Eyeworld

92 | EYEWORLD | APRIL 2019 R EFRACTIVE by Maxine Lipner EyeWorld Senior Contributing Writer RESEARCH HIGHLIGHT Contact information Lai: ecl2001@med.cornell.edu W hen selecting a monovision ap- proach for presbyopia, it is very important to keep the patient's in- dividual needs in mind, according to Edward Lai, MD. In a review 1 published in Current Opinions in Ophthalmology, various studies in- dicated that old and new methods of monovision and mini-monovision such as implantation of corneal inlays, LASIK, SMILE, and use of IOLs tend to be comparable, although each modality has specific benefits and compromises. One reason investigators wanted to revisit monovision is that they think that near work is different in this era of technology. "The biggest change we see is that people use smartphones and other devices that allow them to increase fonts and lighting so near visual tasks are not as difficult; mini-monovision works well for that," Dr. Lai said. He added that when patients receive full monovision to get good vision for near, large degrees of anisometropia decrease stereopsis and distance vision is poor. Unless a patient had good blur suppression, the technique doesn't work well. But now, people are looking for more of an inter- mediate computer vision in one eye and distance vision in the other, so they need a more moderate correction of around –1.25, which also provides better stereopsis. Examining modalities In the review, the most recent studies on monovi- sion modalities such as use of the KAMRA inlay (AcuFocus), traditional corneal refractive surgery, SMILE, phakic IOLs or refractive lens exchange were compared. Investigators found that all of these methods provided acceptable visual results and comparable patient satisfaction with high rates of spectacle independence. Still, success with such monovision approach- es depends on what the patient wants. "If the patient doesn't read a lot, sometimes the inlays will work well," he said. One of the advantages of the inlays is that this approach is reversible as op- posed to a lens exchange, which carries a higher complication risk, Dr. Lai said. When it comes to use of phakic IOLs for monovision, Dr. Lai has found practitioners tend to shy away from them because of the possibility of pupillary block as well as cataract formation. Practitioners tend to be more comfortable re- placing the lens as they would in cataract surgery. "The only caveat to that is it depends on how old the patient is," he said. "If someone still has some accommodation, monovision with LASIK works well, especially mini-monovision." Successful start Before trying any form of monovision, Dr. Lai recommends giving patients a trial monovision run using contact lenses. If a mildly myopic patient who can read unaided requires surgery, Dr Lai recommends fully correcting the dominant eye for distance and leaving the non-dominant eye as is for reading. That way the patient can see if they like and/or can tolerate monovision. The monovision approach is not for every- one. "If someone doesn't have good blur sup- pression, they won't like it because they can notice a difference between the eyes," Dr. Lai said, adding that it is important to keep in mind the patient's personality and reading habits. Dr. Lai thinks that until a better multifocal lens comes out, practitioners should consider mini-monovision as a good alternative for greater spectacle independence. Surgeons are likely to get more patient satisfaction in this era of expandable fonts and well-lit screens, he concluded. Monovision methods A patient is tested for her dominant eye. Source: Y. Ralph Chu, MD About the doctor Edward Lai, MD Associate professor of ophthalmology Weill Cornell Medical College New York Reference 1. Mahrous A, et al. Revisiting monovision for presbyopia. Curr Opin Ophthalmol. 2018;29:313–317. Financial interests Lai: None

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