Eyeworld

51 EW FEATURE August 2016 • Presbyopia treatment "I think we are on the cusp of very exciting things when it comes to pre-cataract presbyopic correction of younger patients—that is, on a corneal level or even with drops," Dr. Yeu said. "For now, I have no qualms saying to someone who is 38 or 40 years old, 'Don't even worry about the fact that you are in the age that would require reading glass- es—there will be great options for you.' … There are different technol- ogies that are on the verge of being ready for prime time, and I think in the next five to 10 years, we're going to see a lot in the field." EW Editors' note: Dr. Yeu has financial interests with Bausch + Lomb, Alcon (Fort Worth, Texas), Abbott Medical Optics (Abbott Park, Illinois), and i-Optics (The Hague, Netherlands). Dr. Schallhorn has no financial interests re- lated to her comments. Dr. Trattler has financial interests with Abbott Medical Optics, Bausch + Lomb, and Refocus Group (Dallas). Dr. Garg has financial interests with Abbott Medical Optics. Contact information Garg: gargs@uci.edu Schallhorn: jschallhorn@gmail.com Trattler: wtrattler@gmail.com Yeu: eyeulin@gmail.com people can't get past it, and other people are able to adapt." Monovision LASIK lends itself very well to contact lens trials ahead of time because there is no cataract to impede the simulation. Still, Dr. Garg said he is clear with patients that the ultimate goal is not to eliminate spectacles altogether but to decrease dependence. "Patients need to understand that one eye will be for distance and the other for intermediate or near—and there will likely be a gap in their vision," Dr. Garg said. "I also mention to them that the goal is to have functional vision, not perfect vision. Setting appropriate expecta- tions is key." Presbyopia-correcting IOLs When it comes to presbyopia-cor- recting IOLs, Dr. Trattler said while first generation options were good, the latest IOLs in this category have "significantly improved." Dr. Garg has found that his discussions regarding the technology have changed as the next generation has become available. "It used to be that I would have to educate patients on halos, glare, and low-light reading issues, but now I find that the technology has improved to the point that [while] I do mention these issues, I don't dwell on them," Dr. Garg said. Dr. Schallhorn said she'll talk about the possibility for halos and glare at night so that it's not a sur- prise to patients should they experi- ence these symptoms after surgery. "I also talk about the limita- tions of near vision with presby- opia-correcting IOLs, particularly in low-light settings, like a dimly lit restaurant with a small-print menu," she said. "Again, if you prep the patient that these symptoms or conditions may exist postoperative- ly, the conversation is usually much easier following the procedure." Dr. Trattler pointed out that ad- dressing preoperative conditions and ocular surface disease are particularly important for determining candida- cy and acquiring accurate measure- ments for these lenses. "All patients get a preoperative OCT and preoperative topography. We want to make sure patients don't have any contraindications for the presbyopic IOL," such as a macular problem or corneal asymmetry, he said. "Ocular surface disease needs to be identified and treated, as it can also impact the measurements for IOL calculations. Once dry eye is treated, determining the appro- priate IOL power for surgery is more accurate." Intracorneal inlays Similar to other presbyopia- correcting technologies, Dr. Garg said he will advise patients inter- ested in intracorneal inlays—his practice is starting to offer KAMRA (AcuFocus, Irvine, California)—that they decrease spectacle dependence but don't necessarily provide perfect vision. Dr. Schallhorn reminds her pa- tients that inlays do not necessarily work "right out of the box" as their brain needs to adjust to this new technology. Dr. Yeu, whose practice is look- ing into inlays but hasn't started using them, said while the technol- ogy is exciting, she has some mild reservations. "I think that like any kind of new disruptive technology, the problem is that it's experience and hindsight that teaches us what we can do to get better outcomes. This is going to be true of anything as disruptive as a corneal inlay," she said. "My reservation as a corneal surgeon is that the corneal stroma, from what I can tell, does not 'like' having non-biologic objects put in— that's my fear. "The cornea has a robust re- sponse … That being said, it does seem that well over 90–95% of cor- neas, looking at experience outside of the U.S., do tolerate having an inlay in them, and they can help provide great vision, when done right." Dr. Yeu said that she looks forward to more information that could predict patients who are less likely to have a fibrotic response or the potential for scarring with inlays. Unhappy patient post-surgery— now what? What to do in the event a patient is not satisfied with his or her outcome depends largely on what surgical option was used, Dr. Trattler said. If a patient is unhappy after a presbyopia-correcting IOL, for example, Dr. Trattler said the patient might just be off target, requiring a fix of the refractive error. He added that dry eye is often under-diag- nosed and treating it in these situa- tions will optimize the patient's tear film, which can improve the visual quality as well as overall patient satisfaction. If the refraction is on target and the ocular surface is healthy, Dr. Schallhorn said the physician needs to take into account the patient-spe- cific experience. "If everything is perfectly on target with refraction and the ocular surface and they are still unhappy with their degree of glare and halos at night, it may be time to exchange a lens," she said, noting that in her experience delaying a lens exchange by a lengthy period of time to give the patient time to adapt has done nothing to improve patient satisfac- tion. "If patients are dissatisfied with their visual symptoms and they have no other ocular surface or refractive issues, I think they are unlikely to accept the lens after increased time with it." On the whole, Dr. Yeu said the future of surgical presbyopia correction continues to improve and remain promising. " Given the multitude of options, I also counsel patients that there is no right answer among the treatments we have. I tell patients that everyone is different, and the important part is finding a solution that works for them. " –Julie Schallhorn, MD

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