Laser vision advancements have made safe, reliable and stable procedures a reality.
LASIK has a long-standing history of success in the treatment of myopia, hyperopia and astigmatism. But what about presbyopia? Recent data estimate that close to 2 billion people worldwide have this condition, and, with many finding glasses inconvenient for their lifestyles, the need for a laser-based solution is clear.1
I have been performing laser vision correction on presbyopic patients for the past 25 years. However, with no commercially available solution, to begin with I had to find my own way to provide my patients with something more than monovision.
Initially, I achieved this by using dual zone laser vision correction, but, although it worked, it always felt like a temporary solution to a permanent problem. We needed a standardised protocol to meet the growing need for customised multifocal vision correction for people with presbyopia. Fortunately, the past decade has given rise to major advancement in this domain with the advent of commercially available presbyLASIK platforms.
In my practice I use Supracor (Technolas Perfect Vision GmbH, part of Bausch + Lomb), which obtained a CE mark in 2011 after a 2-year clinical trial, to which I contributed. It is a presbyLASIK-based software algorithm that offers the ability to deliver multifocal laser vision correction while preserving the best-corrected visual acuity. It comes with three pre-programmed settings, (mild, regular and strong) and offers a completely customisable and adjustable treatment course that does not induce artifacts such as halos or glare.
Since its introduction, the algorithm has been used mostly for mild and moderate hyperopic patients, and sometimes for myopic patients, and its efficacy has been demonstrated in published literature. It has been shown to deliver a binocular uncorrected near visual acuity of Parinaud 3 (Jaeger 2) or better in the majority of patients, without affecting distance vision, which remains at least 20/25.2–4
I started using the algorithm immediately after its European introduction in 2011, and since then I have used it to treat thousands of eyes. Whereas there is certainly potential for some regression of near visual acuity, the overall stability of the procedure is remarkable: I have followed patients for a decade and observed good stability with no loss in near and distance visual acuity in most of them. The treatment also offers good reproducibility and can be customised to fit the profile of each patient.
Whilst observing these encouraging outcomes among my presbyopic patients, I could not ignore the fact that my own vision was troubling me. I am a 62-year-old presbyopic and slightly hyperopic (+1.25 D in both eyes) ophthalmologist, and I was having increasing difficulty during consultations and whilst performing surgery.
Even though contact lenses helped with clarity, they were uncomfortable and constraining, and I could not shake the feeling that I needed a permanent solution. I decided that it was time to undergo the presbyLASIK procedure myself.
First, I had to find a fellow surgeon willing to operate on me. Fortunately, that did not prove too difficult and by November 2020 it was time for me to become the patient. So, how did I find the operative and postoperative experience? In all, the surgery was uneventful. The lid retractor felt uncomfortable but the laser itself was not bothersome.
During surgery I experienced different feelings in my right and left eye, which I believe could make some patients feel anxious if they have not been suitably warned that this may happen. I also noticed some glare during the procedure, which made fixation difficult, and I experienced photophobia and tearing for a few hours after surgery.
However, as I was a well-informed patient, I knew exactly what to expect, which made the healing process easier. Days later, everything was back to normal, and, despite some morning eye dryness, I was fully rewarded with crisp spectacle-free near vision with no loss of distance vision – I was at 20/25, 1 week postoperatively.
Now, 8 months after surgery, I am free of contact lenses and glasses, I have Parinaud 2f (Jaeger 1) near vision with good light, Parinaud 3 (Jaeger 2) in everyday life, and 20/20 distance binocular vision with a natural visual continuum. I have regained approximately the vision of my forties. Given my age, I expect to be stable for a long time.
During my time using the algorithm for my patients, I have found that the learning curve can be challenging, and this is why surgeons have to opt for the standardised protocol on carefully selected patients when they first begin. Once the surgeon gains confidence, outcomes become very predictable and they can begin to add further customisation for each patient.
In terms of patient satisfaction, getting a feel for a patient’s goals and how they use their eyes can provide considerable insight into whether they will make a good candidate or not. A school bus driver has different visual needs from an elderly retiree and these considerations must be incorporated into the surgical plan and the personalisation of surgery.
It is also essential to manage the patient’s expectations appropriately. They should be informed to expect some compromise, which I often phrase as “balance”. I like to tell patients, “I’m going to take your vision back to the way it was 15 to 20 years ago.”
That helps to put things into perspective, so they can temper their outlook and not expect to regain the vision they had in their twenties, which is unattainable. It is important to relay all this information before the procedure, as this will ultimately lead to higher overall satisfaction.
Besides stability, predictability, reproducibility and customisation, another key strength of this procedure is that it does not complicate future cataract or glaucoma surgery. This eliminates a common worry associated with performing refractive surgery, especially on presbyopes, and these patients will only require a standard monofocal lens implant, which I favour over diffractive IOLs because of optical axis issues.
The treatment does have some disadvantages, and, like any refractive surgery treatment, it can induce eye dryness or aggravate pre-existing dry eyes. In some cases, this can turn into serious discomfort that interferes with proper healing and visual recovery, so it is vital to treat dry eyes thoroughly before the procedure.
Considering that patients who undergo presbyLASIK tend to be older, the issue of dry eyes impacting visual outcomes is particularly relevant, making it even more important to treat dry eye prior to the procedure and more so during recovery after surgery.
As both surgeon and patient, I have experienced first-hand the impact presbyLASIK can have on the life of the average presbyopic individual who wants to have the clear vision and to enjoy life without the inconvenience of spectacles and contact lenses. It is clear that there is a demand for presbyopic laser vision correction, and new technologies are ensuring that such correction can be provided both safely and reliably, and with results remaining stable over time for the majority of patients.
In my opinion, Supracor PresbyLASIK sits at the top of the list of these technologies, helping to better meet patient needs by offering a complete range of treatments to enhance their overall vision.