Lifetime vision plans tailored to treat patients’ personal and future needs

Like any other part and function of the body, the eye and vision change over time. In the last two decades, advanced solutions have been developed to meet the needs of individuals at each stage of this process, allowing them to maintain healthy eyesight and enhance quality of life through spectacle-free vision. With such a wide spectrum of options available, it makes sense now to overcome fragmentation and give patients what they need at different stages of ocular maturity within the framework of a lifetime plan for vision.

“Historically, eye care was segmented in different subspecialties, but more and more of us have embraced the concept of vision for a lifetime and the concept of refractive cataract surgery, which goes above and beyond how we historically addressed cataract,” Healio/OSN Board Member George O. Waring IV, MD, FACS, said.

From this first step, in which two subspecialties have merged together, he has seen an increasing number of surgeons move toward a more holistic approach to vision correction, structured around the changing needs of patients and offering a set of procedures tailored to each stage of their life.

Source: George O. Waring IV, MD, FACS

“Encompassing the future in our surgical decision-making and recommendations is routine practice for most of us, but the expanding variety of procedures we can offer almost compels us to make plans and share them with our patients,” OSN Cataract Surgery Section Editor John A. Hovanesian, MD, FACS, said.

According to OSN Refractive Surgery Board Member Sonia H. Yoo, MD, having a lifetime strategy for vision makes a lot of sense, “as it does for so many other aspects of our lives.”

Stage 1: Treating refractive error

There are basically three stages, or “milestones of ocular maturity,” Waring said, in which patients may require a refractive procedure. The first is in the late teens or early 20s, when congenital refractive errors stabilize. The second is presbyopia, when the lens progressively loses its ability to accommodate. The third is cataract, when the lens becomes opaque.

“My colleagues and I have introduced the term ‘dysfunctional lens syndrome’ (DLS) as a scientific method of characterizing the aging spectrum of the human crystalline lens, describing changes ranging from loss of accommodation to visually significant cataract,” Waring said.

The first stage is mainly dealt with by corneal laser surgery. Blended vision with LASIK is known to be a safe and efficacious option for stage 1 DLS. “We inform all our patients that we think of safety, vision quality, lifestyle and cost, in that order, when recommending a vision correction procedure,” he said. The overall cost of LASIK, as compared with spectacles and contact lenses, is much lower over a lifetime, and patients often realize a cost savings.

“If you calculate the cost involved in a lifetime of spectacles and [contact lens] fruition, typically people would have paid for their laser vision correction multiple times. And we cannot put the dollar sign on quality of life, which is a significant added passive-use value,” Waring said.

LASIK and SMILE are Yoo’s procedures of choice for young adults older than 21 years with stable moderate myopia and astigmatism or hyperopia.

“With high myopia from –8 D, I think about phakic lens implantation. For hyperopia, phakic IOLs are not approved in the U.S., and we have limited options for high hyperopia until patients reach the age where we can think about clear lens exchange (CLE),” Yoo said.

As a flapless procedure, SMILE is the best choice when patients have occupations or hobbies that put them at risk for flap dislocation or for patients with dry eye, she said. From a future perspective, however, the downside is that enhancement can only be performed as a surface ablation in the United States due to lack of SMILE enhancement software.

LASIK, as the most widely known and accepted procedure, is preferred by Hovanesian. Patients should, however, be aware they will need spectacles for reading at some point in their life.

“I tell them that we will be able to offer other options when the time comes if they want to continue being spectacle-free. Some are already available, including monovision and Kamra (CorneaGen), and more will become available in the future,” he said.

Stage 2: Addressing presbyopia

For presbyopia, many options are available, but none are gold standard and unanimously accepted. Regarding monovision solutions, opinions are divided.

“Most people have a negative reaction to the idea of having a procedure in only one eye, whether it is laser or a corneal inlay, and it adds to their fear of having surgery. Patients prefer binocular solutions,” Hovanesian said.

Yoo has a different experience and performs monovision LASIK in many of her patients in their mid-40s.

“It works for a lot of patients. I try monovision with a contact lens first to test adaptation. Some of my patients may stay with the contact lens, while the vast majority of adaptors go on to refractive surgery,” she said.

In patients who previously underwent LASIK in their 20s and come back 15 to 20 years later, she performs PRK with mitomycin C.

“At 3 years after primary LASIK, the incidence of epithelial ingrowth with re-treatment goes way up as compared to the first several years in the postoperative course. Typically these patients are much further out from their primary LASIK,” she said.

All three physicians are looking forward to presbyopia-correcting drops becoming available.

“I am very optimistic about how eye drops will help patients and help our industry move forward,” Hovanesian said. “For many, it might be a final solution or an interim solution until they have cataract surgery. I think drops are probably going to be a go-to solution for many patients who don’t want monovision and are not ready to commit to one of the other procedures for restoring accommodation.”

“I really like the idea of drops for presbyopia,” Yoo said. “People are not afraid of eye drops, and the idea of not having a permanent change is less scary. They may have a limitation because they only give you a certain degree of near vision, which may, however, be satisfactory for younger presbyopes.”

Waring has been involved in the study of many of the technologies for early presbyopia. He has proposed an algorithm for the treatment of presbyopia that encompasses these emerging technologies and is framed around the various stages of lens dysfunction.

“Drops fit well in the earlier stage, or incipient presbyopia. Later in the first stage of dysfunction, we can start thinking about a minimally invasive surgical treatment, whereas this is blended vision LASIK or minimally invasive treatment of the sclera. At the second stage, when the lens is becoming slightly cloudy, we turn our attention to lens-based solutions, recommending [refractive lens exchange], or dysfunctional lens replacement. We have a lower threshold for this recommendation in hyperopes. Third stage, we obviously perform cataract surgery or prevent this stage by performing lens replacement,” he said.

Think wisely when the lens is still clear

In general, Yoo does not recommend lens surgery until patients are in their 50s to 60s. This is because the ability to hit the refractive target is still better with corneal laser surgery than IOLs, despite the availability of advanced imaging techniques and improved biometry formulas. However, each case should be considered individually.

“In a transition age between 50 and 60 years, I might recommend CLE with a multifocal lens or maybe a monofocal lens and monovision if a patient who had hyperopic LASIK 15 years ago comes back hyperopic again, +3 D or +4 D. On the other hand, to a patient of the same age who had myopic LASIK 15 years ago and comes back with a little myopic regression, such as –1.5 D in both eyes, I would recommend PRK to correct one eye for distance. In that age range, you need to recommend CLE or corneal surgery depending on individual circumstances,” she said.

Premium IOLs have been the biggest change in refractive practices, and technology is continuously improving, with more options becoming available in the U.S.

“Trifocal IOLs, trifocal toric, EDOF — such a wide choice allows us to correct most refractive errors, and so the age at which many surgeons are recommending lens surgery has fallen. However, we should think wisely,” Yoo said.

Multifocal lenses should be used with caution in patients with previous refractive surgery because increased higher-order aberrations may lead to significant disturbances in quality of vision.

“It is very important to examine those eyes carefully, look at corneal aberrations and see whether or not they would be good candidates for multifocal lenses. In principle, we should proceed with caution with multifocal IOLs in these patients, but there may be appropriate cases that are eligible for these types of lenses,” Yoo said.

Stage 3: The many options for refractive cataract

Plano presbyopes who develop cataract have a wide variety of IOL options that can provide high satisfaction for the rest of their lives, Hovanesian said.

“It is a continuously evolving technology. We are just getting started with PanOptix (Alcon), but early results are very exciting. It is going to be a game changer in the U.S. Patients want a lens that does it all, and this is the first time we can provide a trifocal that gives good vision at distance, intermediate and near alike. European colleagues tell me that it is well tolerated and it gives great vision and minimal issues with halos,” he said.

Long-term planning must take into account that some patients will develop age-related problems later in life, including glaucoma and macular degeneration. However, this theoretical worry has not materialized as being a major issue, Hovanesian said.

“The average cataract patient is 69 years old, and the average life expectancy in the U.S. is 79 years. So, the average patient who undergoes surgery is going to live a further 10 years. We did a study 5 years after surgery with multifocal and accommodating implants, to go half a distance to life expectancy, and we found a satisfaction rate of about 90%, the same rate as 1 month after surgery. And these patients were like anybody else, prone to have mild maculopathy, dry eye and other problems,” Hovanesian said.

For those who develop wet AMD and lose vision, having or not having a multifocal implant will not make a significant difference in the long-term outcomes, he said.

“What we know for sure is that in the years in between surgery and the onset of AMD, they have enjoyed a better quality of life. I am not in favor of implanting multifocal lenses in patients who have AMD, but I am also not in favor of avoiding these implants because of the theoretical fear that they may one day develop AMD. It would be depriving our patients of the opportunity for a better quality of life in the meantime,” Hovanesian said.

Lifetime plan begins in the nursery

A lifetime plan for vision begins with the first examination in the nursery, according to OSN Pediatrics/Strabismus Board Member Erin D. Stahl, MD.

The red reflex is assessed shortly after birth to detect early cataract or other obscuration of the visual axis. As children grow, vision screening becomes part of their regular checkup during infancy, preschool and school years.

“Screening devices and careful exams allow primary care physicians to identify eye problems and to refer the child to a specialist when needed. Early diagnosis of strabismus, amblyopia and refractive error has helped us in setting up effective treatment programs to prevent vision impairment,” Stahl said.

Treating children requires looking ahead and seeing the continuum over their lifetime. This far-reaching perspective is part of the patient-centered model adopted at Children’s Mercy in Kansas City, Missouri, where Stahl is head of ophthalmology.

“In eye care, we are used to segmenting people according to age, but maintaining a lifetime perspective is key when you are taking care of a child,” she said.

One example is the implantation of an IOL after congenital cataract surgery, which can be performed in children from 9 months of age.

“I calculate the IOL power based on the visual acuity I want to achieve in adulthood. The child wears spectacles on top of the pseudophakic eye, which are progressively adjusted to the development of the eye until they may no longer be needed. In this way, children only have one IOL implanted in their lifetime, avoiding the risks of multiple surgeries,” Stahl said.

In patients who remain aphakic, she considers IOL implantation at around 16 to 18 years, when it will be possible to choose the best lens for each patient among a wide variety of options.

Similar considerations make Stahl conservative in her approach to refractive surgery in pediatric patients.

“I do perform refractive surgery on kids, but I believe that in most cases refractive error should be corrected with spectacles or contact lenses. Children accept them very well, and refractive surgery can be postponed to later in life,” she said.

Children who do not fall into this category include those with significant developmental delays because they are often resistant to wearing correction. In these children, refractive surgery can be beneficial, she said.

Myopia prevention and control

The exponential growth of myopia worldwide has stimulated researchers to study methods for myopia prevention and control. Early data were published in Singapore showing that low-dose atropine has an effect in slowing down myopia progression if used consistently through childhood.

“There have been other studies supporting the use of different types of contact lenses and demonstrating that increased time spent outdoors is effective in preventing myopia,” Stahl said.

Myopia prevention and control are important steps toward a patient-centered lifetime plan for good vision because of the increased associated risks for glaucoma, cataracts, retinal detachment and myopic maculopathy.

“Early screening techniques allow us to detect myopia, and then if myopia is progressing, we can offer myopia control maneuvers to contain it. Consequently, children will have a lesser chance of retinal problems, glaucoma and cataract when they get older. When they become visually mature, they may be candidates for laser refractive surgery and will continue to have good vision without correction until maybe their late 50s or early 60s. At that point, they are significantly presbyopic and can have their lens exchanged with a multifocal lens that gives them both distance and near vision,” Stahl said.

Philosophy behind practice management

“People in their 20s typically do not think about something that is going to happen in 30 or 40 years. Nevertheless, they like to know that we care about their future. I talk to them about the potential need for further surgery. I explain that we specialize in all stages of life and will be able to take care of them at every stage that comes,” Hovanesian said.

Patients also like to know that their physician has expertise in a variety of procedures, and that what he or she proposes to them is not the only procedure he or she performs.

“If the only thing you have is a hammer, everything looks like a nail. Patients need to know that when you are choosing a procedure, it is because it is the best for them, not because it is the one and only you perform. Nothing wins the good favor of patients like knowing the doctor makes decisions based on their best interest,” he said.

For Waring, planning with his patients over a lifetime is a philosophy and a style of practice management.

“I inherited this from my late father, who pioneered the concept of ‘vision for a lifetime.’ We educate our clients in this way and take them on a digital tour of their eye. We detail all the age changes and identify at what stage of their ocular maturity they are. If they are in the second stage, presbyopia, we further define the stage of their dysfunctional lens,” Waring said.

This preliminary educational process of vision analysis helps patients understand what they need and why, and ensures that the appropriate options are offered based on their needs.

“They may come in because we provide so many different vision correction procedures and customize them based on their specific stage of ocular maturity and lens dysfunctionality,” Waring said.

Adopting a collaborative eye care model is key in the success of a practice that takes care of vision over a lifetime. Monitoring patients with annual eye exams allows for a smooth transition from stage to stage, in which changes are seen in the process and needs are detected promptly.

“We work in a collaborative eye care model with co-managing optometrists for having patients checked and to provide us with annual eye exams. We also collaborate closely with co-managing doctors, on which we count on to provide medical care throughout the patients’ lifetime as well. This is also part of a holistic approach to our patients,” Waring said. – by Michela Cimberle

• References:
• Chia A, et al. Ophthalmology. 2016;doi:10.1016/j.ophtha.2015.07.004.
• Davidson RS, et al. J Cataract Refract Surg. 2016;doi:10.1016/j.jcrs.2016.05.003.
• Hovanesian JA. Clin Ophthalmol. 2018;doi:10.2147/OPTH.S182943.
• Leo SW, et al. Curr Opin Ophthalmol. 2017;doi:10.1097/ICU.0000000000000367.
• Patel RH, et al. Int Ophthalmol Clin. 2016;doi:10.1097/IIO.0000000000000106.
• Recko M, et al. Mo Med. 2015;112(2):116-121.
• Stahl ED. Curr Opin Ophthalmol. 2017;doi:10.1097/ICU.0000000000000384.
• Tay SA, et al. Strabismus. 2017;doi:10.1080/09273972.2016.1276940.
• Waring GO, et al. Use of dysfunctional lens syndrome grading to guide decision making in the surgical correction of presbyopia. Presented at: American Society of Cataract and Refractive Surgery annual meeting; May 5-9, 2017; Los Angeles.
• Wu PC, et al. Eye (Lond). 2019;doi:10.1038/s41433-018-0139-7.
• Yesilirmak N, et al. Int Ophthalmol Clin. 2016;doi:10.1097/IIO.0000000000000120.
• Yesilirmak N, et al. J Refract Surg. 2016;doi:10.3928/1081597X-20160217-07.

• For more information:
• John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Laguna Hills, CA 92653; email: drhovanesian@harvardeye.com.
• Erin D. Stahl, MD, can be reached at Children’s Mercy Hospital Kansas City, 3101 Broadway Blvd., Kansas City, MO 64111; email: edstahl@cmh.edu.
• George O. Waring IV, MD, FACS, can be reached at Waring Vision Institute, 735 Johnnie Dodds Blvd., Suite 101, Mt. Pleasant, SC 29464; email: gwaring@waringvision.com.
• Sonia H. Yoo, MD, can be reached at Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, 900 NW 17 St., Miami, FL 33136; email: syoo@med.miami.edu.

Disclosures: Hovanesian reports he is a consultant for Alcon, Allergan, Johnson & Johnson Vision, Carl Zeiss Meditec, Refocus Group and AcuFocus. Stahl reports she is a consultant for Avedro and TreeHouse Health. Waring reports he is a consultant for Johnson & Johnson Vision. Yoo reports she is a consultant for Avedro and Carl Zeiss Meditec.

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