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Young presbyopes have high expectations, limited treatment options
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Developments in corneal and lens-based refractive surgery enable surgeons to meet patients’ high expectations for vision quality. Ongoing research centers on presbyopia treatment because presbyopia has fewer treatment options than myopia and hyperopia.
An emerging group of patients — young presbyopes — has the desire and the means to seek the latest treatments for age-related loss of near vision. According to some experts, these patients want vision correction without the cosmetic shortcomings of spectacles and expect good vision well into middle age and beyond.
According to Daniel S. Durrie, MD, OSN Refractive Surgery Section Editor, refractive surgery is undergoing a significant shift toward younger, more educated patients.
Patient expectations need to be discussed early in the decision-making process, according to Richard J. Duffey, MD.
Image: Ketchum D
“We’re having that switch from people having LASIK surgery when they’re burned out on glasses and contact lenses between the ages of 38 and 45. We’re now having patients have this done when they’re 18 to 25,” Durrie said. “Their parents got it done. To them, the sooner they have it done, the more benefits they get and the more money they save on glasses and contact lenses. It’s a big trend.”
A recent survey and anecdotal accounts show that monovision is the leading treatment option for younger presbyopes.
Jay S. Pepose, MD, PhD, said despite advances that approximate some aspects of accommodation and others that also improve near vision, there is no ideal presbyopia treatment.
“I don’t see that there’s a perfect answer right now,” Pepose said. “If we had an accommodating lens that would uniformly give you 3 D of accommodation and not create nighttime visual disturbances, that would be a phenomenal event. You couldn’t keep something like that on the shelf. That would be fantastic. But we don’t have that as yet. Everything else is sort of a compromise.”
The young presbyope
Jeffery Machat, MD, said that he sees young presbyopic patients who are educated, financially secure and highly motivated.
“They’re very intelligent. They have the financial means. They’re looking for a solution that will help them perpetuate their youth. They come in and are more than willing to spend the money. They want the very best. And it has increased my practice dramatically,” Machat said.
Sondra Black, OD, an optometrist practicing in Toronto, said that there is a large segment of the presbyopic market that is emmetropic and may never have had an eye examination.
Sondra Black
“They don’t really know what’s going on, but all of a sudden they can’t read, and they go to their optometrist for the first time,” she said. “What ends up happening is that the optometrist will say, ‘Yeah, there’s nothing you can do, it is a normal part of the process and you have to wear reading glasses.’ What does that tell the young presbyope? ‘I’m getting old.’ That’s the last thing in the world they want to hear.”
Many eye care providers who are not giving patients alternatives to reading glasses lose patients, Black said. She noted that many of these patients buy generic reading glasses at their local drugstore and never return.
“And they’ll probably never get seen again unless they have another problem,” Black said. “So, if [doctors] want to maintain them as patients … they have to be able to present all other options for these patients.”
For young “Gen Y” patients, LASIK can be more cost-effective in the long run than buying glasses or contact lenses for a number of years, according to Durrie.
“They’re figuring that out. It’s just financing it over a little longer period of time. It isn’t going to be an affordability issue with them,” he said. “[But] if you’re 40 and you’ve already spent money on glasses and contact lenses, you don’t have that extra savings.”
Young presbyopes’ primary motivation is acute dissatisfaction with loss of near vision, Durrie said.
“The young presbyopia patient does not like presbyopia at all. They’re unhappy with getting older and losing something that they had before,” he said. “Whether they’re wearing glasses or contact lenses, or they’ve never worn anything and now they’re picking up the readers or getting bifocals, they’re not happy with their present situation.”
Durrie also said that many young presbyopes are not aware of available treatment options.
“It’s something that their primary ophthalmologist or optometrist is not telling them can be fixed,” he said. “Most of their friends have not had it done. They’ve been told in the past that LASIK surgery doesn’t work for this. So, they are in a position where they’re a very good candidate for it, but they don’t know it.”
Underserved and dissatisfied young presbyopes are the easiest patients to find through marketing, Durrie said.
“The presbyopic group is either wearing reading glasses or they need bifocals. So, identifying them is very easy,” he said.
Patient examination and education
Treatment options should be presented as cornea-based and lens-based, especially for younger patients who face decades of treatment, Durrie said.
Daniel S. Durrie
“I’ve already told them that they’re going to get a cataract someday and that the one advantage of the lens-based solution is that it’s going to keep them from getting a cataract down the road. Then, they understand that,” he said.
Presbyopia is an early stage of dysfunctional lens syndrome, a degenerative cascade that leads to the formation of visually significant cataracts, Durrie said.
“Most people don’t understand that reading glasses and bifocals are the beginning of a cataract. They don’t put two and two together and clearly define that,” he said. “So, we make sure that gets clearly defined in the examination when we examine these patients. … If we don’t start connecting the dots here for the patients and start talking about it, we’re really not going to do a service to our patients.”
Family history is another important consideration; most patients know someone in their family who has gone from bifocals to trifocals to cataract surgery, Durrie said.
Durrie said that he gives each patient a lifetime vision plan, consisting of a scenario of vision changes the patient is likely to experience as he or she ages.
“I tell them what’s going to happen to their eyes in the future,” he said. “We really want to give them a layout of the plan because it’s important for everybody to know that presbyopia continues to get worse.”
Richard J. Duffey, MD, OSN Refractive Surgery Board Member, emphasized educating patients about potential outcomes and complications.
“It’s all about expectation. You’ve got to have those discussions on the front end,” Duffey said.
Patients should be educated about the diminishing benefits that can occur with accommodating IOLs, Duffey said.
“They all carry with them some sort of baggage, the accommodating lenses,” he said. “My biggest issue is that, long term, they tend to change. You can get some decent accommodation early on, but they tend to have less accommodation later. So, the typical accommodative patient is happy early and not happy long term.”
There is no perfect lens-based treatment for presbyopia, Pepose said.
“I’m very cautious in explaining to patients, particularly a young presbyope, somebody who’s 45 years old or 48 years old, that in my opinion, at least until they become really significantly presbyopic, God has a pretty good patent on the lens,” Pepose said.
Presbyopia treatments frequently involve tradeoffs in terms of benefits and side effects. For example, multifocal IOLs may involve glare, halos and other photic phenomena, Pepose said.
“Many people will neuroadapt to that, but some may not. So, you have to explain to patients that if having some halo around point sources of light at night, such as headlights of a car or a lamp post, would be a completely unacceptable outcome, then this may not be for you,” he said.
Accommodating lenses typically provide about 1 D of accommodation, Pepose said.
“In order for [a 50-year-old patient] to read comfortably at a normal reading distance, they would need 2 D or 2.5 D of accommodation, not 1 D. So, you have to explain to them that if we set both eyes exactly the same, the odds are you’re going to get good distance vision and excellent intermediate vision, but you still may need low-powered reading glasses for reading,” he said.
Monovision, LASIK or RLE
Duffey said he classifies young presbyopes as those who are emmetropic and those who are ametropic.
“To me, it’s relatively easy,” Duffey said. “If you take the young hyperope that’s presbyopic and hyperopic, then we do have some things that I think are reasonable for those patients. I do a fair amount of monovision LASIK, correcting one eye for distance and the other for near, as long as we have enough corneal thickness to be able to do a hyperopic correction in the near eye where you’re not exceeding the limits of what you can do with hyperopes.”
However, a patient who has good distance vision and wants better near vision is not a good candidate for monovision, Duffey said.
“I’m less inclined to do monovision on them because now you’re taking an eye that can see well at distance and you’re blurring it at distance to give it good up close,” he said. “Whereas if they were ametropic to begin with, where they had poor distance and near vision, then the eye that you’re setting for near never had good distance vision anyway. So, all you’re doing is you’re taking poor distance vision and turning it into very good near vision. I tend to make those patients pretty happy. That’s kind of my starting point.”
Monovision or RLE may be suitable for a 55-year-old hyperope, Duffey said.
“If they’re emmetropic at 55, I’m much less inclined to go in and do a multifocal lens implant because they’ve already got good distance vision. You run the risk that if you’re off on the power of the lens implant, that you’ve given them less-than-perfect distance vision, which is what they had before,” he said. “But if they’re 55 and they’re hyperopic in both eyes, then they’re a great candidate for monovision or a multifocal lens implant, correcting both the hyperopia and the presbyopia.”
Machat said that custom LASIK may be suitable for a 45- to 50-year old mild hyperopic presbyope who needs 1 D of correction. LASIK may eliminate the need for reading glasses in such a case, he said.
This patient may also benefit from future implantation of a Kamra inlay, Machat said.
Monovision with a contact lens may be a good option for some patients contemplating LASIK, Pepose said.
“In some patients that you’re considering for LASIK monovision, it might be beneficial to show that to them with a contact lens. But on the other hand, if you have a patient who has never worn a contact lens, sometimes they come back to you and say, ‘I didn’t like it.’ What they really meant was that they didn’t like wearing the contact lens, not the optical effect. So, it can be a little bit confounding in that situation,” Pepose said.
Black said that mild LASIK monovision — 0.5 D in the nondominant eye — is a good precursor to Kamra inlay implantation for some patients.
“They’re coming away saying, ‘I can see my food again. This is amazing,’” Black said. “Then, in a couple of years when that starts to go and all of a sudden they’re fully into presbyopia, then we can deal with the inlay.”
Current treatment methods
Corneal approaches to presbyopia treatment include excimer laser ablation, femtosecond laser intrastromal correction, contact lenses and intracorneal inlays. Monovision LASIK, a form of presbyopic LASIK, involves correcting one eye for distance vision and the other eye for near vision. Monovision is also performed with contact lenses and conductive keratoplasty.
Two laser correction methods are in development: Intracor and Supracor. Neither procedure is approved by the U.S. Food and Drug Administration, but both have a CE mark in Europe for hyperopic presbyopia.
Intracor, performed with the Technolas femtosecond laser (Bausch + Lomb Technolas), involves flapless intrastromal correction without the need to excise the corneal surface. Intracor is in FDA clinical trials.
“I think there will be a role [for this] once it’s approved,” Duffey said. “But we’ve learned, if nothing else, that the FDA takes a long time, and unless you’re a part of those trials, you just sit back and see what gets approved and start seeing where it’s going to apply to your patients.”
Supracor, performed with the Technolas excimer workstation, uses a similar corneal shape profile as Intracor but is designed for presbyopia correction in combination with a LASIK procedure.
Two inlays are undergoing FDA clinical trials: the Kamra inlay (AcuFocus) and the Raindrop near vision inlay (ReVision Optics).
The Kamra involves a pinhole aperture that filters out excess light and prevents halos and dysphotopsia.
According to Black, the Kamra may revitalize the refractive surgery market by virtue of its suitability for young presbyopes. Black underwent implantation of a Kamra inlay in June.
“I really think that it’s going to change the whole refractive surgery space, as long as people are conservative in their approach and they are finding the right patients and not just thinking, ‘this is for everybody,’” Black said. “No procedure is for everybody.”
Lenticular options for presbyopia treatment include multifocal and accommodating IOLs. The four lenses approved by the FDA are the Crystalens AO accommodating IOL (Bausch + Lomb), the Trulign toric presbyopia-correcting IOL (Bausch + Lomb), the Tecnis multifocal IOL (Abbott Medical Optics) and the AcrySof ReSTOR 3.0 multifocal IOL (Alcon).
Global trends, surgeon preferences
According to a trade release from Alcon, presbyopia affects almost 1.7 billion people worldwide and is expected to affect 2.1 billion by 2020. In the United States, the number of presbyopes is expected to rise from almost 111 million to about 123 million by 2020.
Amid the ongoing global surge in presbyopia, only 10% of people in the United States know that they should discuss presbyopia-related changes in vision with an eye care professional, and only 18% of presbyopes are aware of multifocal contact lenses as a treatment option for presbyopia, the release said.
According to the U.S. Trends in Refractive Surgery: 2012 International Society of Refractive Surgery survey that Duffey presented at the 2012 joint meeting of the American Academy of Ophthalmology and Asia-Pacific Academy of Ophthalmology, 71% of respondents had implanted presbyopic IOLs.
Survey results showed that 41% of respondents favored monovision as the preferred surgical method for pre-cataract presbyopia, 30% favored modified monovision, 15% preferred a multifocal IOL and 4% favored an accommodating IOL.
Sixty percent of respondents cited LASIK as the preferred treatment for a 45-year-old 3 D hyperope, and 20% cited refractive lens exchange as the favored treatment.
For a 45-year-old 5 D hyperope, 62% of respondents preferred refractive lens exchange and 9% favored LASIK.
Results of the survey also showed that the percentage of surgeons who perform at least 75 LASIK procedures a month declined from 27% to 9% over the past decade.
“I think a lot of the decline in procedure volumes has to do with price confusion. Patients just simply do not understand how LASIK can cost a few hundred dollars at one clinic and a couple thousand at another,” Machat said. “I look at the marketplace today, and I am confused myself. The technology is better than I ever thought it would be, yet I’m probably doing half as many LASIK procedures as I was doing at its peak. Presbyopia has changed all that. For the baby boomers reaching this age, it’s a completely different world.”– by Matt Hasson
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How young is too young for patients to undergo surgical procedures for presbyopia correction?
Lenticular surgery appropriate for some younger patients
Presbyopia is a ubiquitous disorder affecting an estimated 140 million presbyopes in the United States. In other parts of the world, presbyopia can affect patients at a much younger age than we are accustomed to. In fact, nearly half of Asia’s population is presbyopic, where patients in the early- to mid-40s may display clinical loss of accommodation. A significant portion of my practice is helping those who wish to get out of reading glasses or bifocals or who are incipient presbyopes who wish to reduce their dependence on reading glasses as they age.
George O. Waring IV
I typically have a discussion with patients beginning in their early 40s who desire correction of their congenital refractive error about addressing this progressive age-related refractive disorder. I describe it to them as “planning for the future,” and that if we address this at the time of surgery, that they will be less dependent on glasses at all distances for a much longer time. Of course, this is a patient-specific process, and all the normal decision processes come into play to determine patients’ desires, goals and candidacy.
George O. Waring IV, MD, is director of refractive surgery and an assistant professor of ophthalmology at the Medical University of South Carolina in Charleston. Disclosure: Waring has no relevant financial disclosures.
Lenticular surgery for older patients
Now that I am beginning to experience presbyopia symptoms myself, I can certainly understand a patient’s desire to improve near vision. Anytime a patient is experiencing difficulties with vision due to presbyopia, exploring the surgical options is warranted.
The key question that I ask is, “What would I want for my own eyes?” And my feeling is that corneal procedures are preferred for patients who are relatively younger (mid-40s to mid-50s), whereas lenticular surgery is often a better choice for older patients, particularly when early cataract changes begin. Monovision remains the mainstay of treatment, with presbyopia-addressing IOLs and corneal inlays being other options.
Uday Devgan
Every effort to keep the crystalline lens intact should be made in patients who still have some degree of accommodation. These patients can do well with monovision excimer laser corneal ablations if they have successfully completed a contact lens trial. This is appropriate even for early presbyopes who are in their 40s. We can even plan for the future when doing myopic LASIK on patients in their late 30s by undercorrecting one eye in anticipation of presbyopia years later.
Lenticular surgery should be reserved for patients with minimal existing accommodation, which typically means closer to age 60, unless the patient has a large refractive error such as high hyperopia, as well. These hyperopic patients tend to experience presbyopia earlier since they are using much of their accommodative power for distance vision.
However, care must be taken to educate patients about the limitations of our surgical options. While monovision, presbyopic-addressing IOLs and corneal inlays are all reasonable options to improve near vision, none of them actually reverse the presbyopia and certainly none work as well as the young human lens.
Uday Devgan, MD, is Healio.com/Ophthalmology Section Editor. Disclosure: Devgan has no relevant financial disclosures.
Inlays may supplant monovision for emmetropic presbyopes
The upcoming availability of new presbyopia treatments like intracorneal inlays will probably change the approach of most refractive surgeons to the young presbyope.
For presbyopes with significant refractive error, monovision PRK or LASIK has long been the preferred choice, with lens-based approaches being reserved for patients with some degree of cataract or extreme ametropia. For the emmetropic presbyope, monovision has really been the only choice that most refractive surgeons are uniformly comfortable with.
John A. Hovanesian
Many younger presbyopes, though, could never become comfortable with the idea of monovision, let alone putting it into practice. Here is where corneal inlays are a real gift.
Inlays like Revision Optics’ Raindrop or the AccuFocus Kamra provide acceptable intermediate and near vision with much less loss of distance acuity than patients experience with monovision. Adapting to these optical approaches tends to be much easier for younger patients, as well. While some loss of low-contrast acuity is experienced in the treated eye, functioning under challenging lighting conditions is only minimally affected.
John A. Hovanesian, MD, FACS, is OSN Cataract Surgery Section Editor. Disclosure: Hovanesian is a consultant for ReVision Optics.