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Essentials in Ophthalmology
Series Editor: Arun D. Singh

Jorge L. Alió
Joseph Pikkel Editors

Multifocal
Intraocular
Lenses
The Art and the Practice
Second Edition
Essentials in Ophthalmology

Series Editor
Arun D. Singh

More information about this series at http://www.springer.com/series/5332

Jorge L. Alió • Joseph Pikkel
Editors

Multifocal Intraocular
Lenses
The Art and the Practice

Second Edition
Editors
Jorge L. Alió Joseph Pikkel
Research & Development Department Department of Ophthalmology
and Department of Cornea Assuta Samson Hospital
Cataract, and Refractive Surgery Ashdod
VISSUM Corporation and Miguel Israel
Hernández University
Alicante Ben Gurion University
Spain School of Medicine
Beer-Sheva
Israel

ISSN 1612-3212     ISSN 2196-890X (electronic)

Essentials in Ophthalmology
ISBN 978-3-030-21281-0    ISBN 978-3-030-21282-7 (eBook)
https://doi.org/10.1007/978-3-030-21282-7

© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To our dear wives and children who follow us along the routes
of medicine, encourage, and support us – the reason for all that
we do and the joy of our lives, and to our patients from whom
we have received the inspiration and expertise to build up the
second edition of this book.
Jorge L. Alió and Joseph Pikkel
Alicante (Spain)/Safed (Israel)
Fall 2019
Preface

In our modern world, now on the first quarter of the twenty-first century,
medicine faces, more than ever before, the challenge of not only fighting
diseases and saving lives but also improving quality of life. While life expec-
tancy rises, patients’ activities remain at the same level that they were used to
being young and hence their visual demands keep being high. While in previ-
ous decades older people tended to lessen their activity, nowadays older peo-
ple do not reduce daily activities as driving, sport activities, and various
hobbies that require good visual acuity to different distances and are more
convenient if multifocality exists.
This evolution derived – among other things – new techniques and new
approaches of cataract surgery. The evolution of cataract surgery and IOL
implantation during the last decade has been, not surprisingly, focused on
improving the quality of vision and the quality of life of our patients.
Near vision and intermediate vision have been identified as one of the
reasons by which quality of life is really acknowledged by our patients.
Another trend in recent years is the tendency to operate younger patients than
before with better visual acuities, even with mild cataracts, which means that
patients are less tolerant to visual disabilities, and moreover the advances in
refractive surgery have educated them in their request for spectacle indepen-
dence. While usually we succeed in achieving good far vision without spec-
tacles or contact lenses, optimal multifocality for far, intermediate, and near
vision is still a challenge to be met.
Since multifocal lenses, by definition, divide light into different foci, using
multifocal intraocular lenses causes a dispersion of the energy of light enter-
ing into the eye and, consequently, distributing the light in different foci. This
causes a change in distribution of light and images at the level of the visual
function at the level of the retina. This is the reason why neuroadaptation,
which means the capability of the brain to adapt to changes, is necessary to
adjust neurophysiology to the changes that are induced in the quality of the
retinal image by dispersion of light. Moreover, the overlapping of different
foci is neither physiological nor normal in the human or animal evolution. To
the best of our knowledge, no visual system is multifocal in nature and it has
not existed in the human being throughout evolution. For this reason, neuro-
processing is the main challenge of multifocal intraocular lenses. The new
technologies emerging in recent years have aimed at smoothing the changes
in visual perception and to make a much more physiological division of light,

vii
viii Preface

but even in these conditions, their effectivity has to be demonstrated and con-
firmed by an improvement in the subjective quality of vision of the patient.
About four years ago we published the first edition of this book which was
welcomed by many ophthalmologists around the world. In recent years, a
tremendous advance in the field of multifocal intraocular has been made. In
this second edition, we bring the updated information on multifocal intraocu-
lar lenses techniques and about lenses available in the market today as well as
our personal experience on the subject. The main aims of this book are how
the practical ophthalmologist and ophthalmic surgeon can select an adequate
multifocal intraocular lens, how to differentiate them among the different
technologies, how to identify the best on the market, and how to use evidence
in favor of the selection of the best for the benefit of the patients.
We hope that the reader will find this book useful for the purpose for which
it was created, independent opinion, information, and credibility, and also
unbiased information on the subject of multifocal intraocular lenses, which is
constantly progressing and takes more and more part in our daily clinical
practice. If we achieve this goal, the time and work dedicated to this book will
be worthy.

Alicante, Spain Jorge L. Alió

Ashdod, Israel Joseph Pikkel
Contents

1 Multifocal Intraocular Lenses: What Do They Offer Today?������   1

Jorge L. Alió and Joseph Pikkel

Part I Historical Background and Clinical Indications

2 Multifocal Intraocular Lenses: Historical Perspective����������������   9

Kenneth J. Hoffer and Giacomo Savini
3 Multifocal Intraocular Lenses: Basic Principles �������������������������� 31
Vicente J. Camps, Juan J. Miret, María T. Caballero,
David P. Piñero, and Celia García
4 Multifocal Intraocular Lenses: Preoperative
Considerations���������������������������������������������������������������������������������� 43
Jorge L. Alió and Joseph Pikkel
5 Multifocal Intraocular Lenses: Neuroadaptation ������������������������ 53
Jorge L. Alió and Joseph Pikkel
6 Multifocal Intraocular Lenses: Considerations
in Special Cases�������������������������������������������������������������������������������� 61
Jorge L. Alió and Joseph Pikkel
7 Multifocal Intraocular Lenses and Corneal Refractive
Surgery���������������������������������������������������������������������������������������������� 67
Jorge L. Alió and Joseph Pikkel
8 Multifocal Intraocular Lenses: Complications����������������������������� 73
Roberto Fernández Buenaga and Jorge L. Alió
9 Multifocal Intraocular Lenses: Postimplantation Residual
Refractive Error������������������������������������������������������������������������������ 93
Maja Bohac, Ante Barisic, Sudi Patel, and Nikica Gabric
10 Multifocal Intraocular Lenses: Solutions
for the Unhappy Patient������������������������������������������������������������������ 103
Richard B. S. Packard
11 Multifocal Intraocular Lenses: Neuroadaptation Failure
Corrected by Exchanging with a Different Multifocal
Intraocular Lens������������������������������������������������������������������������������ 111
Olena Al-Shymali and Jorge L. Alió

ix
x Contents

Part II Multifocal Intraocular Lenses: Types and Models

12 Multifocal Intraocular Lenses: Types and Models ���������������������� 123

Michael Mimouni and Jorge L. Alió

Part III The Zeiss Family Multifocal IOLs

13 Multifocal Intraocular Lenses: AT LISA tri 839 MP ������������������ 177

Peter Mojzis, David Pablo Piñero, and Jorge L. Alió
14 Multifocal Intraocular Lenses: AT LISA Tri
Toric 939 M/MP ������������������������������������������������������������������������������ 193
Peter Mojzis
15 Multifocal Intraocular Lenses: AT LISA 809 Diffractive
Bifocal Intraocular Lens������������������������������������������������������������������ 207
Ana B. Plaza-Puche and Jorge L. Alió
16 Multifocal Intraocular Lenses: The Hanita Family
of Lenses�������������������������������������������������������������������������������������������� 213
Jorge L. Alió, Alfredo Vega-Estrada, and Ana B. Plaza-Puche
17 Multifocal Intraocular Lenses: The Acriva Family
of Lenses�������������������������������������������������������������������������������������������� 221
Minoru Tomita

Part IV The Alcon Family Multifocal IOLs

18 Multifocal Intraocular Lenses: AcrySof ReSTOR®

SN6AD2 + 2.5 D Lens���������������������������������������������������������������������� 231
Rodolfo Mastropasqua, Francesco Aiello, Emilio Pedrotti,
and Giorgio Marchini
19 Multifocal Intraocular Lenses: AcrySof ReSTOR
SN6AD1 Lens ���������������������������������������������������������������������������������� 237
Ana B. Plaza-Puche and Jorge L. Alió
20 Multifocal Intraocular Lenses: AcrySof IQ PanOptix
Trifocal Lens������������������������������������������������������������������������������������ 243
Ana B. Plaza-Puche and Jorge L. Alió
21 Multifocal Intraocular Lenses: The Johnson and Johnson
Family of Lenses������������������������������������������������������������������������������ 249
Béatrice Cochener-Lamard
22 Multifocal Intraocular Lenses: FineVision (PhysIOL)
Lens �������������������������������������������������������������������������������������������������� 275
Verónica Vargas and Jorge L. Alió
23 Multifocal Intraocular Lenses: Fyodorov Gradiol������������������������ 279
Boris Malyugin, Tatiana Morozova, and Valentin Cherednik
Contents xi

24 Multifocal Intraocular Lenses: Sector Rotational

Asymmetrical Refractive Lenses���������������������������������������������������� 309
Ana B. Plaza-Puche, Verónica Vargas, and Jorge L. Alió
25 Multifocal Intraocular Lenses: The Rayner Family
of Lenses�������������������������������������������������������������������������������������������� 323
Abison Logeswaran, Bita Manzouri, and Charles Claoué

Part V Extended Depth of Field IOLs

26 Extended Depth-of-Field Intraocular Lenses�������������������������������� 335

Jorge L. Alió, Andrzej Grzybowski, and Piotr Kanclerz
27 Extended Depth of Field Intraocular Lenses: Mini Well
Ready Lens �������������������������������������������������������������������������������������� 345
David Pablo Piñero, Jorge L. Alió del Barrio,
and Vicente J. Camps

Part VI Accommodative IOLs

28 Accommodative Intraocular Lenses���������������������������������������������� 355

Alfredo Vega-Estrada, Jorge L. Alió del Barrio,
and Jorge L. Alió
29 Accommodative Intraocular Lenses: Crystalens�������������������������� 367
Caleb Morris, Mujtaba A. Qazi, and Jay S. Pepose
Index���������������������������������������������������������������������������������������������������������� 375
Contributors

Francesco Aiello, MD, PhD, FEBO, FEBOS-CR University of Rome “Tor

Vergata,” Experimental Medicine, Rome, Italy
Jorge L. Alió, MD, PhD Research & Development Department and
Department of Cornea, Cataract, and Refractive Surgery, VISSUM
Corporation and Miguel Hernández University, Alicante, Spain
Jorge L. Alió del Barrio, MD, PhD, FEBOS-CR Department of Cornea,
Cataract and Refractive Surgery, Vissum Corporation, Alicante, Spain
Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
Olena Al-Shymali, MD Research & Development Department and
Department of Corena, Cataract, and Refractive Surgery, VISSUM
Corporation and Miguel Hernandez University, Alicante, Spain
Ante Barisic, MD Cataract Department, Specialty Eye Hospital Svjetlost,
School of Medicine University of Rijeka, Zagreb, Croatia
Maja Bohac, MD, PhD Department of Cornea and Refractive Surgery,
Specialty Eye Hospital Svjetlost, School of Medicine University of Rijeka,
Zagreb, Croatia
Roberto Fernández Buenaga, MD, PhD Department of Cornea, Cataracts
and Refractive Surgery, Vissum Corporation, Madrid, Spain
María T. Caballero, PhD Department of Optics, Pharmacology and
Anatomy, University of Alicante, Alicante, Spain
Vicente J. Camps, PhD Grupo de Óptica y Percepción Visual (GOPV),
Department of Optics, Pharmacology and Anatomy, University of Alicante,
Alicante, Spain
Valentin Cherednik, PhD Lobachevsky State University, Nizhny Novgorod,
Russia
Charles Claoué, MD, DO, FRCS, FRCOphth, FEBO Department of
Ophthalmology, London, UK
Béatrice Cochener-Lamard, MD, PhD BREST University Hospital, Brest,
France

xiii
xiv Contributors

Nikica Gabric, MD, PhD Department of Cornea and Refractive Surgery,

Specialty Eye Hospital Svjetlost, School of Medicine University of Rijeka,
Zagreb, Croatia
Celia García, PhD Department of Optics, Pharmacology and Anatomy,
University of Alicante, Alicante, Spain
Andrzej Grzybowski, MD, PhD Department of Ophthalmology, University
of Warmia and Mazury, Olsztyn, Warminsko-Mazurskie, Poland
Institute for Research in Ophthalmology, Foundation for Ophthalmology
Development, Poznan, Poland
Kenneth J. Hoffer, MD, FACS Stein Eye Institute, University of California,
Los Angeles, CA, USA
St. Mary’s Eye Center, Santa Monica, CA, USA
Piotr Kanclerz, MD, PhD Hygeia Clinic, Gdańsk, Poland
Abison Logeswaran, MBBS, BSc, MSc Department of Ophthalmology,
Barking, Havering and Redbridge University Hospitals, Romford, Essex, UK
Boris Malyugin, MD, PhD Department of Cataract and Implant Surgery,
S. Fyodorov Eye Microsurgery Institution, Moscow, Russia
Bita Manzouri, MBBS, MRCP, FRCOphth, PhD Department of
Ophthalmology, Barking, Havering and Redbridge University Hospitals,
Romford, Essex, UK
Giorgio Marchini, MD Department of Neurosciences, Biomedicine and
Movement Sciences, University of Verona, Verona, Italy
Rodolfo Mastropasqua, MD, FEBO Department of Neurosciences,
Biomedicine and Movement Sciences, University of Verona, Verona, Italy
Department of Neuroscience, Polytechnic University of Marche, Ancona,
Italy
Michael Mimouni, MD Department of Ophthalmology, Rambam Health
Care Campus, Haifa, Israel
Juan J. Miret, PhD Department of Optics, Pharmacology and Anatomy,
University of Alicante, Alicante, Spain
Peter Mojzis, MD, PhD, FEBO Department of Ophthalmology, Premium
Clinic Teplice, Teplice, Czech Republic
Tatiana Morozova, MD, PhD Ophthalmology, Institute of Biomedical
Problems (BMP), the State Scientific Center of the Russian Federation,
Moscow, Russia
Caleb Morris Pepose Vision Institute, Chesterfield, MO, USA
Richard B. S. Packard, MD, DO, FRCS, FRCOphth Optegra Eye
Hospital, Arnott Eye Associates, London, UK
Contributors xv

Sudi Patel, PhD Specialty Eye Hospital Svjetlost, School of Medicine

University of Rijeka, Zagreb, Croatia
Emilio Pedrotti, MD Department of Neurosciences, Biomedicine and
Movement Sciences, University of Verona, Verona, Italy
Jay S. Pepose, MD, PhD Pepose Vision Institute, Chesterfield, MO, USA
Department of Ophthalmology and Visual Sciences, Washington University
School of Medicine, St. Louis, MO, USA
Joseph Pikkel, MD Department of Ophthalmology, Assuta Samson
Hospital, Ashdod, Israel
Ben Gurion University, School of Medicine, Beer-Sheva, Israel
David Pablo Piñero, PhD Grupo de Óptica y Percepción Visual (GOPV),
Department of Optics, Pharmacology and Anatomy, University of Alicante,
Alicante, Spain
Ana B. Plaza-Puche, MsC, PhD Vissum Corporation, Alicante, Spain
Mujtaba A. Qazi, MD Pepose Vision Institute, Chesterfield, MO, USA
Department of Ophthalmology and Visual Sciences, Washington University
School of Medicine, St. Louis, MO, USA
Giacomo Savini, MD Studio Oculistico d’Azeglio, Bologna, Italy
Minoru Tomita, MD, PhD Tomita Minoru Eye Clinic Ginza, Ginza,
Chuoku, Tokyo, Japan
Verónica Vargas, MD Department of Research, Development and
Innovation at Vissum Instituto Oftalmológico, Alicante, Spain
Alfredo Vega-Estrada, MD, PhD Cornea, Cataract and Refractive Surgery
Department, VISSUM, Alicante, Spain
Research & Development Department, VISSUM, Alicante, Spain
Division of Ophthalmology, School of Medicine, Universidad Miguel
Hernández, Alicante, Spain
 Multifocal Intraocular Lenses:
What Do They Offer Today?
1
Jorge L. Alió and Joseph Pikkel

When considering the latest innovations in oph- describe the current technologies and advances of
thalmology, there is no doubt that one of the lead- multifocal intra ocular lenses.
ing fields is multifocal intraocular lenses. The
quest of patients to be free from wearing glass or
using contact lenses meets the elongation of life 1.1  ow Can We Gain
H
expectancy as well as older people being more Multifocality in Lenses?
active than in previous years, with the improve-
ment of optical technologies and new inventions, A multifocal intraocular lens must incorporate
which results in a constant improvement of mul- some mechanism to focus light from distant
tifocal intraocular lenses. These new lenses and objects and light from near objects at the same
new technologies open a wide variety of solu- time. A redistribution of the light energy will hap-
tions for those who seek to get rid of visual aids pen, with no single focus receiving all the energy
as spectacles or contact lenses. Though a great as it happens in normal physiological accommo-
advancement has been made in recent years in dation. Unlike spectacle multifocal lenses, the
multifocal intraocular lenses designs and pro- multifocal intraocular lens refracts (or diffracts)
duction, there is still no perfect solution for all light from any object for both near and distance
distances, and there is still a lot to be achieved. vision at the same time. Thus there must always
Accommodative lenses might be a solution, and be some light that is not in focus with the light
this fascinating issue will be described and dis- that is in focus. For distant objects, for example,
cussed later in this book. In this chapter, we will the “add lens” steals some of the light that would
have been focused and instead distributes rela-
tively defocused light onto the retina, decreasing
J. L. Alió (*) image contrast and reducing contrast sensitivity.
Research & Development Department and Multifocal intraocular lenses can obtain multi-
Department of Cornea, Cataract, and Refractive
Surgery, VISSUM Corporation and Miguel focality in different ways:
Hernández University, Alicante, Spain
e-mail: [email protected] 1. A combination of two or more different ante-
J. Pikkel rior spherical refractive surfaces for distance
Department of Ophthalmology, Assuta Samson and near correction such as a combination of
Hospital, Ashdod, Israel an anterior spherical and an anterior aspheric
Ben Gurion University, School of Medicine, refractive surface for distance and near
Beer-Sheva, Israel correction
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 1

J. L. Alió, J. Pikkel (eds.), Multifocal Intraocular Lenses, Essentials in Ophthalmology,
https://doi.org/10.1007/978-3-030-21282-7_1
2 J. L. Alió and J. Pikkel

2. A combination of a posterior spherical refrac- Limitations of refractive multifocal intraocu-

tive surface and multiple anterior aspheric lar lenses are:
refractive surfaces
3. A combination of an anterior spherical refrac- 1. Pupil dependence design
tive surface and multiple posterior diffractive 2. High sensitivity for lens centration
structured surfaces for distance and near 3. Intolerance to kappa angle which varies from
correction patient to patient
4. A biconvex lens with longitudinal aberrations 4. Potential for halos and glare due to more non-­
on the anterior surface (making it aspheric), transition area—rough area between the
providing near vision through the center of the zones.
lens, distance vision through the periphery, 5. Loss of contrast sensitivity
and intermediate vision in between
The refractive models reach multifocality by
Intraocular multifocal lenses can be refrac- their different refractive power annular zones
tive, diffractive or of a combined design. and usually provide proper far and intermedi-
Refractive lenses use only differing areas of ate vision; however, sometimes, near vision
refractive power to achieve their multifocality. is not sufficient. They are dependent of pupil
They function by providing annular zones of dynamics, very sensitive to their centering, may
different refractive power to provide an appro- cause halos and glare, and reduce the contrast
priate focus for objects near and far. Refractive sensitivity [1]. In addition, some refractive
bifocal/multifocal IOLs may be affected by designs include a continuous change in curva-
pupil size and decentration, to a greater or ture between zones providing functional vision
lesser degree depending on the size, location, across all distances [2].
and number of refractive zones. The wavefront Diffractive lenses are based on the principle
produced from the refractive lens is non-spheri- that every point of a wavefront can be thought
cal, i.e., it does not have a focus. In these lenses of as being its own source of secondary so-
the inner zone is powered for distance and outer called wavelets, subsequently spreading in a
zone is powered for intermediate vision. The spherical distribution (Huygens-Fresnel prin-
middle zone has an add zone for near vision ciple). The amplitude of the optic field beyond
(Fig. 1.1). this point is simply the sum of all these wave-
The refractive multifocal lens implant pro- lets. When a portion of a wavefront encounters
vides excellent intermediate and distance vision. an obstacle, a region of the wavefront is altered
The near vision is typically adequate but may not in amplitude or phase, and the various seg-
be sufficient to see very small print. ments of the wavefront that propagate beyond

Fig. 1.1 Refractive lens

design: the outer zone
concentrates light rays
from the intermediate
distance (black arrows),
the medial zone
concentrates light rays
from the near distance
(red arrows), and the
inner zone concentrates
light rays from the far
distance (green arrows)
1 Multifocal Intraocular Lenses: What Do They Offer Today? 3

Fig. 1.2 The principle

of a diffractive lens:
light travels slower on
the side of the step of
the lens compared to the
speed of light that moves
through the aqueous
resulting in producing
two foci, one for near
vision and one for far
vision

the obstacle interfere and cause a diffractive later on this book, are trying to provide interme-
pattern. As the spacing between the diffractive diate vision by a redistribution of the diffracted
elements decreases, the spread in the diffrac- light to other foci.
tive pattern increases. By placing the diffrac- The diffractive models are composed by dif-
tive microstructures in concentric zones and fractive microstructures in concentric zones that
decreasing the distance between the zones as get closer to each other as they distance from
they get further from the center, a so-called the center. They generally provide good far and
Fresnel zone plate is produced that can produce near vision, but the intermediate vision may not
optic foci. Thus the distance power is the com- be satisfactory in some cases. They are not so
bined optic power of the anterior and posterior dependent of pupil dynamics and more tolerant
lens surfaces and the zero order of diffraction, to their centering, but they usually affect the con-
whereas the near power is the combined power trast sensitivity in a greater scale [4]. Although
of the anterior and posterior surfaces and the contrast sensitivity in patients with multifocal
first order of diffraction (Fig. 1.2). IOLs is diminished compared with those with
The diffractive multifocal lens implant pro- monofocal IOLs, it is usually within the normal
vides excellent reading vision and very good range of contrast [3].
distance vision. The intermediate vision is
acceptable but not excellent as the far and near
vision. However, multifocal diffractive intraocu- 1.2  DOF: Extended Depth
E
lar lenses are less pupil size defendant and are of Focus
more tolerant to differences of kappa angle.
Bifocal diffractive multifocal lenses only Extended depth of focus (EDOF), or extended
provide two focus points—far and near—and range of vision, is a new technology in the treat-
no intermediate foci; they have a high potential ment of presbyopia-correcting intraocular lenses.
of producing halos and glare due to more non-­ In contrast to multifocal intraocular lenses used in
transition area; and since they cause an equal the treatment of presbyopia, EDOF lenses work
distribution of light for both foci, they cause by creating a single elongated focal point rather
18% loss of light in transaction. These disadvan- than several focal points, to enhance depth of
tages may decrease quality of vision especially focus. The aim of these lenses is to reduce aber-
in mesopic and scotopic conditions when more rations, glare and halos, that are caused by the
zones affect the incoming light rays to the retina. exciting multifocal intraocular lenses (Fig. 1.3).
The modern trifocal diffractive IOLs, provided The SYMPHONY lens uses the described
by different mechanisms that will be explained technic to create EDOF; however, there are other
4 J. L. Alió and J. Pikkel

Fig. 1.3 EDOF lens Light Ray

design

Elongated Focus

Focal distance

technologies that can be applied to enhance the Continuous Focus (WIOL-CF) (Medicem, Czech
range of vision without splitting light. Small Republic). This lens is a one-piece polyfocal
aperture designs and bioanalogic intraocular hyperbolic optics with no haptic elements. It is
lenses can also enhance the depth of focus. In a made from a biocompatible hydrogel 42% water
“nut shell,” there are three groups of design that hydrogel and mimics the properties of a natural
can enhance EDO: crystalline lens with a refractive index 1.43. The
lens enables a continuous range of focus.
• Lenses that use a pinhole effect Since it is not an accommodative lens, the
• Bioanalogic lenses lens has several zones that create different foci,
• Echelette technology lenses the refractive power is maximal in the center
and continuously decreases without steps to the
periphery. Observational studies indicated excel-
1.2.1 “Pinhole Lenses” lent visual acuity for far and intermediate vision
and reasonably good near vision with minimal
Lenses that use a pinhole effect are actually small optical phenomena [4].
lenses design like the IC-8 (AcuFocus, Inc., Irvine,
CA) and the KAMRA corneal inlay (Acu-­Focus,
Inc.). These lenses are made with an embedded 1.2.3 Echelette Technology Lenses
opaque annular mask measuring 3.23 mm in total
diameter that blocks unfocused paracentral lightThis technic is actually used in the Symphony
lens and is based on a design that forms a step
rays while allowing paraxial light rays through its
structure whose modification of height, spacing,
1.36-mm central aperture. Actually, this creates a
pinhole effect that produces an elongated focal and profile of the echelette extends the depth of
range resulting in an extended and continuous focus. These designs in combination with achro-
range of functional vision. matic technology and negative spherical aberra-
The “pinhole lenses“like the IC-8 model tion correction improve simulated retinal image
may be suitable for post-refractive presbyopia, quality without compromising depth of field or
irregular corneas, and monofocal pseudophakic tolerance to decentration [5].
patients. The first intraocular lens that was approved by
the FDA was the TECNIS Symphony IOL (Abbott
Medical Optics, Inc. of Santa Ana, California).
1.2.2 Bioanalogic Intraocular This is a biconvex wavefront-­designed anterior
Lenses aspheric surface and a posterior achromatic dif-
fractive surface with an echelette design. The
These lenses use different materials that mimic lens creates an achromatic diffractive pattern that
the properties of the natural young crystalline elongates a single focal point and compensates
lens. Such is the Wichterle Intraocular Lens-­ for the chromatic aberration of the cornea.
1 Multifocal Intraocular Lenses: What Do They Offer Today? 5

Overall, patients experience less glare and multifocality to all distances far intermediate and
halos with EDOF lenses; however, there is a need near is reachable and might be available to use in
of improving the near vision since the EDOF the near future.
lenses are good for far and intermediate range
and are less satisfactory for near-range vision. Compliance with Ethical Requirements Jorge L. Alió
One of the ways to compensate for the and Joseph Pikkel declare that they have no conflict of
interest. No human or animal studies were carried out by
decrease in near vision in patients with EDOF the authors for this article.
lenses is the mini-mono vision, or mix-and-
match strategies with diffractive low-add lenses
should be considered; however, using the mini- References
mono vision may cause decrease in far vision
and additional halos from the low myopia in the 1. Rosen E, Alió JL, Dick HB, Dell S, Slade S. Efficacy
contralateral eye [6]. and safety of multifocal intraocular lenses following
In any technique that is used to provide multi- cataract and refractive lens exchange: Metaanalysis of
peer-reviewed publications. J Cataract Refract Surg.
focality, the best visual result depends on patient 2016;42(2):310–28.
selection, accurate biometry, astigmatism correc- 2. Alió JL, Plaza-Puche AB, Fernandez-Buenaga R,
tion, and lens centration. These issues as well as Pikkel J, Maldonado M. Multifocal intraocular
others will be discussed in the next chapters of lenses: an overview on the technology, indications,
outcomes, complications and their management. Surv
this book; a pedantic preoperative approach is Ophthalmol. 2017;62(5):611–34.
necessary in order to succeed in multifocal intra- 3. Cochener B, Lafuma A, Khoshnood B, Courouve L,
ocular lenses implant and eventually causing the Berdeaux G. Comparison of outcomes with multifocal
patients to be happy [7]. intraocular lenses: a meta-analysis. Clin Ophthalmol.
2011;5:45–56.
Though, as said before, there is not a perfect 4. Studeny P, Krizova D, Urminsky J. Clinical experi-
solution yet for good vision in all distances, most ence with the WIOL-CF accommodative bioanalogic
of the patients who had a multifocal intraocular intraocular lens: Czech national observational regis-
lens implant are happy and satisfied with the out- try. Eur J Ophthalmol. 2016;26:230–5.
5. Pedrotti E, Bruni E, Bonacci E, Badalamenti R,
come. A recent meta-analysis of peer-reviewed Mastropasqua R, Marchini G. Comparative analysis
publications revealed evidence of high levels of of the clinical outcomes with a monofocal and an
patient’s satisfaction in general. The spectacle extended range of vision intraocular lens. J Refract
independence was 80% or more in 91.6% for Surg. 2016;32:436–42.
6. Cochener B, Concerto Study Group. Clinical out-
distance vision, 100% for intermediate vision, comes of a new extended range of vision intraocu-
and 70% for near vision in the different groups lar lens: international multi-center concerto study. J
studied. The binocular uncorrected vision of 0.30 Cataract Refract Surg. 2016;42:1268–75.
log MAR was achieved in 100% for distance 7. Salerno LC, Tiveron MC Jr, Alio JL. Multifocal
intraocular lenses: types, outcomes, complica-
visual acuity, 96% for intermediate visual acuity, tions and how to solve them. Taiwan J Ophthalmol.
and 97.3% for near visual acuity of the patients 2017;7(4):179–84.
included in the study [8, 9]. 8. Alio JL, Plaza-Puche AB, Javaloy J, Ayala MJ,
So as described multifocal intraocular lenses Moreno LJ, Piñero DP. Comparison of a new refrac-
tive multifocal intraocular lens with an inferior
do provide a good (not perfect) solution for segmental near add and a diffractive multifocal intra-
patients who want to be spectacles free after cata- ocular lens. Ophthalmology. 2012;119:555–63.
ract surgeries. More important is the fact that new 9. de Vries NE, Nuijts RM. Multifocal intraocu-
techniques and new approaches are constantly lar lenses in cataract surgery: literature review of
benefits and side effects. J Cataract Refract Surg.
invented giving us the feeling that the goal of 2013;39(2):268–78.
 Part I
Historical Background and Clinical
Indications
 Multifocal Intraocular Lenses:
Historical Perspective
2
Kenneth J. Hoffer and Giacomo Savini

2.1 Introduction left eye since she was 3 days PO with sutures still
in. She corrected to 20/20 OD and 20/25
Our patients teach us many things [1]. Often it is OS. Since so much of the pupil was aphakic, out
humility, but on rare occasions, their clinical situ- of curiosity, I then refracted each eye in an apha-
ation can spark an idea that leads to analytical kic refraction range of about +10 diopters (D)
thinking and a totally new concept. Such a patient and was astounded that she was also refractable
appeared in my office over three decades ago on to a 20/20 level with a full aphakic refraction. I
November 18, 1982 (Fig. 2.1). She was referred couldn’t understand how this was possible?
to me by a colleague, John Hofbauer MD, for the Then I questioned this 65-year-old educated
necessity of IOL removal due to bilateral IOL and intelligent lady regarding glare, halos, rings,
dislocation. She had received a Shearing style and areas of blurred vision and she denied having
Iolab Hoffer Ridge posterior chamber intraocular any of these symptoms. I was astounded at how
lens (IOL) in each eye, and the implants had each unaffected she was by the dislocated lenses. I told
decentered so that one covered only 50% of the her that her eyes were perfect and sent her on her
pupil OD (right eye) and the other only one-third way. I told the referring surgeon that no interven-
of the pupil OS (left eye) (see hand-drawn dia- tion was necessary at least at this time.
grams in Fig. 2.1). In those days it was more dif-
ficult to get both stiff loops of the shearing lens in
the bag resulting in one loop out of the bag caus- 2.2 Inception of the Concept
ing decentration. I was evaluating her situation to
determine whether one or both of these IOLs That evening while enjoying a Guinness at Ye
should be removed. Olde King’s Head in Santa Monica with col-
After personally refracting each eye at dis- leagues, this lady’s remarkable condition kept
tance and near, there was a high cylinder in the haunting me. How could her distance vision be
20/20 with and without aphakic correction while
she was receiving only 50% of the IOL refracted
K. J. Hoffer (*) light (only 33% in the other eye) without aphakic
Stein Eye Institute, University of California, refractive aid and 20/20 while receiving 50%
Los Angeles, CA, USA
(66% in the other eye) of non-IOL refracted light.
St. Mary’s Eye Center, Santa Monica, CA, USA I analyzed the situation making the assumption
e-mail: [email protected]
that light was entering her pupils and being
G. Savini refracted by two different “lenses”
Studio Oculistico d’Azeglio, Bologna, Italy

© Springer Nature Switzerland AG 2019 9

J. L. Alió, J. Pikkel (eds.), Multifocal Intraocular Lenses, Essentials in Ophthalmology,
https://doi.org/10.1007/978-3-030-21282-7_2
10 K. J. Hoffer and G. Savini

Fig. 2.1 Patient

examination record from
November 18, 1982,
showing drawings of
dislocated posterior
chamber lenses; the left
eye is 3 days
postoperative

s­ imultaneously; one lens had a power of 20 D and

the other was 0 D. If this assumption was true,
then it had to follow that each “lens” (the 20 D
and the 0 D) was creating its own image superim-
posed on the macula simultaneously. The 20 D
lens created a perfectly focused image on the
Fig. 2.2 Depiction of the focal points of a split bifocal
macula with the percentage of light it received
and the 0 D “lens” created a hyperopic blurred
image superimposed on the focused image with and their response was, “You must be crazy.”
(Fig. 2.2). From this I deduced that the retina- Their lack of enthusiasm dampened my excite-
brain had to be ignoring the blurred image com- ment but I finally concluded the concept should at
pletely, thereby accepting only the clear image least be tried. In November 1982 there was sim-
she wanted to see. If this were not the case, she ply no such thing as a bifocal IOL. I realized that
would have complained of some annoying visual animal studies were completely out of the ques-
symptoms. With the aphakic correction, the tion because of the inability to get any feedback
opposite was true; the 0 D “lens” image was now from them. Optical bench testing would also not
in clear focus and the 20 D lens image was com- answer the question of brain suppression. I hast-
pletely blurred and thus the aphakic image was ily concluded that a human trial was the only way
chosen by the brain and the other ignored. to find out if my theory would work at all, and if
Then, after my second Guinness, it dawned on it did, whether it worked for everyone or only a
me that her pupil was actually holding a BIFOCAL select few. I could not do this alone. I needed an
lens! I then wondered, since she could tolerate a IOL manufacturer to fabricate the lens, if it was at
20.0 D difference in the two segments of this all possible. From my decade of experience with
“bifocal,” could she have tolerated a 3 D differ- IOL manufacturers, I knew they would be more
ence. I then proposed this to the colleagues I was receptive and feel more comfortable entertaining
2 Multifocal Intraocular Lenses: Historical Perspective 11

this possibility if the concept had patent protec- theorized that the reason the bifocal IOL might
tion prior to their spending time and money on a work in a posterior chamber IOL better than it
new lens design. does in a contact lens was because the former is
fixed and stationary and, more importantly, that it
is located at the eye’s nodal point rather than on
2.3 Intellectual Property the front of the eye. I also considered and sketched
Protection as many possible configurations and combination
of ways to include more than one optical power
I organized my thoughts and wrote down my con- in the pupil (Fig. 2.4). Besides the simple Split
cept of multifocality for IOLs with the retina-­ Bifocal, one of the possibilities was a central bul-
brain selectivity of clearest image and submitted let for near or distance with the surrounding optic
it to my patent attorney Mr. Howard Silber on for the opposite. I didn’t feel this had much hope
May 3, 1983 (Fig. 2.3a, b). In the document I of success because of its dependence on pupil
location and size and the possibility of IOL
a decentration. With this design I couldn’t decide
whether to make the center bullet for near for
accommodative pupil constriction or distance
correction for outdoor light pupil constriction. A
trifocal triangular configuration was proposed
whereby one 33% segment was for distance, the
second for near, and the third for intermediate.
Annular rings of alternating powers were consid-
ered which, of course, could be a diffractive lens.
Other geometric shapes were considered but
most of them could be affected by IOL decentra-
tion. The patent was then applied for with all
b these ideas.
I decided to proceed experimentally with my
original concept of a simplistic Split Bifocal with
a diameter line through the optical center. With
this design the retina would always receive an
equal amount of light (50%) for both distance
and near, never compromising one over the other
regardless of the pupil size, accommodation, or
lighting conditions. In the patent application, I
specifically stipulated that the bifocal line be par-
allel to the axis of the loops. This was because the
primary cause of posterior chamber IOL decen-
Fig. 2.3 (a) Attorney work sheet for patent application
tration (one loop out of the bag, one loop crimped)
dated May 11, 1983. (b) First page of multifocal patent
application #1365 would cause the lens to decenter in the axis of the

Fig. 2.4 Diagrams of possible configurations for multifocal lenses submitted in the patent application: L-R split bifo-
cal, bullet bifocal, triangulate trifocal, and multiple rings
12 K. J. Hoffer and G. Savini

loops. Any minor to moderate decentration would to do this. I knew Mr. La Haye very well because
still maintain the bifocal line through the center of his willingness to sponsor the Welcome
of the pupil. On the other hand, if the bifocal line Reception at the Annual Meetings of the
was perpendicular to the axis of the loops, even a American Intra-Ocular Implant Society (now
minor decentration would shift one of the focal ASCRS) for which I was the Chairman. Mr. La
zones entirely out of the pupil leading to either a Haye had sold Iolab to Johnson & Johnson in
monofocal lens for distance or one for near. One 1980 but he was still in charge of the company for
unanswered question remained. Would the several years afterward. He told me it would be
patient notice the effect of the “line” through the extremely expensive to fabricate an injection
center of the visual axis? This could only be mold for this so I asked him to slice in half an 18
answered by patient clinical trials. I never imag- D and a 21 D IOL and then glue the opposite
ined in 1982 that it would take eight more years halves together. He promised me he would have
for me to accomplish it. it done in the company’s R&D department. I
recently learned for the first time (11/20/13) from
personal communication with Randall J. Olson
2.4  aking the First Split
M MD (Chair, Department of Ophthalmology and
Bifocal IOL Visual Sciences, John A. Moran Eye Center, Salt
Lake City, UT) that he clearly recalls Mr. La
With the legal protection the manufacturers Haye calling him in that year for advice as to
would need in the works, I proceeded to present whether to proceed with such a “wild idea.” Dr.
my idea to Mr. Peter La Haye (Fig. 2.5), the Olsen remembers telling him that he had no idea
President and CEO of Iolab Corporation (now whether it would work but that the only way it
Bausch & Lomb). Their IOLs were injection could be tested is to implant one in a patient’s
molded and I thought it might be easier for them eye. Perhaps if his advice were otherwise, La
Haye might not have proceeded.
After several months, Iolab finally produced
10 samples for me to look at under the slit lamp
(Fig. 2.6). Note in the figures that the split line is
in the axis of the loops. Also the “circle” that
appears in the center of the optic (Fig. 2.6a) is a
drop of water on the back of the lens sitting on a
flat surface and the peripheral curve of the water
meniscus can be seen as different in the two seg-
ments reflecting the different radius of curvature
of each segment. The lenses looked pretty good
but I was told categorically that these lenses
could not be implanted in a human patient since
it would need protocols and FDA submission.
Also the lenses were not clean or sterilized for
implantation. Not long after that, Mr. La Haye
was scheduled to leave the company as is often
the case in these buyouts and he no longer had
any influence over it anymore. This was not good
for me. I was soon to learn the corporate structure
at Johnson & Johnson was far different from that
of Iolab.
Fig. 2.5 Mr. Peter La Haye, Founder and President of Those now in charge of such things at Iolab
Iolab Corporation (circa 1990) promised me it would be under consideration by
2 Multifocal Intraocular Lenses: Historical Perspective 13

a b

Fig. 2.6 Photographs of Hoffer Split Bifocal IOL made ent peripheral curvature due to the different radius of cur-
by Iolab in 1983 in their R&D department. (a) Note the vature of each half of the optic. Note the bifocal line is in
water meniscus at the back of the IOL (b) shows a differ- the axis of the loops and the lens has a Hoffer Laser Ridge

a committee, and so I waited many, many months. They did make some for me, but I could not find
I was told I had to be patient. After a year, I finally any specimens or photographs of these lenses.
pressured them for an answer I really didn’t want Delays by Cilco in further progress were similar
to hear. I was told they could not proceed with the to those by Iolab. I had also gone to Precision-­
Hoffer Split Bifocal because funds and efforts Cosmet and most all IOL manufacturers includ-
were needed for other more important IOL devel- ing my friend William Link at AMO but they all
opment projects. I later learned that the main just turned me down completely. Things were at
project that took precedence over the bifocal was a standstill. I had a handful of bifocal IOLs but no
“partial depth holes.” For those too young to way to implant them.
remember, all IOLs had a series of two or four
peripheral through and through holes in the optic
to ease manipulating it in the eye with a hook. It 2.5  he First Bifocal IOL
T
was becoming evident that these holes were lead- Implantation
ing to glare and haloes especially with decentered
lenses. They were hoping to eliminate the prob- Then came the surprising day in 1986 when I
lem with holes that did not go completely through read a story in one of the throwaway ophthalmic
the optic. Eventually all positioning holes were newspapers that John Pierce MD had implanted
eliminated from all IOLs, so this was a real bifocal IOLs for the first time in England. The
wasted opportunity on their part. Because of my lenses were manufactured by Precision-Cosmet.
frustration and persistence, they told me that if I My initial reaction was ecstatic since I would
was that eager to do it I should take the lenses finally find out whether my theory of brain sup-
they had made for me and go to Mexico and pression was real. On the other hand, I was some-
implant them. I rejected that idea because I would what exasperated with Iolab and Cilco in that
not be able to explain to the patient appropriately they could have pioneered this in the USA 3 years
what the experiment was (informed consent) or earlier and FDA studies would have been nearing
carefully interrogate a postoperative patient in completion by then. What is most amazing is that
Spanish. I would also need to monitor the patient both companies had gained tremendous success
on a continual basis and was not planning to with their Hoffer Ridge lenses and you might
move to Mexico. I spent another 6 months plead- think they would consider that the inventor might
ing with them but it was to no avail. I then went also invent another reasonable idea.
to Cilco (now Alcon Surgical), who also pro- I was sorry to hear that the central near bullet
duced several prototypes in their R&D divisions (Fig. 2.7) concept was the design chosen to be
by lathe cutting rather than injection molding. implanted because of the inherent problems I
14 K. J. Hoffer and G. Savini

Fig. 2.7 (a) Diagram a

of Iolab NuVu lens.
(b) Ray tracing of Iolab
NuVu. (c, d)
Photographs of
postoperative eyes with
the Precision-Cosmet
(Iolab NuVu) bifocal
IOL implanted. Note
the decentration of the
central “bullet” zone
in both eyes

b
D

c d

predicted above. Soon thereafter, Johnson & degeneration? On the other hand, it is not subject
Johnson (Iolab) purchased Precision-Cosmet and to the vagaries of pupil size, position, or IOL
ironically inherited the mantle of the first bifocal decentration. All the other designs can be com-
IOL manufacturer. They ceased communicating promised by the pupil or IOL decentration and in
with me in any way after this. Not long after, 3 M the percentages of light available for each desired
presented a diffractive bifocal meniscus lens image position.
(Fig. 2.8) followed by several manufacturers try- My patent application was ultimately turned
ing variations on the bullet and annular ring down by the US Patent Office. They based their
themes (see below). The data looked promising at rejection on prior art based on an abandoned
that time but there were definite problems and bifocal contact lens patent application by Jack
compromises associated with all the various Hartstein MD of Missouri several years earlier. In
designs. I was pleased to see that my multifocal discussing a contact lens manufacturing process,
concept did seem to work. he mentioned “this could also be done with IOLs”
The diffractive bifocal causes a complete loss which had nothing to do with a bifocal IOL No
of almost 20% of the incoming light through the matter how much we protested their incorrect
pupil leaving about 40% of the light for distance reasoning, it was rejected. The cost to fight this
and 40% for near. Is this enough in contrast-­ was estimated at $200,000 ($486,720.63 in
compromised eyes such as those with macular 2019). Things again were not going so well.
2 Multifocal Intraocular Lenses: Historical Perspective 15

Fig. 2.8 Photographs of a b

the early 3 M diffractive
PMMA IOLs with
closed (a) and open (b)
loops. (c) Diagram of
3 M diffractive lens. (d)
Diagram of ray tracing
through the diffractive
lens. (e) Diagram of
diffractive process of
3 M lens

d
D

Zone boundaries are where optical path

distances increase by 1 wavelenght

Near Distance
Phase delays at steps
are not 1 wavelength
16 K. J. Hoffer and G. Savini

2.6  he First Hoffer Split Bifocal

T lens, which I used exclusively at the time. I went
IOL Implantation 1990 to Mr. Rainin and asked if he might do me a favor
and check the dioptric power of the bifocals Iolab
By 1989 I was completely frustrated and decided had made, clean, polish, and sterilize them for
to take things into my own hands. I had the lenses implantation in human patients. He told me he
but they were not finished, clean, or sterile. Years would only do it if I promised not to tell anyone it
earlier I had developed a working relationship was done by Ioptex. He did this for me and I will
with Kenneth Rainin (Fig. 2.9), the owner of always be grateful to him for doing so. Now with
Ioptex Research (bought by Smith & Nephew, implantable Split Bifocal lenses in hand, I wrote
later by Allergan). In the 1980s, I had lectured up an extensive informed consent and began dis-
extensively on the benefits of their short C-loop cussing the idea with many of my cataract
patients. I now had to offer the lens to only those
patients whose emmetropic IOL power calculated
to 18.0 D. Many patients were eager to try it.
After thorough informed consent, three
patients agreed and were eager to have the Split
Bifocal. I promised them they would be the first
in history to receive such a lens and that if it
didn’t work, I would immediately remove it and
replace it with a normal lens at no charge to them
for the surgery or hospital. For those unfamiliar
with the US FDA, they only have jurisdiction
over manufacturers but not over surgeons. If a
surgeon has a specially made device, he may
implant it without FDA approval. The surgeon’s
only jeopardy is a malpractice action by the
patient in civil court for implanting a non-FDA-­
approved device. I believe that this is still true
today.
On my 47th birthday, October 10, 1990
(Fig. 2.10), I implanted my first Split Bifocal lens
in the right eye of 78-year-old Lenore Clannin
Fig. 2.9 Kenneth Rainin, President of Ioptex (since deceased). Then less than a month later, on

a b

Fig. 2.10 (a) Clinical photograph of the first implanted same day. Note that even under high power, there is no
Hoffer Split Bifocal dated October 18, 1990, labeled “PO bifocal line visible in this photo. It is obviously not visible
1 week OD” (Clannin.) (b) Another photograph taken the when photographed in aqueous
2 Multifocal Intraocular Lenses: Historical Perspective 17

Fig. 2.11 (a) Clinical a b

photograph of the
second implanted Hoffer
Split Bifocal dated
November 7, 1990
labeled “PO 1 day OD;
20/100 J10”
(Antonucci). Note the
thickened bifocal line
visible superiorly at
11:30. (b) and (c)
Photograph of a similar
unimplanted lens
showing the same
obvious line thickness
superiorly c

Fig. 2.12 Operating a

room records
documenting Split
Bifocal implantations in
1990: (a) For the first
implant, Lenore
Clannin. (b) For the
second implant, Jessica
Antonucci
b

November 7, 1990, I implanted the second one Bifocal”. Both lenses were a Shearing posterior
(Fig. 2.11a) in the right eye of 71-year-old Jessica chamber lens with a Hoffer Ridge: 18.0 D dis-
Antonucci (since deceased). The operations tance power and 21.0 D near power. [Those pow-
records from the operating room document the ers I chose before I ever did the calculations.] To
names and dates of the implants (Fig. 2.12) show- my great joy, both patients were able to see
ing implantations of IOLs labeled “Hoffer #002 clearly at distance with a mild over-refraction
Another random document with
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 By the marriage of Ann Mortimer, sister of the Earl of March, with
Richard de Conysburgh, Earl of Cambridge, the manor fell to the
house of York, for their son, Richard Plantagenet, Duke of York,
succeeded them; and in 11 Henry VI., the King granted to Richard,
Duke of York, livery of Weymouth, and all the castles, manors, lands,
etc., which Ann, late wife of Edmund, Comes Marchiæ, held in dower
of the inheritance of the Duke.
The town is mentioned by Leland (1538), Coker (1630 circa), and
Camden. The first-named writes:
The Tounlet of Waymouth lyith strait agayn Milton
(Melcombe) on the other side of the haven, and at this
place, the Trajectus is by a bote and a rope, bent over the
haven, so that yn the fery-bote they use no ores.
In another part of the Itinerary we read:
Waiymouth Town rite agen Milton, on the other side of
the Haven yt is bigger than Miltoun ys now. The Est South
Est point of the Haven of Waymouth ys caulid St. Aldelm’s
point, being a litl foreland. Ther ys a Chapelle by on the
Hille. The Paroch Chirch ys a mile of—a Kay for shippes in
the town—the Haven Mouth almost at hand. Half a mile
and more to the New Castelle—an open Barbecane to the
Castelle. Weimouth is counted 20 miles from Pole.
Camden states that in the reign of Edward III., the King got
together a powerful army and fleet for the purpose of invading
France, and the town provided twenty ships and 264 mariners for the
siege of Calais; but these figures are disputed by Hackluit, who says
there were but fifteen ships and 263 mariners. In March, 1347, the
bailiffs of Weymouth seized all the goods, chattels, jewels, and
armour of Geoffry, Earl of Harcautly, who had joined the army of the
French King. In 1377 the town suffered considerably from the fleet of
Charles V., when great portions of the ports of Dartmouth, Plymouth,
Portsmouth, Hastings, and Weymouth were destroyed.
 The next event of importance was the landing here, on April 14th,
1471, of Margaret of Anjou, the consort of Henry VI., on her return
from France with her son, Prince Edward.
So the tide of history swept on, with periodical ravages from
pirates and enemies, until the appearance off the harbour of a large
foreign fleet of eighty sail, which had voyaged from Middleburg on
January 10th, 1505, to escort Philip and Johanna to their Kingdom of
Castile; but a violent hurricane caused the ships to run to Weymouth
for shelter. The inhabitants, being unaware of the quality of their
visitors, and alarmed at so formidable an array of vessels, speedily
armed themselves, and sent word to Sir Thomas Trenchard, at
Wolfeton, who, with Sir John Carew, marched into the town at the
head of some hastily improvised troops. On the rank of the visitors
becoming known, Sir Thomas invited them to his house at Wolfeton
until he could advise the King, Henry VII., of the fortuitous
circumstance. As soon as Henry had notice of the arrival of these
royal visitors, he despatched the Earl of Arundel with a troop of 300
horse, carrying torches, to escort them to London.
There is much in the minor history of the town that one would fain
linger over, but we must confine ourselves to those larger and more
far-reaching historical events with which the old life of Weymouth
was so closely bound up.
In 1544 the bailiffs of Weymouth received the following letter from
the King, Henry VIII.:—
(By the King.)
Henr. R.
Trustie and well beloved, we greate you well. And
whereas betweene us and the Emperor upon provocation
of manyfolde injuries committed by the Frenche Kyng unto
us both particularlie; And for his confederation wyth the
Turke, against ye whole commonwealthe of
Christendome. It ys agreede that eche of us aparte, in
person, with his puissant Armie in several parties this
 soommer, shall invade the Realme of Fraunce; and beyng
not yet furneyshed as to our honour appertayneth:—
We have appoynted you to send us the nombre of xv
hable fotemen, well furneyshed for the warres as
appertayneth, whereof iii to bee archers, every oone
furneyshed with a goode bowe in a cace, with xxiii goode
arrows in a cace, a goode sworde, and a dagger, and the
rest to be billmen, havyng besydes theyre bill, a goode
sworde, and a dagger, to be levyed of your owne servants
and tenants.
And that you put the saide nombre in such a redyness,
furnished with coats and hosen of such colours as is
appointed for the battel of our Armey.
As they faile not within oone houres warnyng to march
forward to such place as shall be appoynted accordinglie:
—
Yeven under our Sygnete at our palace of Westmr., the
vth daie of June, the xxxv yere of our reigne.
Henr. R.
Weymouth had been created a borough in the reign of Edward II.,
at the time that his nephew, Gilbert of Clare, Earl of Gloucester, was
lord of the manor (one of whose sisters had married Piers Gaveston,
and the other sister was the wife of Hugh le Despencer); and
although the town is styled a “burg” in several documents relating to
previous reigns, it was not until the nineteenth year of the reign of
Edward II. that it returned a representative to Parliament.
The borough of Weymouth and the adjoining one of Melcombe
(which together now make up modern Weymouth) had long viewed
each other with jealous eyes; and so many complaints being made
through their respective members, the Parliament prepared a
charter, at the suggestion of Cecil, it is said, which was approved by
Queen Elizabeth in the thirteenth year of her reign, which united
these two discordant elements into one borough.
The merchants of the town, like all those of our southern ports,
played a zealous and active part in fitting out ships to fight the
Armada; and from a MS. in the Cottonian Library we learn that the
following vessels set out from Weymouth in 1588, with instructions to
guard the coast and seek out the Invincible Armada:—
Name. Tonnage. Master. Men.
The Gallion 100 Richard Miller 50
The Catherine 60 30
The Heath Hen 60 30
The Golden Lion 120 60
The Sutton 70 Hugh Preston 40
The Expedition 70 50
 Sidney Heath

A Relic of the Armada.

Notwithstanding that their largest vessel was only of 120 tons, the
Weymouth contingent captured two of the galleons and brought
them as prizes into the harbour. The only other vessels sent by the
county on this occasion were two from Lyme Regis—The Revenge,
of 60 tons, and The Jacob, of 90 tons—and four from Poole. In the
Guildhall there is a memorial of the event in the shape of a massive
iron-bound chest (see illustration), believed to have been brought
from one of the captured galleons; and many other relics are
scattered over the county, as at Bingham’s Melcombe, where there is
a magnificent oval dining-table, of massive form and marvellous
workmanship, with the crest of a Spanish grandee in the centre, the
whole mounted on a sea-chest in lieu of legs. Many Spanish coins
have been washed ashore on the Chesil Bank, and it is possible that
others of the ill-fated ships sank in the vicinity of Portland, or that the
dons threw their money and valuables overboard rather than let
them fall into the hands of their captors.
Little is recorded during the next fifty years, save the building of a
wooden bridge of seventeen arches to unite the two towns, in 1594;
and thirteen years later the town was visited by one of those great
plagues which periodically swept over mediæval England.
The outbreak of the Civil War in 1642 found the county fairly
evenly divided in support of the rival parties, and Corfe Castle
became the headquarters of the Royalist, and Bingham’s Melcombe
that of the Parliamentary forces. In 1643 the Earl of Carnarvon
seized and held for the King, Weymouth, Melcombe, and Portland,
and left them in charge of Prince Maurice, whose troops are said to
have pillaged and ravaged the district. The following year the Earl of
Essex defeated the Royalist troops, and took the town for the
Parliament, when he was assisted by a fleet under the Lord High
Admiral, the Earl of Warwick. The towns proved a rich prize for the
captors, as, in addition to much ammunition, etc., no less than sixty
ships fell into their hands. The troubles of the inhabitants, however,
were far from over, as in 1645 Sir Lewis Dyves received orders from
the King to make an attempt to re-capture Weymouth, which, with
the help of Sir W. Hastings, the Governor of Portland, he succeeded
in doing, and drove the defenders across the harbour into
Melcombe. On June 15th, 1644, the town surrendered to the
Parliamentary Commander, Sir William Balfour, the final overthrow
being largely due to the Earl of Warwick, who appeared off the
harbour with a large fleet, originally mobilised for the relief of Lyme
Regis. The spoils of war which fell into the hands of the captors
included 100 pieces of ordnance, 2,000 muskets, 150 cases of
pistols, 200 barrels of powder, and 1,000 swords, in addition to sixty
ships of various tonnage lying in the harbour. The losses sustained
by the combined towns in the Civil War amounted to £20,000, as a
certificate from the Justices, in the Parliamentary Roll, testifies. The
town to-day shows no trace of the fierce bombardments it
underwent, but a house in Maiden Street has a “bogus” memento in
the shape of a cannon ball foolishly inserted in the masonry some
decades since.

Sidney Heath

Sandsfoot Castle

In 1649 the inhabitants petitioned Parliament for a grant of £3,000,

to enable them to enlarge Melcombe Church, build a new bridge,
and free the harbour from rubbish.
 Doorway Sandsfoot Castle

The “Old Castle,” otherwise Sandsfoot Castle, situated about half

a mile from Weymouth proper, is to-day nothing but a mere shell of
the former stronghold. It was built by Henry VIII., about 1539, and
was part of his scheme for the fortification of various parts of the
coast, particularly Portsmouth, Portland, and Weymouth, against a
possible invasion on the part of Papal Europe on his throwing off the
Roman yoke in 1540. Leland calls it “a right goodlie and warlyke
castel, havyng one open barbicane.” The existing masonry shows its
form to have been a parallelogram, and from its commanding
position it, no doubt, was a fortress of considerable strength. It is
difficult to identify, from its crumbling remains, the various portions of
the castle, but that portion to the north, from its vaulted character,
appears to have been the Governor’s apartment; while fronting south
was the gun platform, as the embrasure shows. This platform would
also flank its east and west sides, which were also pierced for big
guns, while almost level with the ground was the barbican, with two
tiers of loop-holes for small arms.
On a tombstone at Whitchurch Canonicorum is the following
inscription:—
Here lyeth Iohn Wadham of Catherstone, Esquyer, who
deceased a.d. 1584, who was dewring his life time
Captayne of the Queene’s Maties castell called
Sandesfote, besides Waymouth in the countye of Dorset.
Among its other Governors were George Bamfield, 1631; Sir
Anthony Ashley Cooper, 1643; Colonel Ashburnham and Colonel
William Sydenham, 1644; and Humphrey Weld, of Lulworth, 1685. It
is a matter for regret that this old building should have been so
neglected, as each year sees large masses of its masonry falling
over the cliff. As a writer as long ago as 1829 said:
Its remains even now attract many an inquisitive enquiry
as to why it has been so neglected, as where the neighing
of hostile steeds, and the busy clang of arms once
sounded to the battle’s din, the humble grass now grows,
its walls are the dormitories of the birds of the air, and its
rooms afford pasturage to the cattle; a change certainly
more gratifying to us as a nation; but still its bold towering
 appearance, as seen ascending the hill, or viewing it from
the hill, reminds us of some bygone tale.
In addition to the castle, the town was further protected by several
forts. Probably none of these were in the nature of permanent
fortifications, except the Blockhouse, which stood near the east end
of Blockhouse Lane. The New Fort, or Jetty Fort, was erected at the
entrance of the harbour, at the end of the old pier, and was
dismantled in 1661, although in Hutchins’ time three guns were
placed in position on the same site. Then there was Dock Fort, under
the hill, west of the Jetty Pier, St. Nicholas’ Chapel converted into a
fort by the Parliamentary troops, and a small fort called the Nothe
Fort.
Few events seem to have occurred during the Protectorate that
need recording beyond the great naval victory gained by Blake over
Van Tromp, off Portland; and, as some compensation for the
damage done to their property during the reign of his father, Charles
II. granted the town in 1660 an annuity of £100 a year for ten years
from the Customs’ dues. It was during this reign that tradesmen
coined small money or tokens for the convenience of those wishing
to buy small quantities of goods, as but little small money was coined
by authority. In 1594 the Mayor of Bristol was granted permission to
coin a token, and the benefit to the community proved so great that
the custom spread to other towns. Weymouth coined many of these
tokens (see illustration), which were made of copper, brass, or lead,
and decorated as fancy dictated. Every person and tradesman in the
town was obliged to take them, and they undoubtedly answered the
purpose of providing the people with small money. In 1672, however,
Charles II. ordered to be coined a sufficient number of half-pence
and farthings for the exigencies of the State, and these numorum
famuli were prohibited as being an infringement of the King’s
prerogative.
The grant of armorial bearings to Weymouth and Melcombe Regis
bears the date of May 1st, 1592. The seals of the town were eight in
number, a description of which is recorded in Ellis’s History of
Weymouth.
 When the ill-starred Duke of Monmouth
landed at Lyme Regis in 1685, no
Weymouthians seem to have flocked to his
standard. Upon the failure of the rebellion the
participants of the neighbourhood were quickly
disposed of by Judge Jeffreys, who opened his
Bloody Assize at Dorchester, and ordered them
to be hanged at Greenhill, and their bodies to
be dismembered and exhibited throughout the
county as a warning to rebels.
So we come down to the close of the
seventeenth century with little to record save
devastating fires, plagues, and storms. A
general period of poverty and depression
seems then to have overtaken the two towns.
The causes leading to this change, which had
begun to show itself in the reign of Elizabeth,
were many and various, and may be briefly
ascribed to the concrete result of the vicious
rule of the Stuarts, the removal of the wool
trade to Poole, the loss of the Newfoundland Some Weymouth
Tokens
trade, and the injury received during the Civil The Town Token
War. Ellis tells us that, at the beginning of the Thomas Hyde
Bartholomew Beer
eighteenth century, “scarcely any idea can be James Stanley
formed of the general devastation and James Budd
depression that everywhere prevailed. Houses
were of little value ... the population had dwindled to a mere nothing
... old tenements fell down ... the inhabitants consisted chiefly of
smugglers and fishermen.”
Before we turn to the brighter days which set in towards the middle
of the reign of George III., a short account must be given of the
larger memorials of the town—e.g., the old bridge, the priory, and the
parish church, although it must be confessed that of important
antiquities dating before the Georgian era the town has little to show
beyond a few remnants of Jacobean houses, part of one solitary
pillar of the chapel, and possibly a few old doorways; and in later and
 minor
memorial
s the
town is
little
better off.
There is,
in the
Guildhall,
the fine
iron-
bound
chest
Arms of Weymouth before
mentione
d, and another, said to be of similar origin, bequeathed by the late Sir
Richard Howard. There is also an ancient chair with a cardinal’s hat
carved on the back, and the old stocks and whipping-post; but for the
most part nothing has survived save the truly Georgian, such as
round windows, picturesque doorways, and part of the old
Gloucester Lodge, now an hotel—an altogether disappointing record
in comparison with the long and varied history of the place.
 Sidney Heath>

Old House on North Quay. Weymouth

Of the old chapel,[52] the one remaining stone is preserved in the

wall of a school. The chapel was a chapel of ease to Wyke Regis,
the mother-church of Weymouth, and was dedicated to St. Nicholas.
It stood on the summit of a hill overlooking the old town of
Weymouth, and its site is commemorated in the name “Chapelhaye,”
by which the district is known. There are several documents extant
relating to this chapel, and among extracts from the Liceirce is the
following:—
None shall fail at the setting forth of the procession of
Corpus Christi day, on pain of forfeiting one pound of wax,
and each brother shall pay six pennies to the procession,
and pay yearly.
 Old Chair at Weymouth.

This relates to the fraternity or guild in the Chapel of St. Nicholas,

which was founded by a patent granted in 20 Henry VIII. to Adam
Moleyns, Dean of Sarum, and certain parishioners of Wyke Regis,
and known as “The Fraternity or Guild of St. George in Weymouth.”
Before the building of a bridge across the harbour the means of
direct communication between the two towns was, so Leland says in
1530, by means of a boat, drawn over by a rope affixed to two posts,
erected on either side of the harbour, a contrivance which was in use
at Portland Ferry as late as 1839. In 1594 this primitive method of
crossing gave way on the erection of the wooden bridge before
referred to, erected at the expense of several wealthy merchants of
London, who appear to have had trading interests here. This, in its
turn, was so seriously injured during the Civil Wars, that it fell to
pieces, and was rebuilt in 12 Anne by Thomas Hardy, Knt., William
Harvey, James Littleton, and Reginald Marriott, the towns’
Parliamentary representatives, and it continued in use until 1741,
when a bridge sixty yards long, with a draw-bridge in the centre, took
its place. The celebrated Bubb Dodington, the first and only Lord
Melcombe, contributed largely to its cost. In 1770 another bridge was
erected some seventy yards westward, thus increasing the length of
the harbour; but as the inhabitants were forced to make a
considerable detour to reach it, they petitioned against the proposed
alteration, but to no purpose. In 1820 it was determined to erect the
first bridge of stone,[53] which is still in use, and only calls for
mention here from the fact that on pulling down some adjacent
houses an urn filled with silver coins of Elizabeth, James I., and
Charles I. was found; and it is said that some of the inhabitants had
a fine haul of “treasure trove” on this occasion. More interesting,
perhaps, was the discovery of a gilt brass crucifix, four inches long;
and on the wall of one of the demolished houses was painted the
following verse:—

God saue our Queene Elizabethe,

God send hir happie dayes;
God graunt her grace to
Persevir in his most holie wayes.
A. Dom. 1577.
 The old priory, or, as it was more commonly called, the “Friary,”
stood in Maiden Street. It was a house of the Dominican Friars,
dedicated in the name of St. Winifred, although Speed gives Dominic
as the dedicatory saint. Leland writes of it as “a fayre house of
Freres in the est part of the town.” The ancient chair now in the
Guildhall came from this priory, and it was said to possess
miraculous powers of healing the sick, and otherwise blessing the
devout who were privileged to sit upon it. The priory shared the fate
of the other monastic foundations at the Dissolution.
Of churches which can be rightly considered as memorials,
Weymouth has no example, as the oldest is that of St. Mary, the
parish church. The foundation-stone was laid on October 4th, 1815;
this church was erected partly on the site of a former church. It is a
large, simple, and unpretentious building, of which some hard things
have been said and written, but it is at least well built and free from
sham, although of its architecture the less said the better. It is,
however, somewhat redeemed by an excellently designed cupola
containing one bell. Inside, an altar-piece by Sir James Thornhill, a
native of the town, whose daughter married his pupil Hogarth, claims
attention; as also does the following curious inscription, in which the
artist, by contracting the word “worthiest,” has conveyed the very
opposite estimate of the deceased’s character to that intended:—
UNDERth LIES Ye BODY OF
CHRISr. BROOKS ESQ. OF JAMAICA
WHO DEPARd. THIS LIFE 4 SEPr. 1769
AGED 38 YEARS, ONE OF Ye WORst. OF MEN
FRIEND TO Ye DISTRESd.
TRULY AFFECTd. & KIND HUSBAND
TENDER PARt. & A SINCr. FRIEND.
An old chalice belonging to the former church which stood on this
site was in the possession of Mr. Ellis. It was made of pewter,
weighed (without the lid, which was missing) 4½ lbs., and held four
pints. On the front was engraved:
 HOLINESS UNTO THE LORD,
ZACH. XIV., VER. 20.
JOHN STARR,
CHURCHWARDEN,
1633.
About the middle of the eighteenth century a gentleman of Bath,
Ralph Allen (the original of Fielding’s “Squire Allworthy”), having
been recommended sea-bathing for his health, found the shore of
Melcombe so suitable for his purpose that he spoke of it to the Duke
of Gloucester. His Royal Highness came, sampled the salt water,
and built Gloucester Lodge, to which house he shortly afterwards
invited the King, George III., who spent eleven weeks here, with his
Queen and family, in the summer of 1789. The result of this and
subsequent visits was that His Majesty purchased the house and
converted it into a royal residence. A great stimulus was thus given
to the town, which entered upon a period of prosperity; for here
George III. held court, and heard the news of some of Nelson’s and
Wellington’s victories. Very gay, indeed, was the life of those days,
with music, feasting, and dancing, which took place in what is now
called “the Old Rooms” (formerly an inn), across the harbour. It was
at Gloucester Lodge that His Majesty received his ministers, and
from whence he and Queen Charlotte used to walk to the little
theatre in Augusta Place to witness the performances of Mrs.
Siddons and her contemporaries. Queen Charlotte’s second keeper
of robes was Fanny Burney (Madame D’Arblay), the chronicler of
George III., and the author of Evelina and Camilla, for which last she
received 3,000 guineas, with which sum she built Camilla Cottage, at
Mickleham, near Dorking.
At Weymouth, in 1785, was born Thomas Love Peacock, the
author of The Monks of St. Mark, and other works. He was Under-
Secretary to Sir Home Popham, and afterwards Chief Examiner and
Clerk to the East India Company, from which post he retired in 1856
with a pension of £1,333 per annum. He was a friend of Shelley,
whom he had met on a walking tour in Wales in 1812. He died in
1866, aged eighty years.
 In the long list of eminent men who have represented the towns in
Parliament we find the names of Francis Bacon (Lord Verulam), Sir
Christopher Wren, and the celebrated political adventurer, Bubb
Dodington.
One of the most interesting studies for the topographer lies in
tracing the origin of the names of the streets of a town; and the
names of the principal streets of Weymouth are distinctly traceable
to their origin. St. Nicholas’ Street derives its name from the patron-
saint of maritime towns; Francis Street comes probably from
Franchise; Boot Lane (formerly Buckler’s), from an inn called “The
Boot”; Helen Lane, from Queen Eleanor, who held the manor of
Melcombe; Maiden Street, from Queen Elizabeth, who united the
boroughs; and St. Edmund’s Street, St. Thomas’ Street, and St.
Mary’s Street, possibly from chapels dedicated in honour of these
saints.

The Old Stocks, Weymouth.

 THE ISLE OF PORTLAND
By Mrs. King Warry
O the stranger of antiquarian or geological tastes
Portland must ever be of interest; but the casual visitor
—seeing it for the first time in the glare of the noonday
sun, amidst eddying clouds of stone-dust tossed hither
and thither by blustering winds, or when the over-
charged atmosphere settles like a misty cap on the Verne Heights—
is apt, if he have formed expectations, to be woefully disappointed.
The fact is that nowhere, perhaps, is the Spirit of Place more coy
and difficult of access than in modern Portland, having retreated
before barracks, fortifications, and prison, before traction-engines
and signs of commercial prosperity. But, properly wooed, it can still
be won, and once found, how well it repays the trouble of seeking! A
mere cycle run or drive through the island is emphatically not the
way to see Portland Isle, especially the Portland of the past. The
visitor needs to walk, saunter, and lounge idly for at least a few days,
and then, if he have a well-stored mind and fail to experience the
subtle, indefinable sensation called “charm,” he must be strangely
lacking in that spiritual perception which alone makes man feel at
one with the universe and with God.
The convict establishment and Government quarries have
displaced much which lent an interest to the island; the barracks and
harbour works have displaced still more—but fortunately we retain a
few records which, scanty though they be, reveal a something of the
past. Gone is the barrow of that king whose very name is lost; and
this supposed last resting-place of a mighty chieftain, swept through
long centuries by pure sea-laden breezes, is now desecrated by
quarrying operations: the barrow of Celtic Bran is but an empty
name, though Mound Owl still remains in part, a silent witness of