Eyeworld

EW REFRACTIVE 64 January 2018 Presentation spotlight by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer of 38 patients with bilateral cataracts aiming for spectacle independence corrected one eye for distance and the other for near vision. All patients achieved uncorrected distance visual acuity of at least 20/40, uncorrect- ed near visual acuity of at least J3, and intermediate visual acuity J3 in 90%. More than 97% of the patients claimed to be satisfied/very satisfied with their outcomes. 1 Another study on monovision with modest refrac- tive targets demonstrated that good visual function and patient satisfac- tion could be achieved without the inherent visual symptoms associated with multifocal IOLs. The uncorrect- ed distance visual acuity was 20/30 in 96%, with 92% achieving J4 or better for near. One fourth of the 52 eyes (26 patients) were spectacle free. 2 Despite overwhelmingly posi- tive visual outcomes, Dr. Thompson sees certain aspects of monovision as problematic in select scenarios. "I am not always excited about mono- vision in some of my patients," he said. "We need to be aware of things like the reduction of stereop- sis. These patients may have to use glasses to compensate for the lack of depth perception. Also, in my experience it seems like my female patients adapt to it better than my male patients. Another thing I keep in mind is the accommodative loss table. It shows that 65-year-old patients can still accommodate up to 1 D, so I will be careful about taking him to plano with a monofocal implant unless he has a spherical aberration in his cornea or a small pupil—something helping him with depth of focus, sometimes referred to as 'pseudoaccommodation.'" A prospective study that evalu- ated the effects of three increasing powers of monovision contact lenses (+0.75 D, +1.50 D, and +2.50 D) in the non-dominant eye of 50 emme- tropic presbyopic patients (mean age 55 years) showed a reduction in stereopsis with increasing mono- vision. Near vision improved with increased lens power, but distance vision was degraded objectively and subjectively. The study demonstrat- ed an optimal power of +1.50 D for optimal near and distance vision. 3 with night time driving and other low light image quality situations, but it is not unusual for them to be taking their glasses off to read and not reading too badly, especially in quality light. I am thinking about how I am going to handle this, real- izing that this is the type of patient who has thought about having refractive surgery over the years and is hoping it is his or her shot to have everything taken care of at once. The various options available for trying to make patients happy include monovision, multifocal and EDOF lenses. In general, patient satisfaction after monovision is reported to be high without as many complaints about glare and halos as with multifocals. We use it a lot in corneal refractive surgery, and it also works well with implants." According to Dr. Thompson, spectacle independence is only reported in about one-fourth of monovision patients, with patient satisfaction reported between 75% and 96%. The majority of mono- vision patients, however, will use glasses for some aspect of their vision. A study performed in 76 eyes Trying for spectacle independence R efractive surgeons have become uniquely adept at sizing up their patients' needs, intuiting visual out- come scenarios that will best fit the individual, and devising treatment plans that provide their patients with highly satisfactory, in- dividually tailored visual outcomes. But the thought process that leads to making the right choice is important to understand, as are the pitfalls of what might be the wrong choice. Spectacle independence Many patients want spectacle independence. Refractive surgeons know that there are many ways to approach this but none that allows complete spectacle independence. What they need to do is listen care- fully to understand their patients' visual habits and thoroughly discuss the possible outcomes. According to Vance Thompson, MD, Sioux Falls, South Dakota, who spoke on the topic at the 2017 ASCRS•ASOA Sym- posium & Congress, it is best never to promise spectacle independence. In a case study he presented, Dr. Thompson discussed his treat- ment options for a 65-year-old patient with –2.00 myopia and cataracts OU, who was comfort- able removing his glasses to read preoperatively. The patient wanted maximal spectacle independence at distance and near. Dr. Thompson considered a few options for him: bilateral multifocal IOLs with +3.25 D or +2.75 D adds; extended depth of focus (EDOF) IOLs in both eyes; multifocal mix-and-match IOLs with an EDOF lens in one eye and +3.25 D add multifocal in the second eye; or monovision with one eye plano and the other –1.75 D or –2.00 D. As postop expectations are everything, Dr. Thompson got the patient to talk to him about the patient's exact wants and desires before making a recommendation. "This is a tough one when these folks who are used to taking their glasses off to read come in for cataract surgery," Dr. Thompson said. "Many patients I see with this amount of myopia have difficulty Corneal dilemmas continued on page 66

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