BLOG: Vision correction in the hyperopic presbyope
In recent years, there has been a clear trend toward lens-based rather than cornea-based refractive surgery for moderate to high hyperopes. This is due in part to recognition of the limitations of corneal optics in hyperopic LASIK and the increased chance of hyperopic regression.
High hyperopes, in my experience, are also more likely to have narrow angles, so a lens procedure can even be considered therapeutic. In a study I was involved in a few years ago, we showed that hyperopes with axial length less than 23.5 mm had a 58% improvement in the anterior chamber angle after cataract surgery — statistically significantly more than the angle change in eyes with axial length greater than 24 mm. With a single procedure, the patient can achieve deepening of the angle, correction of refractive error and presbyopia, and avoidance of cataract all at once, rather than as staged procedures.
In older patients with mild hyperopia, I’m also increasingly likely to recommend a lens procedure. A patient who is in the 55- to 60-year-old age range, for example, is likely to already be in stage 2 of dysfunctional lens syndrome. Rather than perform hyperopic LASIK, we can potentially improve their contrast sensitivity and quality of vision by exchanging the lens and reducing the light scatter associated with age-related lenticular changes.
The big challenge is what to do with younger near-plano hyperopic presbyopes. These patients have enjoyed excellent visual acuity and, typically, complete spectacle independence most of their lives, until they suddenly “fall off the cliff” in their 40s and early 50s. Now they are struggling at all distances and typically intolerant of readers or progressive spectacles.
In their myopic counterparts, we often perform a blended laser vision correction, leaving one eye slightly myopic for better near vision. This approach has additional considerations for the plano or hyperopic presbyope, however, because we would need to perform additional hyperopic ablation treatment to make the reading eye myopic.
I have had great success with refractive lens exchange with a mid-add multifocal IOL in the nondominant eye only. With this strategy, patients retain stereoacuity and achieve excellent distance vision, but now they can read — and their reading ability won’t continue to decline as they get older. In fact, the low hyperope presbyopes who undergo laser-lens replacement surgery are among my happiest patients.
Schroeder AM, et al. Analysis of biometric anterior chamber parameters using Scheimpflug imaging and IOP after laser cataract surgery in hyperopic eyes. Presented at: American Society of Cataract and Refractive Surgery meeting; April 21, 2015; San Diego.
Disclosure: Waring reports he is a consultant for Johnson & Johnson Vision and a member of the Johnson & Johnson Vision optics advisory board.