EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/618732
EW REFRACTIVE SURGERY 52 January 2016 by Rich Daly EyeWorld Contributing Writer in that one eye, and patients often maintain 20/20 or 20/25 Snellen uncorrected distance vision. "They do need to understand there is a slight reduction in contrast sensitivity at night but not nearly as much as with monovision," Dr. Thompson said. "That is one of the things that I love about inlays: They don't blur distance as much as monovision. As a result, there are typically less [patients] wanting them removed versus having their monovision lessened." Another advantage of inlays— particularly for patients in their 50s—is that inlay vision doesn't involve the amount of distance blur monovision creates to get them to read up close, which often is too powerful for good intermediate vision. One of the strong points of inlays is the intermediate vision improves along with near. With monovision, the power needed for a 55-year-old to read can make com- puter vision blurry. "Another powerful point we identified in our inlay research was that the longevity of the correction was much longer," Dr. Thompson said. "We have patients who are in their upper 50s still reading great with their inlay, whereas after you induce monovision, a gradual reduc- tion in its effectiveness occurs. So the amount of time that a patient gets a near image is variable in San Antonio, and adjunct assistant professor, Rosenberg School of Op- tometry, University of the Incarnate Word, San Antonio, uses a custom- ized approach that gives patients a chance to see their options preop through a simulation. For presby- opic patients, that means using a blended vision trial, which is a sim- ulation of what can be accomplished with monovision LASIK versus introducing multifocal optics into their system. "We'll display a couple of different powers of monovision in the non-dominant eye via a contact, and we also show them multifocal optics with a multifocal lens simu- lator," Dr. Parkhurst said. "Usually after seeing that the patients will guide us." Dr. Parkhurst will either perform LASIK surgery or consider inlays or multifocal IOLs for patients who like multifocal optics. Instead of performing a trial to see if the patient accepts monovi- sion, Stanley B. Teplick, MD, med- ical director, Teplick Custom Vision, and adjunct professor of ophthal- mology, Pacific University College of Optometry, Beaverton, Ore., shows patients—through a pinhole demon- stration—their potential near vision gains from an inlay. When inlays are preferred In patients who don't want to blur distance much, corneal inlays can sometimes provide the near image Careful preop screening and education as well as some adjunctive treatment should precede inlay use T he first step in assessing a presbyopia treatment is for surgeons to ensure they are properly selecting a corne- al-based procedure over a lens-based procedure. One of the favorite techniques of Vance Thompson, MD, professor of ophthalmology, Sanford School of Medicine, Sioux Falls, S.D., for checking whether patients' lenses are clean is to ask about their night- time image quality. He also measures the optical or objective scatter index (OSI) with the HD Analyzer (Visiometrics, Terrassa, Spain) to check the forward scatter or how light is affected as it travels through the cornea and lens. Dr. Thompson uses the Pentacam (Oculus, Arlington, Wash.) to measure the lens density. After those steps, Dr. Thompson uses an objective diagnostic test, the iTrace (Tracey Technologies, Hous- ton) to further ensure lens clarity. Then Dr. Thompson discusses with patients why he only treats one eye. "It is an exercise in compro- mise when you are going to do a corneal correction of presbyopia," Dr. Thompson said. "I want them to understand that even if we get their reading eye doing well, sometimes in the distance eye the near blur can affect the near image quality." In patients sensitive to those issues, a contact lens test is conduct- ed with a plus 1.25 D lens contact— typically in the non-dominant eye, which is the best choice for reading in about 80% of patients. There are some who prefer their dominant eye as their reading eye. "If they say, 'I love the vision from that contact, and I love the contact' then I say, 'Wear the con- tact,'" Dr. Thompson said. "If they say, 'I love the vision but I don't love the contact' I tell them about refractive surgery. And monovision is still a great option. They just need to understand it blurs distance more than inlay vision." Gregory D. Parkhurst, MD, physician CEO, Parkhurst-NuVision, Laser or inlay? Helping patients with a new decision Refractive editor's corner of the world C orneal inlays are an exciting new option for our presbyopic patients, but with new options come new challenges, especially in our communication to patients. Our role as surgeons is to help these candidates successfully navigate to their best option, providing our expert guidance and final treatment recommen- dation. There are many considerations that will affect how we come to these decisions, from routine diagnostic measurements, to more nebulous interpretations of patient preference. Drs. Thompson, Teplick, and Parkhurst provide excellent pearls for all refractive cataract surgeons to adapt into practice for success with these new technologies. Steven C. Schallhorn, MD, refractive editor The KAMRA corneal inlay Source: AcuFocus continued on page 54