Creating Hybrid Monovision with 7.0 mm XL Optic and High-Add AMD Intraocular Lenses (XL-MAGS) in a Patient with Retinitis Pigmentosa

case reports in ophthalmology
02 Dec, 2019 ,

Andreas F. Borkenstein and Eva-Maria Borkenstein report a case of a patient with progressed retinitis pigmentosa (RP) who underwent bilateral cataract extraction with implantation of a monofocal enlarged optic in the far dominant eye and a high-add AMD intraocular lens (IOL) in the near dominant eye (hybrid monovision XL-MAGS). A 71-year-old woman presented to our clinic complaining of reduced visual acuity additionally to her diagnosis of RP. The high-add IOL LENTIS® MAX LS-313 MF80 (Oculentis, Germany) was implanted in the right eye and the 7.0 mm optic ASPIRA-aXA IOL (HumanOptics, Germany) in the left eye. Six months postoperatively, the uncorrected distance visual acuity improved from hand motion to 0.5 logMAR in the right eye and to 0.3 logMAR in the left eye. Similarly, best corrected near visual acuity significantly improved to 0.4 and 0.7 logMAR, respectively. The patient's subjective quality of life and autonomy improved significantly. RP is a severe retinal disease which leads to loss of vision and typical “tunnel vision” with visual field defects. As this genetic disorder is incurable, many ophthalmologists are not willing to perform cataract surgery. However, this case report shows that creating hybrid monovision with a high-add lens and a 7.0 mm optic IOL led to improvement of visual function and, more importantly, enhanced quality of life and self-autonomy of the patient.

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A 71-year-old female patient, diagnosed with RP more than 30 years ago, presented at our clinic for a second opinion because her visual acuity (VA) had significantly decreased over time to hand motion (distance 1 m) in both eyes. A review of her medical records showed that about 5 years prior to this consultation, her corrected distance VA (CDVA) was 0.4 logMAR in the right eye and 0.5 logMAR in the left eye. However, visual field measurements over the last 20 years revealed slow progressing loss of the peripheral vision with reduced overall sensitivity. Upon examination in our clinic, it appeared that the patient had brunescent mature senile cataracts, preventing further visual field tests. Intraocular pressure measurement was within acceptable limits, with values of 18–20 mm Hg in both eyes without any therapy.

Together we decided upon bilateral extraction of the cataract to improve VA. We performed a standard phacoemulsification procedure with implantation of a new high-add AMD lens (LENTIS® MAX LS-313 MF80, Oculentis, Germany) in the right, near dominant eye and, 2 weeks later, with implantation of a monofocal, 7.0 mm optic IOL (ASPIRA-aXA, HumanOptics, Germany) in the left, far dominant eye. In the latter, an enhanced capsulorhexis of 6.5 mm was created, which has been shown to be beneficial in RP eyes. Despite identifying weak zonules, both surgeries with implantation of capsular tension rings were uneventful. We observed that the enlarged optic IOL enables better view of the fundus and a best possible visual field in combination with a wider capsulorhexis, whereas the magnifying IOL enables a 3× magnification at 15 cm distance.

There were no postoperative complications. Patient's satisfaction was high and subjective improvement was reported immediately after surgery. VA increased significantly over time. One week postoperatively, uncorrected distance VA was 1.0 and 0.7 logMAR in the right and left eye, respectively, and further improved to 0.7 and 0.5 logMAR 4 months after surgery. Subjective refraction was OD −0.5/+0.5 × 100 and OS −0.75/+0.5 × 90, resulting in a binocular CDVA of 0.3 logMAR. With a near addition of +1.0 dpt and +3.0 dpt, the patient's corrected near VA (CNVA) at 40.0 cm improved to 0.4 and 0.7 logMAR in the right and left eyes, respectively, leading to binocular CNVA of 0.5 logMAR. The slit-lamp examination showed no changes to preoperative results.

Six months after the surgeries, CDVA was 0.5 logMAR in the right eye and 0.3 logMAR in the left eye. For near vision (CNVA), it was 0.4 and 0.7 logMAR in the right and left eye, which led to binocular VA of 0.4 logMAR. The patient did not wear distance glasses as there was no subjective improvement in VA. Nonetheless, near addition of +1.75 dpt was necessary in both eyes. The patient preferred the same slight add power for near distance in the reading glasses and was able to vary the distance to the object (e.g., book) between 30–45 cm. Intraocular pressure remained with values of 16 and 15 mm Hg, respectively. Slit-lamp examination revealed clear IOLs in situ without any further findings other than RP, which remained stable as visualized with optical coherence tomography (OCT) and fundoscopy 1 year after surgery.