Hyperopic refractive surgery still on a learning curve

An international round table discusses indications, options and results for hyperopic refractive surgery.

Differences between myopes and hyperopes

Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 710 E 24th St, Suite 106, Minneapolis, MN 55404; (612) 813-3600; fax (612) 813-3660; e-mail: rllindstrom@mneye.com. Dr. Lindstrom has no direct financial interest in the products mentioned in this article. He is a paid consultant for Bausch & Lomb, Visx, AMO, Refractec and C&C Vision.

Richard L. Lindstrom, MD: If we look at the demographics of hyperopia in the United States, about 24% of the population is myopic and about 26% of the population is hyperopic. So one would think that we should be doing an equal number of hyperopic as myopic surgeries. But if we look at the numbers we are doing much less hyperopic surgery. We are, however, getting a lot of new treatment options, and we’re learning more about the hyperopic patient and what they want out of refractive surgery.

Let’s talk about the typical hyperopic patient. What are their goals for refractive surgery, and how do they differ from myopes?

In our practice the typical myope is in the 35- to 40-year-old range. The typical hyperopic patient receiving surgery is in the 55-year-old age. So clearly the hyperope is an older patient.

What are their goals? The 35-year-old myopes, basically all their life they were not able to see things far away. Most of them have the goal that they want to see well in the distance. What about the hyperope? What are they looking for?

Daniel S. Durrie, MD: I see two different groups of hyperopes. The really hyperopic patients, the +4 D, the +7 D, are interested in getting rid of their glasses — just like our highly myopic patients. They’ve had poor vision all their life. They’re younger and more or less just like our myopic patients.

But the biggest group of patients has really had great vision all their life. Maybe they started losing it at age 35, or maybe not until 55, but they had good vision at one point, and it was a gradual loss. Eventually they get frustrated and hope something is available for them.

But most of them don’t know there are surgical options for hyperopia. We’ve spent 30 years telling the myopes that there are options, all the way back to radial keratotomy. If you’re myopic, you can get rid of it. A lot of hyperopes still don’t know that something can be done.

They are starting to come in more now, because we have been spending 4 or 5 years telling them that there is something. The percentage is constantly increasing.

Dr. Lindstrom: What percentage of what you do today is hyperopia?

Dr. Durrie: I’m fairly sure, even including conductive keratoplasty (CK), it’s still less than 10% of total patients. But it used to be 2%.

Michael C. Knorz, MD: I’d say it’s about 10% to 15% of all the refractive procedures I do are for hyperopes.

I agree with Dan, there are basically two groups of hyperopes. The higher hyperopes will probably call because their distance vision is poor, and they usually require procedures other than LASIK.

The more interesting group, and this is clearly underrepresented, is the low hyperopes. In my experience, they have a misconception. The age is about 40 to 45 when they come in, and their problem is that they can’t read without glasses, from +1 to +2 D. They feel that they cannot read very well, and they don’t really know yet that they don’t see well at distance. It’s difficult to explain to these patients what we’re going to do with them. They think they have no need for better distance vision, they feel they see well at distance.

David R. Hardten, MD, can be reached at 710 E 24th St, Suite 106, Minneapolis, MN 55404; (612) 813-3600; fax: (612) 813-3658; e-mail: dhardten@mneye.com. Dr. Hardten has no direct financial interest in the products mentioned in this article. He has participated in clinical trials for STAAR and Ophtec.

David R. Hardten, MD: And their need is progressive, not stable as it was for the past 20 or 30 years. They are going to get worse than they are now, and they don’t believe you when you tell them that.

Dr. Lindstrom: This is different from myopia, because myopes, by the time they’re 25 or 30 and –3, they’ve been –3 a long time, and the world looks about the same.

But for this group of patients, it’s changing every year. First, they can’t read, and then they have trouble with intermediate, then they can’t see in the distance. They accept the reading glasses, but when finally they’re wearing glasses all the time, even for distance, then they’re really unhappy.

Dr. Knorz: When these patients come in early, say at the age of 45, and they can still see well at distance but they cannot read, they will not sign up for surgery because they say, “Well, I can see well at distance. OK, you can make me see well for reading as well maybe for a couple of years, but that’s not what I need.”

So they do not sign up for LASIK surgery, and we lose them from a marketing perspective because we can’t explain to them. They come back, but it will not be until they can’t see at distance either.

Vance M. Thompson, MD: My experience is that people want what they don’t have. The myopes that have had a decent near image want good distance. The hyperopes, who haven’t had a good near image and maybe have progressed in presbyopia to reduced intermediate or even poor distance, they really want what they haven’t had, and that’s a near point of focus.

The presbyopic myopes are more willing to wear reading glasses and go for good distance and intermediate, and some want to do monovision if they did that with contact lenses.

So I find there’s more interest in addressing the reading issue in low presbyopic hyperopes than in my myopic population, which has been able to enjoy that near image but has not had good distance.

Elizabeth A. Davis, MD, FACS, can be reached at Minnesota Eye Consultants, 710 E 24th St, Minneapolis, MN 55404: (952) 885-2467; fax: (952) 885-9942; e-mail: eadavis@mneye.com. Dr. Davis has no direct financial interest in the products mentioned in this article. She is a paid consultant for AMO.

Elizabeth A. Davis, MD, FACS: The hyperopes focus, as Michael said, primarily on their near vision, even though they’re progressively discovering hyperopia is affecting their distance vision. They’ll still say that they have excellent vision when it’s only 20/30 or 20/40. It’s almost as if they don’t want to admit it. Maybe they see well at infinity, but otherwise they’re not seeing well.

But from their perspective, distance vision is not a problem, even though it has started to become one. Their main focus is on their near vision since it’s aggravated that much more.

Dr. Lindstrom: So, we talk about real estate being location, location, location. For myopia it’s good distance, distance, distance. But for the 55-year-old hyperope, it’s near, near, near.

Dr. Durrie: It’s really important that people understand this. If you take on the +3, even +4 hyperope and make them 20/20 at distance, they’re not happy because they still can’t read. I have several patients like this. I show them how bad their vision was, with 20/200 at distance, but they say, “I want my money back. I can’t read.”

I am now counseling my hyperopes differently, even the ones I think I can make better at distance. I’m not quite sure I can make them happy unless I can make their near vision good without sacrificing their distance vision. It is a complicated group of patients.

Dr. Hardten: Unlike the myope, they’re not willing to sacrifice. The myope is willing to sacrifice near for distance. The hyperope is not willing to sacrifice distance for near because distance never was a problem for them until recent time. So they want both. And they are more demanding.

R. Bruce Wallace, MD: The 45-year-old hyperope is going to be a tough sell because they still have reasonable near vision. They’re not as committed to reading glasses as the 55-year-old. People over age 50 will be the most unhappy with their near vision and distance vision as well, if they have low levels of hyperopia.

Another point is that these hyperopes don’t identify themselves as spectacle wearers. Most myopes have been wearing glasses since teenage years. When the hyperopes start to become dependent on glasses, that’s not their self-identity. And so for them it is something to keep inside. Maybe they’re not coming to see us because they’re keeping it inside, not voicing their concerns, but they are there. Once they get to age 50 and they can’t see their watch, their cell phone, that’s when they get concerned, but they don’t know anything is out there to help them.

Dr. Lindstrom: Many myopes have seen an eye doctor once a year their whole life, and a lot of hyperopes have never seen an eye doctor.

Dr. Hardten: We interact more in our practices day by day with the myopes, but even the myopes who have had surgery don’t think it’s available for hyperopia. Many myopes will say, “My husband is farsighted, and I know there’s nothing you can do for him.” And the husband comes in and he is +1.5, and there are options.

Marketing

Dr. Lindstrom: Let’s talk about marketing to this population. We’ve established that there are all these hyperopes out there, low hyperopes/early presbyopes with mild latent hyperopia, who have a meaningful handicap, and many of them haven’t seen an eye doctor for 10 or 12 years. What are you doing to get the word out that there’s something available for them, before we even talk about what it is?

Dr. Durrie: Marketing for these patients is simple: “If you can’t read this ad without your reading glasses, we may have something for you. If you can’t read this ad, you may need CK.”

Even the +3 hyperope is not going to come in unless you talk about their reading vision. Now that we’ve figured that out, hyperopia surgery is starting to get more interest. The old line, “If you want to get rid of your glasses, …” they don’t get that. It has to involve their reading vision to tweak their interest.

Dr. Lindstrom: When we first started with laser refractive surgery for myopia, we all did awareness marketing to let people know it existed. Many people today have quit doing much external marketing for myopia. They haven’t found it valuable. Do you think we need awareness marketing to let the hyperopes know there’s something for them? Is it like it was on the myopic side 8 or 10 years ago?

Dr. Thompson: I’m not doing much hyperopia-specific marketing, but I would echo that awareness needs to be addressed because so many of them don’t think they have an option.

I plan on marketing to a different demographic also, because my demographics for myopia have been a younger patient population than what we’re planning on doing for hyperopia.

Dr. Wallace:We’ve done marketing for CK, and I’m frankly surprised that we haven’t seen as much response as we expected. The Refractec people say they’ve seen this in other markets like ours. Maybe we’re just not approaching the patients properly and not using the right buzzwords. I’m not an expert in that area. But I want people to know that there are products available, such as CK and presbyopic lens exchange (PRELEX) so they can make their own choice.

Vance M. Thompson, MD, can be reached at Ophthalmology, Ltd, 1200 S Euclid Ave, Suite 104, Medical Building 1, Sioux Falls, SD 57105; (605) 336-6294; fax: (605) 336-6970. Ocular Surgery News could not confirm whether Dr. Thompson has a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.

Dr. Thompson:A little marketing gets a little response, and a lot of marketing gets a lot of response.

Dr. Wallace: We’ve done, let’s say, initial marketing. You’re right, we need to give it more time. It takes months to years for this to work.

Dr. Thompson: It’s going to be an investment well worth it. I see this as our future.

Dr. Lindstrom: The opportunity is large because the baby boom wave is now presbyopic, and 26% of them are hyperopic. And they’re fairly affluent and can afford the options.

We are going to have to do some awareness marketing. We tried some hyperopic marketing talking about hyperopia, and we got nowhere. Dan, you really have it right. A simple ad to say that there’s something for people who have trouble reading without glasses.

Dr. Durrie: And I don’t think a typical ad on the radio is going to be as effective as things that focus on their reading problem. We just ordered magazine covers for our magazines. “If you need reading glasses to read this magazine, ask us about CK.” Our local Cheesecake Factory now has our ad in their menus. “If you need reading glasses to read this menu … .”

I’m trying to get more focused. I think we have to be creative because these patients are not going to respond to a TV, radio or print ad in the same way.

Dr. Thompson: That’s interesting. All our myopia marketing is at a distance — the TV, billboards. Dan’s hyperopia advertising is at the problem distance, on magazines and menus. That’s a great point.

Dr. Knorz: But on the other hand, the procedure cannot cure the disease you are marketing for. We seem to market this for presbyopia, and we know presbyopia will affect their reading vision more in the future. The cure will not be a lasting one. That’s one of the dilemmas I see in Europe and Germany especially. We do not do any targeted marketing for hyperopic patients because we need to address presbyopia absolutely.

We have to market that they cannot read, and that’s what they come for, but that’s something we cannot treat. So once they’re in, we have to explain that reading will get better for a couple of years, but it’s not a lasting effect. So I see a dilemma here, and I’m a little careful with marketing.

Dr. Wallace: It gets back to the basic eye exam, and how often we’re measuring near vision and paying attention to it. In the typical ophthalmology practice, they check near vision on initial exam, but on an ongoing basis it’s not something people pay much attention to. Consequently, even after surgery when someone has these procedures performed, near vision is not looked at as carefully as would be the myopic correction for distance vision. So we have to go through a paradigm shift on measuring as well.

The pre-presbyopic patient

Dr. Lindstrom: Let’s talk about three groups of hyperopic patients. The first group is the plano to +1 D presbyope, which is about two-thirds of the presbyopic market. The second group is +1 D to +3 D, which is about 30% of the market. And the third group, when you get out to two standard deviations, is +3 D and more, and there is only 5% of patients over +3 D.

Let’s look at these groups starting with the third first. As we said earlier, the high hyperope often comes in at a younger age. Some might cut it off at 3 D, some might cut it off at 4 D. Let’s say 3.25 D and up. Start with the younger, nonpresbyopic high hyperopes that still have accommodation but are dependent on glasses for distance and near.

What procedures do you like? Also talk about any special elements in the workup that would be appropriate.

Dr. Knorz: For the very high hyperope in the pre-presbyopic age, I would recommend a phakic IOL. That’s OK for Europe, but it’s not available in the States. A phakic IOL would be my first choice. This is limited in that the anterior chamber is too shallow in about 60% or 50% of hyperopic patients, because of pushout of the anterior chamber.

Another option is refractive lens exchange, but I do not encourage that at a younger age. I’ll do it if they insist, but it’s not a recommended technique. I’d say, “Well, refractive lens exchange is an option, but you may decide not to have it because you lose accommodation.”

Dr. Davis: I agree with Michael. That would be my initial choice, although I will go up to +4 D with hyperopic LASIK. Because these patients are so visually impaired, they’re less picky than the myopic patients. A well-done LASIK in the +3 to +4 range can still be successful.

Tobias H. Neuhann, MD, can be reached at 8 Marienplatz, Munich, 80331 Germany; (49) 89-230-8890; fax: (49) 89-230-8896; e-mail: tneuhann@aol.com. Dr. Neuhann has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Tobias H. Neuhann, MD: My recommendation is the same, phakic IOL. If there is no possibility to implant a phakic IOL, and the patient insists to have this treated, let’s say a +8 D or +10 D, then I would go to the accommodative IOL and refractive lens exchange. We have seen now after 2 years that these lenses will work, and they have an accommodative range. It depends on the patient, and it depends on what he is motivated to do. If it is a clever patient who wants to read and starts to use this lens, then he can read.

Dr. Lindstrom: The impression I get as I look at the data is that accommodating IOLs work better in younger patients. Has that been your experience?

Dr. Neuhann: Absolutely. But it’s not that you can say, “He has an accommodative range of 2 D, and this one is 3 D, and this guy has only 1 D.” You don’t know preoperatively. Our results show that if the lens is in both eyes, it works better than in only one eye.

Dr. Lindstrom: Do you ever consider a multifocal lens implant in these patients, or would you always use an accommodating IOL?

Dr. Neuhann: I have used multifocal IOLs, and I chose the wrong patients. They were clever. They were intelligent. They wanted to read. And of 11 lenses, I had to remove eight. And when I exchanged them to a normal silicone lens, these patients said the impression was like a new cataract surgery, their improvement and quality of vision was that great.

And the fault was not of the patients, it was mine. I chose the wrong patients. They were about 50, 55, 60. With these patients, you can implant the accommodative lens. You have to motivate them to use the lens. This was what we did wrong in the early studies. We wanted these patients to have accommodative range. It didn’t work really, so we prescribed normal reading glasses, 2.5 D. This was wrong. Now the reading glasses we prescribe are between 0 D and 1.5 D, not 2.5 D.

Dr. Knorz: My experience is just the opposite. I’m not using accommodative IOLs because I have found their amplitude of accommodation insufficient.

My lens of choice in these hyperopes is a multifocal, usually the AMO Array, which is also available in the United States.

I agree patient selection is the key issue. I usually show a video available from AMO, which shows the patient what night driving is like. I find, in this population, in hyperopic patients motivated to have the surgery, the results are perfect. I would assume that the patients Dr. Neuhann had problems with were cataract patients and not refractive lens exchanges.

Dr. Neuhann: Yes, that’s right.

Dr. Knorz: That’s a different story. If you have a high hyperopic patient, his acceptance of an Array multifocal lens is much better than a cataract patient. A totally different motivation.

Dr. Lindstrom: A key issue with extreme hyperopes is anterior chamber depth. Michael, you mentioned that maybe half of them don’t qualify. David, what have you found?

Dr. Hardten: Less than that. We’ve done screening for hyperopic phakic IOLs now for 2.5 years for investigational studies. Within the FDA studies, we’re restricted to an anterior chamber depth of at least 2.8 mm from the endothelium, 3.2 mm from the epithelium. In our practice, only one in 10 qualify.

Maybe it’s just the patient population that’s coming in because of the study. Maybe it’s because we’re choosing the higher hyperopes. I think the average range that we screen is a +5 D, not a +3 or a +4, because we’re comfortable doing LASIK up to +3 or +4, and because it’s investigational and we don’t want to go through the extra work if we can do LASIK. So our average range is shifted up.

But for every 10 that we screen, we get only one patient who meets the anterior chamber depth criteria.

Dr. Lindstrom: If we look at the numbers objectively, even in that group of patients where only one in 10 qualify, the complication rate in phakic IOLs is much higher with the hyperopic eye than the myopic eye, probably because it’s a more crowded anterior segment.

Whether it’s pupillary block, secondary cataract, endothelial cell loss or chronic inflammation, the complication rate in the studies I have seen is three to four times more in the hyperope than it is in the myope.

So for most of these patients, nine out of 10 will not qualify for a phakic IOL, and even then I’m nervous about the complication rate. It’s either tell them no surgery or consider refractive lensectomy.

Bruce, are you comfortable with refractive lensectomy in the pre-presbyopic eye with high hyperopia?

Dr. Wallace: A patient came in to me, a farmer in central Louisiana, contact lens intolerant, 35 years old, very unhappy with his +3 D hyperopia. We did a lens exchange with an Array lens, and he did extremely well.

Younger patients tend to adjust to this new vision system. We have to plant the seed and let them understand that this is not like the vision they had before. Their brains learn to sort this out — that when they’re looking at distance they want to use the distance portion of the lens, and if they want to look at something close they tune out the distance portion and look at the near.

That takes them awhile. In the younger patient, it may be days to weeks. For an older patient, more like months. But once they’re there, they do well.

And their near visions are at a high level. J1s are common in this group. I’m not sure I can explain it. It may be that there’s a little bit of accommodative effect in the lens itself, rather than just the multifocal optics that gives a little boost because they’re younger. Whatever reason, they tend to adapt well.

So the handful of patients I have seen in this category have done well, but we have to be cautious. Obviously, this is more surgery than some other procedures. I’m not sure it’s much more surgery than a phakic IOL, though, with the newer techniques we have for lens removal.

The presbyopic patient

Dr. Lindstrom: Let’s move now to the presbyopic +4 patient. Will you still consider a phakic IOL in a presbyopic patient?

Michael C. Knorz, MD, can be reached at University Eye Hospital, Klinikum Mannheim, Theodor Kutzer Ufer 1-3, 68167 Mannheim, Germany; (49) 621-383-3410; fax: (49) 621-383-1984; e-mail: knorz@eyes.de. Dr. Knorz has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Dr. Knorz: No. In a presbyopic patient, my first choice always is refractive lens exchange and a multifocal IOL. Remember what their need usually is; they come in because they want to see near. So what we want to do is give them near vision. Even with a monofocal IOL, they are by far not as happy as when they have the multifocal.

It’s just like when you correct these +3 patients and they can see well at distance but they’re still not happy. They want to read. So these are usually not patients for LASIK. They’re patients for refractive lens exchange with the multifocal, not any IOL. It must be multifocal or maybe accommodative.

Dr. Lindstrom: We probably are slowly advancing toward a different definition of cataract. A 55-year-old lens is not giving the quality of vision that a 20-year-old lens did, when we look at mesopic contrast sensitivity, etc. So, while it’s maybe a 20/20-minus on the Snellen chart, a lot of those 55-year-old patients have a mild cataract as well. And then is there anyone who doesn’t favor refractive lensectomy?

Dr. Hardten: I think in that population, the LASIK limit goes down. So for example, in a 55-year-old hyperopic patient, I’m not nearly as willing to go to LASIK for +4 as I would be in a 25-year-old hyperopic patient. In a 55-year-old, my LASIK limit ratchets down to maybe not more than 1.5 D or 2 D, whereas in the pre-presbyopic group I’m more willing to go to 3 D or 4 D. It’s not really addressing the second half of what they want, which is near vision.

Dr. Durrie: Another thing, too, is that this population really gets dry eyes from LASIK. It is definitely worse. Especially postmenopausal women will have longer and more severe transient dry eye, so that gives the lens procedures an advantage. They’re not disrupting the corneal nerves as much.

The moderate hyperope

Dr. Lindstrom: Let’s take now the +1 D to +4 D patient or, for me, the +1 D to +3 D range patient. I’m not going to break it into the two age groups this time. Tell me the typical age group you’re seeing these patients in, and then what your thought process is for alternatives. Certainly age makes a difference, but when do you usually see them?

Dr. Hardten: That population of patients has started to come in more often in the past year and half than they did 2 or 3 years ago. We’re seeing either some benefit of word of mouth or of the marketing we’ve done.

But in that patient population, the average age is 50 to 55. The younger ones have the higher error, toward the +3 end. I agree, I rarely go over +3 with LASIK in that group of patients. That’s the range that I like LASIK in, especially in the younger patients.

We are seeing more of those patients than we did a few years ago, but it’s still not proportionate to what you would think the demand should be.

Dr. Lindstrom: If they are 50 to 55, what refractive result are you targeting to make them get both distance and near vision?

Dr. Hardten: If they’re over 40 I have a serious discussion with them about their goals. Is their goal to have distance vision with the recognition that they are going to need near correction? Do they want the technology that gives them both distance and near, such as either an accommodative or multifocal IOL? Of course, now even with LASIK we get some boost at near because of the augmented prolate shape with the system we use.

It’s a complex discussion because if I’m going to do a refractive lensectomy I’d rather do that now. If I do a LASIK now, then in 5 years when they become more presbyopic, I may have to go back and do a second procedure, a refractive lensectomy.

With the two procedures you have separate issues. You’ve got extra variability regarding your IOL power calculations with refractive lensectomy. And with LASIK you’ve got the dry eye issues that Dan mentioned. So even at age 43 or 44, if they’re going to do something I’d rather do it just once. It’s a complex decision because I think you have to cover presbyopia for that patient population.

Dr. Durrie: For me, this is my laser range. This is the time. The younger patient who can still accommodate, who is in the +1 to +3 range, they do quite well with the lasers we have now. They should be counseled in regard to the balance between near and distance. But I do monovision on them routinely and overcorrect the nondominant eye to about a –1 D, –1.25 D. I almost make them go that direction, because I know that if I just correct them at distance I’m going to be back doing something else soon. We sometimes do contact lens trials to show them what monovision is like and have long discussions with them. But lasers do very well in this population.

I am doing more surface ablation in these patients. If they have blepharitis or dry eyes, I’ll do it on the surface. With the new lasers, I get good results with surface ablation for hyperopia. PRK is not a bad word anymore. It was for a while, but I think we’re more comfortable with it again. Our European colleagues have been smarter than we have with this for a long time.

As David said, with older patients you have to look at their cataracts and ask them about their family history. If they’ve got a strong family history of cataracts it might be a good idea to lean them in the direction of refractive lensectomy if they’re in the presbyopic age group.

Dr. Thompson: I’m wary about doing LASIK in people after the age of 55, even if I don’t see much lens change. I definitely don’t do people in their 60s anymore, even the low errors that I used to consider kind of slam-dunk happy patients. There’s just something about the way hyperopic LASIK focuses those light rays. I don’t know if it’s focused more into the nuclear portion of the lens or what. It seems like it’s easy for those patients to end up unhappy.

I actually have reversed a few 60-year-old low dioptric hyperopes. Two were referred to me, one was my own. And then I went for their lens and made them happy. So those early 60-year-old people, even the 1 D and 2 D hyperopes where I wouldn’t have dreamt of going for their lens a few years ago, I now will go for their lens.

In the 50-year-olds, I feel comfortable with refractive lensectomy. In the presbyopic 40-year-old, even 46, 47, I still have a hard time with refractive lensectomy at that age, and I consider a phakic IOL.

And in hyperopes of any patient population, once they get over +3 or +4, if they’re happy with a contact lens, I have them consider continuing to wear it because these technologies seems to be unfolding so rapidly.

Like others here, for people in the pre-presbyopic age range, I’m comfortable with LASIK up to 3 D. I’ll consider it up to 4 D if they have flat corneas.

Dr. Lindstrom: It is important to expand on this concept of reversal that you mentioned. I had a few patients early on in the hyperopic LASIK trials in whom I did +4 D, +5 D, +6 D treatments and created a lot of central steepening with symptoms from dryness over that apex. Even though they were 20/20 distance, J1 near, they weren’t happy with the quality of their vision. In those patients, you’re right, if you flatten the cornea back out again and then address their lens, they are much happier with the quality of their vision.

We may be afraid to do that because, obviously, you have to get it perfectly centered and so on, but that’s a useful technique to reestablish the prolate cornea and then address their error with lens surgery.

Dr. Thompson: I’ve found that the people who don’t like having their corneas steepened are those with early nuclear sclerosis, even if it’s tough to perceive, and people with steep corneas. Steepening the steep cornea, it starts to act like a cone.

Dr. Davis: Something else to consider: If the patient does not want an intraocular procedure, or if they have dry eyes, or if you’re concerned about future IOL calculations, CK is an option if the patient doesn’t have a lot of astigmatism. The advantages are that you’re going to have a lower incidence of dry eye; to the patient, it appears noninvasive; and for your IOL calculations, you’re not changing the corneal thickness. But really the patient should have minimal astigmatism for CK.

Dr. Lindstrom: In how high hyperopia will you attempt CK?

Dr. Davis: I’ll go up to between 2.5 D and 3 D if it’s a well-done cycloplegic refraction and I’m addressing most of the hyperopia. Probably no more because that’s a maximal treatment, and you’re not going to be able to enhance beyond that. If the patient still wants correction, you’re going to have to do LASIK for any residual amount. But in the patient with that refractive error you can’t offer them monovision because you can’t go much further.

Dr. Lindstrom: Although you can do a LASIK in one eye and CK in the other. Dan, what’s your max for CK?

Dr. Durrie: As I’ve been doing more and more CK, I’m doing it for lower and lower levels. I’m also doing more of them because I’m doing that next group we’re going to talk about, which is the low hyperopes. But I’ve found, as Liz alluded to, that if they’re +2 D or +2.25 D, I can get them to see at distance, and then they come back and say, “I can’t read.” I can’t get enough with CK to get them over on the reading side.

So I really limit it to patients that I can get over to –1 D to –1.25 D in the nondominant eye, which means about +1 D. That gives me enough room to give them some reading vision.

That’s pretty much my upper limit. I don’t do people who wear glasses for distance. That’s an easy screening tool. If they wear glasses at distance, I don’t do CK. If they need only reading glasses, they fall in the CK candidate group.

Dr. Neuhann: We talk so much about lens exchange at the age where the human lens becomes a blue light filter. We remove the lenses at that point where the protection from the retina for our fovea goes back and the human lens becomes the blue filter. And the fovea is still healthy. When we remove the lenses at this age, which lens shall we implant? And since we have the Alcon AcrySof Natural lens now, I think it is important that we implant these new lenses with this filter, because they have no disadvantage and only advantage.

Dr. Knorz: Is there good science showing that a yellow filter will actually lower the risk of maculopathy? I think this is anecdotal right now.

Dr. Neuhann: I don’t think it’s really proved that the IOL mimics the human lens at that time. But there’s absolutely no disadvantage because the lens is otherwise identical to the regular AcrySof.

Dr. Lindstrom: Well, there is a small disadvantage. Before any ophthalmologist chooses to widely implant those lenses, they should buy themselves a pair of Dow-Corning CPF-450 eyeglasses and walk around during the day and at night with them. They should try to read in a dark environment, like in a restaurant, with them on. They should try to drive at night. And they should look at the color perception with them on. And then you can get an insight and see whether or not they really like that vision.

When you say there’s no disadvantage, I would suggest to you that if you put the Dow-Corning CPF-450s on when you’re driving at night, you’re going to see differently than you do without them. That is basically what you’re implanting. And if we really believe that as ophthalmologists, we can also prescribe it as an eyeglass for them to wear during the day, and then at night when they’re driving or in their restaurant trying to read a menu, they don’t have to wear it. I think the science is very soft.

Dr. Knorz: It’s very soft, and I disagree that we should take up something that is, in my opinion, mainly a marketing thing, and recommend it. I would say no, let’s wait for the science. There is some indication, but far from any proof.

Dr. Thompson: In the United States there is a randomized trial of that implant, funded by the National Eye Institute, beginning in patients with early drusen. It is randomized based on the two different eyes, and it is being done to address that issue. They looked at the number of eyes it will take to actually prove a benefit, and it’s a huge number.

The low hyperope

Dr. Lindstrom: Let’s move to the last group, which is plano to +1.

Daniel S. Durrie, MD, can be reached at Durrie Vision, 5520 College Blvd, Suite 200, Overland Park, KS 66211; (913) 491-3737; fax: (913) 491-9650; e-mail: ddurrie@hunkeler.com. Dr. Durrie has no direct financial interest in the products mentioned in this article. He is a paid consultant for Bausch & Lomb, Alcon, Refractec and Ophtec.

Dr. Durrie: This is probably the most interesting and exciting thing that’s happened lately, the emergence of this group of people who are plano to +1 and are 53 to 55 years old. They are tired of their reading glasses, and they are a unique group because they are extremely conservative. They don’t want to have surgery of any kind, and one of their prized possessions all their life has been their distance vision. To even think about having surgery is a major event for them.

That’s where CK has fit in. I’m not saying this is the cure-all or the greatest thing in the world from a scientific standpoint, but from the patient’s standpoint, they like something that’s not cutting, that doesn’t give them dry eyes, that can be done in the office and doesn’t cost very much.

They don’t want to think of it as surgery, they want to think of it as like having their teeth whitened. It’s an anti-aging thing to them. They do dye their hair. They do get their teeth whitened, and they do have Botox injections. They do go on diets and all these other things to try to avoid the normal aging changes.

This has been pretty fascinating because I’m not good at that. I’m not in the Botox business, not in the cosmetic business. So it’s been interesting to talk to these patients. They’re starting to come in a lot. And CK is the first of many presbyopia procedures that will start bringing these patients in. I’ve been enjoying watching these patients get what they wanted.

One thing we do for these patients, which has to do with meeting their needs, is we don’t use eye charts. We show them certain props. We show them a golf card. Can you read this? Can you read a menu? Can you read the phone book? And then afterwards, at 3 months, we show them all those and they can read them, and they’re excited about their procedure.

With a near card, they always want to read that top line that they can’t read, but this shows them that they really get functional vision.

So in the CK patients I do, I talk to them about vision for living, reading a menu, writing a check, dialing a telephone, reading your cell phone. All those things they seem to accomplish quite easily with CK.

In the patients I select, I only do 16 spots in one eye. I give them a little bit of near vision, and then I’ve got lots of room to do things in the future. And I tell them they’ll come back and see me again later as they get older.

Dr. Lindstrom: Tell them they need a second treatment.

Dr. Durrie:I tell them they will need a second treatment, and I’ll be around to help them then. If you told your myopic patients they need a second treatment, they go to somebody else to operate on them. So this is definitely a different group of patients.

Dr. Wallace: What if they come in when they’re 60?

Dr. Durrie: I don’t treat them any differently if they’re 60, as long as they don’t have any cataract. I agree with what everybody has been saying. CK doesn’t work on a cataract patient either. If they have a cataract or if they have a history of it, they should go the lens exchange route. But I don’t treat the 48-year-old any different from the 60-year-old. I do the same.

Dr. Lindstrom: You still target –1 D and still do just one eye?

Dr. Durrie: Yes, and still target –1. And we have a lot of 60-year-olds with this procedure that are very happy. Some that were in the clinical trials that we did 3 years ago are still reading without their glasses 3 years later.

Dr. Lindstrom: Do you ever do LASIK in that age group, in that range?

Dr. Durrie: I had LASIK, and I was a presbyope. I tell them that’s the procedure I had done, but these patients say, “Well, I don’t want LASIK. What else do you have?”

Dr. Lindstrom: What preoperative screening you do on those patients? The 50-year-old with +0.5 D hyperopia, not wearing glasses. Do you do a contact lens trial?

Dr. Durrie:These patients respond well to interaction. Glenn Strauss taught me this. You give them a +1.5 D lens and say, “How do you like that?” And they try it up close and they try it at distance. That actually works better than a contact lens trial. If the patient puts it in and says, “Oh, I don’t like that. That really hurts my distance vision,” I don’t even talk about it anymore. But if they say, “Well, I don’t see any difference at distance,” and “Boy that’s really great. If you can make me see like that I’d really like it,” then that’s good. And I’ve only given them +1.5 D. The data shows they’re going to see more like +2.25 D. So you’re going to underpromise.

If the patient has a personality I’m worried about, then I’ll put them in a contact lens trial after that. But in general I don’t have to. The loose lens test seems to be a better test at the screening stage. You certainly don’t want to operate on somebody if you’re going to hurt their distance vision.

Dr. Hardten: I have a pair of the cheap readers that I give to my LASIK presbyope patients. I pop the right lens out of a +1.25 D spectacle. And I have another one in the lane that has the left lens popped out. I have them try them on and do the reading, the distance. And they walk around the office, sit out there in the waiting room for awhile. And if they like it, then they like it. If they don’t, then the discussion is different.

Dr. Durrie: I think this is important. I have done CK on somebody that I had to reverse because I didn’t do a good screening and they didn’t get what they wanted. You have to screen these patients very well.

But the loose lens test seems to be very interactive, and then you can give them a +2.5 D and see what it does to their distance vision. If +2.5 D doesn’t bother their distance vision at all, you know they’re going to do well. It is a nice little test.

Dr. Lindstrom: Probably the +1.5 is enough.

Dr. Durrie:Yes. It’s a good test. I like David’s idea, too, because sometimes they don’t hold the lens right or they move it back and forth. But just putting on the glasses with one lens would be convenient.

Dr. Lindstrom: Is anybody else here doing the same thing with LASIK or PRK in that patient group?

Dr. Knorz: I have no experience with CK or laser thermokeratoplasty, but I do exactly the same thing with LASIK or PRK. Usually it’s LASIK.

Basically we’re talking about monovision. In these patients, remember, the target is they want to read without glasses. If I can fulfill this goal with monovision, OK, I will do that in the respective eye of that patient.

However, my experience is that in these patients that response is unlikely. Maybe German patients do not like monovision. I have found that less than 10% of my patients like monovision, which I understand is totally different from what you find in the States.

So with these patients, at least over the age of 50 I would rather recommend refractive lens exchange, even if they have low hyperopia. For them it’s either lens exchange, or I don’t have anything at all. Of course, if they have LASIK and they’re not happy with the result, it’s better that they did not have LASIK, because they say to others “I’m not happy, and he did the surgery for me.”

Dr. Lindstrom: I don’t think that is different from what we experience here. We don’t find a lot of people who really like monovision either. Not the vast majority.

Dr. Wallace: That’s one of the reasons for that loose lens test. We don’t even talk about how it works a lot of times. I know some practices don’t. We just say, “Try this. How do you like it?” Because when you introduce the idea of one eye for distance and one eye for near, and you specifically state that that’s what we’re going to create in your eyes, patients have a negative attitude for that.

Dr. Thompson: That’s why I find a lot of benefit in contact lens testing. People come in who want that, and I’ll say, “Prove to me that you’re going to be OK with the image degradation at a distance. I want you to go drive and do all sort of things with it.” There is a fair number who choose to do nothing, and with the ones who choose monovision after that test, I have a high chance of making them happy.

Dr. Lindstrom: With +1 D or +1.25 D you could actually give them a pair of glasses to go home with to try it out.

Dr. Thompson: Yes. Because the anisometropia won’t be too bad.

Dr. Davis: Do you think there are patients who have an adaptation period where they initially might reject it, but then over time might grow to like it?

Dr. Wallace: Liz makes a good point. That’s one of the difficult situations with both monovision and with multifocal lenses. There is a large amount of cortical adaptation going on. I wish we could figure out which patients will adjust or adapt faster than others, more effectively and more consistently. It would solve a lot of problems.

Some papers have shown, with time, 96% acceptance of monovision. But you have to get through the adjustment. For 2 to 3 weeks it still may be uncomfortable and unnatural. But over a period of time, the brain learns to adjust, just as we learn to adjust to so many other things in our life over time — ringing in the ear or other factors that come along that we just learn to ignore. That’s why it’s so hard to screen these patients, because we can’t factor in what the brain can do for a patient.

Dr. Hardten: We have also found that the traditional dominant eye isn’t always what we expect. I’ve always thought we’ll steepen the cornea of your nondominant eye and make that your reading eye. But sometimes we find the nondominant eye is not the best for reading. And that’s where that loose lens test is very helpful. I do the same thing with the contact lens test. Try it on both sides. Go out there and see which one you think you’ll like.

Dr. Knorz: It’s important that we test. I agree that that there is a lot of adaptation, but I think it’s too risky to count on this. I’d rather not treat patients who don’t like monovision after half an hour test. I think that’s the safest way to do it.

Combining modalities

Dr. Lindstrom: This is a bit speculative, but maybe we can discuss using different lenses in two eyes of the same patient. We haven’t gotten a true, fully accommodating IOL yet, according to what I have heard today. We get a 1.5 D to 2 D accommodative amplitude in an accommodating IOL. If we can get a slightly near-dominant multifocal, why not put an accommodating IOL in the dominant eye and the near-dominant multifocal IOL in the non-dominant eye?

Have any of you tried this? Michael, you’re disappointed with accommodating IOLs. Thomas, you’re more enthusiastic. Many people use monovision, but why couldn’t you take for instance the new Alcon ReStor diffractive multifocal, which is said to be more near-dominant, and put that in one eye, and put an accommodating IOL in the other? The accommodating IOL ought to get good distance and intermediate vision with no problem at night. And the multifocal one might have a little halo but would have good reading vision, and the two together would give you a pretty good range of vision. Has anybody done that?

Dr. Knorz: I would be afraid of that because the visual systems are so different. The way they work is different. So the patient’s adaptation is going to be very slow, if at all. I’d rather take this idea a step further and, say, put an accommodative IOL in the dominant eye, perfectly achieving emmetropia, and in the nondominant you go for maybe –0.75 D.

Dr. Lindstrom:That’s what many people are doing.

Dr. Knorz: That’s probably a good idea because 0.75 D is still OK for distance. If you get another 1.5 D accommodation, you have enough in the nondominant eye to read.

Dr. Lindstrom: I have several healthy, happy patients that I implanted with the Iolab bull’s-eye bifocal IOL in one eye and a monofocal in the other eye 15 years ago. That’s what the contact lens people call modified monovision. You need a near-dominant multifocal. A single Array might give you J4 or J5, but patients want to be J2 or J3. Have you done any of the Alcon diffractive IOLs?

Dr. Knorz: Yes. I usually get J1, J2 in patients postoperatively. I find a significant difference from the Array.

Dr. Lindstrom:If I could get that kind of near vision, I would want to try a little modified monovision with it, because I had great results.

Dr. Wallace: We’ve done 15 eyes of 15 patients with the Alcon diffractive multifocal. They are definitely stronger at near.

Dr. Lindstrom: My Array patients are quite frequently disappointed with their near.

Dr. Wallace: Well, once they’re bilaterally implanted and once we address the dry eye problem, which most of them have for awhile, we’ve seen more J1s and J2s out of the Array, but it takes them a lot longer to get there.

Dr. Hardten: Opening the capsule seems to help, too.

Dr. Lindstrom: I have heard about all the things that help, but it’s still a little weak on the near side.

Dr. Wallace:The Alcon is better at near, but we still have to see about intermediate That’s a very important area, something that none of the trials really examined. The FDA trials, they have not asked for intermediate vision data. If you think about patients’ everyday activities, computer distance can be very important.

Dr. Lindstrom: The Array study looked at intermediate. That’s why the Array got labeled as multifocal. They did go to the FDA with intermediate data and showed that there was intermediate benefit.

And the accommodating lens is going to give you intermediate vision with no side effect at all.

Dr. Neuhann: Patients with the accommodative lens may find that some print is too small, perhaps, for reading. But this larger type they can read, and a little larger they can read. So we have newspapers that are a little larger they can read. The intermediate acuity for computer is great.

Dr. Lindstrom: That’s good information to have because we may get approval of the C&C Vision lens this year.

I must say that in my bilateral Array patients, for example, there are some complaints of night vision issues. But patients who 15 years ago got a monofocal in the dominant eye and a bull’s eye, because that was the protocol back then with Iolab, those patients don’t seem to complain of the halos.

I won’t be surprised if this Alcon lens gives us really good enough near to get modified monovision with one eye. They’ll have 20/20-minus in one eye and 20/20-plus in the other eye. And then their intermediate vision will bring them up to perhaps 1.5 D for the near and the other eye will be at 3.

And the other thing that the multifocal patients are teaching us is that if the two eyes are within a 1.25 D to 1.5 D of each other, they don’t develop the relative amblyopia that sometimes you have with true monovision. If you’re within 1.25 D and 1.5 D in each eye you maintain binocular vision and you don’t suppress the one eye. You can still use it. So we can stay at intermediate, stay at near and stay at distance from that 1.25 D to 1.5 D range if we do an accommodating IOL in one eye and a multifocal in the other.

Final comments

Dr. Lindstrom: I’d like to get a final comment from everybody.

I personally think that reshaping the cornea is going to stand the test of time as a treatment for myopia. We’re still going to be doing LASIK for myopes as far ahead as I can see. It really does meet the demand. But bending or reshaping the cornea isn’t really solving the problem that we have with most hyperopes, who really want to have restoration of their accommodation.

If you talk to these patient and they ask, “What part of my body is failing?” we tell them it’s the lens. And they say, “Then how come you’re fixing my cornea?” What they want is a new lens.

So I believe that hyperopia surgery is going to go toward refractive lensectomy, with replacement of the natural lens with an accommodating IOL.

I’d like to get everyone else’s opinion, whether they think that will be the dominant procedure, whether they think we really are going to be able to develop a true accommodating IOL, and if so how long it will be before we get it. Because to make patients happy we’re going to have to get about 3 D or 4 D of accommodative amplitude. Right now we’re at maybe 1.5 D to 2 D of accommodative amplitude, and that’s better than what we’ve had. Are we going to get to 3 D and 4 D, and do you think that will then dominate hyperopic refractive surgery?

Dr. Neuhann: Absolutely. This is the first generation of accommodative lenses. We’re learning what the lenses are doing. We’re learning techniques. We’re learning the correct optic size and many other things. We will study all that.

We know that the lenses have an accommodating effect, and in a great variety of patients it’s still active, they are 75 and they have an accommodating range. So I’m absolutely sure the next generation of these accommodative lenses will give us more accommodation.

The only thing is, as with all these things we have discussed, now we have to talk to the patient to make sure that he uses that accommodation. He must learn that this is another optical effect, and the expectation that we just put the lens in and then he will be reading like when he was young doesn’t work. It takes time. It takes time to accommodate and to learn to use this new optical device. I’m sure that we, over time, will get more accommodating effect.

Dr. Davis: I agree that accommodative IOLs are probably going to be the way of the future because they offer both distance and near. In the meantime the most important thing will be good counseling of patients based on what we have as our current options and what they are looking for.

We really have to empathize, so it might require more chair time and explaining to the patient so they can be certain they understand what they’re going to get.

But the future, I think, will be really treating presbyopia in a true sense, rather than creating something halfway between like monovision.

R. Bruce Wallace III, MD, can be reached at 4110 Parliament Dr, Alexandria, LA 71303; (318) 448-4488; fax: (318) 448-9731. Ocular Surgery News could not confirm whether Dr. Wallace has no direct financial interest in the products mentioned in this article. He is a paid consultant for AMO.

Dr. Wallace: We have to go all the way for near vision with these patients and give them the quality that they want. I don’t think we can accomplish that with the present-day accommodative IOLs, from what I’ve been hearing. Unfortunately, in the United States, we don’t have access to them unless we’re in a study. But it may pan out that they’ll be designed better. Already the C&C Vision accommodative lens has been redesigned four or five times as I understand it.

I think we are now in a state of flux. I agree with you, Dick, that we will be going inside the eye for hyperopia, and not just because we’ll have lenses that work, but because we’ll also have procedures that are less risky than they even are today. Patients certainly enjoy a wonderful procedure, and now we’re going to go to bimanual phaco and smaller incisions, possibly with ThinOptX materials, possibly with adjustable IOLs.

Jack Holladay presented a paper at a meeting recently that discussed some material in development that is moldable, that goes through a small incision and is fully accommodative. You don’t even have to worry about the lens design. It goes into the bag and works. And antimetabolites are coming along to reduce the chance of capsular opacification

As all this comes together, it’s really, hopefully, going to answer the need. Because the need is growing so rapidly. As we see the presbyopes increasing in number on a significant scale over the next 10 years, everyone out there, not just surgeons but manufacturers, are hopefully going to step up and give us the materials and techniques we need.

I’m excited about the future. But even present day, I’m excited about what we can do with the lens right now. I encourage doctors that are doing lens surgery not to wait for these technologies because there’s a golden opportunity to hone their skills with cataract surgery. Once they feel comfortable, not just the surgeon but the entire office staff, following their outcomes, once they get to that feeling of self-confidence, they can offer these surgeries to patients that have “pre-cataract” or not clinically significant cataracts so to speak, but some lens changes. And they can do that with confidence and help out these presbyopic patients.

Dr. Hardten: I think there is and will continue to be a role for hyperopic LASIK for small levels of correction. A few patients are going to end up hyperopic after a myopic surgery. They’re going to end up slightly hyperopic after lens implant surgeries. So I think there will still be a role for hyperopic LASIK, but in a low and limited range.

We have a tremendous opportunity now for patients whose expectations meet what we currently have available to us. For example, we have IOLs with an accommodative range of up to 1.5 D. We have multifocal IOLs that have distance and near but with optical aberrations. And there are patients for which that meets their expectations. It solves their desires for independence from glasses, and they’re OK with it.

But that’s the early-adopter phase. To make it a big area of entrance for the bulk of patients, the technology is going to have to get better than what it is now. Multifocal IOLs will have to get fewer aberrations, and accommodative IOLs will have to get 4 D of accommodation so they can really use that near vision and not have to blend the vision with accommodative IOLs. Then we’ll see the bulk of the middle-adopter phase, much like we got to with myopic LASIK a few years ago.

Dr. Knorz: I agree with you, Dick. I feel that the dominant procedure for the hyperope will be an intraocular procedure. There’s a place for LASIK because not everybody achieves emmetropia from intraocular procedures, and LASIK will be the choice for the re-treatment, to try to adjust for any refractive residual error.

I disagree, however, regarding accommodative IOLs. I don’t hold so much hope for them for the foreseeable future. I think right now we have excellent multifocal IOLs available. For example, Alcon, with their Restore lens, took care of the too-low near vision that is currently associated with the Array. And AMO itself is bringing up new designs with better near vision. So for the time being only a multifocal IOL is really able to offer the reading capability patients will require. The accommodative IOLs are interesting technologies but as of today, on average, they cannot provide reading vision. In selected cases, but not on average. It will get better, but for the time being they are not up to this demand yet.

Dr. Thompson:I see a bright future for hyperopia, and I agree with you, Dick. I think it’s going to be lens-based, and with the improvements in multifocal technology and accommodating IOLs, I think we’ll be going a lot towards the lens.

But there are two reasons I think we’ll see an increase in the amount of hyperopic LASIK we do. One is that wavefront-guided ablations are going to show us an improvement in correcting low hyperopia and even moderate hyperopia for certain individuals. But we’re also going to be using laser as an enhancement for the increased numbers of hyperopic lens surgeries we will be doing. And I think we’ll be doing that on the corneal surface, with hyperopic PRK and LASEK. I see both procedures, and the CK-type procedures, working in these low and plano and even –0.5 D, 55-year-old presbyopes who want a little bit more myopia.

So I see a bright future for both corneal and lens procedures, but with the lens eventually being the dominant hyperopic route.

Dr. Lindstrom:I thank our panelists very much for your time.