EyeWorld Asia-Pacific December 2011 Issue

December 2011 18 EW FEATURE Lens- and cornea-based treatments in the pipeline may make that decision easier to address for refractive surgeons F ew refractive surgeons would disagree that the most difficult patient to educate and treat today is the near-emmetropic presbyope. These patients have rarely gone to an eyecare professional and may not completely comprehend why their vision is not as crisp as it once was. In short, they are a highly frustrated group of people, and today’s technologies cannot fully restore their accommodative vision. The loss of contrast sensitivity for only a partial gain of accommodation is not ideal, most surgeons agree. EyeWorld asked several leading surgeons how—or if—they would treat this particularly finicky patient group and what future technologies under investigation might alter their opinions. “Have we reached a point in our intraocular lens technology that would justify and legitimize an emmetropic, presbyopic lens exchange? No,” said Louis “Skip” Nichamin, MD , private practice, Laurel Eye Clinic, Brookville, Pa., Presbyopia: How to treat the near emmetrope by Michelle Dalton Senior EyeWorld Contributing Editor USA, adding he “can count on one hand” the number of near emmetropes he has implanted. “I believe in my heart of hearts that will change down the road,” he said. Stephen S. Lane, MD, medical director, Associated Eye Care, Stillwater, Minn., USA, and adjunct clinical professor, University of Minnesota, Minneapolis, Minn., USA, said while he offers refractive lens exchange to his presbyopic population, “I do it infrequently because I’m not a real enthusiast of the current technologies.” Hitting both distance vision and near vision targets to give the patient what he/she wants “is a very tall order,” he said. “Unless and until we get to a place where we have basically a risk-free procedure with a near perfect or perfect result, the near- emmetropic presbyope will remain one of ophthalmology’s most difficult challenges,” said Jack L. Weiss, MD, private practice, Gordon & Weiss Vision Institute, San Diego, Calif., USA. “I do offer refractive lens exchange to some near emmetropes, but not to everyone.” If the patient is +0.5 D or +0.75 D, “those are fair game,” said Paul “Butch” Harton, MD, private practice, Harbin Clinic Eye Center, Rome, Ga., USA, who prefers to offer monovision to those who have had some experience with monovision contact lenses. For now, Douglas D. Koch, MD, professor and the Allen, Mosbacher, and Law Chair in ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA, avoids accommodative lens-based surgery in this group. “The best, most predictable thing we can currently offer is monovision. One eye won’t need surgery, and you’re putting a lens implant in the other eye that will induce myopia,” he said, noting there is not enough accommodative range with current technology, and he’s “very concerned” with the quality of vision the multifocal lenses can offer “if the patient is an emmetrope without visual problems other than presbyopia.” “This is a patient that as an ophthalmologist I would love to be able to do something for, but I need to take a step back and be cautious,” Dr. Lane advised. “I may not be able to meet the patient’s expectations. I may be able to hit the refractive target, but it may take several whacks to meet it. Patient AT A GLANCE • Near-emmetropic presbyopes remain one of ophthalmology’s greatest challenges; finding an optimal treatment would be “the holy grail” • Current technology does not provide enough accommodative effect for this patient group • Newer lens-based and cornea-based procedures have great potential, but only if they can offer more than 5-6 D of accommodation Red reflex view of a Synchrony dual-optic lens after 1 year post-op Source: Victor Bohórquez, MD The AkkoLens accommodating IOL uses the ciliary muscle to move sliding aspheric surfaces laterally Source: Victor Bohórquez, MD continued on page 20