Eyeworld

133 EW REFRACTIVE March 2018 Research highlight by Maxine Lipner EyeWorld Senior Contributing Writer will generally have less visual symp- toms and a little higher 3-month postop satisfaction if LASIK monovi- sion is performed, and there will be less risk of a retinal detachment." Overall, Dr. Schallhorn thinks that with the current technology of monovision LASIK versus multifocal IOLs, there are inherent trade-offs. "A multifocal IOL provides good monocular near vision and distance vision; the trade-off is night visu- al symptoms," he said. For LASIK monovision, the near eye has blurry distance vision and the distance eye is blurry at near. "There are trade-offs that have to be made in the decision of how to correct presbyopia in a patient who desires correction," Dr. Schallhorn said. "It is important that the pa- tient understands these and chooses a procedure that best meets his or her needs and expectations." EW Reference 1. Schallhorn SC, et al. Monovision LASIK versus presbyopia-correcting IOLs: compari- son of clinical and patient-reported outcomes. J Refract Surg. 2017;33:749–758. Editors' note: Dr. Schallhorn has financial interests with AcuFocus (Irvine, California) and Carl Zeiss Meditec (Jena, Germany). Contact information Schallhorn: scschallhorn@yahoo.com symptoms relating to monovision LASIK, especially at night. Clinical issues Because both groups of patients did well with little difference between them, this can have important implications clinically. "Overall, it is reasonable to have the informed patient preference drive the type of procedure offered," Dr. Schallhorn said. "If a patient who can toler- ate monovision says, 'I don't want to have anything inside my eye; I want to have LASIK,' as clinicians we shouldn't immediately respond, 'You will not be happy with LASIK.'" One important caveat is that this was a short-term, 3-month study, and the RLE procedure offers a more permanent solution by removing the pre-cataract crystalline lens. While patient satisfaction was a little higher for moderate to high myopes with monovision LASIK, this should be weighed against other factors. "If you do LASIK for a patient with high myopia, there will be a more significant change in the corneal shape," Dr. Schallhorn said, adding that this will have a greater impact on the IOL power calculation when the patient eventually has a cataract procedure. "There will likely be more variability in the post-cata- ract refraction if LASIK was previous- ly performed on a high myope," he said. "On the other hand, patients were treated, Dr. Schallhorn noted. "There were similar near vision out- comes between the two procedures, and patient satisfaction was similar," he said. However, there were more visual symptoms at night with the RLE procedure. Investigators further subdivid- ed patients into different refractive ranges, including moderate to high myopia, low myopia, plano pres- byopes, and hyperopic patients. In these groups the patients had similar outcomes, with slight variations. "The hyperopic patients did slightly better with a multifocal intraocular lens, but most of the outcomes were similar," Dr. Schallhorn said, adding that in the hyperopic group, patient satisfaction was a little higher with the intraocular approach. For those in the high myopia group, the LASIK monovision approach had a slight edge. "Patient satisfaction was a little higher for moderate to high myopes with laser vision correction, with LASIK monovision," he said. What Dr. Schallhorn found the most striking were how similar the outcomes were. "I think the most significant outcome was the surpris- ingly similar vision outcomes and the patient satisfaction," he said, adding that another finding was that night visual symptoms were high- er in the refractive lens exchange group. That was somewhat sur- prising because there can be visual Studying monovision LASIK versus presbyopia- correcting IOL I t's a current dilemma for physicians: What to do with a presbyopic patient without a cataract? Is it better to remove the crystalline lens and replace it with a presbyopia-correcting IOL or to perform monovision LASIK? "If a 45- to 60-year-old patient has good best corrected vision and does not have a visually significant cataract, the physician community is split," said Steven Schallhorn, MD, profes- sor of ophthalmology, University of California San Francisco. Dr. Schallhorn launched a study published in the Journal of Refractive Surgery that showed that results were surprisingly similar in the early post- operative time period. 1 Examining the approaches Included in the retrospective study were 590 patients who underwent refractive lens exchange (RLE) with a multifocal IOL implanted and 608 who were treated with monovision LASIK. Investigators only included patients if they met the refractive indications beforehand to have un- dergone LASIK. Patients were given a careful examination at the start and again at the 3-month mark, when they also were given a standard-of- care questionnaire from where they Presbyopia preference pre-cataract With LASIK monovision patient satisfaction was a little higher in moderate to high myopes. Hyperopic patients did slightly better with a multifocal intraocular lens, but most outcomes were similar. Source: Steven Schallhorn, MD

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