We went through the article by Kamiya and associates, which is the largest series of cases of explanted multifocal intraocular lenses (IOLs). The subjective and objective reasons for explantation, associated procedures, and the postoperative satisfaction have been discussed well. Overall it was an interesting article, but it does not give any new information. Instead it only confirms the information that we have in literature. On thorough study of the article, we had a few concerns as well.
Some of the patients may have been missed because they underwent multifocal IOL explantation elsewhere. Patient satisfaction has been calculated based on records supplied by referring ophthalmic surgeons. This could have led to bias. It may have been more prudent to have patients with monofocal IOL explantation as the control group for satisfaction analysis. The control group characteristics, such as baseline data, preoperative and postoperative visual acuity, and contrast sensitivity, should have been mentioned.
Personality and professional needs of patients could be a confounding variables in the study. Objective assessment of each symptom (glare and halos) and contrast sensitivity, will give an idea about which patient actually needs exchange. The symptoms of the patients should have been quantified, but may be limited by the retrospective nature of the study.
Duration of IOL exchange ranged from 3 days to 40.5 months. The reasons for early explantation and late explantation could give us insight about which patients need early intervention. Ten patients had incorrect multifocal IOL power but only 5 underwent multifocal IOL exchange. Two eyes had underlying retinal pathology. How visual symptoms were attributed to multifocal IOL alone in these cases has not been mentioned by the authors. The authors mention that there were no complications during explant surgery or re-implant surgery. Though multifocal IOL explantation is a viable option, complications of explantation are known, and specific practice guidelines are not evident in this paper.
Five patients had undergone yttrium-aluminum-garnet (YAG) capsulotomy prior to explantation. The details of symptoms for which YAG capsulotomy was considered, but did not help the patient, would help us analyze our patients with similar complain. It is prudent to ascertain whether posterior capsular opacity or multifocal IOL was the cause of the symptoms, and capsulotomy must be deferred until the surgeon is sure that explantation will not be required.
Forty percent patients underwent explant surgery in another institution. This has been attributed to trust issues of the patient and nonfamiliarity of explant techniques to some surgeons. This could also be attributable to the surgeon’s appetite, meaning the surgeon who has implanted the IOL is less likely to advise a patient for IOL explant surgery.