I WAS TOLD BY MY BUSINESS partner many years ago that my approach and perspective in the management of my presbyopic patients would change dramatically once it became an issue for me. I can’t tell you how true those words were!
As I enter my sixth decade (I hit the big 5-0 this past October), I continue to find new and novel ways to navigate the journey that is presbyopia. As a 24-year post-LASIK (essentially emmetropic) presbyope, I simply don’t want to rely on eyeglasses or contact lenses. I admit, I became very spoiled by my life, which was essentially independent of eyewear (except for a great pair of sunglasses!). I had an amazing 20-year ride! Like many of my patients who have had refractive surgery or have never required a significant prescription, the reality of our loss of accommodation is making our lives a bit more difficult than we’d like.
In my experience, many emmetropic and post-refractive surgery patients are not as easy to please with more conventional eyewear options. Most of us are bothered by progressive addition lenses (PALs), which are more easily tolerated by folks who always needed a distance correction. We find the designs to be difficult to use with our monitors, and we find ourselves removing our spectacles to drive and view distance objects. We then discover that we can’t see our dashboard, GPS, or phones when we glance at a more near viewing distance. To address the many and varied viewing distances, I fit many patients successfully in soft multifocal contact lenses. My soft multifocal contact lens fit success rate in new, modern designs and materials is more than 90%. However, my success rate for emmetropes and post-LASIK/photorefractive keratectomy (PRK) patients is less than 60%. The change from a prolate to an oblate corneal surface after the “flattening” of the central cornea in refractive surgery impacts quality of vision in the post-refractive surgery patient population. Induced higher-order aberrations may also play a role. Regardless, this patient population is more difficult to fit in soft multifocal contact lenses.
Whatever the cause, many of these patients are frustrated. And many of my patients fall into this category because we had an on-site refractive surgery center in our practice for many years. I have dabbled in presbyopia eyedrops in this patient population, and we have fit every type of contact lens, from monovision soft to multifocal gas permeables, hybrids, and sclerals. Many patients feel that these options leave them dissatisfied with one area of vision or another. Some of these possible solutions are not effective for a long workday, or they leave patients needing multiple pairs of eyeglasses to meet their needs (eg, computer glasses, reading glasses, and/or an occupational prescription).
Over the past couple of years, after some conversation with our surgical team, we have begun to suggest clear lens extraction as an option for patients for whom most traditional eyewear has fallen short. Clear lens extraction is exactly what it sounds like: our cataract surgeons remove the crystalline lens of a patient that has no visually significant cataracts. To be clear, we broach this option not as a first choice but as an option for those who are good candidates, who understand the risks of an invasive lens replacement surgery, and who are failing to achieve the vision they need with conventional eyewear. These patients must also be comfortable with the cost of such a surgery and must be properly informed of the potential shortcomings of some of the intraocular lens (IOL) technologies.
We have probably all had a patient in our exam chair state the following: “Doc, I really do not want to wear glasses!” I have heard this many times, and it will not be a surprise to hear that it is almost always from a post-refractive surgery patient who has loved life without eyewear. There are other cases as well. I have had patients who found contact lenses and eyeglasses did not work for them due to their profession. These are typically firefighters, police officers, EMTs, or other first responders. We have had patients for whom conventional contact lenses or eyeglasses were not an option due to their incredibly high prescription. The distortion/weight/limitations of these high-power lenses were making them unable to perform work duties or normal activities of daily living. In any of these cases, a clear lens extraction surgery may be a great option.
It goes without saying that the advances in IOL technology have been a major factor in my decision to recommend a clear lens extraction in recent years. With patient expectations raised to an all-time high by the success of refractive surgery, many patients believe that achieving the same quality of vision at all viewing ranges should be just as straightforward as maximizing distance with LASIK/PRK. Of course, this is not always the case.
I begin all conversations about the expectations of a clear lens extraction surgery by stating clearly that there is no surgical option that will ever guarantee patients that they will not need eyeglasses after surgery. The semantics here are very important! I say that our goal is to make patients as spectacle independent as possible, and this could mean different things to different patients. Taking a very thorough history and documenting exactly which levels of vision (distance, midrange, near) are most important not only plants the seed that we may not make all levels perfect, but it also helps with IOL selection. I also find it very important to inform my patients that an IOL will only do its job as well as we can expect if the other ocular tissues are also healthy. We discuss proactive and preventive therapies for dry eye disease, floaters, and any retinal conditions. If I am confident that all ocular tissues are healthy, I can be confident in my refraction and the choice of IOL(s). Lastly, I verify that all systemic diseases, primarily diabetes and other cardiovascular conditions, are under good control. Once this discussion is complete and the conversation properly documented, we move on to the fun part: IOL selection!
For patients with no prior corneal surgery, the IOL options are virtually unlimited. We discuss monovision as an option if (and only if) the patient has had a long history of successful monovision in contact lenses (or refractive surgery). We present the numerous multifocal IOL options that are on the market and explain the pros and cons of each. Many true multifocal IOLs are a simultaneous vision design with alternating rings of power. While patients who have been successful with multifocal soft contact lenses often do well with a simultaneous design IOL, the optics are not the same. I try not to overpromise with any multifocal as each patient’s experience is unique. However, I have found that many patients who adapt well to a multifocal contact lens design tend to adapt well to a multifocal IOL as well. In addition to multifocal designs, manufacturers have also brought trifocal design IOLs to market in recent years. Theoretically, a trifocal lens design will introduce fewer aberrations and 3 more discrete areas of clear vision vs. a multifocal design.
We have some great options in our arsenal for patients that may be more concerned about some of the possible limitations of simultaneous design IOLs (such as haloing or glare). More recently, we have begun offering increased depth of field IOLs. One such lens is Vivity (Alcon). While not a true multifocal, the Vivity lens is essentially a monofocal lens with a small “aperture” in the center that works on the pinhole effect. The small central aperture creates a zone of near correction that allows for excellent midrange vision for most patients. We recommend increased depth of field IOLs for patients who admit to hours of screen time each day for work or pleasure. They typically need a light near correction in glasses for small print.
One of the greatest and most impressive IOL options with which I’ve had the pleasure of working is the Light-Adjustable Lens (LAL, RxSight). An LAL is an implant that can be modified in vivo, which means that its power can be adjusted by changing the IOL shape using ultraviolet light. Our surgeons implant the LAL in many of our patients who are post-refractive surgery and have unique corneas. Having the ability to adjust the power of the IOL after it has stabilized in the eye allows for very precise outcomes. The IOL can be “touched up” a couple of times before the power is “set” by a final ultraviolet (UV) treatment. We have found that our post-refractive surgery patients who did well with monovision appreciate the option of having the lens “tweaked” to achieve the vision they desire at the working distance(s) that they require. One consideration that we communicate to patients who opt for an LAL is that they will have to wear UV-blocking eyewear while awake for several weeks after surgery. This is necessary to prevent unwanted IOL power changes. Once the IOL is stable and the refractive goal is met, the final lock-in UV treatment is performed, and the patient can remove UV blocking eyewear and return to wear as needed.
A Successful Clear Lens Extraction Case
One of the early cases of clear lens extraction that I comanaged with our surgical team involved a veterinary surgeon. Dr. Jones (not his real name) presented to my practice as a frustrated new patient. His frustration was largely with his inability to comfortably perform surgical cases on his canine patients due to a lack of clear vision. He presented wearing a gas permeable multifocal design (aspheric) with his dominant eye set for distance/intermediate and his nondominant eye set for intermediate/near. He reported that he had tried other combinations of powers, fit philosophies, and materials and chosen his current lenses because they were the best he could find. He described how his reduced depth perception was making it nearly impossible to tie sutures and how he had resorted to using loupes, magnifiers, and glasses over his contacts in some cases. Generally speaking, he was not happy with his vision or his visual performance in his contact lenses.
After I explained his other options and carefully examined his ocular health, it became clear that his corneas were no longer tolerating his rigid gas permeable (RGP) contact lenses. He had signs of hypoxia and some peripheral corneal opacification and scarring from decades of RGP use. He asked if there were any options that would allow him to be spectacle and/or contact lens independent. Dr. Jones was 54 years old at the time and did not have visually significant lens changes. I let him know that I would speak to our surgical team and inquire as to whether they would consider him as a clear lens extraction candidate. Fortunately, our surgical team does presurgical assessments for our cataract patients in our office. I was able to sit in while our surgeon explained the pros and potential cons of a clear lens extraction. In the end, Dr. Jones was excited about the prospect of being essentially free of contact lenses and eyeglasses, and he decided to proceed with the clear lens extraction surgery.
Dr. Jones was given multiple IOL options and settled on a true multifocal design given his needs at near. A simultaneous vision design lens was implanted in each eye 2 weeks apart. When I saw Dr. Jones for his 1-day postop on the second eye, it was perhaps the first time I had ever seen a grown man cry tears of joy in my exam chair! He was ecstatic. What was most surprising to him was the improvement in color/contrast and his improved depth perception. Over the following weeks and months, he would report back on how the clear lens extraction surgeries had improved his love of his work. He described how it would likely keep him performing surgery for many years (he was contemplating retirement prior to his surgeries).
This is just one case of many in which clear lens extraction made a significant difference in the lives of one of my patients frustrated by conventional eyewear. While I realize this option is not right for everyone, I feel much more comfortable recommending clear lens extraction for patients given the expertise and advanced intraoperative surgical equipment used by our team. It doesn’t hurt that there are constant advancements in IOL technology as well. I would make the following recommendation to any colleague: have a discussion with your surgeon. Find out what his/her comfort level is with performing a clear lens extraction, and then consider this option for our struggling presbyopes. As a 50-year-old, it is definitely on my radar! ■