EyeWorld Asia-Pacific June 2018 issue

June 2018 52 EWAP REFRACTIVE Views from Asia-Pacific Hiroko BISSEN-MIYAJIMA, MD, PhD Professor, Tokyo Dental College Suidobashi Hospital 2-9-18 Kandamisaki-cho, Chiyoda-ku, Tokyo, Japan 101-0061 Tel. no. +81-3-5255-1856 Fax no. +81-3-5275-1912 bissen@tdc.ac.jp T he consensus for presbyopia correction in cataract patients is the implantation of presbyopia correcting IOL or monovision by monofocal IOL. However, presbyopia correction in pre-cataract cases is a challenge, since patients want to keep a good quality of vision. As Dr. Steven Schallhorn mentioned, there are two mainstream approaches: refractive lens exchange (RLE) with a multifocal IOL implant and monovision LASIK. The third alternative would be the implantation of a phakic IOL under the condition of monovision or with multifocal design if the depth of anterior chamber meets the indication. This retrospective study shows the similar outcomes regarding near vision and patient satisfaction in both RLE and monovision LASIK. Slight variation was found depending on the refraction, such as hyperopia, low to moderate myopia, and high myopia. We know the characteristics of the patients’ desire for their vision depending on the refraction and should consider the most suitable method of correcting presbyopia. Hyperopic patients between the ages of 45 and 60 years often complain about poor uncorrected vision at both distant and near. Any approach can improve their functional vision. This study found slightly better results in RLE. At our hospital, the challenges for presbyopia correction in hyperopia are regression following LASIK and the quality of distance vision following the implantation of multifocal “ ...the challenges for presbyopia correction in hyper- opia are regression following LASIK and the quality of distance vision following the implantation of multifo- cal IOL. ” - Hiroko Bissen-Miyajima, MD, PhD IOL. If the refraction is over +2.0 D, I usually recommend RLE. Patients remember a high quality of vision when they were young and explaining the limited outcomes in any refractive procedure is mandatory. To consider phakic IOL, the depth of anterior chamber is the issue. As for myopia, they can see near without any aid at certain distance depending on the strength of myopia. Patients with low to moderate myopia have higher expectation of good reading vision. Thus, the near visual acuity with monovision LASIK usually does not match their desire. On the other hand, high myopic patients dream about reasonable vision without spectacles or contact lenses in their daily life. Both RLE and monovision LASIK can change their vision to an acceptable level of their expectation. When we consider RLE, we can select the multifocal IOL with adequate near addition. I agree that we need to help patients choose the best procedure according to their wishes and should not forget to explain the trade-offs before the surgery. Editors’ note: Dr. Bissen-Miyajima declared no relevant financial interests. Damrong WIWATWONGWANA, MD Department of Ophthalmology, Chiang Mai University 110 Inthawarorot Street, Tambol Sriphoom, Muang, Chiang Mai, Thailand 50200 Tel. no. +66823837401 Fax no. +6653936121 drwiwatwongwana@gmail.com P resbyopia is the most common refractive disorder in patients over 40 years of age. In modern day practice, more and more patients seek options that will make them free of glasses. For older patients with visually significant cataracts, the procedure of choice would undoubtedly be cataract surgery with IOL implant. The more difficult question is how would we correct presbyopia in a patient with a clear lens? There are several options that can be attempted to treat presbyopia such as LASIK, contact lenses, corneal inlays, accommodative IOLs or multifocal IOLs. A study by Dr. Schallhorn compared 590 patients who underwent refractive lens exchange (RLE) with a multifocal IOL and 608 who were treated with monovision LASIK for presbyopia correction. All patients were without visually significant cataract and were subdivided according to refractive error (as moderate to high myopia, low myopia, plano presbyopes, and hyperopia). The study found that patient satisfaction and near vision outcomes were similar between the two procedures. There have been conflicting reports in previous studies concerning near vision with monovision LASIK achieving inferior results compared to RLE. 1,2 In my practice, if the patient can accept monovision, this has been a concern that must be discussed with the patient preoperatively, especially those who are heavy readers. Moreover, the patient must be warned of reduced depth perception, glares and haloes, and reduced night vision. I would not recommend monovision LASIK for patients whose occupation or lifestyle requires excellent stereoacuity, for example golfers, tennis players or pilots. However, there are several advantages of monovision LASIK over RLE, including excellent distance and intermediate vision, no need for intraocular surgery (especially for high myopes who are at risk for retinal detachment), and the overall cost may be less. In my experience, patients near the age of 50 tend to opt for RLE as they realize that visually significant cataracts may occur in the near future and do not wish to have more than one operation on their eyes. Although there is less anisometropia and a higher chance that the patient will be spectacle free under almost all conditions, the tradeoffs for RLE are risks of intraocular surgery, postop residual refractive error, dysphotopsias, higher cost, and the need for neural adaptation which can take up to 6 months. Each procedure has its advantages and disadvantages but the key to successful outcome and patient satisfaction is good patient selection and a well-informed patient with realistic goals. References 1. Braun Eh, et al. Monovision in LASIK. Ophthalmol. 2008;115(7):1196–202. 1. Barisic A, et al. Comparison of different presbyopia treatments: Refractive lens exchange with multifocal intraocular lens implantation versus LASIK monovision. Coll Antropol. 2010;34(Suppl 2):95-98. Editors’ note: Dr. Wiwatwongwana declared no relevant financial interests. Presbyopia preference – from page 51