EyeWorld Asia-Pacific June 2016 Issue

June 2016 EWAP CORNEA 51 Views from Asia-Paci c Robert T. ANG, MD Senior Consultant, Asian Eye Institute 8th Floor Phinma Plaza Rockwell Center, Makati City, Philippines Tel. no. +63-2-8982020 Fax no. +63-2-8982002 angbobby@hotmail.com S ome patients view presbyopia as an inconvenience, others view it as a disability. Whatever their motivations are, when given a choice, patients would rather not wear any form of eyeglasses. I categorize presbyopic patients into four groups: naturally emmetropic presbyopes, post-surgical emmetropic presbyopes, ametropic presbyopes, presbyopes with cataracts (with or without refractive errors). Age-wise, I consider 40 years and above as presbyopic age and discuss with them their condition whether they are symptomatic or not. Myopic patients usually do not realize they are presbyopic unless they wear full correction contact lenses and are wearing reading glasses to supplement reading vision. For patients between 40 and 55 years of age, I stay with corneal presbyopic treatments. Those above 60, whether they have visually significant cataracts or not, I suggest lens exchange procedures. Those in the grey area of 55–60 years may go either way depending on the discussion with the patient. The on-label indications for corneal inlays are the naturally emmetropic presbyopes. Emmetropes encompass refractive errors within +1.00 to –0.50 D. I recommend using the KAMRA inlay (Acufocus, Irvine, Calif.) on patients with +0.00 to –0.50D, with a bias towards the mild myopia side because the mild myopia enhances the depth of field for better near vision and the pinhole effect compensates for the myopia and improves the far vision. For patients with refractive error of +0.25 to +1.00 D, I suggest using the Raindrop inlay (ReVision Optics, Lake Forest, Calif.) because the inlay improves the depth of field and also causes a mild myopic shift towards emmetropia. Off-label indications may include post-refractive surgery emmetropes and ametropic presbyopes when combined with LASIK. For the post-LASIK emmetrope, corneal thickness and integrity are my concerns when considering inlays. I am worried about creating a tunnel under the LASIK flap interface because it might be too deep into the cornea if a high refractive error was corrected. During dissection into the tunnel, we may inadvertently connect into the previous flap interface which may lead to scarring or unwanted aberrations. For ametropic presbyopic patients with significant refractive error, I prefer to go for a presbyopia LASIK procedure (Supracor, Bausch + Lomb, Bridgewater, NJ). With PresbyLASIK, I can correct the refractive error and presbyopia in one procedure under a thin flap. If an inlay is combined with LASIK, a 200-micron flap has to be created limiting the amount of refractive error to be corrected or risking ectasia. Additionally, the inflammatory reaction on the same interface may affect the visual outcome. My experience with KAMRA inlays has been rewarding mainly because I follow the surgical guidelines and stay within the recommended indications. I select patients on the mild myopic side and disqualify patients with corneal or dry eye problems. I do not combine inlay with LASIK. Some of my KAMRA patients have reached 6 years of follow up. About 5% use reading glasses most of the time, 10–15% use glasses occasionally when the print is too small or lighting is not enough, but about 80% rarely or never use reading glasses since we implanted the KAMRA. None of them use glasses for distance vision because the pinhole effect reinforces distance vision. I emphasize to patients that it is crucial they come for regular follow ups. I have observed some changes in refraction towards hyperopia, at times accompanied by haze formation around the inlay. I treat them with loteprednol for 1–3 months. The refraction stabilizes and near vision improves although the haze may remain. Artificial tears are important long term because any dryness especially over the central cornea affects both near and distance vision. I explanted a KAMRA inlay in one eye when the patient complained of difficulty driving at night because of haloes. I have not experienced any corneal melt or inlay extrusion. With proper guidance and follow up, I would not hesitate to continue recommending the KAMRA inlay to qualified presbyopes. It is an exciting time for presbyopic treatment. Surgeons can now offer a wide spectrum of options. But we have to keep in mind that no single solution can treat all the different conditions. Editors’ note: Dr. Ang is a consultant for Acufocus and Bausch + Lomb. Durrie reported. “I have patients who are 9 years postop and they’re still seeing well, so it seems to be quite stable over time,” he said, adding that this also works well with lens replacement. “You can leave the inlay in place and go to lens procedures and the depth- of-focus principle still works,” he said. “That’s comforting to both doctors and patients that you don’t have to look at taking it out down the road once patients need a lens implant.” On the other hand, it is not a problem if it does need to be removed. “That was one of the positives that came out of the clinical trials—that if the inlay was removed, the patient returned to the preoperative best corrected vision in almost all cases,” Dr. Durrie said. The negatives are that it’s newer and more expensive for the patient than monovision and that neuroadaptation is required. “The vision isn’t instantly recovered—it’s recovered over the first month,” Dr. Durrie said. “But patients don’t seem to care because it’s getting rid of their reading glasses. If they have to wear their reading glasses for a couple more weeks and then get out of them, that’s fine with them.” In Dr. Durrie’s experience, 15% of patients were out of their reading glasses as early as the first week, and everyone had reached that mark by the end of the first month. Dr. Tamayo mainly uses the Flexivue inlay. While he has used other inlays before, he likes the idea that with the Flexivue, the presbyopic correction is more in the periphery. “I think the continued on page 53