The report is a product of the VA/HSR Evidence Synthesis Program.

Comparing Effectiveness of Intraocular Lenses for Cataract Surgery and Lens Replacement

Cataract is an eye condition in which the natural crystalline lens becomes cloudy and can ultimately lead to poor vision. Usually associated with aging, cataract affects more than 24.4 million Americans age 40 and older, and it is estimated that half of all Americans older than age 75 have cataract or have had cataract surgery. Surgical removal of cataract and the implantation of a prosthetic lens is one of the most common surgeries performed in the United States.

Monofocal intraocular lenses have been the "gold standard" for cataract surgery and lens replacement. However, the most commonly used type of advanced intraocular lens implant in the U.S. is the multifocal lens, which is now FDA approved and produces multiple focal points at far and near distances. Another alternative is accommodating intraocular lens implants which can provide a depth of focus rather than distinct focal points. Additional lens designs are available internationally and are currently under development in the U.S.. While there are potential advantages to these advanced lenses, there also may be disadvantages including unwanted visual symptoms (i.e., glare and halo). Moreover, many pre-existing ocular conditions are considered contraindications to their use.

This systematic review was requested to assess the benefits and harms of these types of intraocular lens implants so that further guidance on their use within VA can be provided. Investigators with VA's Evidence-based Synthesis Program (ESP) Center in West Los Angeles, CA searched PubMed from 1/1/2006 to 4/30/2017 to identify literature that would offer insight into the comparative effectiveness of multifocal, accommodative, and monofocal intraocular lenses for cataract surgery and lens replacement. After identifying 760 potentially relevant citations, of which 93 abstracts were reviewed as full-text publications, 12 were used in this review.

Summary of Findings
Multifocal intraocular lens (IOLs) compared to monofocal IOLs produce better uncorrected near vision and a greater proportion of patients who are spectacle independent, but they are associated with worse contrast sensitivity and a greater risk of glare and halos. Current evidence is insufficient to reach conclusions about resource requirements and other outcomes, such as additional enhancements or IOL exchange. More specifically,

• Moderate-strength evidence supports the conclusion that — compared to monofocal IOLs — multifocal IOLs achieve better outcomes on spectacle independence and uncorrected near visual acuity, without sacrificing uncorrected or corrected distance vision.
• Low-strength evidence supports the conclusion that multifocal IOLs result in better visual function/quality of life than monofocal IOLs. More limited data support that multifocal IOLs achieve better spectacle independence than monovision (use of monofocal intraocular lenses to aim one eye distance and one eye near).
• Moderate-strength evidence indicates that multifocal IOLs result in worse contrast sensitivity and a greater risk of glare, and low-strength evidence suggests that they result in a greater risk of halos.
• Low strength evidence exists that monofocal IOLs result in greater IOL exchange due to dissatisfaction.
• Data are very limited about accommodative IOLs (only 1 RCT).

Note
No studies were performed in VA populations, or even U.S. populations; therefore, the applicability of these results to VA patients with cataracts is uncertain. Further, IOL technology is changing rapidly, and newer lenses may have differences in the benefits and harms reported here for older lenses.

Future Research
A VA-sponsored multi-site randomized clinical trial would provide higher quality evidence than what currently exists about the benefits, harms, needed pre- and post-operative resources, and costs of multifocal IOLs compared to monofocal IOLs.

**A cyberseminar session titled "Comparative Effectiveness of Multifocal, Accommodative, and Monofocal Intraocular Lenses for Cataract Surgery and Lens Replacement" will be held on Wednesday, June 13, 2018 from 3:00pm to 4:00pm (ET).. Register for this session.**

Reference
Khandelwal SS*, Jun J*, Mak S, Shanman R, Booth M, Beroes JM, Shekelle PG. Comparative effectiveness of multifocal, accommodative, and monofocal intraocular lenses for cataract surgery and lens replacement. VA ESP Project #05-226; 2017. (*These two authors contributed equally to this report.)

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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