ARTICLE

Effect of astigmatism on visual acuity in eyes

with a diffractive multifocal intraocular lens
Ken Hayashi, MD, Shin-ichi Manabe, MD, Motoaki Yoshida, MD, Hideyuki Hayashi, MD

PURPOSE: To examine the effect of astigmatism on visual acuity at various distances in eyes with
a diffractive multifocal intraocular lens (IOL).
SETTING: Hayashi Eye Hospital, Fukuoka, Japan.
METHODS: In this study, eyes had implantation of a diffractive multifocal IOL with a C3.00 diopter
(D) addition (add) (AcrySof ReSTOR SN6AD1), a diffractive multifocal IOL with a C4.00 D add
(AcrySof ReSTOR SN6AD3), or a monofocal IOL (AcrySof SN60WF). Astigmatism was simulated
by adding cylindrical lenses of various diopters (0.00, 0.50, 1.00, 1.50, 2.00), after which
distance-corrected acuity was measured at various distances.
RESULTS: At most distances, the mean visual acuity in the multifocal IOL groups decreased in pro-
portion to the added astigmatism. With astigmatism of 0.00 D and 0.50 D, distance-corrected near
visual acuity (DCNVA) in the C4.00 D group and distance-corrected intermediate visual acuity
(DCIVA) and DCNVA in the C3.00 D group were significantly better than in the monofocal
group; the corrected distance visual acuity (CDVA) was similar. The DCNVA with astigmatism
of 1.00 D was better in 2 multifocal groups; however, with astigmatism of 1.50 D and 2.00 D,
the CDVA and DCIVA at 0.5m in the multifocal groups were significantly worse than in the
monofocal group, although the DCNVA was similar. With astigmatism of 1.00 D or greater, the
mean CDVA and DCNVA in the multifocal groups reached useful levels (20/40).
CONCLUSION: The presence of astigmatism in eyes with a diffractive multifocal IOL compromised
all distance visual acuities, suggesting the need to correct astigmatism of greater than 1.00 D.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2010; 36:13231329 Q 2010 ASCRS and ESCRS

It is widely accepted that implantation of a multifocal
intraocular lens (IOL) is the most effective way to
achieve useful far and near vision without spectacles
after cataract surgery.1 Multifocal IOLs can be refrac-
tive or diffractive, with many new diffractive IOL
models recently becoming commercially available.26
These new-generation IOLs provide better near visual
Submitted: November 14, 2009.
Final revision submitted: January 29, 2010.
Accepted: February 11, 2010.
From the Hayashi Eye Hospital (K. Hayashi, Manabe, Yoshida) and
the Department of Ophthalmology (H. Hayashi), School of Medi-
cine, Fukuoka University, Fukuoka, Japan.
Corresponding author: Ken Hayashi, MD, Hayashi Eye Hospital,
4-7-13 Hakataekimae, Hakata-Ku, Fukuoka 812-0011, Japan.
E-mail: hayashi-ken@hayashi.or.jp.
acuity than refractive multifocal IOLs. However, there
is controversy about whether some types of diffractive
multifocal IOLs and refractive multifocal IOLs impair
contrast sensitivity.68
Multifocal IOLs produce useful visual acuity at both
far and near. Reasons include less induced
astigmatism,911 a larger pupil diameter,1215 and less
IOL decentration.12 Of these factors, postoperative
astigmatism significantly affects the visual function
in eyes with a refractive-type multifocal IOL,911 al-
though not everyone agrees with this finding.16,17 In
a previous study of a refractive monofocal IOL,11 we
used astigmatism simulation and found that all-
distance visual acuity worsened in proportion to the
degree of astigmatism in eyes with the refractive mul-
tifocal IOL. However, to our knowledge, no study has
evaluated the effect of astigmatism on the visual acuity
at various distances in eyes with a diffractive multifo-
cal IOL.

Q 2010 ASCRS and ESCRS 0886-3350/$dsee front matter 1323

Published by Elsevier Inc. doi:10.1016/j.jcrs.2010.02.016
1324 EFFECT OF ASTIGMATISM ON DIFFRACTIVE MULTIFOCAL IOL
Therefore, we designed a study to compare eyes
with a diffractive multifocal IOL and eyes with
a monofocal IOL and the effects of refractive astigma-
tism on visual acuity at far to near. Manifest astigma-
tism was simulated by adding cylindrical lenses of
various diopters (D). Furthermore, we sought to deter-
mine the limit of astigmatism at which useful far and
near visual acuity was achieved with diffractive multi-
focal IOLs.
PATIENTS AND METHODS
This prospective nonrandomized comparative study in-
cluded consecutive patients who wished to participate in
a clinical trial of an apodized diffractive multifocal IOL be-
tween March and August 2008. Eyes of patients scheduled
to have implantation of a monofocal IOL of the same design
and materials between May 2008 and April 2009 were en-
rolled as a control group. The Institutional Review Board,
Hayashi Eye Hospital, approved the study protocol, and
all patients provided written informed consent.
The patients were not randomized because it would have
not been ethical to implant a monofocal IOL in patients who
were candidates for multifocal IOL implantation. After hear-
ing an explanation of possible advantages and disadvan-
tages of each IOL, patients decided whether they would
participate in the multifocal IOL clinical trial and if not,
which IOL they wished to receive instead. In cases of
bilateral IOL implantation, only information from the first
operated eye was analyzed in this study.
Exclusion criteria were serious pathology of the optic
nerve, macula, or cornea; severe opaque media other than
cataract; history of ocular inflammation or surgery; corneal
astigmatism greater than 1.50 D; need for routine nighttime
driving; and difficulty in follow-up or analysis.
Intraocular Lenses
Study patients had implantation of a diffractive multifocal
IOL with a C3.00 diopter (D) addition (add) power (AcrySof
ReSTOR SN6AD1) or a C4.00 D add power (AcrySof Re-
STOR SN6AD3) (both Alcon, Inc.). Both models are single-
piece hydrophobic acrylic and have an aspheric surface
with an apodized diffractive multifocal structure on the an-
terior optic. The apodized multifocal structure in the central
3.6 mm optic zone consists of 12 or 9 concentric steps of grad-
ually decreasing height and creates multifocality from far to
near. The refractive region of the optic, which is used for far
vision, surrounds the diffractive region. The optic and haptic
are tinted yellow.
Control patients had implantation of a monofocal IOL
(AcrySof SN60WF, Alcon, Inc.). The IOL is of the same mate-
rial and has the same optic and haptic design as the study
IOLs but without the multifocal structure.
Surgical Technique
The same surgeon (K.H.) performed all cataract extrac-
tions and IOL implantations using the same technique,
which has been described.18 First, a 2.5 mm clear corneal in-
cision was created at the 9 oclock meridian with a stainless
steel keratome. A continuous curvilinear capsulorhexis
approximately 5.5 mm in diameter was made with a bent
needle. After thorough hydrodissection was completed,
J CATARACT REFRACT SURG - VOL 36, AUGUST 2010
endocapsular phacoemulsification of the nucleus and aspira-
tion of the residual cortex were performed. The incision was
enlarged to 2.65 mm with another steel keratome for IOL im-
plantation. The lens capsule was inflated with an ophthalmic
viscosurgical device (OVD), and the IOL was placed in the
capsular bag using an Alcon Monarch II injector. After IOL
insertion, the OVD was thoroughly evacuated. No sutures
were placed.
Main Outcome Measures
Patients were examined approximately 3 months after
surgery. After various degrees of astigmatism were simu-
lated as previously described,11 distance-corrected visual
acuity was measured at infinity and at 5.0 m, 3.0 m , 2.0 m,
1.0 m, 0.7 m, 0.5 m, and 0.3 m using an all-distance vision tes-
ter (AS-15, Kowa Co., Ltd.) The vision tester measures equiv-
alent visual acuity from far to near as the examiner places
a spherical lens and various visual targets at proper dis-
tances along the visual axis. In this study, visual acuity at in-
finity and at 5.0 m was defined as far visual acuity; that at
1.0 m, 0.7 m, and 0.5 m, as intermediate visual acuity; and
that at 0.3 m, as near visual acuity. Against-the-rule (ATR)
astigmatism was simulated by adding 0.00 D, 0.50 D, 1.00
D, 1.50 D, and 2.00 D cylindrical lenses at the 90-degree me-
ridian at the spectacle plane after full distance correction.
Because most eyes with senile cataract have ATR astigma-
tism,19 only this type of astigmatism was examined.
The keratometric cylinder was measured with an auto-
keratometer (KR-7100, Topcon Corp.). The spherical and cy-
lindrical powers were determined subjectively; the manifest
spherical equivalent (SE) was calculated as the spherical
power plus half the cylindrical power. Pupil diameter was
measured with a Colvard pupillometer (Oasis Medical). Ex-
perienced ophthalmic technicians who were not aware of the
objectives of the study performed all examinations.
Statistical Analysis
Decimal visual acuity was converted to the logMAR scale
for statistical analysis. The Kruskal-Wallis test was used to
compare differences between the 3 IOL groups in the follow-
ing parameters: far to near visual acuity by degree of added
astigmatism visual acuity at far to near, SE, corneal astigma-
tism, pupil diameter, and other continuous variables. Cate-
gorical variables were compared using the goodness test of
fit for chi-square. When a statistically significant difference
was found between the 3 groups, the difference between 2
groups was further compared using the Mann-Whitney U
test or the chi-square test with Bonferroni adjustment. A P
value less than 0.05 was considered statistically significant.
RESULTS
Each IOL group comprised 30 eyes of 30 patients. All
90 patients attended all scheduled examinations. The
mean age of the 18 men and 72 women was 69.9 years
G 8.3 (SD) (range 40 to 86 years). Table 1 shows the pa-
tient demographics by IOL group. There were no sta-
tistically significant differences between the 3 groups
in age, the ratio of men to women, the ratio of left to
right eyes, manifest SE, keratometric cylinder, or pupil
diameter. All surgeries were uneventful, and all IOLs
were implanted in the capsular bag.
 EFFECT OF ASTIGMATISM ON DIFFRACTIVE MULTIFOCAL IOL 1325

Table 1. Patient demographics by IOL group.

IOL Group

Parameter C4.0 D Multifocal C3.0 D Multifocal Monofocal P Value

Mean age (y) 69.5 G 11.8 69.9 G 5.9 70.3 G 5.9 .9951
Sex (M/F) 7/23 3/27 8/22 .2326
Left/right eyes 15/15 12/18 10/20 .4181
Mean astigmatism (D)* 0.89 G 0.65 0.57 G 0.24 0.83 G 0.53 .1549
SE (D) 0.21 G 0.34 0.27 G 0.38 0.38 G 0.69 .7472
Pupil diameter (mm)
Far 3.6 G 0.4 3.7 G 0.4 3.6 G 0.6 .6612
Near 2.9 G 0.4 3.1 G 0.4 3.1 G 0.6 .2097

Means G SD
IOL Z intraocular lens; SE Z spherical equivalent
*Keratometric cylinder

Manifest spherical equivalent

The mean distance-corrected visual acuity at most
distances was significantly reduced in proportion to
the diopters of added astigmatism in the C4.00 D mul-
tifocal IOL group (Figure 1) and the C3.00 D multifo-
cal IOL group (Figure 2) (P%.0451, except at 0.5 m in
C4.00 D multifocal group). In the monofocal IOL
group (Figure 3), the mean visual acuity at all dis-
tances changed significantly per the degree of added
astigmatism (P%.0148). Although the corrected dis-
tance visual acuity (CDVA) decreased significantly in
proportion to the degree of added astigmatism in the
monofocal group (P!.0001), the distance-corrected
near visual acuity (DCNVA) at 0.3 m and distance-
corrected intermediate visual acuity (DCIVA) at
0.5 m improved significantly as added astigmatism in-
creased (P%.0066). However, the decrease in CDVA
was more prominent in the multifocal groups than in
the monofocal group. The assumption was that
a visual acuity of 20/40 would be necessary for far
and near in eyes with a diffractive multifocal IOL;
the mean visual acuity in both multifocal IOL groups
reached this level at far and near when astigmatism
was within 1.00 D.
Figure 4 compares the mean visual acuity from far to
near in the 3 IOL groups. With added astigmatism of
0.00 D or 0.50 D, the CNVA at 0.3 m in the C4.00 D
multifocal group and the DCIVA at 0.5 m and DCNVA
in the C3.00 D multifocal group were significantly bet-
ter than in the monofocal group; there was no signifi-
cant difference in CDVA between the 3 groups. With
astigmatism of 1.00 D, the DCNVA in the 2 multifocal
groups was significantly better than in the monofocal
group; there was no significant difference in DCIVA
or CDVA between the 3 groups. However, with astig-
matism of 1.50 D or 2.00 D, the CDVA and DCIVA at
0.5 m in the 2 multifocal groups was significantly

Figure 1. Change in mean distance-corrected visual acuity from far Figure 2. Change in mean distance-corrected visual acuity from far
to near by diopters of added astigmatism in the C4.00 D multifocal to near by diopters of added astigmatism in the C3.00 D multifocal
IOL group. IOL group.

J CATARACT REFRACT SURG - VOL 36, AUGUST 2010

1326 EFFECT OF ASTIGMATISM ON DIFFRACTIVE MULTIFOCAL IOL
Figure 3. Change in mean distance-corrected visual acuity from far
to near by diopters of added astigmatism in the monofocal IOL
group.
worse than in the monofocal group, whereas the
CNVA was similar. Furthermore, the percentage of
eyes that achieved 20/40 at both far and near was sig-
nificantly greater in the multifocal groups than in the
monofocal group when astigmatism was 1.00 D or
less (P!.0001); no significant difference was found be-
tween the 3 groups with astigmatism of 1.50 D or 2.00
D (Table 2).
DISCUSSION
In our study, the mean visual acuity at all distances de-
creased in proportion to the degree of added astigma-
tism in eyes with a diffractive multifocal IOL with
a C3.00 D or C4.00 D add. We assumed in the study
that a visual acuity of 20/40 would be necessary for
useful CDVA and DCNVA with a diffractive IOL.
This is because distance visual acuity of 20/40 is likely
needed to drive a car and near visual acuity of 20/40 is
sufficient for reading a newspaper. With these criteria,
eyes with astigmatism of 1.00 D or less reached this
level. In contrast, eyes with a monofocal IOL had a de-
crease in CDVA that was proportional to the degree of
added astigmatism, although the CNVA and DCIVA
improved as astigmatism increased. However, the de-
crease in CDVA was more prominent in the 2 multifo-
cal IOL groups than in the monofocal IOL group. In
other words, the CDVA with a diffractive multifocal
IOL was worse than with a monofocal IOL when astig-
matism was 1.50 D or higher.
We compared the mean visual acuity from far to
near between the 3 IOLs with simulation of astigma-
tism of various degrees. With astigmatism of 0.00 D
and 0.50 D, CNVA at 0.3 m with the C4.00 D multifo-
cal IOL and DCIVA at 0.5 m and DCNVA with the
C3.00 D multifocal IOL were significantly better
than with the monofocal IOL. Furthermore, with
J CATARACT REFRACT SURG - VOL 36, AUGUST 2010
astigmatism of 1.00 D, the CNVA was better with
both multifocal IOLs than with the monofocal IOL.
However, with astigmatism of 1.50 D and 2.00 D, the
CDVA and DCIVA at 0.5 m was worse in the 2 multi-
focal IOL groups than in the monofocal IOL group, al-
though the CNVA was similar in all 3 groups. These
results indicate that the multifocal effect of the 2 dif-
fractive multifocal IOLs is useful when the postopera-
tive astigmatism is approximately 1.00 D or lower.
Previous studies911 report that postoperative astig-
matism affects visual function in eyes with a refractive
multifocal IOL, although controversy remains.16,17
Ravalico et al.9 found that that optical quality of the
Array refractive multifocal IOL (Abbot Medical Op-
tics, Inc.) was worse in eyes with astigmatism greater
than 1.00 D than in eyes with lower astigmatism,
and Dick et al.10 found that eyes with astigmatism
greater than 1.00 D had a greater halo effect than
eyes with lower astigmatism. Furthermore, in a previ-
ous study, we found that visual acuity at any distance
worsened in proportion to the degree of astigmatism
in eyes with a refractive multifocal IOL. However, to
our knowledge, no study in the literature reports the
effect of astigmatism on all-distance visual acuity in
eyes with a diffractive multifocal IOL. The current
study first verified that the diffractive multifocal effect
is useful when astigmatism is approximately 1.00 D or
less. Therefore, when preexisting astigmatism is 1.50 D
or higher, astigmatism correction (eg, corneal relaxing
incisions,2022 excimer laser keratectomy,23,24 use of
a multifocal IOL with an incorporated toric compo-
nent2528) may be necessary. In particular, because
toric IOLs may have advantages over keratorefractive
procedures, including predictability, reversibility, and
mechanical stability of the cornea,29 we believe that
a diffractive multifocal IOL with a toric component
should be developed.
The CNVA with the diffractive multifocal IOLs
also decreased in proportion to the added astigma-
tism. In contrast, the CNVA and DCIVA in eyes
with a monofocal IOL improved as astigmatism in-
creased. It is apparent that the manifest SE value (fo-
cal point of the eye) shifted toward myopia based on
the extent of astigmatism. Furthermore, it has been
shown that myopic astigmatism enhances the depth
of focus in the presence of a monofocal IOL.30,31 Ac-
cordingly, the improvement in CNVA and DCIVA
with astigmatism greater than 1.50 D may be a result
of the enhanced depth of focus and the myopic shift
in the manifest SE.
A limitation of this study was that we only evalu-
ated ATR astigmatism. This is predominantly because
patients would have to expend too much effort in
a study of the effects of other types of astigmatism.
Furthermore, most patients with senile cataract have
 EFFECT OF ASTIGMATISM ON DIFFRACTIVE MULTIFOCAL IOL 1327

Figure 4. Comparison of mean distance-corrected visual acuity from far to near in the 3 IOL groups.

ATR astigmatism.19 However, it has been suggested
that near vision may differ according to the types of
astigmatism.30,31 In particular, Trindade et al.32 report
that uncorrected near visual acuity in eyes with ATR
astigmatism was better than in eyes with with-the-
rule astigmatism. Accordingly, it is possible that actual
near vision may be worse than that obtained in this
study. Additional study is necessary to examine the
effects of other types of astigmatism on visual function
of diffractive multifocal IOLs.
In conclusion, when simulated astigmatism was ap-
proximately within G1.00 D, the diffractive multifocal
IOLs provided significantly better CNVA and DCIVA
than the monofocal IOL, although CDVA was similar
with the 3 IOLs. Based on our findings, we believe that
eyes with astigmatism of approximately 1.00 D or

J CATARACT REFRACT SURG - VOL 36, AUGUST 2010

1328 EFFECT OF ASTIGMATISM ON DIFFRACTIVE MULTIFOCAL IOL
Table 2. Eyes achieving a visual acuity of 20/40 at both far and near by IOL group.
IOL Group, n (%)
Astigmatism (D) C4.0 D Multifocal
0.00 30 (100.0)
0.50 30 (100.0)
1.00 26 (86.7)
1.50 12 (40.0)
0.00 1 (3.3)
IOL Z intraocular lens
*Number of eyes in monofocal IOL group significantly less than in both multifocal IOL groups
lower are good candidates for implantation of a dif-
fractive multifocal IOL. In addition, with astigmatism
of 0.50 D or less, the CNVA with the C4.00 D multifo-
cal IOL was better than with the C3.00 D multifocal
IOL, whereas the DCIVA was better with the C3.00
D multifocal IOL than with the C4.00 D multifocal
IOL. Therefore, implantation of a C4.00 D multifocal
IOL in 1 eye and a C3.00 D multifocal IOL in the fel-
low eye may be an option to achieve useful far, near,
and intermediate vision. However, when astigmatism
is greater than 1.00 D, the surgeon should consider
a different form of astigmatism management, such as
use of a multifocal IOL with an incorporated toric com-
ponent. Other studies should be performed to examine
the effects on visual function of diffractive multifocal
IOLs that incorporate a toric component.
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First author:
Ken Hayashi, MD
Hayashi Eye Hospital, Fukuoka, Japan