Accepted Manuscript

Reduction in mean deviation values in automated perimetry in eyes with multifocal

compared to monofocal intraocular lens implants

Marjan Farid, MD Garrick Chak, MD Sumit Garg, MD Roger F. Steinert, MD

PII: S0002-9394(14)00220-7
DOI: 10.1016/j.ajo.2014.04.017
Reference: AJOPHT 8894

To appear in: American Journal of Ophthalmology

Received Date: 27 January 2014

Revised Date: 17 April 2014
Accepted Date: 22 April 2014

Please cite this article as: Farid M, Chak G, Garg S, Steinert RF, Reduction in mean deviation values in
automated perimetry in eyes with multifocal compared to monofocal intraocular lens implants, American
Journal of Ophthalmology (2014), doi: 10.1016/j.ajo.2014.04.017.

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 ACCEPTED MANUSCRIPT

Reduction in mean deviation values in automated perimetry in eyes with

multifocal compared to monofocal intraocular lens implants

Marjan Farid, MD

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Garrick Chak, MD
Sumit Garg, MD

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Roger F. Steinert, MD

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Gavin Herbert Eye Institute
University of California, Irvine, Department of Ophthalmology
850 Health Sciences Road

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Irvine, CA 92697 AN
Corresponding Author:
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Marjan Farid, MD
Gavin Herbert Eye Institute
University of California, Irvine, Department of Ophthalmology
850 Health Sciences Road
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Irvine, CA 92697
Phone: (949)824-0327
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Fax: (949)824-4015
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Short title: Visual field testing in multifocal intraocular lens eyes.

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Abstract

Purpose: To evaluate differences in mean deviation values in automated perimetry in

healthy eyes with multifocal compared to monofocal intraocular lens (IOL) implants.
Design: Prospective, age-matched, comparative analysis.

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Methods:
Setting: Single-center, tertiary referral academic practice.
Patient Population: A total of 37 healthy eyes in 37 patients with bilateral multifocal (n =

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22) or monofocal (n = 15) IOL implants were studied.
Intervention/Observation Procedure: Humphrey Visual Field 10-2 (Zeiss Meditec,
Dublin CA) testing was performed on all patients.

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Main Outcome Measures: Mean Deviation (MD) and Pattern Standard Deviation (PSD)
numerical values were evaluated and compared between groups.

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Results: The average MD 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 = 0.006). There was no significant
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difference in PSD between the two groups (p = 0.99). 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.
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Conclusion: Multifocal IOL implants cause significant non-specific 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
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visual field reduction may not be tolerated, such as macular degeneration, retinal
pigment epithelium changes, and glaucoma.
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Introduction
Non-pathological 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, 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)

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and pattern standard deviation (PSD) can be studied.

Multifocal intraocular lenses (IOLs) produce simultaneous retinal images with different

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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
superimposed, and approximately 18% of transmitted light in diffractive IOLs, which

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may vary depending on intraocular lens (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 haloes, and reduced contrast sensitivity.8-15 Mesopic

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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
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disturbances, we evaluated the effect of diffractive multifocal IOLs on a common clinical
test, Humphrey Visual Field analyzer (Zeiss-Meditec, Dublin, CA) (HVF) 10-2, to
determine the impact on performance in patients with bilateral multifocal or monofocal
IOL implants.
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Several studies have previously reported the effects of intraocular lenses on visual field
testing. Mutlu, et al demonstrated that monofocal IOLs may reduce MD in Humphrey
Visual Field 24-2 testing compared to healthy phakic patients.22 Specifically, the effects
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of multifocal IOLs on perimetry have been evaluated with Octopus 101 autoperimetry,23
Goldmann manual perimetry,24 frequency doubling technology matrix perimetry,25
automated Esterman binocular field test,26 and Humphrey visual field 30-2.27 With
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appreciation of the previous contributions, 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 ten degrees of vision.
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Materials and Methods

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Institutional Review Board (IRB)/Ethics Committee approval was obtained from the
University of California, 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 = 22) or monofocal IOLs (n = 15). Cataract surgeries had been previously
performed by one of three surgeons (MF, RFS, SG). 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

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hypertension, amblyopia, irregular corneal astigmatism, corneal dystrophy, or significant

capsular opacity. Dilated exams 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 multifocal IOLs had
aspheric diffractive optics (no refractive multifocal IOLs were included). Any patients

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with psychological or neurological 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

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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

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astigmatism. No patients with monovision were included. All refractive errors were lens
corrected during Humphrey Visual Field 10-2 testing.

All Humphrey Visual Field10-2 automated perimetry testing was measured with the

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Swedish Interactive Threshold Algorithm (SITA) standard threshold test algorithm, white
stimulus, size III target, and standard Humphrey background luminance of 31.5 apostilb.
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The earliest visual field testing was measured at post-operative month one. 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.
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Nevertheless, careful refractive measurements were performed at the testing distance

and if an add power was required, it was given by corrective lenses. MD, PSD, as well
as reliability indices including fixation losses, false positive, and false negative numeric
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values were recorded. Poor tests with high fixation losses, or false positive/negative
values were repeated for reliability. Statistical analysis was performed comparing the
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multifocal group to the monofocal group using a two-tailed student’s t-test under the
assumption that the two groups had unequal variance (www.studentsttest.com).
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Results
Thirty-seven patients were included in the study. One eye from each patient was
selected randomly for analysis: 22 eyes with multifocal IOLs and 15 eyes with
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monofocal IOLs. The multifocal IOLs included the 1-piece Tecnis ZMB00 (n=11) and
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the 3-piece Tecnis ZMA00 (n=6) (Abbott Medical Optics, Santa Ana, Ca.) as well as the
Acrysof IQ Restore SN6AD1 (n=5) (Alcon, Fort Worth, Tx.). The monofocal IOLs
included the 1-piece Tecnis ZCB00 (n=7) and the 3-piece Tecnis ZA9003 (n=6) (Abbott
Medical Optics, Santa Ana, Ca.) as well as the Acrysof IQ SN60WF (n=2) (Alcon, Fort
Worth, Tx.). There was no significant difference in age or gender between the groups.
The average age was 73 years in both groups with 14 females in the multifocal group
(63.6%) and 10 females in the monofocal group (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 = 0.006) (Figure 1). The average

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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 = 0.99) (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 to 34 months), and averaged 4.9 months in the monofocal IOL group

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(range = 1 to 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 fewer than 6 months (n = 7) compared to those

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with time to visual field testing greater than 6 months (n = 15) were -1.65 dB and -2.98
dB, respectively, with no significant difference between the two (p = 0.15) (Figure 3).
Discussion

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This is the first case-controlled study to evaluate and quantify differences in Humphrey
Visual Field 10-2 testing in healthy eyes with diffractive multifocal versus monofocal

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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 Aychoua et al. study
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using Humphrey Visual Field 30-2 testing in the multifocal versus monofocal IOL
analysis.27 Patients with multifocal IOLs have been shown to have reduced contrast
sensitivity,12-15 particularly in mesopic conditions.16-17 Standard automated perimetry,
which measures differential light sensitivity thresholds at various locations across the
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visual field, is a reliable measure of this subclinical reduction in visual sensitivity in

diffractive multifocal IOL eyes. 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
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studies confirm the 2 Db reduction in MD in multifocal normal eyes, a new baseline in

Humphrey Visual Field testing may be established in this population.
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Previous studies of visual field effects from multifocal IOLs have been reported. A
prospective nonrandomized clinical study by Bi, et al used Octopus 101 autoperimetry
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to compare visual field results in patients who had multifocal IOL (AcrySof ReSTOR
SA60D3) with patients who had monofocal IOL (AcrySof SN60AT) and found no
significant difference between the two groups.23 In another prospective comparative
analysis, Kang, et al demonstrate that patients with multifocal IOLs (3M diffractive
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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
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intensity.24 In another prospective comparative analysis, Stanojcic, et al studied the

effects of multifocal IOL (Tecnis ZM900) versus monofocal IOL adjusted for monovision
on binocular visual fields, evaluated by automated Esterman binocular field, and found
no statistically significant difference between the two groups.26 While this study was
intended to assess differences in binocular visual fields and visual disability for UK
driving evaluation, when it comes to monocular central vision, the Esterman test
inherently screens for larger scotomas and does not evaluate subtle depressions in
central visual field.32 In another prospective comparative study, Bojikian, et al
demonstrate no difference between an apodized diffractive multifocal IOL (AcrySof

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ReSTOR) and a monofocal IOL (AcrySof IQ) on frequency doubling technology

perimetry results, which is used to for early detection of glaucoma, as the perimeter
predominantly stimulates the magnocellular ganglion cell pathway and is less sensitive
to optical blur as compared to automated perimetry.25

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The reduction of MD in static perimetry with multifocal technology has been previously
reported. Madrid-Costa et al. 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 et al. recently

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evaluated the effects of varying lens status comparing multifocal IOL (Tecnis ZM900
silicone 3-piece diffractive IOL and also Zeiss 809M acrylic one-piece diffractive IOL),
monofocal IOL, and also phakic controls on Humphrey Visual Field 30-2 perimetry and

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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

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subgroup analysis, no outstanding differences between these models were revealed,
suggesting that the reduced visual sensitivity is inherent to the diffractive multifocal optic
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and not specific to the brand.

Neuroadaptation, which is believed to represent a learning adaptation in the image

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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
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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
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may need training regimens. One study evaluated 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 one eye and a
refractive IOL in the other, and concluded that at least 6 months was necessary.28 In our
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study, there was no significant difference in Humphrey Visual Field 10-2 performance
between those that had testing done in the first 6 months as compared to those who
had testing done after post-operative month 6 in the multifocal IOL group. The
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reduction in MD on central visual field testing, regardless of evaluation time

postoperatively, is presumably from decreased contrast sensitivity that is inherent to the
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multifocal optic and does not appear to decrease with neuroadaptation. Interestingly,
there appeared to be a trend towards worsening MD with time, although this did not
reach statistical significance.

The multifocal group of patients in this study had no subjective dissatisfaction from their
IOL and had an otherwise healthy ocular exam with no IOL malfunction. The decrease
in MD on Humphrey Visual Field 10-2 testing seen in this study is thus related to

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subclinical inherent IOL properties and does not translate to patient dissatisfaction or
visual complaints.

Patients taking systemic hydroxychloroquine or chloroquine for rheumatologic diseases

may demonstrate early paracentral visual field loss on Humphrey Visual Field 10-2
assessment despite the absence of known risk factors that lead to retinal toxicity.35-38

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A reduced MD with a multifocal IOL may limit the ophthalmologist’s ability to detect early
toxicity on Humphrey Visual Field 10-2 in patients taking hydroxychloroquine or
chloroquine. If a patient on either medication already has a multifocal IOL, we

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recommend screening the patient with concurrent spectral domain OCT and/or
multifocal electroretinogram in order to detect early parafoveal toxicity,39 as visual field
10-2 testing may be confounded and unreliable in this group of patients.40

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Based on our findings, the authors propose that multifocal IOLs should be used with
caution in patients with macular pathology, optic neuropathies, and glaucoma where

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loss of optic nerve has occurred and regular visual field testing is required.
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ACKNOWLEDGEMENTS/DISCLOSURES

a) Financial Support:
Supported in part by a Department Developmental Grant from Research to
Prevent Blindness (RPB)

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b) Statement of Financial Interest:
Dr. Chak- none

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Drs. Farid, Garg, and Steinert are consultants for Abbott Medical Optics.

The authors have no proprietary interest to disclose.

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c) Contributions:
Design of the study: Dr. Farid

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Conduct of the study: Drs. Farid, Garg, and Steinert
Management, analysis, and interpretation of the data: Drs. Chak, Farid, Garg,
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and Steinert
Preparation, review, or approval of the manuscript: Drs. Chak, Farid, Garg, and
Steinert
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Figure Legends

Figure 1: Mean deviation values on Humphrey Visual Field 10-2 testing in patients with
multifocal and monofocal intraocular lens implants. Note that there is a significant

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difference between the two groups (p = 0.006).

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Figure 2: Pattern standard deviation values on Humphrey Visual Field 10-2 testing in
patients with multifocal and monofocal intraocular lens implants. Note that there is no
statistical difference between the two groups (p = 0.99).

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Figure 3: Mean deviation values on Humphrey Visual Field 10-2 categorized by patients

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who had testing within 6 months post multifocal intraocular lens implantation and
patients who had testing after 6 months post multifocal intraocular lens implantation.
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Mean Deviation

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1
0

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-1
-2

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dB

-3
-4

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-6
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Multifocal Monofocal
(N=22) (N=15)
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Pattern Standard Deviation

2.5

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2

1.5
dB

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1

0.5

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0
Multifocal Monofocal
(N=22) (N=15)

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Mean Deviation over time

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0

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-1
-2
-3

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-4
-5

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-6
< 6mo > 6mo
Time from surgery to Humphrey Visual Field testing
(n=7) (n=15)

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Marjan Farid, MD

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

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Ophthalmology.

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