EyeWorld Asia-Pacific June 2018 issue

June 2018 EWAP REFRACTIVE 51 Presbyopia preference pre-cataract by Maxine Lipner EyeWorld Senior Contributing Writer Monovision LASIK versus presbyopia-correcting IOLs I t’s a current dilemma for physicians: What to do with a presbyopic patient with- out a cataract? Is it better to remove the crystalline lens and replace it with a presbyopia-cor- recting IOL or to perform monovi- sion LASIK? “If a 45- to 60-year-old patient has good best corrected vision and does not have a visually significant cataract, the physician community is split,” said Steven Schallhorn, MD , professor of ophthalmology, University of Cali- fornia San Francisco. Dr. Schallhorn launched a study published in the Journal of Refractive Surgery that showed that results were surprisingly similar in the early postoperative time period. 1 Examining the approaches Included in the retrospective study were 590 patients who underwent refractive lens exchange (RLE) with a multifocal IOL implanted and 608 who were treated with monovision LASIK. Investigators only included patients if they met the refractive indications before- hand to have undergone LASIK. Patients were given a careful examination at the start and again at the 3-month mark, when they also were given a standard-of-care questionnaire from where they were treated, Dr. Schallhorn noted. “There were similar near vision outcomes between the two proce- dures, and patient satisfaction was similar,” he said. However, there were more visual symptoms at night with the RLE procedure. Investigators further subdivid- ed patients into different refractive ranges, including moderate to high myopia, low myopia, plano pres- byopes, and hyperopic patients. In these groups the patients had similar outcomes, with slight vari- ations. “The hyperopic patients did slightly better with a multifo- cal intraocular lens, but most of the outcomes were similar,” Dr. Schallhorn said, adding that in the hyperopic group, patient satisfac- tion was a little higher with the intraocular approach. For those in the high myopia group, the LASIK monovision approach had a slight edge. “Patient satisfaction was a little higher for moderate to high myopes with laser vision correc- tion, with LASIK monovision,” he said. What Dr. Schallhorn found the most striking were how similar the outcomes were. “I think the most significant outcome was the sur- prisingly similar vision outcomes and the patient satisfaction,” he said, adding that another finding was that night visual symptoms were higher in the refractive lens exchange group. That was some- what surprising because there can be visual symptoms relating to monovision LASIK, especially at night. Clinical issues Because both groups of patients did well with little difference between them, this can have important implications clinically. “Overall, it is reasonable to have the informed patient preference drive the type of procedure offered,” Dr. Schallhorn said. “If a patient who can toler- ate monovision says, ‘I don’t want to have anything inside my eye; I want to have LASIK,’ as clini- cians we shouldn’t immediately respond, ‘You will not be happy with LASIK.’” One important caveat is that this was a short-term, 3-month study, and the RLE proce- dure offers a more permanent solu- tion by removing the pre-cataract crystalline lens. While patient satisfaction was a little higher for moderate to high myopes with monovision LASIK, this should be weighed against other factors. “If you do LASIK for a patient with high myopia, there will be a more significant change in the corneal shape,” Dr. With LASIK monovision patient satisfaction was a little higher in moderate to high myopes. continued on page 52