CASE OVERVIEW
A 55-year-old male presented with an interest in vision correction surgery to improve both distance and near vision. He spends the majority of his working day on a computer or cell phone.
His refractive error in the right eye was +3.25 -0.75 x 145 with 20/20 vision, and in the left eye, it was +2.75 -1.25 x 130 with 20/20 vision. Corneal topography and macular OCT imaging were normal. He had no prior history of laser vision correction.
WHAT ARE THE REFRACTIVE TREATMENT OPTIONS?
1. LASIK
Although laser vision correction is an option with monovision, at 55 years of age, mild lens changes have typically developed, which interfere with quality of vision. In addition, his nondominant eye was his right eye, and to create monovision with reading in this eye, the hyperopic correction would be at the upper limit.
2. REFRACTIVE LENS EXCHANGE
This is a popular procedure today given advances in surgical techniques and implant designs to allow the full range of vision. It is typically performed in presbyopes. There are a variety of implant options:
- Multifocal implants: Patient satisfaction can be very high with reading at the level of J1 to J3 in both eyes, and good intermediate and distance vision. There is a risk of some halos and glare, especially at night, but this is typically mild and usually improves with time secondary to neuroadaptation. This type of implant is avoided in those that do a lot of night driving, have any corneal irregularity, or macular disease.
- Extended-depth of focus implants: A mini-monovision can be performed to achieve distance and near vision. Some experience positive dysphotopsias with the Vivity lens (Alcon) and occasionally limited near vision. The PureSee (Johnson and Johnson) is the newest lens approved in Canada, but some patients may not achieve satisfactory near vision. It is hoped that further clinical research will help determine eye characteristics (short eye, long eye, small pupil, large pupil, etc) that will allow for better selection of patients in this category of implant.
- Advanced monofocal lens: The Eyhance™ (Johnson and Johnson) typically provides excellent quality of vision, and a mini-mono vision can allow for distance and near vision.
- Light adjustable lens: A specialized silicone lens can be used to create mini-mono vision. The implant power is refined postoperatively with a UV light delivery system. Typically, one or two adjustments are performed after 17 days, followed by two lock-in treatments. It is a precise method of vision correction. Patients require a minimum pupil size of 5.3 mm so that the UV laser can reach the implant, usually low degrees of astigmatism (< 3 D), a commitment to wearing UV protection glasses outside during the process, and more followup visits.
WHAT WAS DONE:
The patient desired the full range of vision in each eye and chose a multifocal toric implant (PanOptix, Alcon). The implants were centered on the line of sight. The femtosecond laser was used to create a capsulotomy centered over the visual axis and divide the lens in to six segments. No phacoemulsification was required as the smaller lens pieces broken up by the femtosecond laser could be aspirated.
RESULT:
One week postoperatively he saw 20/20 in each eye and read J2. At 3 months postoperatively, the low degree of halos at night resolved. He was very pleased with his outcome and quality of vision. If his postop refractive error had not been ideal then LASIK or a piggyback lens could be performed at 2-3 months postop.
KEY CONSIDERATIONS:
- Patients should be fully informed of all available IOL options during the consent process.
- Many patients desire complete freedom from glasses for both distance and near vision. They often feel frustrated by needing reading glasses every time they check their cell phone, use a computer, or read a price tag.
- Multifocal IOLs differ in terms of reading and intermediate focal points, low-light reading ability, distance vision quality, and dysphotopsia rates.
- Neuroadaptation helps improve visual quality over time.
