EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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May 2013 EW CATARACT 33 Gender preferences with multifocal IOLs by Enette Ngoei EyeWorld Contributing Writer Study finds gender differences in satisfaction levels with new multifocal IOLs W hile the new generation of multifocal IOLs may bring high patient satisfaction rates, gender differences in satisfaction levels among the available lenses remain, according to a study by Magda Rau, MD, Augenklinik Cham, Germany. About a decade ago, Dr. Rau and colleagues found a significant difference in the acceptance of multifocal IOLs between female and male cataract patients in a previous retrospective multifocal IOL study (19982003), she said. The results showed that the satisfaction of men and women was different after implantation with different multifocal IOLs. Although the explantation rate was low, it was interesting that there was a gender difference in the explantation of IOLs; explantation was performed in seven males and one female. More recently, with a new generation of multifocal IOLs available, Dr. Rau wanted to see if there was still a difference in the acceptance of these IOLs. She and colleagues conducted a retrospective clinical study on new multifocal IOLs implanted between 2004 and 2012. A total of 296 eyes of 173 patients were evaluated. The Tecnis multifocal (Abbott Medical Optics, Santa Ana, Calif.) was implanted in 80 eyes of 19 men and 21 women between 2004 and 2006. The mean age was 56. Uncorrected distance vision was 0.92 while the uncorrected near vision was 0.88 D. Fifty-seven percent of women and 35% of men were satisfied with the lens after implantation. The OptiVis (Aaren Scientific, Ontario, Calif.) was implanted in 48 eyes of 14 men and 10 women between 2009 and 2011. The mean age was 70. The uncorrected distance vision was 0.76 D, the uncorrected near vision was 0.76 D, and the uncorrected intermediate vision was 0.68 D. Thirty-one percent of women and 49% of men were satisfied with the lens after implantation. The Lentis Mplus (Oculentis, Berlin, Germany) was implanted in 120 eyes of 45 men and 40 women between 2009 and 2011. The mean age was 60. The uncorrected distance vision was 0.88 D, the uncorrected near vision was 0.76 D, and the uncorrected intermediate vision was 0.64 D. Twenty-four percent of women and 66% of men were satisfied with the lens following implantation. This is interesting, Dr. Rau said, because the distance vision in these lenses is less likely to be associated with dysphotopsias than some other lenses. The FineVision trifocal lens (PhysIOL, Liège, Belgium) was implanted in 48 eyes of 12 men and 12 women between 2011 and 2012. The mean age of patients was 62. The uncorrected distance vision was 0.79 D, the uncorrected near vision was 0.88 D, while the uncorrected intermediate vision was 0.78 D. Fifty-four percent of women were satisfied while 42% of men were satisfied with the lens. Dr. Rau said that as a small amount of myopia had been targeted here, it is interesting that men prefer good distance vision and women prefer good reading vision when multifocal lenses are implanted. The main reason for dissatisfaction following implantation in women was poor near vision, while for men, it was glare and halos during while night driving. Dr. Rau said that for the women it was important to have excellent near vision because woman have been more interest in fine details, and they appreciate the independence from reading glasses. Reading addition and unwanted visual effects will lead to different acceptance of MF IOLs. Therefore, the Tecnis and FineVision trifocal IOLs with their high greater addition achieved higher satisfaction among women, Dr. Rau said, while the OptiVis and Lentis Mplus scored better among men. A new term, gender medicine, has been established. Based on academic and administrative suggestions, this field is beginning to be generally accepted. The knowledge that the appearance and development of diseases as well as the effects of medicinal drugs on women and men is different is being introduced into research, teaching, and further education. "Taking gender differences into account as a factor for patient acceptance allows you to optimize satisfaction after the implantation of a MF IOL," Dr. Rau said. Gender and personality Mark Packer, MD, Mark Packer MD Consulting, Miami, said he thinks Dr. Rau may be on to something. While he has not had any experience with a couple of the lenses in the study as they are unavailable in the U.S., Dr. Packer said his experience with multifocal IOL implantation has been that men are more bothered by the halos and dysphotopsia in general. "We only have the diffractive lenses here and that would fit with what Dr. Rau was saying—basically that the satisfaction among women is higher for the diffractive lenses because of the better near vision, while in her study, men preferred the refractive type of lenses with better quality of vision for night driving," he said. Dr. Packer said he has had a higher frequency of dissatisfaction and explantation of diffractive multifocal lenses among men as compared to women. "It's interesting because I think personality differences outweigh these gender differences; there are women and men who are more prone to dissatisfaction or problems with the optical side effects but it seems that a higher number of them are men," he said. Dr. Packer said he would not go so far as to only use a certain lens for male patients. "I think the personality differences and the goals in terms of achieving spectacle freedom vary and that's the most important thing, but this is worth taking into account to be a little more careful with the diffractive multifocals among men," he said. Achieving target outcomes and guiding patient expectations Eric Donnenfeld, MD, co-chairman, cornea, Nassau University Medical Center, East Meadow, N.Y., found Dr. Rau's study interesting but said, "My experience is that there have been very few differences in patients receiving multifocal IOLs and that the number one rate limiting step in patient satisfaction with multifocal IOLs is achieving the refractive target. As long as you achieve the refractive target, men and women are equally satisfied, in my experience," he said. Significant glare and halo is an uncommon problem in patients who receive the new generation multifocal IOLs, Dr. Donnenfeld said. "The aspheric optics of both the Tecnis multifocal and the ReSTOR multifocal IOL [Alcon, Fort Worth, Texas] have allowed patients to have a higher quality visual acuity. As with all cataract surgery, the number one reason for glare and halos is not achieving the refractive target." In patients who do achieve the refractive target, Dr. Donnenfeld said he and colleagues have found that approximately 1 in 50 patients will have significant glare and halo and may require an IOL exchange. "We always speak to patients about this possibility prior to implantation and that brings me to the second most important point in patient satisfaction—having reasonable expectations," he said. Prior to implanting a multifocal IOL, Dr. Donnenfeld said a detailed discussion is conducted with patients at his practice. Patients are told that glare and halo are a normal part of the procedure and usually not significant. As a matter of fact, he said, in the FDA trials, glare and halos were significant in only about one in five patients and in those patients, satisfaction was still very high. Most patients have little glare and halo with these lenses but it's important to counsel patients that it is a possibility, Dr. Donnenfeld said. EW Editors' note: Drs. Donnenfeld, Packer, and Rau have no financial interests related to this article. Contact information Donnenfeld: ericdonnenfeld@gmail.com Packer: mark@markpackerconsulting.com Rau: info@augenklinik-cham.de