GLOBAL PRACTICE PATTERNS s

STRATEGIES FOR CORRECTING | Surgeons share their preferences.

Previsit Counseling Is Telling BALAMURALI K. AMBATI, ncreasing maturity (ie, age) comes happens before and after surgery. with reduced focusing adjustment Previsit counseling using Surgiorithm’s MD, PHD, MBA, AND NORALIZ (ie, ). In patients with system has increased the percentage GARCÍA-O’FARRILL, MD cataracts, the restoration of excellent of our patients who elect to undergo visual function can be achieved astigmatic and presbyopia correction Eugene, Oregon Ithrough cataract extraction coupled at the time of from with presbyopia technology. 43% to 53%. This system synergizes educational videos, a lifestyle PREFERENCES AND PROCESSES questionnaire, and information on In the surgical suite. Table 1 shows our available options. preferences for correcting presbyopia. During the preoperative visit, patients preoperative measurements in these Although most presbyopia-correcting learn that they may see rings after eyes and the higher touch-up rate as IOLs can correct only 2.57 D of surgery because of lens-edge effects, will a result. No matter the patient, it is , that is not an upper likely have dry eyes for a few months essential to optimize the corneal surface limit because lens technology can be postoperatively, will likely need laser before planning presbyopic cataract combined with intrastromal corneal treatment for scar tissue behind the surgery (Table 2). ring segments, laser arcuate incisions, lens implant in 4 to 12 months after Younger patients without cataracts and limbal relaxing incisions to allow surgery, and may need a free touch-up are offered refractive lens exchange presbyopia correction even in patients for residual astigmatism or refractive (RLE), especially if they have high with 6.00 or 7.00 D of preoperative error. Preoperative measurements refractive errors, or monovision LASIK astigmatism. Short or long eyes may are typically performed on at least with a general target of -1.25 D sphere require a piggyback lens in addition to a two different occasions for patients in the nondominant eye if they are not presbyopia-correcting lens. who have a history of radial keratotomy highly dependent on depth perception. In the clinic. Equally important to improve accuracy, and counseling In patients who have not tried to what occurs in the OR is what addresses the lower precision of monovision before, we first perform a trial. TABLE 1. TOOLKIT FOR PRESBYOPIA* Caution is required when treating Equipment Application patients in the zone of or low (0 to -3.00 D) because they Femto LDV Z8 femtosecond laser Arcuate incisions, capsulotomy, lens chop have adapted well to their situation. Argos-Verion integrated Lens centration, incision placement, and multifocal toric IOL alignment Rocking the boat, so to speak, can be digital marker microscope traumatic. These patients assume that they will retain their preexisting focal ORA Intraoperative aberrometry point and their quality and range of Lenses Application vision and that their visual function will increase. In reality, there are trade-offs. AcrySof IQ PanOptix Used for most patients We ask patients specifically if they read AcrySof IQ Vivity • Patients with near point of 2.00 D (19.7 inches) or less without glasses and if they will be okay • Mild corneal scar, mild epiretinal membrane, prior radial keratotomy with a change in their near point. • Need to minimize night halos; willingness to use reading glasses for fine work (can enhance near vision with a target of -0.50 D for CONCLUSION nondominant eye) In the future, patients with Tecnis models ZLB00/ZLU Patients with high myopia and/or a very close desired near focal point presbyopia but not cataracts and patients with low myopia may benefit Tecnis models ZKB00/ZKU Patients with history of myopic LASIK, high positive corneal spherical from presbyopia-correcting eye aberration, and a desired near point of approximately 2.20 D (17.9 inches) drops. For now, however, we prefer *Manufacturing information: Femto LDV Z8 (Ziemer); Argos, Verion, ORA, AcrySof IQ PanOptix, AcrySof IQ Vivity (Alcon); Tecnis Multifocal, Tecnis Multifocal Toric II the presbyopia-correction methods (Johnson & Johnson Vision). discussed herein.

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TABLE 2. STRATEGIES FOR MANAGING CORNEAL CHALLENGES BALAMURALI K. AMBATI, MD, PHD, MBA Corneal challenge Preoperative or Concurrent Management n Professor of Ophthalmology, University of Keratoconus Intrastromal corneal ring segments Oregon, Eugene n Pacific Clear Vision Institute, Eugene, Oregon Salzmann nodules, pterygium Lesion removal, amniotic membranes n [email protected]; [email protected] Epithelial-basement membrane dystrophy Debridement and polishing, amniotic membrane n Financial disclosure: None Significant ocular surface inflammation Blepharitis therapy NORALIZ GARCÍA-O’FARRILL, MD Clinically significant Fuchs dystrophy DMEK (done by a DMEK expert) combined with AcrySof IQ PanOptix n University of Puerto Rico School of Medicine, or AcrySof IQ Vivity lenses (targeting -0.50 D of myopia) San Juan n Pacific Clear Vision Institute, Eugene, Oregon Abbreviation: DMEK, Descemet membrane endothelial keratoplasty; Manufacturing information: AcrySof IQ PanoOptix and AcrySof IQ Vivity (Alcon) n [email protected] n Financial disclosure: None

An Overview of Past and Current Solutions FRANCIS RAYMOND had relatively few options for correcting reducing contrast sensitivity as much as MENDOZA-CASTOR, presbyopia when I started practice earlier generations of these IOLs. MD, FPCS, FPAO in 2007. Monofocals were the most The Lentis Comfort LS-323 MF15 IOL commonly used lenses, and I opted (Teleon Surgical) has a low near add Calamba City, for monovision strategies in select (+1.50 D) and acts like an extended Philippines Ipatients. My approach was conservative depth of focus (EDOF) lens. This IOL is in patients with mild glaucoma or retinal built on the company’s Mplus platform. pathology; I targeted emmetropia or I typically use the Düsseldorf strategy in mild myopia and prescribed spectacles. normal eyes and in patients who have My approach has evolved with advances glaucoma or retinal disease. With this in lens technology. approach, emmetropia is targeted in either the dominant or better-seeing THEN eye, and -0.50 D is targeted in the 36.6 ±1.4 dB in the monofocal group. Multifocal IOLs can decrease contrast nondominant or worse-seeing eye to In both MD and foveal threshold, there sensitivity, which is a problem in patients produce a mini-monovision effect. was a significant difference between the whose vision has been compromised by For patients with full visual fields, I bifocal and the EDOF and monofocal glaucoma or retinal disease. For patients implant a Lentis Comfort lens in the groups (P < .001) but no difference with glaucoma or retinal disease, my dominant eye and either a Lentis Mplus between the EDOF and the monofocal earliest choice of a presbyopia-correcting MF20 or MF30 in the contralateral eye, groups. In my experience, EDOF IOLs IOL was the Crystalens (Bausch + depending on the patient’s visual needs. afford a better quality of vision for my Lomb), which provided distance acuity I have been using this strategy for most patients who have glaucoma without comparable to that achieved with a of my patients and have found that it compromising visual field monitoring. monofocal IOL and better contrast enhances visual performance at both I have used the aforementioned sensitivity and uncorrected intermediate intermediate and near. strategy for patients with mild to visual acuity than a multifocal IOL.1 Compared with monofocal lenses, moderate glaucoma, those with a stable Later, I transitioned to using the EDOF IOLs do not seem to affect visual epiretinal membrane, and those with AT LISA 839 MP (Carl Zeiss Meditec) or field sensitivity. I have safely implanted stable diabetic macular edema.3 I seek the FineVision (PhysIOL) for patients EDOF IOLs in glaucoma patients with to maximize the visual potential of with relatively uncompromised central mild visual field loss not affecting the the better-seeing eye and to improve visual fields and stable glaucoma. central 10º. functional near and intermediate visual Takahashi et al2 compared the mean acuity in the worse-seeing eye. NOW deviation (MD) in eyes implanted with I look forward to using other EDOF Some of the latest presbyopia- bifocal, EDOF, and monofocal lenses. MD lenses and accommodating lenses correcting IOLs can improve near and was -0.24 ±0.58 dB in the EDOF group, when they become available in the intermediate visual acuity without -1.38 ±0.58 dB in the bifocal group, and Philippines, where I practice.

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1. Vilupuru S, Lin L, Pepose JS. Comparison of contrast sensitivity and FRANCIS RAYMOND MENDOZA-CASTOR, MD, n Attending surgeon, The Medical City through focus in small aperture inlay, accommodating intraocular lens or multifocal intraocular lens subjects. Am J. Ophthalmol. 2015;160:150-162. FPCS, FPAO South Luzon and Manila Doctors Hospital, 2. Takahashi M, Yamashiro C, Yoshimoto T. Influence of extended depth of n Member, Board of Directors, and former Philippines focus intraocular lenses on visual field sensitivity. PLoS One. 2020;15(9). 3. Grzybowski A, Kanclerz P, Tuuminen R. Multifocal intraocular lenses and Chairman, Department of Ophthalmology, n [email protected] retinal diseases. Graefes Arch Clin Exp Ophthalmol. 2020;258(4):805-813. Calamba Eye Center–Calamba Medical Center, n Financial disclosure: None Calamba City, Philippines

Current Technology Provides Excellent Results,

Newer Treatments Are on the Horizon ALAA ising life expectancy and a greater scotopic pupil. This algorithm addresses ELDANASOURY, dependence on digital devices induced spherical aberration, and it uses MD, FRCS have increased patients’ demand increased depth of focus from spherical for good functional vision at aberration and a mini-monovision Jeddah, Saudi distance, intermediate, and near. strategy to deliver excellent quality of Arabia RMy experience with laser treatments and vision and functional visual acuity at IOLs for presbyopia correction has led near, intermediate, and distance. me to recommend one of two options Study results. In a small study that my Three months after surgery, binocular to most of my patients: excimer laser colleagues and I conducted (unpublished uncorrected distance visual acuity was ablation using the Optimized Prolate data), 15 patients underwent bilateral 20/20 or better in 92% of patients. Ablation (OPA; Nidek) algorithm1 or LASIK using the Navex Quest excimer Binocular uncorrected near visual acuity implantation of a FineVision IOL. I base laser system (Nidek) with OPA and a was J3 or better in all of the patients my recommendation on the patient’s target of -0.30 µm of spherical aberration and J1 in 40%. No eye lost 2 or more age, lens status, occupation, and lifestyle. aimed at increasing the depth of focus lines of best-corrected distance visual for both eyes. The average age of acuity. Spherical aberration decreased by EXCIMER LASER ABLATION patients was 48 years, and the average -0.26 µm, and the modulation transfer The algorithm. The OPA ablation manifest refractive spherical equivalent function decreased by 0.03 for the cohort. algorithm incorporates patient-specific was -4.29 ±1.83 D. Full correction was Patient selection. In my experience, ocular spherical aberration, corneal planned for the dominant (distance) eye this ablation strategy is effective, topography, and corneal curvature and undercorrection of -0.50 D for the predictable, and safe for the correction to maintain a prolate cornea over a nondominant eye. of presbyopia in young patients with myopia who have no or only mild nuclear sclerosis and retain some accommodative reserve (Figure 1). IOL IMPLANTATION Study results. The FineVision diffractive trifocal IOL (Figure 2) is designed to address the drawbacks of bifocal IOLs and to enhance intermediate vision. In Figures 1–3 courtesy of Alaa Eldanasoury, MD, FRCS an unpublished study, my colleagues and I recently evaluated results in 38 patients who underwent bilateral Figure 1. Examinations (top, preoperative; bottom, 2 years Figure 2. Model POD F of the FineVision IOL in situ. implantation of spherical (model postoperative) of an eye that underwent LASIK using the This hydrophilic acrylic, apodized, one-piece, foldable, Optimized Prolate Ablation profile. Axial maps (left) show diffractive, aspheric IOL has a multizonal design. The POD F) and toric (model POD FT) a postoperative prolate cornea over the mesopic pupil diffractive steps, placed on the anterior surface of the versions of this aspheric IOL. The mean entrance. Aberrometry (center) of the entire eye shows lens, divide incoming light to create two additional add age of patients was 54.7 ±9.2 years. the induced negative spherical aberrations. Zernike graphs powers (+1.75 and +3.50 D) at the IOL plane corresponding Patients achieved excellent (right) show -0.25 µm of negative spherical aberration with to 80- and 40-cm foci, respectively. functional vision and objective visual a 6-mm pupil after surgery. quality (Figure 3). The mean manifest

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Patient selection. Trifocal IOL implantation and RLE are appropriate options for patients who have cataracts and for patients in whom laser vision correction and phakic IOL implantation are contraindicated. CONCLUSION The preoperative discussion of presbyopia correction with patients must address the inherent compromise of reduced Figure 3. Binocular defocus curve for 36 patients 6 months after binocular implantation optical quality and the potential for photic phenomena after of a diffractive trifocal IOL (models POD F and POD FT of the FineVision IOL). The curve surgery. It is important to ensure that patients have realistic presents a visual acuity of -0.07 logMAR with defocus of 0.00 D, simulating distance vision, expectations about the outcomes of presbyopia-correcting surgery. and -0.02 logMAR with defocus of -2.00 and -2.50 D, simulating 50 and 40 cm, respectively. In addition to the technologies I currently use, I look forward The intermediate logMAR visual acuity was 0, 0.02, and 0.06 with defocus of -0.50 D (2 m), to introducing the latest version of the EVO Visian ICL (STAAR -1.00 D (1 m), and -1.50 D (67 cm), respectively. Surgical), the EVO Viva presbyopia-correcting lens. Early results refractive spherical equivalent decreased from -1.82 ±5.15 D in patients with -0.50 to -20.00 D of presbyopic myopia have preoperatively to -0.01 ±0.54 D at 6 months. Binocular UCVA been promising. was 0.1 logMAR or better at 4 m in 32 patients (94%), at 80 cm 1. Eldanasoury A. NIDEK Optimized Prolate Ablation for the treatment of myopia with and without astigmatism. J Refract in 30 patients (83%), and at 40 cm in 28 patients (78%). Based Surg. 2009;25(1):S136-S141. on these results, we concluded that both IOL models provided excellent distance, intermediate, and near visual acuity. An informal patient survey indicated a high level of ALAA ELDANASOURY, MD, FRCS postoperative satisfaction. In general, patients reported that n Chief Medical Officer, Magrabi Hospitals and Centers, Jeddah, Saudi Arabia the benefits of spectacle independence for their daily activities n [email protected] outweighed the drawback of a slight reduction in vision quality. n Financial disclosure: Consultant (Nidek, PhysIOL, STAAR Surgical)

Excited For What’s to Come

ach of the current options for Postoperatively, neural adaptation can the correction of presbyopia has take up to 4 weeks. During this period, advantages and disadvantages. patients may experience some blurring ERIKA N. ESKINA, MD Selecting an approach depends on and a decrease in distance visual acuity. the patient’s expectations, precise Postsurgical observation of my Moscow, Russia Ediagnostics, the surgeon’s knowledge patients now extends beyond 5 years, of and experience with the technology and treatment has remained effective and its underlying principles, and the for that time.2 Theoretically, the effect accessibility of postoperative support of treatment could be preserved after MULTIFOCAL AND EDOF IOLS for the patient. I favor two strategies for the development of a cataract because The second strategy I use is RLE. correcting presbyopia, but I am excited of the stability of the corneal profile. Because this option is permanent, about a third on the horizon. I recommend this form of presbyopia it is essential to ensure that it will correction to patients whose crystalline satisfy the patient’s expectations and LASER ABLATION lenses are clear, who: visual needs both at present and in the Sphere Eye Clinic is a reference • Retain some accommodative future. It is also important to consider center for Schwind and Carl Zeiss amplitude; any concomitant diseases and their Meditec. My colleagues and I therefore • Have a strong desire for spectacle potential impact on visual function. have been working predominantly independence; and Generally, the decision in our practice with the Schwind CAM PresbyMax • Prioritize comfort and a long-lasting is mostly between bifocal and trifocal module (Schwind eye-tech-solutions), effect but are not ready to undergo IOLs, but we also implant EDOF lenses. which creates a multifocal cornea, intraocular surgery. Candidate selection takes into account induces slight anisometropia, and The software is designed to allow a patient’s need to drive at night, level extends depth of focus by increasing reversal of the procedure, but fortunately, of perfectionism, corneal spherical spherical aberration in the cornea.1 we have yet to test reversibility. aberration and ability to tolerate

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Monbl Augenheilkd. 2017;234(9):e29-e42. a period of neural adaptation, and THE HORIZON unwanted visual phenomena. An ideal solution to presbyopia It is important for surgeons to does not currently exist. I am excited, ERIKA N. ESKINA, MD understand the specifics of each lens however, about pharmaceutical agents n Head (CEO and Chief Doctor), Eye Clinic SPHERE, design, including light distribution, main (ie, presbyopia-correcting eye drops) in Moscow points of focus, and optics. We consider development for the treatment of this n Professor, Ophthalmology Department, Academy these parameters in conjunction with condition. of the Postgraduate Education FSBF FRCC of the the size and mobility of patients’ pupils 1. Eskina EN, Manjago T, Shkurenko IV, Rybakov PO, Parshina VA, Stepanova FMBA of Russia, Moscow MA. Experience of PRESBY LASIK operations on excimer laser system SCHWIND n [email protected] and their visual requirements. AMARIS. Prakticheskaja Medicina. 2012;1-4(59):55-58. 2. Pajic B, Massa H, Eskina EN. Presbyopiekorrektur mittels laserchirurgie. Klin n Financial disclosure: None

The Demand for Presbyopia Correction Is Growing ERIK L. he demand for presbyopia- Cornea-based procedures. Monovision MERTENS, MD, correcting procedures increases laser treatments such as PRK, FEBOPHTH year over year, and the surgical LASIK, SMILE, and SmartSight options keep expanding as a (Schwind eye-tech-solutions) correct the Antwerp, Belgium result. When the gradual loss of dominant eye for distance vision and Tvision interferes with simple everyday leave the nondominant eye nearsighted. tasks, including reading, looking at a The problems with this approach are smartphone or tablet, and working that depth perception may be affected on a computer, many patients and distance vision often is not as crisp find that it is time to seek a more as it could be. Careful preoperative lenses can be removed when patients permanent and convenient solution selection is therefore crucial. are not satisfied with the result. than reading glasses. This is especially Presbyopic LASIK (presby-LASIK) Some available options include the true today, when wearing a face mask procedures increase the magnitude of Implantable Phakic Contact Lens (IPCL, in public aggravates the drawbacks negative or positive spherical aberration Care Group), which has a diffractive associated with wearing glasses. in order to provide the eye with some optical zone of 5.8 mm and is available Before counseling patients on their multifocality. The same careful patient with near additions between +1.50 and options, I evaluate them for presbyopia selection as with monovision is required 4.00 D, and the EVO Viva ICL (STAAR with a simple eye exam. I then explain with this technique. Surgical), an EDOF posterior chamber to them that there are a lot of possible The implantation of corneal inlays phakic lens that uses higher-order solutions available to help them. I note is another option. However, these aberrations to smooth out the dips in that multifocal eyeglasses and multifocal implants require precise centration the defocus curve. Early clinical results or monovision contact lenses are simple during surgery, and they may decrease are encouraging.2 options for presbyopia correction and the patient’s distance vision and increase RLE may be performed when discuss with them the aesthetic concerns the risk of corneal haze, blurred vision, corneal laser surgery is not possible or and nuisances. Monovision contact starbursts, and refractive regression. For cannot achieve the desired refractive lenses can be problematic for those these reasons, I no longer offer corneal outcome.3 In some clinics, RLE is a who have a difficult time with neural inlays. Allograft inlays recently became controversial practice because the adaptation because visual acuity and available, and early reports suggest that risk of endophthalmitis can be more depth perception can be affected. they are well tolerated.1 As with corneal devastating than corneal infections after inlays, a precise implantation technique keratorefractive surgery. Moreover, RLE PREFERENCES is required. (Editor’s note: Allograft inlays may carry a higher risk of complications When patients express interest in will be covered in more detail in CRST’s such as retinal detachment than the surgical correction of presbyopia, February issue.) conventional cataract surgery, especially I recommend the solution that I think Lens-based procedures. Posterior in younger patients and those with is best suited for them. I do not have chamber phakic IOLs can be used to high myopia. a preference for one procedure over correct presbyopia. Patients typically Over the years, I have used many another in general, but I recognize that experience a fast visual recovery and different presbyopia-correcting all procedures involve a compromise. good refractive stability. Further, the IOLs, including bifocal, trifocal,

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EDOF, accommodating, hybrid, and correction depends on the patient’s age, rotationally asymmetric models. In the lifestyle, status of distance vision, and ERIK L. MERTENS, MD, FEBOPHTH end, I always come back to trifocal IOLs. personal preferences. n Medical Director and Physician CEO, In my hands, these lenses deliver the Medipolis-Antwerp Private Clinic, 1. Cummings AB. Allograft lenticules for the treatment of presbyopia. Cataract & highest rate of patient satisfaction. Refractive Surgery Today. 2019;6:76-80. Antwerp, Belgium 2. Packer M, Alfonso JF, Aramberri J, Elies D, Fernandez J, Mertens E. Performance and safety of the extended depth of focus implantable collamer lens (EDOF ICL) in n Chief Medical Editor, CRST Europe CONCLUSION phakic subjects with presbyopia. Clin Ophthalmol. 2020;14:2717-2730. n 3. Ang M, Gatinel D, Reinstein DZ, Mertens E, Alió Del Barrio JL, Alió JL. Refractive [email protected] The best solution for presbyopia surgery beyond 2020. Eye (Lond). July 24, 2020. doi:10.1038/s41433-020-1096-5 n Financial disclosure: None

Preferred Strategies in Mexico and a Personal Experience With RLE

ore than 25 million people (Carl Zeiss Meditec), so the adoption FRANCISCO SÁNCHEZ live in Mexico City, and the of the company’s Presbyond Laser LEON, MD, AND metropolitan area is considered Blended Vision procedure is low. Even the most competitive place refractive fellows within the country who ROCÍO SANCHEZ in the country in terms of have access to one of the company’s SANOJA, MD Mpracticing ophthalmology. Including us, excimer lasers are not convinced that there are close to 1,500 board-certified, this innovative corneal laser procedure Ciudad de registered ophthalmologists practicing is effective. In Latin America, the México in Mexico City but only a few biggest reason for the low adoption of colleagues with training in the latest Presbyond and other laser blended vision corneal laser and phaco techniques techniques is economic. to correct presbyopia. A variety of presbyopia-correction techniques LENS-BASED CORRECTION PREFERRED used in our country are described herein. The most popular approach to One of us (F.S.L.) was involved in the correcting presbyopia in Mexico is the AcrySof IQ PanOptix (Alcon), development of various corneal inlays, lens-based. Premium IOLs, including Liberty (Medicontour), and SeeLens including the Kamra (Figure 4; AcuFocus), multifocals, have been used for the past MF (Hanita). and their implantation techniques. decade for both cataract surgery and Although corneal inlays recently fell RLE. The latter is mainly performed on PRACTICE WHAT YOU PREACH out of favor, they may become popular patients who are at least 50 years of age. After seeing the positive results again if surgeons can learn to control Popular premium IOLs in Mexico— achieved by my patients, I (F.S.L.) the reproducibility of femtosecond laser and our preference—include the recently chose RLE for myself. My friend corneal dissection and to avoid scarring trifocal IOLs manufactured by and colleague Ricardo Acosta, MD, and the light scatter it causes. PhysIOL. With the introduction of performed my surgery at the Puerta Corneal procedures such as Intracor the company’s Triumf and IsoPure, de Hierro Hospital in Guadalajara (Bausch + Lomb) have also been this family of lenses represents a (Figures 5 and 6) in November 2020.* used to treat presbyopia with some complete portfolio of options, including A FineVision Tri Toric POD F IOL was success, but until femtosecond lasers hydrophilic, hydrophobic, EDOF, and implanted bilaterally. This apodized, incorporate both a visual axis eye tracker toric lenses. We also use the AT LISA, hydrophilic, diffractive IOL has a and a corneal remodeling lock, like the which is available in bifocal and double C-loop haptic design and 5º lasers used for CXL, these procedures trifocal designs. This IOL platform is a of angulation for excellent centration will not enjoy widespread popularity. good option when a patient needs a and stability. I chose a hydrophilic IOL Among the corneal laser-based surgical lens with an extremely low power or because it delivers fewer chromatic options for presbyopia correction, requires between 6.00 and 12.00 D of longitudinal aberrations compared monovision-planned excimer laser astigmatism correction. We are also to hydrophobic materials.1-3 The lens surgery is therefore still the most excited about the Tecnis Eyhance and features UV filtration and a blue-light common strategy used by refractive Tecnis Synergy IOLs (both from Johnson blocker. The optic body diameter is surgeons in Mexico. Very few clinics have & Johnson Vision), which should be 6 mm, and the overall diameter is the MEL 80 or 90 excimer laser platforms available in early 2021. We also use 11.4 mm. In addition to its far refractive

62 CATARACT & REFRACTIVE SURGERY TODAY | JANUARY 2021 GLOBAL PRACTICE PATTERNS s STRATEGIES FOR CORRECTING PRESBYOPIA

A B C Figures 4–7 courtesy of Francisco Sánchez Leon, MD

Figure 4. The Kamra corneal inlay in situ. Figure 5. Dr. Sánchez Leon undergoes RLE at Puerta de Hierro Hospital (A–C). power, the FineVision POD F provides two foci for intermediate and near visual acuity, with addition powers of 1.75 and 3.50 D, respectively.4 Combining laser cataract surgery and intraoperative aberrometry has been shown to optimize the positioning of a toric IOL.5 With keratometric astigmatism of 1.50 D in my right eye and 1.25 D in my left, I thought that this procedure was the best choice for my eyes. It has also been shown that eyes undergoing cataract extraction Figure 7. One week after his RLE procedure, Dr. Sánchez and implantation of a toric IOL aided Leon performs 26 cataract procedures in a single day. by intraoperative aberrometry are 2.4 times more likely to have less rates. We are sure that many of our than 0.50 D of residual astigmatism colleagues in Mexico will use presbyopia compared to standard methods of drops when they become available. 6 astigmatism correction. However, this 1. Bozukova D, Pagnoulle C, Jérôme C. Biomechanical and optical properties of 2 new hydrophobic platforms for intraocular lenses. J Cataract Refract Surg. procedure is cost-prohibitive for many 2013;39(9):1404-1414. patients in Mexico, so most RLE and 2. Vinas M, Dorronsoro C, Garzón N, Poyales F, Marcos S. In vivo subjective and objective longitudinal chromatic aberration after bilateral implantation of cataract surgery procedures here are the same design of hydrophobic and hydrophilic intraocular lenses. J Cataract Refract Surg. 2015;41(10):2115-2124. performed with a manual technique. 3. Poyales F, Garzón N, Pizarro D, Cobreces S, Hernández A. Stability and visual outcomes yielded by three intraocular trifocal lenses with same optical zone Figure 6. Dr. Acosta and his team perform laser cataract design but differing material or toricity. Eur J Ophthalmol. 2019;29(4):417-425. RESULTS 4. Loicq J, Willet N, Gatinel D. Topography and longitudinal chromatic aberration surgery on Dr. Sánchez Leon with intraoperative characterizations of refractive–diffractive multifocal intraocular lenses. J I had good near and distance visual aberrometry assistance to decide the magnitude and axial Cataract Refract Surg. 2019;45(11):1650-1659. 5. Orts P, Piñero DP, Aguilar S, Tañá P. Efficacy of astigmatic correction after acuity on postoperative day 1, even alignment of the chosen IOL. femtosecond laser-guided cataract surgery using intraoperative aberrometry when driving at night, and I had sharp in eyes with low-to-moderate levels of corneal astigmatism. Int Ophthalmol. 2020;40:1181-1189. visual acuity by postoperative day 7. In my near vision, and I enjoy clinic and 6. Hatch KM, Woodcock EC, Talamo JH. Intraocular lens power selection and positioning with and without intraoperative aberrometry. J Refract Surg. fact, 1 week after my RLE procedure, I surgery again. 2015;31(4):237-242. performed 26 cataract surgeries at our Novavision Acapulco Clinic without CONCLUSION a problem (Figure 7), and I noticed an Lens-based presbyopia correction FRANCISCO SÁNCHEZ LEON, MD increase in my 3D perception under the using a variety of premium IOLs is the n Medical Director, Novavision Laser Center, microscope. most popular technique in Mexico. A Ciudad de México Nine days after surgery, I performed manual RLE/cataract surgery procedure n [email protected] three penetrating keratoplasties, one is preferred over laser cataract n Financial disclosure: None deep anterior lamellar keratoplasty, and surgery with intraoperative aberrometry one Descemet stripping endothelial because of economic issues. ROCÍO SANCHEZ SANOJA, MD automated keratoplasty. At the time Cornea-based presbyopia correction n Opthalmology Resident, Fundación Conde de of this writing (2 weeks after surgery), with monovision is also common in Valenciana, Ciudad de México my visual acuity is excellent. I have this country, whereas laser procedures n [email protected] had a positive experience recovering such as Presbyond have low penetration n Financial disclosure: None

*Editor’s note: Dr. Sánchez Leon would like to share his deepest gratitude to Dr. Acosta and Lina Preciado, MD, both from Puerta de Hierro Hospital, for his near vision recovery and their professionalism and kindness. JANUARY 2021 | CATARACT & REFRACTIVE SURGERY TODAY 63 s GLOBAL PRACTICE PATTERNS STRATEGIES FOR CORRECTING PRESBYOPIA

Consider Long-Term, Evidence-Based Outcomes When Selecting a Procedure POOJA KHAMAR, he most common modality for essential. Evaporative and aqueous MD, PHD, FCRS; the treatment of presbyopia is deficient DED is increasingly prevalent SNEHA GUPTA, MD; spectacle correction.1 However, in older age groups.7,8 Assessments in the current era of refractive for DED are mandatory before any AND ROHIT SHETTY, surgery, the surgical correction presbyopia-correction surgery is planned. MD, PHD, FRCS Tof presbyopia has gained traction. Further, tear film quality may be assessed Presbyopia can be managed surgically quantitatively with the Optical Quality Bangalore, either through dynamic approaches that Analysis System (Visiometrics). India use the eye’s residual accommodative Pupil evaluation. Preoperative power such as accommodating IOLs pupillography plays a significant role and scleral expansion devices or through in planning central and peripheral static approaches that improve near presby-LASIK.9 Patients with poor or good choices for patients with myopia vision by increasing depth of focus such sluggish pupillary dilation are not good and emmetropia and that Supracor as monovision LASIK, presby-LASIK, candidates for presby-LASIK. (Bausch + Lomb), PresbyMax symmetric, corneal inlays, conductive keratoplasty, Orthoptic evaluation and assessment Custom Q (Alcon), and Presbyond Intracor, and lens-based surgery. of strabismus. These evaluations are are good choices for patients with There is a plethora of options in essential to prevent the postoperative hyperopia.5 Most of the time, presby- lens-based presbyopia correction, development of diplopia and eye strain LASIK is executed as a hybrid procedure including multifocal IOLs, monovision, and to detect latent nonstrabismic by incorporating some monovision. and phakic multifocal IOLs—although binocular vision anomalies.4 The algorithm in Figure 8 this last option is more suitable for Aberrometry. The measurement of outlines how we typically select the patients in their 40s.2,3 Variety exists refractive power with aberrometry presbyopia-correcting procedure for in the cornea-based approach of is necessary to assess the internal our patients. In our experience, patients presby-LASIK. Procedures in this aberrations, grade the dysfunctional lens with a normal dysfunctional lens index category can be divided into three syndrome,6 and detect the presence of (DLI), normal corneal topography, groups: central presby-LASIK, peripheral early cataractous changes.6,10,11 and good tolerance of monovision are presby-LASIK, and laser blended vision. Counseling. Patients should be best suited for monovision LASIK and counseled on the best type of treatment presby-LASIK. Patients with a normal DLI PATIENT SELECTION AND WORKFLOW for their eyes, and they should and suspicious findings on topography or Careful patient selection for the surgical understand the dynamic nature of ocular surface abnormalities tend to do correction of presbyopia is crucial.4-6 presbyopia versus the static nature of well with phakic IOLs. In patients with an This requires a thorough preoperative treatment. The amount of near vision impaired DLI, RLE with a monofocal or workup that includes general correction should be based on the multifocal IOL can be planned. considerations for presbyopia correction. patient’s profession and how much and Nonsurgical treatment of presbyopia Dominant eye. It is important to how long they perform near work. They in the form of eye drops is being identify the dominant eye, especially should be told that comparing the vision explored. Studies suggest that these eye when planning a monovision-based of both eyes is counterproductive and drops improve near vision by 2 to 3 lines procedure. For this, emmetropia that a neural adaptation period of up to without affecting distance vision,12 but is targeted in the dominant eye to 3 months should be expected. this approach requires further research. provide good distance vision, and the nondominant eye is targeted for low APPROACH TO PRESBY-LASIK AND CONCLUSION myopia to aid near vision. OTHER PROCEDURES Long-term, evidence-based outcomes Tolerance test. Patients must be able Outcomes with presby-LASIK depend should be considered before decisions on to tolerate anisometropia, especially with on the patient’s age, occupation, need the medical management of presbyopia monovision treatments. and type of near work, and personality. are made. We have found our current Dry eye evaluation. Evaluating Studies have shown that PresbyMax, protocol to be useful for selecting a patients for dry eye disease (DED) is Presbyond, and monovision LASIK are presbyopia-correcting procedure. n

64 CATARACT & REFRACTIVE SURGERY TODAY | JANUARY 2021 principles, planning, and outcomes. Indian J Ophthalmol. 2020;68(12):2723-2731. 6. Kaweri L, Wavikar C, James E, Pandit P, Bhuta N. Review of current status of refractive lens exchange and role of dysfunctional lens index as its new indication. Indian J Ophthalmol. 2020;68(12):2797-2803. 7. Schaumberg DA, Nichols JJ, Papas EB, Tong L, Uchino M, Nichols KK. The international workshop on meibomian gland dysfunction: report of the subcommittee on the epidemiology of, and associated risk factors for, MGD. Invest Ophthalmol Vis Sci. 2011;52:1994‑2005. 8. Herbaut A, Liang H, Denoyer A, Baudouin C, Labbé A. Tear film analysis and evaluation of optical quality: a review of the literature. J Fr Ophtalmol. 2019;42:e21‑35. 9. Wilhelm H, Wilhelm B. Clinical applications of pupillography. J Neuroophthalmol. 2003;23:42‑49. 10. Faria‑Correia F, Lopes B, Monteiro T, Franqueira N, Ambrósio R Jr. Scheimpflug lens densitometry and ocular wavefront aberra- tions in patients with mild nuclear cataract. J Cataract Refract Surg. 2016;42:405‑411. 11. Fernandez J, Rodriguez‑Vallejo M, Martinez J, Tauste A, Piñero DP. From presbyopia to cataracts: a critical review on dysfunc- tional lens syndrome. J Ophthalmol. 2018;2018:4318405. 12. Krader C. Topical drops show promise as treatment for presbyopia. Ophthalmology Times Europe. 2016;12:18-20.

SNEHA GUPTA, MD n Department of Cataract and Refractive Surgery, Narayana Nethralaya, Bangalore, India n Financial disclosure: None POOJA KHAMAR, MD, PHD, FCRS n Department of Cataract and Refractive Surgery, Narayana Nethralaya, Bangalore, India Courtesy of Sneha Gupta, MD; Pooja Khamar, MD, PhD, FRCS; and Rohit Shetty, MD, PhD, FRCS n [email protected] n Financial disclosure: None Figure 8. Algorithm for the selection of a presbyopia-correcting surgical procedure. ROHIT SHETTY, MD, PHD, FRCS 1. Wolffsohn JS, Davies LN. Presbyopia: effectiveness of correction strategies. Prog Retin Eye Res. 2019;68:124‑143. n Department of Cornea and Refractive Surgery, Narayana Nethralaya, 2. Charman WN. Developments in the correction of presbyopia II: surgical approaches. Ophthalmic Physiol Opt. 2014;34:397‑426. 3. Zare Mehrjerdi MA, Mohebbi M, Zandian M. Review of static approaches to surgical correction of presbyopia. J Ophthalmic Vis Bangalore, India Res. 2017;12:413‑418. 4. Muthu S, Jethani J, Annavajjhala S, Gupta S, Gupta K, Khamar P. Integrating binocular vision assessment in refractive surgery n [email protected] work-up: proposition and protocol. Indian J Ophthalmol. 2020;68(12):2835-2846. n 5. Shetty R, Brar S, Sharma M, Dadachanji Z, Lalgudi VG. PresbyLASIK: a review of PresbyMAX, Supracor, and laser blended vision: Financial disclosure: Research grants (Alcon, Carl Zeiss Meditec)

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