1. Neeti Parikh, MD Fuxiang Zhang, MD Department of Ophthalmology Henry Ford Hospital A Comparison Of Patient Satisfaction With Modified Monovision Versus The ReSTOR ® Intraocular Lens *The authors have no financial interest in the material presented

2. PURPOSE To compare patient satisfaction of visual function with modified monovision vs. with ReSTOR ® lens implantation  Monovision: a type of presbyopic correction in which one eye is corrected for distance and the other eye for near  Modified monovision: smaller refractive difference between the two eyes (Between 1.00 - 2.25 D anisometropia )  ReSTOR: a multifocal intraocular lens that provides patients with a range of vision, near through distance  ReSTOR® : a multifocal intraocular lens that provides patients with a range of vision, near through distance

3. METHODS Part 1: Retrospective Chart review  Charts for patients who had cataract surgery between January 2005 and January 2007 from one clinical practice in the Henry Ford Health System reviewed Inclusion criteria: Bilateral cataract extraction and implantation of either a conventional intraocular lens with the goal of modified monovision or an AcrySof ® ReSTOR ® lens Exclusion criteria: Other ocular co-morbidities (moderate to severe diabetic retinopathy, glaucoma with significant visual field defects or optic nerve damage, ARMD) or Toric IOL implantations  Minimum of 1 month follow up post operative visit  Preoperative refraction, keratometry, IOL calculations  All patients underwent conventional phacoemulsification and in the bag implantations with Alcon SN60 WF or SA60 AT lens or ReSTOR ® : SN60D3 ReSTOR  Postoperative uncorrected visual acuity (distance and near), postoperative refraction Part 2: Patient satisfaction survey  Visual function questionnaire- 25 (VFQ-25), validated by the National Eye Institute  Amended to include questions about glare, halos, intermediate vision, and use of glasses after surgery  Completed by patients 3- 24 months postoperatively

4. RESULTS Modified Monovision  67 charts reviewed, 1 surgeon  57 completed survey (85%)  31% male  69% female  94% Caucasian, 6% other  Mean Age: 73 (SD =7 years)  modified monovision= 1.00 - 2.25 D anisometropia Mean=1.4D,standard deviation=.3D 81% 1.00- 1.50 D ReSTOR ®  76 charts reviewed, 8 surgeons  68 completed survey (89%)  40% male  60% female  97% Caucasian, 3% other  Mean Age 68 (SD =12 years )

5. VFQ-25 Results- Mean Satisfaction scores for Distance, Near, Driving P>.05 for all

6. How much difficulty do you have………? No difficulty at all............................................ 1 A little difficulty................................................ 2 Moderate difficulty........................................... 3 Extreme difficulty............................................. 4 Stopped doing this because of your eyesight...5  Computer vision: ReSTOR ® : 1.82 ±.92 Modified Monovision 1.42 ±.59 p=.036 VFQ-25 Results-Intermediate vision

7. VFQ-25 Results-Halos/Glare I am bothered by glare/halos …. All of the time………………….….1 Most of the time……………….….2 Some of the time………………......3 A little of the time…………………4 None of the time…………………..5 Glare: ReSTOR® : 3.74 ±1.21 Modified Monovision: 3.98 ± 1.03 p=.339 Halos: ReSTOR® : 3.39 ± 1.42 Modified Monovision: 4.66 ±.72 p <. 001

8. Uncorrected Visual Acuity at 1 month p=.002 p=.162

9. Freedom from glasses Modified Monovision: 14% of patients (who completed survey) never wear glasses ReSTOR® : 84% of patients (who completed survey) never wear glasses Modified Monovision ReSTOR ® Distance61%8% Intermediate67%19% Near62%18% Driving53%9% p<.001for all Use of glasses among “satisfied” patients (% pts who had little to no difficulty with driving, distance, intermediate, or near activities but still used glasses for these activities):

10. CONCLUSIONS/DISCUSSION  Uncorrected distance visual acuity better in ReSTOR ® group (20/40 or better)  No statistical difference in uncorrected near acuity (J3 or better) between the two groups  Modified monovision patients have more dependence on glasses (for all activities) Modified monovision falls short of correcting for full monovision  Average of only 1.4 D difference between 2 eyes  May not be enough to achieve high rate of glasses independence  No preoperative tolerance test performed for this group This is the reason for the modified approach to monovision in these patients Astigmatism  ReSTOR ® patients with ≥ 1 D of astigmatism treated with limbal relaxing incisions  26% of modified monovision patients had ≥ 1 D of preoperative astigmatism that was not corrected  Patients with toric implants who had monovision were excluded from this study

11. CONCLUSIONS/DISCUSSION  Monovision patients more likely to wear glasses, but still very satisfied No statistical difference in satisfaction scores for driving, distance, or reading between 2 groups Statistically significant higher satisfaction score in modified monovision group for intermediate (computer) vision Modified monovision patients had no out of pocket costs for the surgery ( ReSTOR® cost to patient = $1895 per eye )  Modified monovision patients more likely to be willing to pay for glasses

12. REFERENCES  Boerner, C.F., Thrasher BH. Results of Monovision Correction in Bilateral Pseudophakia. American Intraocular Implant Society Journal, 10. 1982. 49-50  Greenbaum S. Monovision Pseudophakia. Journal of Cataract and Refractive Surgery. 28, 2003, 1439-1443  Handa et al. Ocular Dominance and patient satisfaction after monovision induced by intraocular lens implantation. Journal of Cataract and Refractive Surgery, 30. 2004, 769-774  Maloney, W.F. Conventional IOL presbyopia correction:six steps to success. Ocular Surgery News U.S. Edition March 1,2006.  Maloney, W.F. 20 years of developing conventional IOL presbyopia correction. Ocular Surgery News U.S. Edition January 1, 2006.  Maloney, W.F. Conventional IOL still offen best choice for presbyopia correction. Ocular Surgery News U.S. Edition November 1, 2005.  Maloney, W.F. Presbyopia success depends on comprehensive preop evaluation. Ocular Surgery News U.S. Edition August 1.2005.  Maloney, W.F. Presbyopia correction will set a new standard for cataract surgery. Ocular Surgery News U.S. Edition July 1,2005.  Mangione, C. M., Lee, P. P., Gutierrez, P. R., Spritzer, K., Berry, S., & Hays, R. D. (2001). Development of the 25 – item National Eye Institute Visual Function Questionnaire (VFQ – 25). Archives of Ophthalmology, 119, 1050-1058  Mangione, C. M., Lee, P. P., Pitts, J., Gutierrez, P., Berry, S., & Hays, R. D. (1998). Psychometric properties of the National Eye Institute Visual Function Questionnaire, the NEI – VFQ. Archives of Ophthalmology, 116, 1496 – 1504