EyeWorld Asia-Pacific March 2020 Issue

EWAP MARCH 2020 21 FEATURE minutes if patients are likely to neuroadapt quickly. Dr. Baartman said that the conversation with the 40 to 50-year-old refractive surgery consult is often the most nuanced of conversations in the practice of comprehensive refractive surgery. “Patients often come in envisioning the perfect solution for their problem, many having had friends and relatives that have enjoyed excellent outcomes from LASIK in their younger, pre-presbyopic years,” he said. “Whenever discussing the option of monovision laser with patients of this type, I explain that the drawbacks to this solution include a loss of depth perception, contrast sensitivity, and image blur in one eye or the other at any distance.” Dr. Baartman added that the brain generally adapts to this and suppresses the blurrier of the two images, but there are still instances where the blur may cause problems, including while driving or reading in dim lighting conditions. “I make sure to tell them that this A sheet used by Dr. Kugler with every patient being evaluated for refractive or cataract surgery. Patients initial by the line corresponding to the level of near vision they expect to achieve after surgery, which helps Dr. Kugler and his practice guide them to the solution that is best able to achieve that, including blended vision for some people, or use the tool to set more realistic expectations, if their desired result is not achievable. Source: Lance Kugler, MD Jodhbir S. Mehta, BSc (Hons.), MBBS, PhD, FRCOphth, FRCS (Ed), FAMS Distinguished Professor in Clinical Innovation in Ophthalmology, Head of Corneal and External Eye Disease Service, Senior Consultant Refractive Service, Singapore National Eye Centre Deputy Executive Director, Head Tissue Engineering and Stem Cells Group,  Singapore Eye Research Institute 11 Third Hospital Ave., Singapore 168751 jodhbirsmehta@snec.com.sg ASIA-PACIFIC PERSPECTIVES D rs. Baartman, Kugler, and Rebenitsch nicely cover an interesting topic in dealing with refractive patients in the presbyopic range. Blended vision as described in the article allows the patient to remain spectacle independent at least until there mid-50s. There are a few points of difference with practices outside the U.S. mainly due to availability of other technologies. Presbyopia is a complex mechanism of lens, scleral, and ciliary muscle changes. There is also a genetic and environmental component. I assess patients for early presbyopia even at the age of 38 years, since you can easily get some young presbyopes, especially, I find, in an Asian population. If they are ametropic, they will need to have some counseling and its important as refractive surgeons to have this conversation documented. Contact trial tests as described are useful and I use them a lot in patients of this age range. I find women seem to be more motivated then men for blended vision and as mentioned there is an adaption period which I find can vary from 1 week to 6 weeks, but most are happy by the latter time point. I do actively ask people to practice after their laser surgery to understand their reading range both intermediate and near. It is also worth testing this before surgery. It is important to assess dominance correctly since it can be divided into motor and sensory components. In most people it will be the same but in the odd person it can switch and it is best not to get caught out. For hypermetropes, I do examine the lens careful. Imaging to assess for dysfunctional lens syndrome with the KR-1W or the iTrace can be helpful. I am reluctant to do laser refractive surgery in this group of patients unless I am totally happy with the lens clarity objectively. Once this has been passed these are often very happy patients postop, but you must warn them about refractive stability. There are some papers showing better stability with the addition of crosslinking in this group of patients. For emmetropes this is a more challenging situation. I prefer to use corneal inlays through a pocket incision rather than a laser refractive procedure. Often, these patients are more prone to dry eye after any flap procedure. Currently, we use a biological corneal inlay implanted with a pocket incision. Presbyopia is the holy grail of refractive surgery and it must be addressed or discussed when patients in this age range come for surgery. 50 maybe the new 30, but your eyes may give your age away. Newer treatments such as presbyopic eyedrops, limited crosslinking, and scleral microporation are all minimally invasive procedures that are in trials at the moment that offer much promise. Editors’ note: Dr. Mehta declared no relevant financial interests.