GLOBAL PRACTICE PATTERNS s STRATEGIES FOR CORRECTING PRESBYOPIA | 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, accommodation). 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 cataract surgery 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 astigmatism, 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 contact lens trial. TABLE 1. TOOLKIT FOR PRESBYOPIA* Caution is required when treating Equipment Application patients in the zone of emmetropia or low myopia (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. JANUARY 2021 | CATARACT & REFRACTIVE SURGERY TODAY 57 s GLOBAL PRACTICE PATTERNS STRATEGIES FOR CORRECTING PRESBYOPIA 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. 58 CATARACT & REFRACTIVE SURGERY TODAY | JANUARY 2021 GLOBAL PRACTICE PATTERNS s STRATEGIES FOR CORRECTING PRESBYOPIA 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).