A 50-YEAR-OLD HIGH SCHOOL computer teacher desires multifocal range of vision. She loves to read and wants the ability to read without spectacles. It is important to her that she can view the computer over her students’ shoulders, so far intermediate is key for her, which was comfortable for her until the past 6 months. The current refraction is -1.00 OD and +0.50 OS.

I am almost 50 years old, and personally, I wish I had a refraction of near plano in one eye and -1.00 in the other (and this current status is often the end target we are aiming for with laser vision correction). That said, it sounds like the patient’s current refractive status is not quite sufficient for her at this time for her daily activities. Traditionally, the 3 approaches a refractive surgeon could offer would be corneal refractive surgery, lens-based surgery, or no surgery at all.

In regard to lens-based surgery, I like to use what I call the “rule of 3” for multifocal, indicating that a multifocal has the ability to treat 3 problems: distance vision, near vision, and lens opacity. I have found that, unless we are solving for at least 2 (and preferably 3) of the problems, a lens-based solution may not be satisfactory to the patient. In this instance, the distance vision is relatively good, there is no lens opacity, and the patient has mild near/intermediate vision problems. In this situation, an intraocular lens (IOL) is only correcting 1 of 3 potential problems, and in my opinion, it is unlikely to lead to a satisfactory result.

With that in mind, let’s consider a corneal refractive surgery approach. A contact lens trial could be conducted to simulate a potential result with laser refractive surgery. Even though the left eye is only +0.50, it is possible that the small hyperopic prescription is just enough to cause blur in distance/intermediate, and a correction may give the patient more function. The -1.00 could be increased to -1.50 to help increase near function. The mild correction in both eyes could be simulated with contacts to see whether the patient notices significant improvement.

The issue with the above monovision approach is that it is a static solution for a dynamic problem such that the patient’s presbyopia will progress, and whatever solution is given today may only provide a temporary fix for the problem. In our practice, we have had success with placing a corneal inlay in the -1.00 eye, which would extend the focus, giving better near vision without taking away intermediate function. Corneal inlays have been falling out of favor in recent years secondary to challenges in biocompatibility, surgeon learning curves, cost, and most importantly improvements in lens-based technologies, which have often made inlays obsolete. However, this refraction would be an ideal starting point for an aperture corneal inlay, and this approach could be considered.

Because the patient is starting with a very functional vision status, it is often hard to offer a surgical solution that carries risks, and the potential rewards in this situation may not outweigh those risks. Thankfully, there is a new nonsurgical option that will be available soon that may be the perfect option for patients like this. Pharmacologic drops have been developed with the goal of creating a miotic pupil to help give patients a near/intermediate boost to their vision. We expect these will be a great temporizing nonsurgical solution to allow patients to become glasses-independent, as they wait for surgical technology to develop for their individual needs. In this case, I would expect pharmacologic drops would allow the patient to regain the function that she was used to recently.

Although pharmacologic drops may allow the patient to buy time, eventually her presbyopia may advance to the point at which drops may not provide enough near/intermediate vision. At that point, contact lenses could be tried with the drops to see whether a combined corneal refractive surgery and drop solution may be required. Furthermore, if the patient enjoys the miotic extended depth of focus vision but has tired of administering daily drops, she may benefit from an aperture IOL, which will simulate a more permanent alternative to miotic extended depth of focus vision. Although not available now in the US, aperture IOLs may be available soon and could provide the next steppingstone for successful pharmacologic presbyopic drop patients.

In summary, often no surgery is the best option for situations that have borderline risk/reward propositions. This patient’s refraction is borderline and raises the idea that no surgical solution may be the best approach. Thankfully, new advances in pharmacology may allow the patient to achieve her spectacle-independence goals and keep the door open for a more appropriate surgical solution in the near future, or alternatively, they may allow for a current corneal refractive monovision solution to provide more longevity as the eyes age and the patient’s presbyopia changes. ■

Dr. Wiley is a board-certified ophthalmologist who has pioneered many eye procedures in the Northeast Ohio area. He is Medical Director of the Cleveland Eye Clinic, and participates in many clinical research studies.