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What is the future of presbyopic correction in patients younger than 65 years old?
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Laser treatment options yield safer, better outcomes
In 2018, modern lasers are able to treat nearly every patient who walks through the door, including presbyopes, with great success. However, the barrier to entry to laser refractive surgery is quite high and the old multifocal corneal treatments had poor safety. On the other hand, refractive lens exchange (RLE) is becoming more popular due to improvements in technology and heavy marketing of multifocal IOLs. I believe this has led to the opinion that RLE is a better treatment for presbyopia than laser refractive surgery.
There are several myths and inaccuracies in the information often provided to patients regarding RLE. The first is that RLE “permanently” corrects vision, whereas the cornea actually reshapes continuously, causing a significant change in one-third of patients older than 40. The second is that everyone will develop a cataract, whereas only about 30% of patients will actually require cataract surgery during their lifetime. Thirdly, the increased risks associated with going inside the eye are often overlooked, or inappropriately minimized, compared with the safety profile of LASIK. RLE in younger patients also increases the risk for retinal detachment and cystoid macular edema as the vitreous is still attached; retinal detachment risk is 20 times higher for a 50-year-old than an 80-year-old. Finally, while current IOL technology is good, better IOL options will be available in the next 10 to 20 years.
For me, safety is the No. 1 priority when considering elective refractive surgery without a visually significant cataract. Presbyond Laser Blended Vision (Carl Zeiss Meditec) combines micro-monovision and increased depth of field to provide a full range of vision without glare and halo at night and avoids the more serious risks of RLE. The outcomes are equal to or better than RLE: 98% of myopic (up to –8.5 D), 95% of hyperopic (up to +5.75 D) and 97% of emmetropic patients with presbyopia end up with 20/20 at distance and can read newspaper (J5) print.
I believe with improved presbyopia corneal laser treatment software options and a greater public dissemination of knowledge pertaining to the truths about RLE, corneal laser refractive surgery will prove to be the victor in the years to come for presbyopic patients without a cataract.
- References:
- Clark A, et al. Arch Ophthalmol. 2012;doi: 10.1001/archophthalmol.2012.164.
- Daien V, et al. Ophthalmic Res. 2017;doi: 10.1159/000456721.
- Hashemi H, et al. Cornea. 2015;doi:10.1097/ICO.0000000000000595.
- Minassian DC, et al. Br J Ophthalmol. 2000;doi:10.1136/bjo.84.1.4.
- Pradhan KR, et al. J Cataract Refract Surg. 2016;doi:10.1016/j.jcrs.2015.09.026.
- Reinstein DZ, et al. J Refract Surg. 2015;doi:10.3928/1081597X-20150423-05.
- Reinstein DZ, et al. J Refract Surg. 2016;doi:10.3928/1081597X-20160310-01.
- Reinstein DZ, et al. J Refract Surg. 2011;doi:10.3928/1081597X-20100212-04.
- Reinstein DZ, et al. J Refract Surg. 2012;doi:10.3928/1081597X-20120723-01.
- Reinstein DZ, et al. J Refract Surg. 2009;25:37-58.
- Ueno Y, et al. J Refract Surg. 2014;doi:10.3928/1081597X-20140218-01.
Dan Z. Reinstein, MD, MA(Cantab), FRCSC, is from London Vision Clinic, London. Disclosure: Reinstein reports he is a consultant for Carl Zeiss Meditec and has a financial interest in Artemis Insight 100 VHF digital ultrasound (ArcScan).
Refractive lens exchange will remain dominant
In 2004, I began using the Crystalens (Bausch + Lomb) as a lens-based treatment for presbyopia. Between 2004 and 2016, lens implants were not often placed into patients in the 50 and younger age group due to undesirable visual side effects or less than adequate presbyopia correction for many patients.
Today we are fortunate to have excellent presbyopia-correcting lens implants that provide outstanding visual outcomes, enabling most patients to function with minimal to no reliance on glasses for near or far. In our experience, the Symfony lens platform from Johnson & Johnson Vision has made refractive lens exchange — or as we refer to it, laser lens replacement — the dominant procedure in our practice. Today, more than 60% of our patients who undergo refractive or cataract surgery receive the Symfony lens. I found the results of the Symfony to be so impressive that I elected to have laser lens replacement as a 49-year-old plano presbyope in March 2017 in order to reduce my reliance on readers to see the computer and near. Needless to say, I have not needed readers since my surgery.
I do not believe that keratorefractive procedures will be the treatment of choice for presbyopia because the lens invariably succumbs to the ravages of father time and inevitably will deteriorate as cataracts form. Any patient who undergoes a cornea-based procedure for refractive correction will experience deteriorating vision over time as cataracts mature and ultimately end up having cataract surgery or lens replacement surgery to optimize vision.
On the other hand, lens replacement surgery patients like me will have more stable vision over time than our LASIK or keratorefractive surgical counterparts, will be able to see near and far without glasses due to current and future presbyopia-correcting lens implant designs, and never need cataract surgery in the future.
Shannon M. Wong, MD, is from Austin Eye, Austin, Texas. Disclosure: Wong reports he is a consultant for Johnson & Johnson Vision.