Eyeworld

EW SECONDARY FEATURE 66 September 2014 by Ellen Stodola EyeWorld Staff Writer Options for presbyopia correction There are laser procedures and lens options for presbyopia correction, and a number of new technologies are being explored F or patients seeking presby- opia correction, technolo- gies include inlays, IOLs, monovision, refractive lens exchange, and a number of other options. Dean Smith, MD, Mississauga, Canada; Sheraz Daya, MD, Centre for Sight, London; and M. Bowes Hamill, MD, Baylor College of Medicine, Houston, commented on the options available and the treatments plans that they use for different types of patients. The options In terms of presbyopia-correcting options, Dr. Smith said there are either laser-based procedures or lens-based procedures. "It depends on a couple of factors, including the patient age, the prescription, and what the test results show," he said. Laser-based procedures include laser vision correction with mono- vision. There are also corneal inlays. Dr. Smith said he considers those laser-based procedures because patients go through a similar process as LASIK patients. Then there are implant options. These are simple monovision or multifocal lenses. With multifocals, surgeons can use multifocals in both eyes or a modified monovision where the surgeon uses a multifocal in just one eye. Dr. Hamill said choosing an option depends almost entirely on an individual patient's particular needs, the refractive error, what the eye exam shows, and what the patient's goals are. "It's so individual that you can't apply one approach across the board," he said. Additionally, there are a number of options that are not yet available in the U.S. that are available over- seas. The choices available to U.S. patients at this point are spectacles, multifocal or monovision contact lenses, or implants to achieve both distance and near vision, he said. Dr. Daya said the option he chooses depends on the patient's age group and axial length. For hyper- opic and myopic patients around the age of 50 and older, he would most likely do a refractive lens exchange using a trifocal diffractive lens. For patients below that age group, he is using the presbyopic LASIK procedure SUPRACOR on the Bausch + Lomb (Bridgewater, N.J.) platform. SUPRACOR has been avail- able to hyperopes for 3 years and myopes for only a few months in the U.S., Dr. Daya said, and he usual- ly does this in one eye, if not both. "It's a bit like monovision, but it's got a greater depth of focus, so the vision initially is not brilliant at distance, but they've got great near vision," he said. The procedure and treatment plan is similar for hyper- opic patients. The distance vision improves with time, but Dr. Daya said this is one possible concern because it can take weeks, months, or in 10% of cases up to a year to improve. For patients seeking presbyopia correction who have a cataract, there are different options. "You have to divide those people into 2 groups: those who medically justify cataract surgery and those who want to have a clear lens extraction," Dr. Hamill said. "There are indications and contraindications for each." Basically, he said, there is a choice between a single vision lens in monovision or a multifocal/ accommodating implant lens. Dr. Hamill's preferred approach is monovision. "It seems to give the best overall functional distance and intermediate vision with the least amount of complications," he said. Dr. Daya said that for cataract patients who are seeking presbyopia correction, he would immediately choose a trifocal lens. Additionally, he has access to the trifocal toric, which may be an option for some of these patients. "For cataract patients, it's strict- ly the lens implant options," Dr. Smith said. When choosing those, surgeons must look at a variety of factors, including the preexisting prescription of patients, what type of vision they had previously, and their visual demands. "The other big considerations are the things that we find on the clinical exam," Dr. Smith said, including dry eye and other corneal conditions such as anterior base- ment membrane dystrophy (ABMD). He also takes a good look at the retina and performs macular OCT. Dr. Smith said that the biometry has to be considered. The optical axial length measurement will determine what type of lens will be appropriate and if the lens is avail- able in the strength required for the patient. The topography becomes important as well because it is key to treating astigmatism. Finally, surgeons need to be able to evaluate corneal wavefront. "If patients have high aberrations on the corneal wavefront, we steer them away from multifocal implants and do more monovision," he said. Dr. Smith said that the most common procedure that he per- forms for patients who have cata- racts is "mini monovision," which is distance vision in the dominant eye and intermediate vision usually somewhere between –1.0 and –1.75 in the nondominant eye. "To achieve that, we're using astig- matism and spherical aberration correcting implants," he said. The main reason for this approach is that not all people are candidates for multifocals. Future options A number of options for presbyopia correction are being explored. "Some of the studies on options coming up, such as the laser surface ablation procedures to try to get multifocali- ty, have promise, but they also have real issues," Dr. Hamill. PresbyLASIK is another option that he said still needs to be explored. Dr. Smith's left eye 1 day postop after a KAMRA pocket procedure An intraoperative photo of one of Dr. Smith's first Flexivue Microlens pocket cases Source (all): Dean Smith, MD

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