Multifocal IOLs produce superior vision at the traditional reading distance of 30cm to 40cm. This makes them ideal choices for patients who read novels or do a lot of detail-intensive near work and still want to see well in the distance.

The near vision benefits of multifocals are often experienced by the patient as soon as the morning after surgery.

Although these lenses produce multiple focal points, we find that patient satisfaction with these lenses is extremely high and does not correlate at all to previous success with multifocal contact lenses.

The typical patient will report surprisingly good near and distance vision at the one-day post-op visit.

As you manage these patients through their recovery period, however, be very mindful of how sensitive this technology is to visual degradation.

Because multifocal IOLs split the available light, they are highly susceptible to visual degradation from a poor ocular surface and mild posterior capsule opacification.

Even the slightest amount of macular edema can produce symptomatic blur that is much more bothersome to the patient than would be experienced with a monofocal lens. Be sure to treat any surface disease aggressively and look closely at the posterior capsule in any patient with visual complaints.

It is not uncommon to have multifocal patients with 20/20 visual acuity claim that they do not see well in the distance if there is mild capsular opacification. At every post-op visit, be mindful to closely look at the posterior capsule and note the presence of any irregularity.

As a general rule, we teach students that if they can see the posterior capsule behind a multifocal lens and patients are having difficulties with their vision, surgical removal should be considered.

Early Intervention Pays Off
The timeframe for capsule removal may be as early as one month postoperatively, depending on the presenting symptoms.

If there is significant residual anterior chamber inflammation, you will want to wait until the anterior chamber is quiet before scheduling the YAG capsulotomy.

Mild capsular fibrosis in a sympto­matic patient with a multifocal intraocular lens implant.
Significant posterior capsular fibrosis in an asymptomatic patient with a mono­focal lens.
This procedure will open a communicating cavity with the posterior pole and could increase the risk of posterior pole inflammation if the anterior chamber is still inflamed.

If the anterior chamber is quiet, a YAG could be scheduled if the patient is symptomatic or not refractable to 20/20.

The YAG capsulotomy procedure takes as little as 10 seconds and is usually painless for the patient.

The patient does need to be dilated before the procedure, and may not notice an immediate visual benefit due to the dilation.

The main complications to look for after this procedure include intraocular pressure spikes, anterior chamber inflammation (rare), inadvertent pitting of the lens by the laser (rarely visually significant), cystoid macular edema and retinal detachment.

Patients can be seen within days of the procedure and visual symptoms should be better.

If posterior capsule opacification is caught early, a YAG capsulotomy can save a multifocal patient a lot of visual distress and help to keep your comanaged patients happy.