EyeWorld India June 2017 Issue

June 2017 EWAP FEATURE 19 that he will be satisfied with corneal inlays. The contact lens test is a great simulation of the reduced image quality at distance and of near gain. I will try testing about 1 D of distance blur because that blurs distance more than a corneal inlay will and can also affect stereoacuity more than a corneal inlay. If the patient is reasonably comfortable with that, there is a good chance he or she will like the inlays. For near vision, it is important to allow the patient to see what it is like to have just one eye that can read and see how the near blur from the other eye feels. Patients should understand that one eye is blurry up close and the other has an image reduction at a distance, with both eyes open. I also like to emphasize the importance of night driving while doing the contact lens test, to fully understand the effects of monovision,” he said. Patient choice When it comes to patient choice, Dr. Kugler had very clear guidelines. “What is great about corneal inlays is that they are the first dedicated technology that we have to address the plano presbyope, which is the last frontier in refractive surgery. We have always had good solutions for people with poor distance vision, but we have struggled for solutions for people with dysfunctional lens syndrome as to how we can help them see up close. I think that corneal inlays are an excellent option for people who struggle with near vision in DLS stage 1, which means they have a clear lens. Once someone gets into the second stage of DLS, then refractive lens exchange is a better option. But for someone with a clear lens who wishes to have a better depth of field for near vision, corneal inlays are an option,” Dr. Kugler said. Dr. Kugler does not implant corneal inlays in people in DLS stage 2 or beyond. He prefers refractive lens exchange rather than corneal inlays for high or moderate hyperopes because refractive lens exchange offers more permanence in these individuals by addressing both distance and near vision in one procedure. Other contraindications to corneal refractive surgery include dry eyes, thin corneas, corneal pathologies like keratoconus, irregular astigmatism, and autoimmune disease. Conditions that make for a poor corneal refractive surgery candidate will typically make for a poor corneal inlays candidate as well, Dr. Kugler said. Personality Apart from a presbyopic patient passing muster for the inclusion criteria for corneal inlays, Dr. Thompson thinks that a patient’s personality can strongly influence his decision making. Experienced refractive surgeons develop an understanding of personality types in terms of whether or not their expectations are realistic and may deny a procedure that is bound to disappoint a picky patient. He elucidated, “I don’t use these on everyone. I have patients who are laid back, who listen, and who are interested in having inlays, and I will usually do the surgery because I am comfortable with their personality. I will do a 1 D loose lens test, and I might move forward with the operation if I am not dealing with a perfectionist, even if the patient opts to not do the contact lens test.” Patients with high standards and expectations may not be suitable for this particular solution to their eye problems. A patient who has never needed glasses before may expect too much. “If the patient is a perfectionist, I am going to reconsider doing any corneal correction of presbyopia, in general,” Dr. Thompson said. “But if he is pushing me to do it because he does not want reading glasses and is uncomfortable with a lenticular approach like a refractive lens exchange, then the contact lens test takes on a very important role. I might suggest it for a longer period of time, and sometimes I’ll do it at 1.25 D, pushing it just a little bit with a perfectionist patient who doesn’t necessarily want to take my recommendation. That is the art of refractive surgery and working with the various personalities.” Eye dominance Eye dominance testing is an important part of planning a corneal inlay correction, with the non-dominant eye generally corrected for near and the dominant eye for distance. A pristine distance correction is of key importance, according to Dr. Thompson, who tries to achieve plano refraction in the dominant distance-corrected eye at all costs. “I tell patients they may need PRK or LASIK to take their refractive error to plano in the eye that is going to be their distance eye. It is important for patients to know that off the bat, and while the idea of additional surgery is troublesome, their happiness is increased later with making sure that the dominant eye is corrected to plano,” Dr. Thompson said. For Dr. Kugler, each patient needs to be carefully assessed for near and distance correction designations. He explained, “Experience with LASIK and monovision lens procedures over several decades now illustrates that eye dominance is very important. Dominance varies from person to person and varies by degrees—some people are strongly dominant, some are weakly dominant, and some are cross dominant. If someone is cross-dominant and you measure continued on page 20