Guest authors
Michael Greenwood, MD
Thomas Meirick, MD
CASE REPORT
A 57-year-old man presents for refractive surgical consultation. He has a history of moderate hyperopia and wants to have the best range of vision without glasses as much as possible after surgery.
- BCVA OD: 20/20; BCVA OS 20/20
- MRX OD: +3.00+0.25x 130 20/20 Glare 20/40
- MRX OS: +3.25+0.25x 015 20/20 Glare 20/40
- CRX OD: +3.00+0.25x 130 20/20 Glare 20/40
- CRX OS: +3.50+0.25x 015 20/20 Glare 20/40
- Pachy: 573/574
- SLE:
- - LL: normal OU
- - C/S: white, quiet
- - K: clear OU
- - a/c: d/w OU
- - Iris: r/r OU
- - Lens: 1+ NS OU
- DFE: WNL OU
IN THIS EDITION OF CLINICAL CASE CORNER, we wanted to start to break down patient types and the effect of this “type” on how we discuss surgical options with our patients. As we all know too well, the patient’s visual reference or “life experience” is an important part of how we form visual expectations, and best acknowledging, appreciating, and referencing these experiences allow us to better connect with our patient; to educate them about their options, expectations, and limitations; and to allow us to tailor our surgical recommendations to meet these expectations.
As we recently discussed the previously myopic patient (Cataract Consultation for a 60-Year-Old Man, Presbyopia Physician, September 2023, pages 40-42), I asked our esteemed contributors to focus on the hyperopic surgical consultation and how discussions and surgical techniques or decisions vary in the hyperopic patient compared to the myopic patient. A bit of compare and contrast, if you will.
How would you approach this case, and how does hyperopia influence your decisions and/or discussion as opposed to (compare and contrast) myopia?
MICHAEL GREENWOOD, MD, Vance Thompson Vision, West Fargo, ND
For refractive cases, I like to understand the patients’ goals with refractive surgery and what they hope to gain by having surgery. In this case, the patient would like as much freedom from glasses as possible. Knowing that he wants to do as much as possible without glasses and given the patient age and refractive error, he is likely presbyopic and dependent on glasses for almost all activities, near and far. Considering all the above, the most reasonable option for him would be refractive lens exchange (RLE) with placement of a multifocal intraocular lens (IOL) for both eyes. Since the patient isn’t complaining of any cataract symptoms, he may not qualify for cataract surgery. Although he is a good candidate for cornea-based procedures (LASIK, photorefractive keratectomy, small-incision lenticule extraction), these procedures would only help to improve the distance vision, and the patient would still need some form of correction for near activity. Monovision is an option but is not as ideal as bilateral RLE, in my opinion.
In comparing a hyperopic patient to a myopic patient, the conversation is usually easier since the hyperopic patient is dependent on glasses for near and far. Therefore, RLE can solve both of those issues. Myopic patients can have very functional near vision, and sometimes the multifocal IOLs do not provide exactly what they are used to, so we need to prepare patients for this outcome. Historically, surgeons would be wary to do multifocal IOLs in myopic patients and considered hyperopic patients the best candidates for multifocal IOLs, but with today’s technology, I feel that both hyperopic and myopic patients, and even emmetropes who are sick of reading glasses, do very well with multifocal IOLs. ■
THOMAS MEIRICK, MD, Wolfe Eye Clinic, West Des Moines, IA
Often in refractive surgery, our difficult choices revolve around a patient’s pathology. Optimizing a patient’s ocular surface prior to surgery, identifying and addressing irregular astigmatism in post-LASIK patients, and obtaining accurate refractions and biometry data in post-radial keratotomy patients can all prove challenging. In this patient, we have someone who would be considered by many to be an ideal candidate for lens-based refractive surgery. He has no dryness noted on exam, a very small amount of regular astigmatism, and visually significant cataracts. Lens-based refractive options to address his cataracts and presbyopia include: monovision, trifocal lenses, extended depth of focus (EDOF) lenses, and light-adjustable lenses (LALs). While a textbook may say that this patient would be happy with most (if not all) of these options, as we all know, our patients often (unfortunately) don’t follow the textbooks. Instead of focusing on the specific pathology to determine the best solution for this patient, we need to spend time determining and fully understanding the patient’s specific goals.
Assuming the patient has no history of monovision, I would not offer it at this time. Now that he has visually significant cataracts, I would also avoid trialing monovision in contact lenses; the contacts won’t address his glare and won’t give him an accurate “trial” of his postsurgical vision.
In discussing the patient’s postoperative goals, I would ask him specifically about reading fine print, whether he has hobbies that require fine work at near distances, and whether he does much work or reading in low light conditions. If he is most interested in maximizing his range of vision and having the best possible near vision, a trifocal lens such as the Panoptix (Alcon) would be one option for him. I would avoid it, however, if he mentioned many low-light scenarios, for example, if he said that he loves reading in low light prior to falling asleep. It would also be important to discuss positive dysphotopsias; I discuss glare and halos as side effects of the lens technology that will be present, not a “possible” side effect. Printed and/or laminated photo examples of halos around car lights at night are helpful in demonstrating this point for patients. This patient in particular is at a high risk for experiencing glare and halos due to his borderline to high chord mu values (0.74 OD and 0.69 OS).
If our patient were concerned about the side effects of glare/halos or was clear in that he valued contrast sensitivity over near vision, EDOF lenses could be another option. While EDOF lenses do not offer the same uncorrected near visual acuity as trifocal lenses, their side effect and dysphotopsia profiles are more similar to those of a monofocal lens. In a hyperopic patient, the slight blur at near is typically less bothersome than in a myopic patient (who is accustomed to seeing perfectly at a very specific near focal length).
For both trifocal and EDOF lenses, it is essential to achieve great distance visual acuity; therefore, postoperative enhancements may be necessary. In this patient, with normal corneal curvature and pachymetry, this would not be a problem—but it is crucial to consider before implanting these lenses.
A third solution for this patient would be the LAL. While the LAL offers an obvious advantage in achieving great distance vision, increasing reports and data support using it as a presbyopia solution as well. While this patient has not experienced monovision, and I would be hesitant to implant traditional lenses targeting monovision, the LAL allows our patient to “test drive” his vision and titrate the amount of anisometropia to best suit his near goals while avoiding any problematic side effects. Furthermore, even in LAL patients targeted for bilateral emmetropia, there are increasing reports of achieving great near vision (J2-J3) due to an “EDOF-like” effect induced in the lens after the light adjustments. While the side effect and dysphotopsia profiles of the LAL are similar to those of a monofocal lens, the frequent follow-ups needed for light treatments and the necessary use of ultraviolet light-blocking glasses during the treatment phase may be a barrier for some patients.
Ultimately, depending on the specifics of our discussion regarding his postoperative goals, I think this patient is best suited for an LAL. His borderline to high chord mu lengths would make me concerned for postoperative dysphotopsias with a trifocal lens. The combination of both an “EDOF-like” effect and the “test drive” of minimonovision would provide us with the tools necessary to provide this patient with his best possible outcome. ■
Dr. Lang’s Approach
I couldn’t agree more with the discussion above and the expertise of my colleagues. When discussing hyperopia vs myopia, it is usually an “easier” discussion with hyperopes, as their current refractive state creates blur at all distances, and improvement anywhere is a win, with multifocal IOLs or EDOF options being a “win-win.” As always, the pros and cons and an “understanding” of the goals or targets of these options are necessary to pair the surgical outcomes with the patient’s personality, lifestyle, occupation, and hobbies.
One caveat to hyperopic consultations, especially with moderate to high hyperopes, is that, when removing the magnification caused by the patient’s spectacle correction, a correction and image size magnification to which the patient’s visual system has adapted over decades can cause quite a shock to the system. This change in image size will require some neuroadaptation by the patient’s visual system, and this neuroadaptation needs to be expected and the patient warned that this adaptation process may take weeks or even months to adjust to this new vision.
One last thought about hyperopes is that they are much more likely than their myopic counterpoints to have strabismus and/or amblyopia pathologies that could interfere with the binocular fusion we lean on when utilizing multifocal surgical corrections, and extra care should be taken to screen these patients for strabismus and amblyopia, which may include a consultation with one of our binocular vision colleagues as part of their presurgical evaluation. ■