An aspheric, apodized, diffractive, multifocal implant for giving patients a range of visual function with aspheric benefits.
Iwas honored to participate as a clinical investigator for the FDA phase 3 clinical trial of the AcrySof IQ ReSTOR IOL +3.0 D (Alcon Laboratories, Inc., Fort Worth, TX) at my facility in Wilkes Barre, PA. The results from this trial1 were remarkable in terms of achieved near, intermediate, and distance vision. The trial compared the AcrySof IQ ReSTOR IOL +3.0 D to its predecessor, the AcrySof IQ ReSTOR IOL+4.0 D. The trial demonstrated an excellent gain in intermediate vision without affecting either near or distance vision compared to the AcrySof IQ ReSTOR IOL +4.0 D. In 2009, Alcon Laboratories, Inc., introduced the AcrySof IQ ReSTOR IOL +3.0 D in the United States, an aspheric, apodized, diffractive, multifocal IOL. In my opinion, this lens has provided excellent results for patients interested in reducing their dependence on spectacles for all activities.
To further demonstrate the notable visual outcomes with this lens, I conducted my own study recently of the AcrySof IQ ReSTOR IOL +3.0 D, in which my patients achieved extraordinary results. My colleagues and I analyzed 82 patients in two clusters: 147 eyes in a distance vision group, and 144 eyes in a near vision group. We found that when only one eye was implanted with the lens, the individual visual acuities were very good. For example, 40% of patients achieved 20/20 UCVA for distance, and 76% achieved 20/25 or better. No eye saw worse than 20/40 UCVA. These results, however, do not tell the entire story about the visual potential for patients.
Individuals implanted bilaterally with the AcrySof IQ ReSTOR IOL +3.0 D achieved much better vision versus unilateral placement. In terms of UCVA in bilaterally implanted patients, 84% and 13% of subjects achieved 20/20 and 20/25 distance vision, respectively. In the patients implanted bilaterally with the AcrySof IQ ReSTOR IOL +3.0 D, 94% read at the J1 level. With the +4.0 D version of this lens, patients could achieve similar results in terms of binocular summation and improvements in visual acuity, although they generally gave up some intermediate vision and depth of field in order to achieve this near vision.
Twenty-five of the patients in my personal cohort required astigmatic correction, for which I used limbal relaxing incisions (LRIs). Eighty percent of patients who received LRIs at the time of surgery enjoyed a successful outcome of 20/25 UCVA or better for distance. These patients’ near visual acuities also remained very good.
I use the AcrySof IQ ReSTOR IOL +3.0 D exclusively now because of its optical power and high patient satisfaction. In my experience, the range of vision for near with the AcrySof IQ ReSTOR IOL +4.0 D was, at best, approximately 8 to 10 cm. When compared to the AcrySof IQ ReSTOR IOL +4.0 D, the +3.0 D lens has a more comfortable near point (~16 in at 20/20) and offers excellent depth of field, capable of extending from 33 to 70 cm (Figure 1). This range is why recipients of this lens experience good intermediate vision in addition to excellent distance and near vision. Furthermore, the transition between near and intermediate viewing is seamless, which produces a more functional visual system compared to the +4.0 D optic. This seamlessness is due to the gentle graduation of the optic’s diffractive step heights, and fewer diffractive rings with the AcrySof IQ ReSTOR IOL +3.0 D (eg, nine vs 12 steps), which optimally distributes light to the retina and the distant focal points. This is an important feature of apodization.
Some surgeons feel comfortable routinely implanting the AcrySof IQ ReSTOR IOL through an incision as small as 2.2 mm, but I prefer a 2.4-mm incision, because I do not have to enlarge it further and I can construct a self-sealing wound that does not leak. I use a D-cartridge (Alcon Laboratories, Inc.) through my 2.4-mm incision to deliver the IOL efficiently. Other IOLs whose insertion devices are not as efficient will have difficulty being implanted consistently through a microincision. This 2.4-mm incision induces approximately 0.20 to 0.25 D of corneal astigmatism. Overall, the implantation of this lens is routine and easy. The IOL opens up in a predictable fashion and centers easily in the capsular bag. My patients’ visual results are also predictable.
As I mentioned, I use LRIs when astigmatic correction is warranted after implanting the lens, but LASIK, PRK, and AK are also viable options. If the residual refractive astigmatism is greater than 0.75 D, patients may experience visual disturbances such as blurring, ghosting, and halos, especially around lights at night. This needs to be explained to any multifocal candidate before the surgery in order to set the right expectations.
The AcrySof IQ ReSTOR IOL +3.0 D has a relatively low rate of posterior capsular opacification (PCO). The square-edged optic and bioadhesive nature of the acrylic material helps reduce the migration of lens epithelial cells and therefore gives added protection against PCO. Additionally, the slow and controlled unfolding of this lens during its implantation makes it ideal for eyes with small irregularities in the capsular bag (eg, a limited central defect). I overlap the optic with the capsulorhexis to further prevent PCO. The ideal capsulorhexis size is approximately 5.0 mm and overlaps the optic for 360°.
I rarely use the +4.0 D multifocal IOL anymore, because the AcrySof IQ ReSTOR +3.0 D IOL supplies stronger reading, intermediate, and distance vision for most patients and generates fewer complaints of halos and hazy distance vision postoperatively. As with all premium refractive IOLs, success with this lens depends largely on proper patient selection (patients who will appreciate multifocality and have realistic expectations) and a superior surgical technique.
Harvey J. Reiser, MD, is in private practice at Eyecare Specialists, Wilkes Barre, Pennsylvania, and he is associate professor at The Commonwealth Medical College, Scranton, Pennsylvania. He is a consultant to and on the Speakers Bureau for Alcon Laboratories, Inc. Dr. Reiser may be reached at (570) 288-7405; firstname.lastname@example.org.