TheRLE Decision Tree

Laser vision correction (LVC) has with greater accuracy and reliability. been the most popular mode of Finally, we are treating more patients refractive correction for decades. Some in their 60s and beyond than we have WHEN IS surgeons have reported seeing their in the past several years. REFRACTIVE LENS LASIK volumes declining; however, this For patients now in their 60s, and is likely due to economic and personal even to some extent those in their late EXCHANGE THE circumstances or preferences, rather or early 50s, many surgeons have begun RIGHT SURGICAL than a reflection of what LVC can to think more carefully about RLE as an achieve. For patients with appropriate option for refractive correction. When CHOICE? prescriptions and in appropriate age patients of this age enter our practice, brackets—including, in many cases, should we be talking to them about BY ALLON BARSAM, MD, MA, presbyopes—LVC can be a fantastic lens- or cornea-based correction? If we FRCOphth choice to decrease spectacle depen- select RLE, how do we decide what kind dence. In some situations, however, of lens we might offer? This is where the refractive lens exchange (RLE) is pref- RLE decision tree comes into play. erable. This article explores some of the situations in which RLE might be THE DECISION TREE the best refractive surgical option for The RLE decision tree considers a appropriate patients and outlines my combination of factors, including age, decision tree for RLE. prescription, degree of , quality of the ocular surface, and other POPULARITY OF RLE factors that might exclude a patient In my practice, the popularity of from LVC, such as an irregular cornea. RLE with our patients appears to be Age is one of the most important increasing, and this may be occur- factors, and I generally would not per- ring for a number of reasons. First, form RLE in a patient who is younger we have newer, better designed IOL than 50. In those patients, LVC and technologies and surgical platforms phakic IOLs are both better options. that allow lens surgery to be carried There are exceptions to the rule, out more precisely and with fewer however, such as patients between the risks than in the past. Second, we also ages of 45 and 50 who are very highly have better diagnostics and improved hyperopic (7.00–9.00 D). In this group, IOL power calculation formulas that the ocular anatomy cannot safely allow us to hit our refractive targets accommodate a phakic IOL. Further, the

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cons of various technology options? • Is he or she motivated to be inde- pendent of glasses and - es? (The more motivated the more likely I will recommend RLE.) • How much time does the patient spend driving at night? (This infor- mation helps me determine what technology would be appropriate.) • How demanding is the patient likely Image courtesy of Rayner Figure 1. Allocation of light energy by the RayOne Trifocal. to be? magnitude of their hyperopia produces are associated with some regression. • Is the patient rational? earlier and more significant presbyopic Furthermore, we know that with time Any corneal must be symptoms than eyes with myopic hyperopes will become more presby- treated at the time of surgery. If a experience. So, for instance, the eyes opic, losing some of their near-vision patient has more than 2.50 D of cor- of a 47-year-old high hyperope behave effect over 5 to 10 years. RLE gives these neal astigmatism, I prefer a monovi- similarly to the eyes of a myope or patients a more permanent option. sion or blended vision strategy with emmetrope in his or her late 50s. In that The other issue in hyperopes is that a standard toric IOL. This is because case, therefore, RLE with a presbyopia- they tend to have smaller eyes and I worry about the combination of correcting lens can be a good option. more crowded angles, which increases coma and toric presbyopia-correcting In patients with established pres- the risk of angle-closure glaucoma. In IOLs with significant residual astigma- byopia, lower prescriptions, and good many cases, removing the natural lens tism, which could be difficult to treat ocular surface condition, I feel that in RLE eliminates that risk. even with a laser enhancement. If the laser blended vision (LBV) can provide patient has less than 2.50 D but more patients with more natural vision, but OTHER PATIENT FACTORS than 1.25 D of corneal astigmatism, a for those who are entering their 50s When it comes to procedure selec- regular cornea, a normal macula, and and have higher prescriptions, I am tion, I am strongly guided by a few a good ocular surface, I will consider more likely to recommend RLE. A good things. First and foremost, what is the a presbyopia-correcting toric IOL. For example would be a 63- or 64-year-old patient’s goal? If it is complete and less than 1.25 D of corneal astigmatism with -10.00 D of . Although this permanent spectacle independence, or less than 1.00 D if against-the-rule, is a perfectly acceptable and safe age to RLE is a more likely choice. On the patients can have on-axis presbyopia- have LVC, in my opinion, RLE is the bet- other hand, if the patient is happy correcting IOL surgery with or without ter choice because he or she is close to wearing reading glasses or occupa- a limbal relaxing incision. It is also the age at which cataracts develop. tional bifocals, I may opt for LVC. If important that, in these situations, a patient has some form of macular patients are accepting of the implica- HYPEROPIC CONSIDERATIONS degeneration, corneal irregularity, or tions of presbyopic-lens technology. There are additional considerations a very poor ocular surface that I don’t for patients with hyperopia. If I treat feel I can treat and improve, I advise PRESBYOPIA-CORRECTING LENS a myopic presbyope with LBV, I typi- him or her to pursue distance correc- CHOICES cally slightly undercorrect one of the tion only, as a presbyopia-correcting The next decision is which type of eyes. For a hyperope, however, I will IOL will not likely be tolerated. presbyopia-correcting lens technology overcorrect to provide myopia in the Most patients want to achieve spec- to use. I prefer a trifocal IOL because nondominant eye. tacle independence. I try to determine the various focal points that these For example, a presbyopic patient their near and intermediate vision lenses generate more closely simulates with a prescription of 3.00 D for dis- requirements by using the following natural vision. Specifically, I tend to tance and an add of another 2.00 D line of questioning and observation: implant the RayOne Trifocal (Rayner). might actually need a 5.00 D hyper- • Would the patient be happy putting With this lens, half of the light is opic treatment in the nondominant glasses on for small print reading, or allocated for distance vision and the eye. This might be a larger correction does he or she want to be spectacle other half is divided between near than some surgeons are comfortable independent for everything? and intermediate vision (Figure 1); the making with LVC. In such cases, I might • Can he or she understand the infor- light energy is split at the 3-mm pupil be more likely to recommend RLE mation you provide? as follows: 52% distance, 22% inter- because high hyperopic LVC treatments • Will he or she accept the pros and mediate, and 26% near. The RayOne

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Lastly, in patients who have very irreg very have who patients in Lastly, , early opacities, and accommodation, early opacities, and increased HOAs. Figure. DLS is characterized by loss of Figure. DLS is characterized by loss of than with trifocals. However, the amountthe However, trifocals. with than D1.75 approximately is add near of tendlenses these so plane, IOL the in intermediateand distance provide to reading.print small than rather vision achievenot do often patients Therefore, independence.spectacle complete previoushad have who or corneas ular less prominent halos with EDOF lensesEDOF with halos prominent less - - Executive Advisor We have moved toward moved toward have We Founder and Medical Director, Waring Vision Institute, Founder and Medical Director, Waring Vision Institute, [email protected] Financial disclosure: None acknowledged Waring Vision Institute, Mount Pleasant, South Carolina [email protected] Financial disclosure: None acknowledged Mount Pleasant, South Carolina CRST      ensure our stage 2 DLS patients patients 2 DLS ensure our stage understand that, although they be candidates for a laser may can also address the lens-based procedure laser procedure, a cornea-based dys Furthermore, in. are interested is what they the problem, if that source of is a single procedure functional lens replacement (ie, refractive lens exchange) the image formation, improve cataract prevent binocularity, can preserve that presbyopia-correcting of focus with restore depth at the retinal plane, and it makes sense, has when IOLs. In our practice, dysfunctional lens replacement, boomers. baby many ways become LASIK for the in GEORGE O. WARING IV, MD, FACS n n n n LARISSA GOUVEA, MD n n n their congenital ametropia, ametropia, congenital their presbyopia, and visual quality and prevents future cataract mind that, formation. Keep in in general, these patients cor presented to us for vision options. rection lens-based refractive proce particularly life, dures earlier in patients. It is a our hyperopic in multifactorial decision-making of: safety, process in order and cost. We optics, lifestyle, - - 2018 focus in near vision than one mightone than vision near in focus experienceto tend also Patients expect. have slight corneal irregularities mightirregularities corneal slight have focusof depth extended an from benefit anprovide can lenses EDOF lens. (EDOF) whopatients in vision of range extended whobut cornea aberrated slightly a have lenses,These LVC. for candidates not are Johnson& (Johnson Symfony the as such ofdepth more much provide Vision), : a spectrum of a spectrum of : MAY

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dysfunctional lens syndrome (DLS) Patients who do a lot of night driving,night of lot a do who Patients Patients with stage 2 DLS are informed that they can either wait to wait to can either that they 2 DLS are informed Patients with stage Once patients are diagnosed and staged with DLS, we reassure them that that staged with DLS, we reassure them diagnosed and Once patients are Enter the concept of concept Enter the Many early presbyopic patients, bothered by their new reading glasses glasses reading presbyopic patients, bothered by their new early Many patients experience a little less glareless little a experience patients islens This vision. night improved and dependentless be to developed also conditions.lighting or size pupil on orprint, small reading for glasses wear Trifocal offers high-quality distance,high-quality offers Trifocal and,vision, intermediate and reading, opticthe on rings fewer has it because designs,IOL trifocal other than surface a lens-based procedure, unless they are high axial myopes (due to risk of of risk (due to myopes axial a lens-based procedure, unless they are high procedure. a cornea-based may defer to retinal detachment), in which case we daily activities— their and HOAs affecting opacity advancing with In patients a cataract procedure. stage 3 DLS—we recommend which addresses procedure, lens-based pursue a cataracts or develop this is a normal aging process. Our patients are taken on a digital tour of their tour of their taken on a digital patients are process. Our aging normal this is a we can perform vision correction on the cor demonstrate that eyes, where we 1 DLS—we lens. In patients with presbyopia only—stage internal the or on nea to high are moderate unless they solution, cornea-based typically suggest a patients with a lens-based procedure. In suggest hyperopes, in which case we recommend typically DLS—we 2 early opacity and increasing HOAs—stage an Oculus Optikgeräte) for lens densitometry, double-pass wavefront technology wavefront technology Oculus Optikgeräte) for lens densitometry, double-pass and analyze ocular light scatter and quantify Analyzer, Visiometrics) to (HD (iTrace, Tracey Technologies) to devices ray-tracing retinal image quality, and clinical can streamline the create a dysfunctional lens index. These diagnostics regarding DLS. patient education and improve decision-making process had progressed through the natural aging changes of the crystalline lens.) lens.) the crystalline aging changes of progressed through the natural had of accom of the lens due to loss a dysfunctionality changes characterized by aberrations (HOAs). higher-order and increased modation, early opacities, distance UCVA, may still have 20/20 (Figure) DLS Although many patients with objectively quantify the characteristics and devices can advanced diagnostic (Pentacam, Scheimpflug imaging an aging lens, including visual function of correction (LVC) procedures at the corneal plane have never been better. better. been (LVC) procedures at the corneal plane have never correction approved by the now corneal inlays are Furthermore, presbyopia-correcting viewed as less invasive procedures could be FDA. In some ways, cornea-based some time trend us noticed a procedures; however, most of intraocular than returning were underwent cornea-based presbyopic LVC ago: Patients who off. (In actuality, they correction had worn their vision years later, stating that BY GEORGE O. WARING IV, MD, FACS; AND LARISSA GOUVEA, MD MD, FACS; AND LARISSA GOUVEA, MD BY GEORGE O. WARING IV, on spectacles. reducing their dependence in hopes of to us come bifocals, or a reality. Laser vision can make this that Today, we have several procedures IS DYSFUNCTIONAL LENS REPLACEMENT LASIK FOR BABY BOOMERS? FOR BABY LASIK REPLACEMENT LENS IS DYSFUNCTIONAL CATARACT & REFRACTIVE SURGERY TODAY EUROPE

52 IS LENS SURGERYIS LENS NEW THE LASIK? s IS LENS SURGERY THE NEW LASIK? s

daunting. Presbyopic patients often have high expectations; therefore, understanding what they want and communicat- ing to them a realistic account of what they are likely to expe- rience in the early, intermediate, and long term is crucial. When used in the right subset of patients, RLE is a precise and positive surgical option that can provide patients with excellent postoperative outcomes in near, intermediate, and distance vision. In my practice, more than 97% of patients with trifocal lenses achieve complete independence from glasses for all activities. The best part is that RLE eliminates the potential need for future and does not disrupt the corneal surface. Whichever approach to presbyopia correction is chosen, it is important to help patients understand that every available option requires some compromise on their part. Patients need to see the procedure as a journey rather than a one-off Figure 2. Available procedures in the refractive surgery spectrum. (Abbreviations: intervention, and helping them to set realistic expectations SMILE, small-incision lenticule extraction; ASA, advanced surface ablation; RLE, is mandatory. When patients know what to expect, they are Image courtesy of Lance Kugler, MD refractive lens exchange) more understanding and accepting of the compromise that RK or PKP, for instance, I implant the IC-8 small-aperture lens they will be agreeing to when it comes to surgery. For most (AcuFocus) in the nondominant eye. I find that this lens gives presbyopic patients, these compromises are acceptable com- about 2.00 D increased depth of focus, which is enough to neu- pared with the alternative of spectacle dependence. n tralize the variation in vision that these patients otherwise get and to compensate for their corneal irregularity. ALLON BARSAM, MD, MA, FRCOphth CONCLUSION n Medical Director, AB Vision, London We have an abundance of surgical options to correct n Member, CRST Europe Editorial Board refractive errors (Figure 2), and deciding what is the most n [email protected] appropriate choice for each patient can sometimes be n Financial interest: Previous consultant (Rayner)

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