EyeWorld Asia-Pacific March 2020 Issue

FEATURE 22 EWAP MARCH 2020 option often requires spectacle use while driving, particularly at night,” he said. Dr. Kugler said you certainly have to be careful with determining which eye to treat for near vision. Sometimes, patients might be left-eye dominant, but they have certain activities where they’re using the right eye as dominant, he said. If you suddenly take that eye and make it see near, those activities could be difficult for them. Part of that conversation is explaining that whatever you’re choosing for the near target is not going to see distance as well, he added. It’s also important to counsel patients about the adaptation period. Any preoperative testing that is special to these patients? Determining the dominant eye is really important, Dr. Kugler said, even though he believes patients still tolerate it well if you make the dominant eye near. “We’ll certainly use contact lens trials in certain situations,” he said. However, he noted, two problems with this are that people spend a lot of time on how the contact feels rather than the vision. If somebody likes the contact lens trial, they’ll like blended vision LASIK, but if they don’t like contact lens trial, they’ll still probably like blended vision LASIK, as a few days isn’t necessarily enough time to determine if you’re going to blend it with your vision, he said. The presbyopic age is complex, Dr. Rebenitsch said, so he recommended careful ocular analysis. We want to make sure the macula is healthy without early AMD or epiretinal membrane, he said, adding that it’s also important to look for the ocular surface disease. “For anyone who has poor ocular surface, blended vision is even more likely to cause blurry, fluctuating vision,” he said, adding that he will treat the ocular surface first, if needed, and likely recommend a lens- based option instead. Dr. Baartman will always personally perform a precision refraction at distance and show non-emmetropic patients what their best-corrected vision can be with both eyes at distance. It’s important for patients to understand the limitations their own eyes are setting, Dr. Baartman said. “With loose lenses, I’ll then add power to their non-dominant eye until they love the monocular near vision and then show them what it looks like with optimal monovision correction at both distance and near,” he said. If they are accepting of this, and the remainder of exam and testing shows good candidacy for corneal-based refractive surgery, Dr. Baartman provides a contact lens trial for at-home, real-life use to ensure this is something they want to commit to. Do you do laser vision monovision for plano presbyopes? Do you do anything different in your process? Plano presbyopes are one of the best challenges to the comprehensive refractive surgeon’s chairside chat, Dr. Baartman said. “This is one scenario where all options must be openly discussed and very detailed conversations are had about vision correction, including monovision LASIK and refractive lens exchange,” he said. “Some of these patients may be disappointed to learn that laser vision correction for enhanced reading vision, in most instances, will be gained at a mild sacrifice to binocular distance vision or depth perception.” Depending on lens status, Dr. Baartman said some of these patients are better candidates for refractive lens exchange and opt for this. In those that are motivated to give monovision a try, he often uses longer trials of contact lens monovision to ensure this is a suitable option for their visual needs and lifestyles. “I’ll often work with the patient’s local optometrist to arrange a proper fitting and prescription, so we can identify the perfect monovision correction, and feel confident when we proceed to the laser suite,” he said. Dr. Rebenitsch said that his decision would depend on a case-by-case basis. For someone who is younger, we’d opt for blended vision with laser vision correction, he said. But for those age 50 and older, he would recommend refractive lens exchange in one or both eyes, depending on the refractive status and level of dysfunctional lens syndrome. He added that these are “some of our happiest patients,” although a well neuroadapted person with blended vision can be just as happy, if not happier. Dr. Rebenitsch also added that there are some technologies in other parts of the world that are not yet approved in the U.S., specifically PRESBYOND (Carl Zeiss Meditec). “In my mind it’s kind of monovision-plus,” he said, adding that this option increases the depth of focus through increased spherical aberration. It’s typically done in the non-dominant eye, and by doing this, the patient maintains better distance vision and increased near over a more traditional blended vision. EWAP Editors’ note: Dr. Baartman is affiliated with Vance Thompson Vision, Sioux Falls, South Dakota, and declared no relevant financial interests. Dr. Kugler practices at Kugler Vision, Omaha, Nebraska, and declared no relevant financial interests. Dr. Rebenitsch practices at ClearSight Center, Oklahoma City, and has relevant financial interests with Carl Zeiss Meditec.