Presbyopia: Strategies in use

A number of procedures are available to address presbyopia, each with its advantages and disadvantages.

Most patients with presbyopia can be treated successfully, and patient satisfaction is high, said Dr Nader Robin, in private practice in Grenoble, France.

He evaluated the results of presbyopic correction using an intrastromal Intracor femtosecond laser procedure (Technolas Perfect Vision), intracorneal ring (Kamra, AcuFocus), and hyperopic presbyLASIK and discussed their use in clinical practice.

Moderate to severe myopia

The 68 patients in this group underwent a conventional thin-flap LASIK procedure that aimed for –1 to –1.5 D of residual myopia for near vision and emmetropia in the fellow eye.

"The patients were highly satisfied in all cases," Dr Robin said. "Six patients still complained of somewhat insufficient near vision."

Mild myopia

Sixteen patients with low myopia underwent bilateral LASIK with the femtosecond laser with the goal of achieving emmetropia. A corneal inlay was implanted under a 180-μm flap in the non-dominant near vision eye. All patients underwent low-dose cortisone therapy for 3 months and dry eye therapy, according to Dr Robin.

All patients expressed high satisfaction with the procedure, with the exception of a 48-year-old woman who expressed dissatisfaction with the eye with the inlay and requested explantation.

Emmetropia

Twenty-six patients underwent an intrastromal Intracor procedure with the femtosecond laser in one or both eyes depending on the visual results in the first operated eye and if the vision in the first operated eye was insufficient for good near vision. A total of 42 procedures were performed. Three patients were dissatisfied with their near vision and two patients underwent a re-treatment procedure. One patient complained about poor night vision 6 months postoperatively.

Hyperopia

Thirty-six patients with hyperopia underwent hyperopic presbyLASIK with an additional multifocal enhancement (central positive correction for near vision) in one or both eyes. Most patients had unilateral presbyLASIK with the goal of achieving emmetropia in the far vision eye with better near vision in the other eye.

Dr Robin said that the patient satisfaction was very high, but all patients had halos and thought that the distance vision was inadequate up until 2 to 3 months postoperatively. He shared his thoughts on correcting presbyopia.

"Presbyopic patients are increasingly asking for surgical solutions to their vision problem, and this patient population is becoming an important part of everyday practice," Dr Robin said. "There is no standard technique to correct presbyopia, and the preoperative evaluation is complex. The patients need to be assessed very precisely by clinicians with specific training in this area, I believe."

He also commented that the post-op follow-up period is longer and patients must feel that they are supported by the clinical team. Re-treatments are being performed more frequently. Acquiring or preserving good distance vision is a key factor in patient satisfaction, even if they can read without correction.

Preoperative identification of the preferred eye for near vision also is a key factor for success. In most cases, simple procedures like monovision can be successful and rewarding. Pure emmetropia is the most difficult to manage.

"With the available techniques, we can offer acceptable treatment for almost all presbyopic patients," Dr Robin said. "Patient satisfaction is usually very high even if there is some loss of best-corrected visual acuity."

Special contributor

Dr Nader Robin is in private practice in Grenoble, France. He may be contacted by E-mail: nr38@wanadoo.fr

Dr Robin has no financial interests in the subject matter.