Abstract
PurposeMultifocal intraocular lenses (IOLs) offer the possibility of spectacle-free vision following cataract surgery compared to standard IOLs. Existing systematic reviews have generally concluded that multifocal IOLs result in better uncorrected near vision and greater spectacle independence, but more unwanted visual phenomena such as glare and halos, compared to monofocal IOLs. However, the certainty of evidence has been low for most outcomes, and pooled analyses have grouped together technologically obsolete lenses with newer lenses, potentially obscuring differences in performance across different lens types.MethodsWe performed a systematic review searching for RCTs of a multifocal IOL to a standard IOL or monovision that reported spectacle independence, visual acuity, or quality of life. Databases were searched from 1/1/2006–4/30/2017. Existing reviews were used to identify older studies. Title/abstract screening and data extraction were done in duplicate. Where possible, random effects meta-analysis was performed to synthesize results. In addition to comparing multifocal IOLs as a group to monofocal IOLs, we also compared newer diffractive lenses to obsolete or refractive lenses.ResultsTwenty-five eligible studies were identified. There was no difference in pooled estimates of corrected or uncorrected distance vision between multifocal and standard IOLs. Compared to monofocal IOLs, multifocal IOLs had statistically significantly better pooled results for the outcome of near vision (10 studies, 1025 patients, mean difference in logMAR of ‐0.26 (95% CI ‐0.37, ‐0.15)); spectacle dependence (12 studies, 1237 patients, relative risk of 0.27 (95% CI 0.20, 0.38)) and borderline significantly better quality of vision (6 studies, 596 patients, standardized mean difference of ‐0.54, (95% CI ‐1.12, 0.04)). Compared to monofocal IOLs, multifocal IOLs had statistically significantly worse pooled results for the outcomes of glare (9 studies, 847 patients, risk ratio of 1.36 (95% CI 1.15, 1.61) and halos (7 studies, 754 patients, risk ratio of 3.14 (95% CI 1.63, 6.08). Newer multifocal lenses had statistically significantly better outcomes than older diffractive lenses or refractive lenses, when compared to monofocal IOLs, in near vision, quality of vision, and risk of halos.ConclusionsMultifocal IOLs compared to standard IOLs or monovision result in better uncorrected near vision and a higher proportion of patients who achieve spectacle independence, but greater risk of unwanted visual phenomena. Newer diffractive lenses may be better than refractive lenses in near vision and quality of vision outcomes, with less risk of halos than older diffractive lenses and refractive lenses.(PROSPERO registration CRD42017069949)
Highlights
Expectations following cataract surgery have become increasingly high with many patients desiring spectacle independence as an outcome
An early systematic review, published in 2003, identified 8 eligible randomized controlled trials (RCTs) [2], and concluded based on pooled analyses that there were no statistically significant differences in distance vision but better near vision and spectacle independence for patients receiving Multifocal intraocular lenses (MFIOL) compared to monofocal intraocular lenses (IOLs)
The most recent Cochrane review [5] included newer lenses but pooled the data from new and old lenses together, concluding that distance visual acuity was no different between multifocal IOLs and monofocal IOLs; there is low-certainty evidence that near visual acuity was better with multifocal IOLs; there is low-certainty evidence that multifocal IOLs resulted in less spectacle dependence; and moderatecertainty evidence that visual phenomena like halos are more common with multifocal IOLs
Summary
Expectations following cataract surgery have become increasingly high with many patients desiring spectacle independence as an outcome. An early systematic review, published in 2003, identified 8 eligible randomized controlled trials (RCTs) [2], and concluded based on pooled analyses that there were no statistically significant differences in distance vision (corrected or uncorrected) but better near vision and spectacle independence for patients receiving MFIOLs compared to monofocal intraocular lenses (IOLs). The most recent Cochrane review [5] included newer lenses but pooled the data from new and old lenses together, concluding that distance visual acuity was no different between multifocal IOLs and monofocal IOLs; there is low-certainty evidence that near visual acuity was better with multifocal IOLs; there is low-certainty evidence that multifocal IOLs resulted in less spectacle dependence; and moderatecertainty evidence that visual phenomena like halos are more common with multifocal IOLs. Random sequence generation Allocation concealment Blinding of participants and personnel Blinding of outcome assessment Incomplete outcome data Selective reporting Other sources of bias Marchini, 200715 Zeng, 200721 Cillino, 200826 Harman, 200821 Palmer, 200832 Zhao,200925 Alio, 201114 Ji, 201223
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