffractive IOL: a prospective
comparative trial. Am J Ophthalmol. 2006; 141:827-832.
29. Hong X, Zhang X. Optimizing distance image quality of an
aspheric multifocal intraocular lens using a comprehensive
statistical design approach. Opt Express. 2008; 16:20920-34.
30. Kohnen T, Nuijts R, Levy P, Haefliger E, Alfonso JF. Visual
function after bilateral implantation of apodized diffractive
aspheric multifocal intraocular lenses with a +3.0 D addition.
J Cataract Refract Surg. 2009; 35:2062-9.
31. Altaie R, Ring CP, Morarji J, Patel DV, McGhee CN.
Prospective analysis of visual outcomes using apodized,
diffractive multifocal intraocular lenses following
phacoemulsification for cataract or clear lens extraction. Clin
Experiment Ophthalmol. 2012; 40:148-54.
32. Ferreira TB, Marques EF, Rodrigues A, Montés-Micó R.
Visual and optical outcomes of a diffractive multifocal toric
intraocular lens. J Cataract Refract Surg. 2013; 39:1029-35.
33. Ferrer-Blasco T, Montés-Micó R, Cerviño A, Alfonso JF,
Fernández-Vega L. Contrast sensitivity after refractive
lens exchange with diffractive multifocal intraocular lens
implantation in hyperopic eyes. J Cataract Refract Surg.
2008; 34:2043-8.
34. Tsorbatzoglou A, Németh G, Máth J, Berta A. Pseudophakic
accommodation
and
pseudoaccommodation
under
physiological conditions measured with partial coherence
interferometry. J Cataract Refract Surg. 2006; 32:1345-50.
35. Alfonso JF, Fernández-Vega L, Baamonde MB, MontésMicó R. Prospective visual evaluation of apodized diffractive
intraocular lenses. J Cataract Refract Surg. 2007; 33:123543.
36. Cillino G, Casuccio A, Pasti M, Bono V, Mencucci R,
Cillino S. Working-age cataract patients: visual results,
reading performance, and quality of life with three
diffractive multifocal intraocular lenses. Ophthalmology.
2014; 121:34-44.
37. Yoshino M, Bissen-Miyajima H, Minami K, Taira Y. Fiveyear postoperative outcomes of apodized diffractive multifocal
intraocular lens implantation. Jpn J Ophthalmol. 2013 Sep 28.
[Epub ahead of print].
38. Toto L, Carpineto P, Falconio G, et al. Comparative study of
Acrysof ReSTOR multifocal intraocular lenses +4.00 D and +3.00
D: visual performance and wavefront error. Clin Exp Optom.
2013; 96:295-302.
165
39. Tsaousis KT, Plainis S, Dimitrakos SA, Tsinopoulos IT.
Binocularity enhances visual acuity of eyes implanted with
multifocal intraocular lenses. J Refract Surg. 2013; 29:246-50.
40. Alfonso JF, Puchades C, Fernández-Vega L, Merayo C, MontésMicó R. Contrast sensitivity comparison between AcrySof
ReSTOR and Acri.LISA aspheric intraocular lenses. J Refract
Surg. 2010; 26:471-7.
41. Rasp M, Bachernegg A, Seyeddain O, et al. Bilateral reading
performance of 4 multifocal intraocular lens models and a
monofocal intraocular lens under bright lighting conditions. J
Cataract Refract Surg. 2012; 38:1950-61.
42. Lehmann R, Waycaster C, Hileman K. A comparison of patientreported outcomes from an apodized diffractive intraocular lens
and a conventional monofocal intraocular lens. Curr Med Res
Opin. 2006; 22:2591-602.
43. Fernández-Vega L, Alfonso JF, Rodríguez PP, Montés-Micó
R. Clear lens extraction with multifocal apodized diffractive
intraocular lens implantation. Ophthalmology. 2007;
114:1491-8.
44. Santhiago MR, Wilson SE, Netto MV, et al. Visual performance
of an apodized diffractive multifocal intraocular lens with +3.00d addition: 1-year follow-up. J Refract Surg. 2011; 27:899-906.
45. Gundersen KG, Potvin R. Comparative visual performance with
monofocal and multifocal intraocular lenses. Clin Ophthalmol.
2013; 7:1979-85.
46. Sun Y, Zheng D, Song T, Liu Y. Visual function after bilateral
implantation of apodized diffractive multifocal IOL with a +3.0
or +4.0 D addition. Ophthalmic Surg Lasers Imaging. 2011;
42:302-7.
47. Alfonso JF, Fernández-Vega L, Blázquez JI, Montés-Micó R.
Visual function comparison of 2 aspheric multifocal intraocular
lenses. J Cataract Refract Surg. 2012; 38:242-8.
48. Alió JL, Plaza-Puche AB, Javaloy J, Ayala MJ. Comparison of
the visual and intraocular optical performance of a refractive
multifocal IOL with rotational asymmetry and an apodized
diffractive multifocal IOL. J Refract Surg. 2012; 28:100-5.
49. Ang R, Martínez G, Cruz E, Tiongson A, De la Cruz A.
Prospective evaluation of visual outcomes with three presbyopiacorrecting intraocular lenses following cataract surgery. Clin
Ophthalmol. 2013; 7:1811-23.
50. Muftuoglu O, Dao L, Mootha VV, et al. Apodized diffractive
intraocular lens implantation after laser in situ keratomileusis
with or without subsequent excimer laser enhancement. J
Cataract Refract Surg. 2010; 36:1815-21.
51. Alfonso JF, Fernández-Vega L, Baamonde B, Madrid-Costa
D, Montés-Micó R. Visual quality after diffractive intraocular
lens implantation in eyes with previous hyperopic laser in situ
keratomileusis. J Cataract Refract Surg. 2011; 37:1090-6.
52. Khor WB, Afshari NA. The role of presbyopia-correcting
intraocular lenses after laser in situ keratomileusis. Curr Opin
Ophthalmol. 2013; 24:35-40.
53. Alfonso JF, Fernández-Vega L, Baamonde B, Madrid-Costa
D, Montés-Micó R. Refractive lens exchange with spherical
diffractive intraocular lens implantation after hyperopic laser in
situ keratomileusis. J Cataract Refract Surg. 2009; 35:1744-50.
54. Muftuoglu O, Prasher P, Chu C, et al. Laser in situ keratomileusis
for residual refractive errors after apodized diffractive multifocal
intraocular lens implantation. J Cataract Refract Surg. 2009;
35:1063-71.
55. Jendritza BB, Knorz MC, Morton S. Wavefront-guided excimer
laser vision correction after multifocal IOL implantation. J
Refract Surg. 2008; 24:274-9.
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
166
MULTIFOCAL APODIZED IOLS: PERFORMANCE AND OUTCOMES
56. Muftuoglu O, Dao L, Cavanagh HD, McCulley JP, Bowman
RW. Limbal relaxing incisions at the time of apodized diffractive
multifocal intraocular lens implantation to reduce astigmatism
with or without subsequent laser in situ keratomileusis. J
Cataract Refract Surg. 2010; 36:456-64.
57. Alfonso JF, Knorz M, Fernandez-Vega L, Rincón JL, Suarez
E, Titke C, Kohnen T. Clinical outcomes after bilateral
implantation of an apodized +3.0 D toric diffractive multifocal
intraocular lens. J Cataract Refract Surg. 2014; 40:51-9.
58. Bissen-Miyajima H, Minami K, Yoshino M, Taira Y. Surface
light scattering and visual function of diffractive multifocal
hydrophobic acrylic intraocular lenses 6 years after implantation.
J Cataract Refract Surg. 2013; 39:1729-33.
59. Zheleznyak L, Kim MJ, MacRae S, Yoon G. Impact of corneal
aberrations on through-focus image quality of presbyopiacorrecting intraocular lenses using an adaptive optics bench
system. J Cataract Refract Surg. 2012; 38:1724-33.
60. Alió JL, Grabner G, Plaza-Puche AB, et al. Postoperative bilateral
reading performance with 4 intraocular lens models: six-month
results. J Cataract Refract Surg. 2011; 37:842-52.
61. Cristóbal JA, Remón L, Del Buey MÁ, Montés-Micó R.
Multifocal intraocular lenses for unilateral cataract in children. J
Cataract Refract Surg. 2010; 36:2035-40.
62. de Vries NE, Franssen L, Webers CA, et al. Intraocular straylight
after implantation of the multifocal AcrySof ReSTOR SA60D3
diffractive intraocular lens. J Cataract Refract Surg. 2008;
34:957-62.
63. de Vries NE, Webers CA, Verbakel F, et al. Visual outcome and
patient satisfaction after multifocal intraocular lens implantation:
aspheric versus spherical design. J Cataract Refract Surg. 2010;
36:1897-904.
64. de Santhiago MR, Netto MV, Barreto J Jr, Gomes Bde
A, Schaefer A, Kara-Junior N. A contralateral eye study
comparing apodized diffractie and full diffractive lenses:
wavefront analysis and distance and near uncorrected visual
acuity. Clinics (Sao Paulo). 2009; 64:953-60.
65. Mastropasqua R, Toto L, Vecchiarino L, Falconio G, Nicola
MD, Mastropasqua A. Multifocal IOL implant with or without
capsular tension ring: study of wavefront error and visual
performance. Eur J Ophthalmol. 2013; 23:510-7.
66. Artigas JM, Menezo JL, Peris C, Felipe A, Díaz-Llopis M. Image
quality with multifocal intraocular lenses and the effect of pupil
size: comparison of refractive and hybrid refractive-diffractive
designs. J Cataract Refract Surg. 2007; 33:2111-7.
67. Soda M, Yaguchi S. Effect of decentration on the optical
performance in multifocal intraocular lenses. Ophthalmologica.
2012; 227:197-204.
68. Gatinel D, Houbrechts Y. Comparison of bifocal and trifocal
diffractive and refractive intraocular lenses using an optical
bench. J Cataract Refract Surg. 2013; 39:1093-9.
69. Madrid-Costa D, Ruiz-Alcocer J, Ferrer-Blasco T, GarcíaLázaro S, Montés-Micó R. Optical quality differences between
three multifocal intraocular lenses: bifocal low add, bifocal
moderate add, and trifocal. J Refract Surg. 2013; 29:749-54.
70. Montés-Micó R, López-Gil N, Pérez-Vives C, Bonaque S,
Ferrer-Blasco T. In vitro optical performance of nonrotational
symmetric and refractive-diffractive aspheric multifocal
intraocular lenses: impact of tilt and decentration. J Cataract
Refract Surg. 2012; 38:1657-63.
71. Vrijman V, van der Linden JW, Nieuwendaal CP, van der
Meulen IJ, Mourits MP, Lapid-Gortzak R. Effect of Nd:YAG
laser capsulotomy on refraction in multifocal apodized
diffractive pseudophakia. J Refract Surg. 2012; 28:545-50.
JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
First author:
Javier Tomás Juan, OD, MSc
Vallmedic Vision Andorra