CASE REPORT

A 55-year-old woman visited the office for “vision-correction options.” She is a flight attendant, and her main complaint was that she “cannot see anything in the middle world.”

• POHx: Cannot tolerate contact lenses. s/p LASIK OU 5/2000; s/p BUL blepharoplasty OU 9/2021
• UCDVA: OD 20/25; OS 20/20
• MRX OD: +0.25 +0.75 x105 (20/20) BAT med 20/25;
• MRX OS: +0.50 +0.50 x 065 (20/20) BAT med 20/25 (LEFT eye dominant)
• CCT: 532/528 µm
• SLE:
• LLL: meibum easy to express, liquid-like quality; no collarettes OU; permanent tattoo liner
• C/S: small nasal pinguecula OU
• K: well-centered, clear LASIK flaps OU
• AC: D/Q
• Lens: 1+ NSC, Mac and DFE WNL
• Schirmer’s 1: 12 mm OU

CAROLINE WATSON, MDAlabama Vision Center at the Range

THIS PATIENT IS A 55-YEAR-OLD WOMAN WHO TRAVELS frequently for her job. When I considered her primary complaint, my first questions to the patient were about dry eye disease (DED) symptoms. She had a significant past ocular history that lent itself to exacerbating DED, including LASIK OU, her age, her occupation, and her blepharoplasty. Her exam was surprisingly normal, and she had a healthy meibum with no signs of blepharitis. The small pinguecula OU and her intolerance to CTLs indicated a chronic, mild DED state; however, her meibography showed only mild gland atrophy, and the Schirmer’s 1 test results were normal. Her objective scatter index was also reassuring and quite low considering her prior history of LASIK.

Her scores indicated that she could tolerate a presbyopia-correcting lens without causing symptomatic dysphotopsias. Her best-corrected visual acuity was stronger in her dominant eye at 20/15 OS and 20/20 OD. Her mild astigmatism was regular, and her LASIK flaps were well centered.

My initial thought was to perform a femtosecond laser-assisted refractive lens exchange (RLE), correct her astigmatism with the laser, and use an extended depth of focus (EDOF) lens, aiming for the first plus in her dominant left eye (up to +0.25 D on biometry). I typically wait 1 week between the first and second eye surgeries. During that time, I bring the patient to the office on the day of the second surgery and perform a vision check on the dominant eye to see if we are on target. If the patient is happy with the distance vision, I proceed to choose the first minus (aiming for -0.25 D) on the nondominant eye, which will give the patient a blended visual range. I also use intraoperative aberrometry to guide the lens choice.

In my experience, EDOF lenses placed in post refractive eyes with mild DED symptoms can perform exceptionally well. They are extremely forgiving and allow me to customize a patient’s vision based on his or her visual goals. I have used this approach a number of times, and the results are excellent, giving the patient J1+ at near and 20/20 or 20/15 distance, with superb intermediate vision. ■

JENNIFER LOH, MDLoh Ophthalmology Associates LLC/Eye Physicians of Florida LLP

ONE OF THE MOST CHALLENGING GROUPS OF PATIENTS for whom we care has excellent distance vision but is presbyopic. We know from this patient’s history of LASIK that she values good vision without contacts or glasses. One would expect that her goal would be to maintain excellent distance vision and gain improved reading vision.

RLE has become more popular in the United States for treating presbyopia with improved intraocular lens (IOL) options. However, studies examining the results with multifocal IOLs in patients with a history of myopic LASIK have a 4% to 42.9% risk of needing additional refractive surgery (depending on the study), according to a review paper by Li Wang, MD, PhD, and Douglas Koch, MD,¹ so while I would mention this option, it is not something I would recommend as a first choice.

Another surgical option is a LASIK enhancement with the goal of monovision. While this is an option (if the patient was happy with a monovision contact lens trial), it is also not something I would recommend as a first choice since I have some worries about the risks of the procedure, as well as ending up on target.

One potential option that can be considered is presbyopia drops. This patient appears to be an excellent candidate. She has good uncorrected visual acuity (UCVA) for distance and a low hyperopic prescription, and she has an average axial length. Currently, we have Vuity (pilocarpine hydrochloride ophthalmic solution; Allergan), which can be used up to twice per day. This drop could help her to gain up to 3 lines of near vision, and it would also help to improve her intermediate vision. The positive of this option is that it is a temporary, reversible option. It could provide a good bridge until she is ready for a surgical option.

If the patient was not happy with the results from the presbyopic drops, I would then discuss the options of refractive lens exchange vs a LASIK enhancement in 1 eye for reading. While she has some DED (Meibomian gland dropout per meibography and a reduced Schirmer’s score) her overall corneal topography looks regular, even with a history of LASIK OU. Her objective scatter index on the HD Analyzer (Keeler) also shows some possible lens dysfunction. With these findings, if the presbyopia drops were not successful, I would recommend that we consider the Light Adjustable Lens (LAL; RxSight) with a mini-monovision outcome to help reduce her dependency on glasses.

The good news is that there are many options for presbyopic patients with good distance UCVA, and the key is proper patient counseling and setting proper expectations. ■

Reference

1. Wang L, Koch DD. Intraocular lens power calculations in eyes with previous corneal refractive surgery: review and expert opinion. Ophthalmology. 2021;128(11):e121-e131.

DAMIEN GOLDBERG, MDWolstan & Goldberg Eye Associates

THIS CLASSIC CASE IS A TYPICAL PATIENT WHO COMES to our office. These patients frequently return for LASIK touch-ups or visit us for the first time to seek a touch-up on their previous laser correction. They claim their LASIK treatment wore off. It doesn’t take long, during a good sit-down conversation, to explain that the loss of intermediate vision is more a physiological effect of presbyopia and that there are some great choices to consider.

Obviously, first on the list and the most conservative approach would be to perform a good refraction and prescribe progressive glasses that would allow the patient to have great functional distance, intermediate, and near vision. I would also want to address any risks for DED. Considering her age of 55, the history of 2 ocular procedures (LASIK and bleph), and the presence of pinguecula, I’d want to make sure her intermediate vision isn’t being affected by fluctuating vision that could be occurring from longer tear break-up time despite not having corneal staining on the exam.

The next level of management to consider would be a pharmacological approach. Vuity 1.25% is the first FDA-approved pharmaceutical treatment for presbyopia. The active ingredient works by modulating pupil size to improve depth of focus. With this improved depth of focus, patients can achieve improved intermediate and near vision. The medication is dosed once or twice daily, and the improvement in near vision can be seen as soon as 15 minutes after dosing. The effect has been shown to last up to 6 hours.

If the patient wants a more lasting and permanent effect, Monovision LASIK can be introduced. Not all patients can tolerate monovision, but the topic can be brought up, and a loose lens or contact lens trial in the nondominant eye can be tried. If the patient tolerates monovision well, you can recommend the monovision photorefractive keratectomy/LASIK touch-up in the nondominant eye. It would just be important to mentally prepare the patient that the near vision correction won’t be a permanent improvement. I warn patients that monovision laser correction could last anywhere from 5 to 10 years, but they should be prepared to reconsider a solution for near vision in 10 years.

If the patient really wants to solve presbyopia surgically, I would discuss refractive lens exchange (RLE). I would present the choice of bilateral Panoptix multifocal IOLs from Alcon or mini-monovision (-0.50 sph) with the light adjustable lens (LAL, RXSight). I would review the pros and cons of multifocals and explain that Panoptix would give the patient the best binocular full range vision, but I would warn about halos at night and disclose that all lens replacement surgeries can have variable outcomes post-LASIK, which may require a second laser correction enhancement.

I would explain that the difference with the LAL is it has the flexibility to address post-LASIK variability, but would also explain how the patient would have to be willing to adapt to mini-monovision. I would set the dominant eye for plano and the nondominant eye at -0.50 sph. ■

DR. YEU’S APPROACH

THIS PATIENT ULTIMATELY DESIRED TO HAVE THE fullest range of vision possible, and strongly desired reading vision. Her uncorrected vision is 20/25 and 20/20 respectively, with a hyperopic refractive spherical equivalent between +0.50 to +0.75. At 55 years old, I would shy away from hyperopic LASIK, particularly in someone who has had prior myopic LASIK. Additionally, our patient strongly desires presbyopia correction, and she did not like monovision in contact lenses in the past.

We could offer topical Vuity as an interim option, but with the hyperopia, it is unlikely to offer her the spectacle freedom at near she is hoping for. Thus, we discussed refractive lens exchange. For her, IOLs for RLE could include the LAL, enhanced monofocals, EDOF (including small aperture), and diffractive multifocal IOL technology options. After considerable chair time, I confirmed she did not have glare or night vision issues after the initial LASIK, and that she was very satisfied with her initial vision. The ablation beds look very well-centered and appear to have been performed with a modern platform with a nice ablation bed size.

While discussing potential side effects of PC-IOLs, such as greater night vision symptoms and potential need for more light with IOLs that have the greatest range of near vision, the patient was willing to accept the potential risk to experience the maximal benefit for uncorrected vision. Thus, I started with the non-dominant right eye, which had the worse uncorrected visual acuity with a spherical Tecnis Synergy IOL and corneal astigmatic relaxing incisions, aiming for plano. After 3 weeks, the patient was extremely satisfied with the overall results of her right eye, achieving UCDVA 20/20, UCIVA 20/12.5, UCNVA J2.

While the initial plan was to proceed with the Synergy IOL in the left eye, she stated that she could read everything even after the right eye having been corrected. But, she was very bothered by how “tinted everything out of the left” unoperated eye looked as compared to the pseudophakic right eye. Thus, she asked for only distance correction left eye, and we proceeded with an Eyhance left eye, resulting in the left eye seeing 20/20, 20/20, J4. Postoperatively, this patient was thrilled with her overall outcome. ■

Dr. Yeu joined Virginia Eye Consultants in 2013, has been a partner since 2014, and continues her commitment to residency training in ophthalmology as an assistant professor of ophthalmology at the Eastern Virginia Medical School. She is medical director of the CVP Mid-Atlantic Surgery Center and sits on the board of directors for the Virginia Eye Foundation.