The last three years has seen significant changes in intraocular lens use.  The accommodative Crystalens became available in Australia in March 2009.  The hope for this lens was that it would flex inside the eye, just like a normal 30 year old persons own natural lens does. It could then provide good distance vision but better reading vision than that available with standard monofocal lenses. The safety profile of the Crystalens was excellent and it had been approved for use by the American FDA prior to its release in Australia.

From March 2009 until mid 2010 I placed a large number of accommodative Crystalens in both cataract and refractive lens patients.  We analysed the results carefully. The safety criteria were excellent, as expected.  The reading ability however was disappointing.  In order to have reasonable intermediate and near vision, a blended or monovision effect was required aiming for deliberate short sightedness in one eye.  This is a compromise that was acceptable to some, but not the majority of patients.  Even with blended vision 50% of patients with the accommodative Crystalens required reading glasses for some activities.  All other metrics were good.  The YAG capsulotomy rate was reasonably high and needed to be performed early to get the best performance from the lens, and this would have been the only other unusual feature of this lens.

Because of the disappointing near vision with the accommodative lens I relooked at the aspheric 3+ ReSTOR^® lens.  This is an apodized multifocal lens and I had first used the previous version with a stronger reading add in 2004 and studied and lectured on it extensively.

My hesitation in returning to the ReSTOR^® multifocal lens was that in the earlier version with the stronger reading add patients had a fair degree of halo and flare at night and took a long time to adapt to this.  Patients who were unhappy at six or twelve months did adapt with time and I have never had to remove a ReSTOR^® +4 multifocal lens.  Indeed what happened in 2010 is that I started to see some of the patients who I operated upon five to six years before and they were universally happy with their visual quality and free of glasses for all activities.

I relooked at the new aspheric version (ie +3 not the +4) and started using this lens.  The safety profile is excellent because it is made of the most biocompatible material.  It is very safely injected into the eye and stable once placed in the capsular bag.  You can see from my use of the lens (figure one) that it is now the dominant lens that I use.  Just over 50% of lenses I implant now are either ReSTOR^® +3 multifocal or the multifocal toric.

If patients achieve a plano endpoint; that is they have no remaining astigmatism, long- sightedness or short-sightedness, they are fairly certain of being free of glasses for all activities.  There is still an adaption period and patients need to understand that in order to get reading and intermediate vision they will have some flare and halo at night for a period, and their brain and eye will need to use the lens in an appropriate way.  It is also a lens that needs to be implanted in both eyes for its best effect.  Since the toric version (ie a version that is able to treat astigmatism) became available in early 2011, that has added to the usefulness of the lens as well.

It has been quite a  transition in the last three years in understanding how best to use these lenses, which patients are best suited to which individual lens and how to get the best from the lens; a difficult transition in some ways as a surgeon, but at all times improving the options for patients.

Dr Michael Lawless