Monovision LASIK, refractive lens exchange with EDOF IOL provide comparable outcomes

Physicians must listen to patients and understand their needs to make the appropriate surgical choice.

Monovision LASIK and refractive lens exchange with implantation of an extended depth of focus IOL lead to comparable patient satisfaction and quality of life, according to a study.

“Obviously they are two very different procedures, and both have strengths and weaknesses, but you should be confident that either of them can work well and improve your patients’ lives,” Steven C. Schallhorn, MD, said in an interview with Ocular Surgery News.

The study included 590 presbyopic patients who underwent refractive lens exchange (RLE) and 608 presbyopic patients who had monovision LASIK, matched to age and preoperative refraction and completed a 3-month follow-up visit. Surgery was performed by 27 experienced surgeons in 37 centers. The LASIK flap was created with the iFS femtosecond laser (Johnson & Johnson Vision), and wavefront-guided ablation was performed with the Star S4 IR excimer laser (Johnson & Johnson Vision). RLE was performed with the Catalys femtosecond laser (Johnson & Johnson Vision), followed by implantation of the Tecnis Symfony or Tecnis Symfony toric EDOF IOL (Johnson & Johnson Vision). Both groups included presbyopes with a wide range of preoperative refractive error.

With both procedures, binocular uncorrected distance visual acuity postop approached 20/20, independent of preoperative refraction. Loss of lines occurred more often with LASIK, mainly associated with ocular surface issues and almost all resolved over time. Monovision LASIK had slightly better near vision outcomes. All eyes had postop refraction close to plano, with slightly, but not significantly, better predictability in the monovision LASIK group.

Patient satisfaction, evaluated through a questionnaire, scored high for both procedures, with 94% of patients in the RLE group and 96% of patients in the monovision LASIK group saying that they would undergo the same procedure again. The only significant difference in patient satisfaction was in favor of monovision LASIK for moderate to high myopia. Dry eye symptoms were comparable in both groups.

Patients in the RLE group, despite the use of the EDOF lens, reported significantly more visual phenomena. Plano presbyopes were particularly affected, likely due to their higher expectations, the authors noted.

Assessing suitability for monovision

“With their different pros and cons, both procedures can be equally successful, provided that patients are carefully selected,” Schallhorn said.

LASIK monovision is less invasive than RLE, but patients need to adapt to monovision. On the other hand, RLE is a more permanent solution and provides near and distant vision simultaneously in both eyes, but visual disturbances can be significantly higher. Complications, although rare, can be more severe than with laser vision correction.

It is essential to listen to patients and understand their needs to recommend the most appropriate procedure.

“Don’t predetermine solutions; listen and decide what procedure is best suited for them. For instance, if a presbyopic patient without cataracts says, ‘I want improved uncorrected distance and near vision, good night vision and don’t like the idea of instruments being placed inside my eye,’ LASIK monovision may be a better option. Conversely, for those patients who won’t likely be bothered by glare/halos/night vision symptoms and want a permanent solution to improve their uncorrected distant and near vision, RLE might be better,” Schallhorn said.

To determine suitability for monovision, a contact lens trial is not necessarily required, he said.

“First of all, look at the history. Some patients may have natural monovision or may have tried monovision contact lenses in the past. These are obviously the easiest cases because they will be able to tell you immediately whether they like it or not,” Schallhorn said.

However, the majority of patients need a trial to determine their suitability, which can often be done in the clinic.

“I have found that many patients are able to decide whether monovision is right for them relatively quickly with an in-clinic trial. These patients either love it or hate it, and that’s a good indication to go on. Patients who say ‘I’m not sure’ will need more time and likely require a multiday contact lens trial,” Schallhorn said.

No guarantees

It is important to appreciate, however, that the preoperative evaluation is not a guarantee of success in all cases. There are patients who enthusiastically choose monovision, either with an in-clinic demonstration or with a contact lens trial, but are unable to adapt to it after surgery and need to be reversed.

“There are also patients who might want uncompromised excellent distance vision and do not mind using reading glasses. Those patients are not a candidate for either of these presbyopic-correcting procedures,” Schallhorn said.

Options in those cases might be LASIK for distance vision and RLE with a monofocal IOL. Another option is a corneal inlay, such as the Kamra (CorneaGen), which restores near vision while maintaining distance vision in the same eye.

“Our paper investigated only two of the most common options for presbyopia, but there are other options, and they should be considered,” Schallhorn said. – by Michela Cimberle

Disclosure: Schallhorn reports he is chief medical officer for Zeiss, a consultant for AcuFocus and chairman of the medical advisory board for Optical Express.

Monovision LASIK and refractive lens exchange with implantation of an extended depth of focus IOL lead to comparable patient satisfaction and quality of life, according to a study.

“Obviously they are two very different procedures, and both have strengths and weaknesses, but you should be confident that either of them can work well and improve your patients’ lives,” Steven C. Schallhorn, MD, said in an interview with Ocular Surgery News.

The study included 590 presbyopic patients who underwent refractive lens exchange (RLE) and 608 presbyopic patients who had monovision LASIK, matched to age and preoperative refraction and completed a 3-month follow-up visit. Surgery was performed by 27 experienced surgeons in 37 centers. The LASIK flap was created with the iFS femtosecond laser (Johnson & Johnson Vision), and wavefront-guided ablation was performed with the Star S4 IR excimer laser (Johnson & Johnson Vision). RLE was performed with the Catalys femtosecond laser (Johnson & Johnson Vision), followed by implantation of the Tecnis Symfony or Tecnis Symfony toric EDOF IOL (Johnson & Johnson Vision). Both groups included presbyopes with a wide range of preoperative refractive error.

With both procedures, binocular uncorrected distance visual acuity postop approached 20/20, independent of preoperative refraction. Loss of lines occurred more often with LASIK, mainly associated with ocular surface issues and almost all resolved over time. Monovision LASIK had slightly better near vision outcomes. All eyes had postop refraction close to plano, with slightly, but not significantly, better predictability in the monovision LASIK group.

Patient satisfaction, evaluated through a questionnaire, scored high for both procedures, with 94% of patients in the RLE group and 96% of patients in the monovision LASIK group saying that they would undergo the same procedure again. The only significant difference in patient satisfaction was in favor of monovision LASIK for moderate to high myopia. Dry eye symptoms were comparable in both groups.

Patients in the RLE group, despite the use of the EDOF lens, reported significantly more visual phenomena. Plano presbyopes were particularly affected, likely due to their higher expectations, the authors noted.

Assessing suitability for monovision

“With their different pros and cons, both procedures can be equally successful, provided that patients are carefully selected,” Schallhorn said.

LASIK monovision is less invasive than RLE, but patients need to adapt to monovision. On the other hand, RLE is a more permanent solution and provides near and distant vision simultaneously in both eyes, but visual disturbances can be significantly higher. Complications, although rare, can be more severe than with laser vision correction.

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It is essential to listen to patients and understand their needs to recommend the most appropriate procedure.

“Don’t predetermine solutions; listen and decide what procedure is best suited for them. For instance, if a presbyopic patient without cataracts says, ‘I want improved uncorrected distance and near vision, good night vision and don’t like the idea of instruments being placed inside my eye,’ LASIK monovision may be a better option. Conversely, for those patients who won’t likely be bothered by glare/halos/night vision symptoms and want a permanent solution to improve their uncorrected distant and near vision, RLE might be better,” Schallhorn said.

To determine suitability for monovision, a contact lens trial is not necessarily required, he said.

“First of all, look at the history. Some patients may have natural monovision or may have tried monovision contact lenses in the past. These are obviously the easiest cases because they will be able to tell you immediately whether they like it or not,” Schallhorn said.

However, the majority of patients need a trial to determine their suitability, which can often be done in the clinic.

“I have found that many patients are able to decide whether monovision is right for them relatively quickly with an in-clinic trial. These patients either love it or hate it, and that’s a good indication to go on. Patients who say ‘I’m not sure’ will need more time and likely require a multiday contact lens trial,” Schallhorn said.

No guarantees

It is important to appreciate, however, that the preoperative evaluation is not a guarantee of success in all cases. There are patients who enthusiastically choose monovision, either with an in-clinic demonstration or with a contact lens trial, but are unable to adapt to it after surgery and need to be reversed.

“There are also patients who might want uncompromised excellent distance vision and do not mind using reading glasses. Those patients are not a candidate for either of these presbyopic-correcting procedures,” Schallhorn said.

Options in those cases might be LASIK for distance vision and RLE with a monofocal IOL. Another option is a corneal inlay, such as the Kamra (CorneaGen), which restores near vision while maintaining distance vision in the same eye.

“Our paper investigated only two of the most common options for presbyopia, but there are other options, and they should be considered,” Schallhorn said. – by Michela Cimberle

Disclosure: Schallhorn reports he is chief medical officer for Zeiss, a consultant for AcuFocus and chairman of the medical advisory board for Optical Express.