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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 499-500

Trifocal toric intraocular lens implantation for cataract in a young patient with congenital nystagmus

1 Chief - Cataract and Refractive Services, Ratan Jyoti Netralaya , Gwalior, Madhya Pradesh, India
2 Consultant, Paediatric Ophthalmology and Strabismus Services, Ratan Jyoti Netralaya, Gwalior, Madhya Pradesh, India

Date of Submission17-Oct-2020
Date of Acceptance15-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Purendra Bhasin
Ratan Jyoti Netralaya, Near Sai Baba Mandir, Gwalior - 474 002, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_3288_20

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We report a case of Trifocal Toric IOL implantation in a patient having cataract with congenital nystagmus. A detailed ocular assessment for pre- and postoperative uniocular and binocular visual acuity, nystagmus characteristics, abnormal head posture, fundus examination, IOP measurement, and biometry was carried out. Preoperative visual acuity was 6/12p and 6/18p in right and left eye, respectively, with binocular visual acuity of 6/12p. Postoperative visual acuity was 6/12 in right and 6/9 in the left eye, respectively. Binocular visual acuity was 6/9 for far and N6 at 40 cm for near after implantation of a trifocal toric IOL. No change in nystagmus characteristics was observed.

Keywords: Multifocal IOL, nystagmus, Trifocal IOL

How to cite this article:
Bhasin P, Dhage A. Trifocal toric intraocular lens implantation for cataract in a young patient with congenital nystagmus. Indian J Ophthalmol Case Rep 2021;1:499-500

How to cite this URL:
Bhasin P, Dhage A. Trifocal toric intraocular lens implantation for cataract in a young patient with congenital nystagmus. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 28];1:499-500. Available from: https://www.ijoreports.in/text.asp?2021/1/3/499/320096

In today's era, multifocal IOLs (MFIOLs) are offered to presbyopic patients with cataract on routine basis. But what if a patient in his early 30s with nystagmus develops cataract––Can we offer multifocal IOL to such a patient? This question seldom arises in our mind since monofocal IOLs are an automatic choice in patients with nystagmus. Nystagmus is an ocular condition, which consists of involuntary, rhythmic, oscillations of both eyes.[1] Nystagmus patients suffer from decreased visual acuity, loss of stereopsis, abnormal head posture, oscillopsia because of these abnormal eye movements.[2],[3] MFIOLs are never considered because of fear of their photic visual disturbances interfering with already compromised vision of a nystagmus patient.[4] We are reporting a case where a young male patient suffering from bilateral cataract and congenital nystagmus was operated and implanted with a trifocal toric IOL. Trifocal IOLs are intraocular lenses that consist of three focal points: far, intermediate, and near. In addition, multifocal IOLs have their own set of limitations and benefits that have to be weighed against patient's clinical condition and needs for best possible postoperative result.

  Case Report Top

A 31-year-old male patient reported to us in December 2018 with complaints of progressive diminution of vision in both eyes since 6 months. He reported presence of shakiness of eyes and abnormal head posture since childhood. He was wearing glasses since childhood. On examination he was using glasses of +4.50DS/+[email protected]0 in right eye and +3.50DS/+[email protected]0 in left eye. His best-corrected visual acuity with glasses was 6/12p and 6/18 in right and left eye, respectively. Binocular visual acuity with manifest abnormal head posture was 6/12p. Studying his old records prior to development of cataract we understood that the best binocular visual acuity was noted as 6/12 for far and N6 at 33 cm for near. We also noted a horizontal jerky left beating conjugate nystagmus in both eyes. He had null point in 300 levo-elevation and showed right face turn with chin depression. Nuclear opalescence and posterior sub-capsular cataract was noted in both eyes. The patient was advised cataract surgery with monofocal IOL in both eyes, but the patient requested on getting a spectacle-free life post this surgery. Patient had used contact lenses before. So he was keen on being free of glasses. After much deliberation a choice of trifocal toric IOL was discussed with the patient. The patient was explained about need for IOL explanation if undesirable visual performance was noted with this IOL. The IOL used for this procedure was Zeiss AT LISA 939MP since the author is acquainted with it. It is a single piece, UV filtering, diffractive non-apodized IOL made of hydrophilic acrylic (25%) material with surface hydrophobic properties. It comes with an intermediate add of 1.66D and near add of 3.33D. IOL power calculation was done by taking into consideration readings from Pentacam, IOL master, Alcon Verion and Zeiss online IOL power calculator. By using various biometric tools we ensured maximum accuracy in determining IOL power.[5] Keratometric data was taken from Verion reference unit which corresponded with the pentacam which gave a fairly accurate keratometric reading apart from manual readings.[6],[7] Axial length was calculated by optical method. This data was then fed into zeiss online calculator and IOL power was calculated. Patient consented for the procedure and left eye Phacoemulsification was undertaken by the author and a trifocal toric IOL was implanted without intra-operative complications. While performing surgery Verion live tracking helped in real time axis management for incision and IOL axis alignment [Figure 1] and [Figure 2]. Surgery for the other eye was also undertaken by the same surgeon after 15 days with the same trifocal toric IOL. 2 weeks post second surgery patient was very satisfied with the results. His uncorrected visual acuity in both eyes was 6/12 individually. Combined visual acuity for both eyes was 6/9 for distance and N6 at 33 cm, but there was no effect on the pre-existing AHP and nystagmus characteristics. The patient was on regular follow up and his last visit was 1 year post surgery. He had maintained his uncorrected visual acuity for distance and near but the nystagmus and AHP showed no improvement or deterioration in character. On further enquiry patient mentioned presence of haloes but it was not visually disturbing.
Figure 1: Shows Trifocal toric IOL aligned with help of Verion in left eye

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Figure 2: Shows Trifocal toric IOL aligned with help of Verion in right eye

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  Discussion Top

Patients with nystagmus suffer from significant refractive error and other visual disturbances hampering their visual performance considerably. Various surgeries to improve visual function and nystagmus intensity has been proposed.[1] Correcting refractive error is the most effective step in managing nystagmus associated visual disturbances.[2],[3] It is a well-known fact that patient with nystagmus benefit more with use of contact lenses since foveation is better in contact lens users due to continuous fixation unlike in spectacles.[3] Taking this into consideration IOL implantation works in similar fashion. But a multifocal IOL consists of different focusing segments- far, intermediate and near. It is largely unknown what will be the effect of implanting a multifocal IOL in a patient with motor nystagmus. We hypothesized that since the patient is suffering from motor nystagmus and dampens on convergence, this intermediate segment would act as a convergence inducer and help to dampen nystagmus and thus improve visual quality. A case report by Alfredo Amigo in journal of refractive surgery in which a 52-year-old patient underwent refractive lens exchange with MFIOL was studied.[8] The authors reported disappearance of asthenopic symptoms while reading but no change was observed in nystagmus characteristics. Similarly we also experienced no change in nystagmus intensity, direction, null point or AHP. No asthenopic symptoms were exhibited by our patient pre and post operatively. Patient's best corrected binocular visual acuity documented prior to development of cataract was 6/12 which improved to 6/9 post surgery but the patient experienced immense subjective improvement in quality of vision. Another case report in which a nystagmus patient underwent bilateral toric phakic IOL for high myopic astigmatism reported good visual outcome along with no change in nystagmus characteristics similar to our case.[9]

  Conclusion Top

In this report we have shared our experience of implanting Trifocal toric IOL bilaterally in a patient having motor nystagmus with a documented history of good binocular visual function. A larger case series or a prospective study to understand safety and viability of implanting Multifocal or Trifocal IOL's in similar patients is needed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Abel L. Infantile nystagmus: Current concepts in diagnosis and management. Clin Exp Optom 2006;89:57-65.  Back to cited text no. 1
Hertle RW. Examination and refractive management of patients with nystagmus. Surv Ophthalmol 2000;45:215-22.  Back to cited text no. 2
Allen ED, Davies PD. Role of contact lenses in the management of congenital nystagmus. Br J Ophthalmol 1983;67:834-46.  Back to cited text no. 3
Salerno LC, Tiveron MC Jr, Alio JL. Multifocal intraocular lenses: Types, outcomes, complications and how to solve them. Taiwan J Ophthalmol 2017;7:179-84.  Back to cited text no. 4
[PUBMED]  [Full text]  
Nazm N, Chakrabarti A. Update on optical biometry and intraocular lens power calculation. TNOA J Ophthalmic Sci Res 2017;55:196-210.  Back to cited text no. 5
  [Full text]  
Lin HY, Chen HY, Fam HB, Chuang YJ, Yeoh R, Lin PJ. Comparison of corneal power obtained from VERION image-guided surgery system and four other devices. Clin Ophthalmol 2017;11:1291-9.  Back to cited text no. 6
Nemeth G, Szalai E, Hassan Z, Lipecz A, Berta A, Modis L Jr. Repeatability data and agreement of keratometry with the VERION system compared to the IOLMaster. J Refract Surg 2015;31:333-7.  Back to cited text no. 7
Amigó A, Bonaque S. Rotationally asymmetric multifocal IOL implantation in acquired nystagmus with spectacle and contact lens intolerance. J Refract Surg 2013;29:506-8.  Back to cited text no. 8
Muñoz G, Belda L, Albarrán-Diego C, Ferrer-Blasco T, García-Lázaro S. Artiflex toric phakic intraocular lens implantation in congenital nystagmus. Case Rep Ophthalmol 2011;2:273-8.  Back to cited text no. 9


  [Figure 1], [Figure 2]


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