Multifocal lens with AMD or glaucoma: can I still have one?

You have early AMD or glaucoma, and you are being offered cataract surgery: can you choose a multifocal lens to become glasses-free? The answer calls for nuance. Premium lenses (multifocal, EDOF) offer real visual independence, but their optical design splits light between several focal points, which lowers contrast sensitivity. In an eye whose macula or optic nerve is already weakened, that drop matters more. Here is how the question of eligibility actually arises, during the pre-operative assessment.

UNDERSTAND

How does a multifocal lens work, and why does it change everything?

A monofocal lens creates only one focal point: it gives you sharp vision at one distance, usually far away, and you wear glasses to read. A multifocal lens or an EDOF lens aims to reduce this dependence on glasses by providing several zones of sharpness. This independence comes with an optical trade-off that must be understood before choosing.

The principle of diffractive lenses is to split the incoming light between two focal points or more. Each focal point therefore receives a fraction of the available light energy. As a result, at every distance the image is slightly less contrasted than with a monofocal lens, which concentrates all the light on a single plane. It is a deliberate compromise, not a manufacturing flaw.

This drop in contrast sensitivity is well documented. The review by Grzybowski et al. (PMID 31955239) recalls that multifocal optics reduce retinal contrast and can produce light phenomena such as halos, especially at night. In a perfectly healthy eye, the retina compensates without difficulty and the patient adapts. The problem arises when the retina or the optic nerve no longer has that margin.

In other words, the question is not “is the multifocal good or bad?” but “does your eye have the visual reserve needed to absorb this trade-off?”. This is exactly where AMD and glaucoma come into play. For a full overview of the options, you can read our comparison of monofocal, multifocal and EDOF lenses.

What is contrast sensitivity?

Contrast sensitivity is the ability to distinguish close shades: grey text on a light background, a pavement in the rain, a face in dim light. It is distinct from the visual acuity measured on a chart of black letters. You can read 20/20 in broad daylight and still feel bothered as soon as the light fades. It is this parameter, more than acuity, that multifocal lenses draw on.

Can I have a multifocal lens if I have AMD?

When significant maculopathy is present, the multifocal lens is generally not advised and the monofocal remains the default choice. The review by Grzybowski et al. (PMID 31955239) points out, however, that this contraindication in maculopathy is not firmly demonstrated: it rests mainly on mechanistic reasoning and a consensus of caution, not on solid comparative trials.

Why this caution? AMD, an epiretinal membrane or diabetic macular oedema already impair the centre of vision, the macula. This is precisely the area that processes fine detail and contrast. If the contrast loss linked to the multifocal is added to an already fragile macula, the patient risks not achieving the hoped-for comfort, while having paid for a premium lens.

The future must also be considered. AMD is a progressive disease. A patient fitted with a multifocal today could see their macula deteriorate in the following years, with a lens that, by then, penalises vision more. This is why the assessment takes the prognosis into account, not just today’s condition. The form of the disease matters: wet AMD under injections does not have the same profile as stable dry AMD under simple monitoring.

In these situations, the reasonable goal becomes once again good sharp distance vision with the monofocal, supplemented by reading glasses. It is a modest goal in appearance, but it protects the remaining vision quality. This does not rule out, in rare cases of very early and stable maculopathy, an individualised discussion, always guided by OCT.

Macular OCT, the examination that decides

The OCT (optical coherence tomography) is a quick, contactless and well-tolerated examination that photographs the layers of the retina in cross-section. It detects macular abnormalities invisible on a simple examination: drusen, oedema, membrane, early atrophy. Before any premium lens project, macular OCT is essential. It is what objectively measures the real visual reserve and guides the choice of lens.

And if I have glaucoma: is a multifocal lens possible?

With glaucoma, the decision depends above all on the stage and on the involvement of the visual field. The systematic review by Hong et al. (PMID 37760095) identifies, among the unfavourable selection factors, advanced glaucoma, a central visual field defect and unstable progression. Early, well-controlled and stable glaucoma does not necessarily close the door, but advanced glaucoma calls for caution.

Glaucoma damages the optic nerve and, with it, the transmission of the visual signal to the brain. Like AMD on the retinal side, it reduces the available contrast margin, but through a different mechanism. Adding a multifocal lens, which lowers contrast further, on an already damaged optic nerve exposes the patient to visual disappointment. The different types of glaucoma do not, moreover, have the same impact.

One practical point deserves mention. Glaucoma monitoring relies largely on optic nerve OCT and on the visual field. Yet some premium lenses and the change in vision they induce can complicate the interpretation of these follow-up examinations. This is an additional argument, raised in the literature on screening examinations, in favour of a simple optic in the glaucoma patient who will need lifelong monitoring.

Here again, the conclusion is not an automatic “no”, but a hierarchy. Advanced glaucoma or central visual field involvement: monofocal strongly preferred. Early, stable glaucoma with only peripheral involvement: a discussion is possible, case by case, weighing the expected benefit against the risk of discomfort.

Monofocal, EDOF or multifocal: which lens when there is a coexisting condition?

The choice is ranked according to the health of the macula and the optic nerve. The American Academy of Ophthalmology guidelines (PMID 34780842) stress individualised patient selection: premium lenses assume realistic expectations and a functional retina. When a significant ocular coexisting condition is present, the AAO advises favouring optics that preserve contrast.

The EDOF lens (extended depth of focus) occupies an intermediate position. Its profile of night halos and contrast loss is generally slightly more favourable than that of the trifocal, which explains the interest in it. But it too splits the light and requires a healthy macula: it is not a workaround for AMD. We detail this point in our article on night halos after an EDOF lens.

The table below summarises the trade-offs. It is not a prescription: your situation is judged on your examinations, not on a general grid.

Note the last row: whichever lens is chosen, astigmatism is corrected with a toric version. So a patient with astigmatism and AMD typically receives a toric monofocal lens: sharp, corrected distance vision, without the contrast trade-off of the multifocal.

The monofocal lens is not a consolation prize

It must be said plainly: choosing a monofocal lens when a coexisting condition is present does not mean giving up good vision. It means regaining sharp distance vision and preserved contrast, which, for an already fragile eye, often represents the most reliable comfort in daily life. Reading glasses are not a failure but a simple and reliable tool. This logic also applies to patients without any coexisting condition who are hesitating, as explained on our page dedicated to the multifocal lens and glasses after 60.

How is the decision made, and where does surgery take place?

The decision is made at the pre-operative assessment, never by default. The AAO guidelines (PMID 34780842) establish patient selection as the decisive step in the success of a premium lens. In practice, this means a full examination of the retina and optic nerve, a measure of your expectations, and an honest explanation of the trade-offs before any commitment.

The pre-operative assessment systematically includes a macular OCT and, if necessary, an assessment of the optic nerve and visual field. These examinations answer a simple question: does your eye have the contrast reserve needed to benefit from a premium lens without suffering its drawbacks? The answer guides the choice, in full transparency with you.

On a practical level, cataract surgery and the placement of the lens, whatever it may be, take place at the Clinique Sainte-Geneviève (Paris 14). Assessments and follow-up take place at the practice, in Cachan or in Paris 13. This arrangement makes it possible to prepare the decision calmly in consultation, then to carry out the procedure in a dedicated surgical setting.

IN PRACTICE

What you can keep in mind before your consultation: bring your OCT and visual field reports if you have them, and come with your questions. The right decision is not the one that promises the most freedom from glasses, but the one that protects your vision over time. A premium lens poorly placed in the wrong candidate creates lasting discomfort; a well-indicated monofocal offers solid comfort.

Sources

• Grzybowski A et al. “Multifocal intraocular lenses and retinal diseases”, Graefes Arch Clin Exp Ophthalmol, 2020. PMID 31955239
• American Academy of Ophthalmology (AAO). “Cataract in the Adult Eye Preferred Practice Pattern”, Ophthalmology, 2022. PMID 34780842
• Hong ASY et al. “Premium Intraocular Lenses in Glaucoma — A Systematic Review”, Bioengineering (Basel), 2023. PMID 37760095