Eyeworld

I N FOCUS 52 | EYEWORLD | DECEMBER 2019 EXAMINING PRESBYOPIA TREATMENTS by Ellen Stodola EyeWorld Editorial Co-Director do not adjust as hoped, we will do a flap lift enhancement at no cost to bring them to full distance correction in both eyes. For hyperopes we tend to recommend distance only or RLE," Dr. Rebenitsch said. What are the negatives you cover with them? For monovision/blended vision candidates, who are typically in their 40s and early 50s, Dr. Rebenitsch said it's important to ensure the lens is clear. "We also simulate blended vision in the clinic," he said, adding that he can typically tell within a few minutes if patients are likely to neuroadapt quickly. Dr. Baartman said that the conversation with the 40 to 50-year-old refractive surgery consult is often the most nuanced of conversa- tions in the practice of comprehensive refrac- tive surgery. "Patients often come in envisioning the perfect solution for their problem, many having had friends and relatives that have enjoyed excellent outcomes from LASIK in their younger, pre-presbyopic years," he said. "Whenever discussing the option of monovi- sion laser with patients of this type, I explain that the drawbacks to this solution include a loss of depth perception, contrast sensitivity, and image blur in one eye or the other at any distance." Dr. Baartman added that the brain generally adapts to this and suppresses the blurrier of the two images, but there are still instances where the blur may cause problems, including while driving or reading in dim light- ing conditions. "I make sure to tell them that this option often requires spectacle use while driving, particularly at night," he said. Dr. Kugler said you certainly have to be careful with determining which eye to treat for near vision. Sometimes, patients might be left- eye dominant, but they have certain activities where they're using the right eye as dominant, he said. If you suddenly take that eye and make it see near, those activities could be difficult for them. Part of that conversation is explain- ing that whatever you're choosing for the near target is not going to see distance as well, he W hen faced with presbyopia correction, there are a variety of options for these patients. Brandon Baartman, MD, Lance Kugler, MD, and Luke Rebenitsch, MD, discussed using monovision, particularly highlighting which patients do best with this option, potential concerns, special testing, and other considerations. What percent of your presbyopic laser vision patients choose monovision? Dr. Kugler said he uses this option in his prac- tice for around 80% of patients over 43 years old. He stressed the importance of referring to it more as "blended vision" rather than "monovision." Monovision implies that the near eye is seeing closer than blended vision, he said. Blended is less near in the near eye, which allows the brain to blend the vision better together. He said almost all patients can tolerate –1 or –1.25 D in the nondominant eye, and it gives them almost a full range of vision. Dr. Baartman said monovision accounts for less than 10% of the laser vision correction in his practice. "However, those for whom I do perform monovision laser often swear by its re- sults, making it something I'm certain to discuss with all eligible patients," he said. "It is gener- ally those myopic presbyopes, who have grown tired of bifocal spectacles or looking over or under their single-vision lenses, who opt for this method of presbyopic vision correction in con- tact lenses and choose to recreate this without the use of contacts." He added that it's critical to not only explain what the correction will do to uncorrected near vision but to show patients as well. For the presbyopic age group, Dr. Rebenitsch agrees with Dr. Baartman. "Blended vision is around 10% of my treatments for the presbyopic age group; 20% choose distance only, while 70% choose refractive lens exchange with a multifocal IOL. It does depend on where they are "coming from." For myopes I am more likely to recommend blended vision. If they 'Blended vision' for presbyopia patients At a glance • Experts stressed the impor- tance of referring to it more as "blended vision" rather than "monovision," as monovision tends to have a negative connotation. • Ideal patient age may be in the 40s to early 50s. • A contact lens trial may be helpful to simulate for patients what their vision will be like after this procedure.

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