In the 16th century, during exploration in the New World of what would later be known as Florida, Juan Ponce de León was purported to have been motivated by tales of the existence of a magical fountain whose waters could restore youth. Simply by drinking its magical effluence, every disagreeable characteristic of aging would instantly disappear, turning back the hands of time to the prime of one’s life. Among the youthful characteristics most cherished and longed for by those in search of the Fountain of Youth, I am convinced, was the ability to see distance and near unimpeded by the need for eyeglasses.
If you fast-forward about 500 years, those of us past the age of 45 continue the same quest—albeit far removed from a humid, alligator-infested jungle. Our search takes place among the shelves of antiaging creams in drug stores, at the gym, in myriad vitamins, and in the operating rooms of surgeons whose skills include those that Ponce’s contemporaries would have paid dearly for. As surgeons gifted with the ability to reverse the age-induced loss of visual function associated with presbyopia, we must both recognize the need for our skill and embrace our quest for excellence as our patients choose in greater numbers those restorative procedures once thought impossible.
What is also true is that the surgical management of presbyopia is not a simple skill to master; it rarely occurs as the result of mastering a single procedure or technology, and not all patients benefit equally.
WHERE ART AND MEDICINE MERGE
The results we seek can sometimes be so variable from one patient to the next that we are forced to deploy our most precious resource—chair time—in an attempt to achieve a greater level of patient satisfaction. This leaves us to recognize that, in addition to surgical dexterity, the personality of one’s practice can elevate the environment in which patients best thrive once their presbyopia is treated. Indeed, given the need for management of patients’ postoperative outcomes and expectations, that environment is where the art of medicine merges with the science.
It is helpful to recognize the pros and cons of the surgical treatment of presbyopia. The biggest supporting argument is obvious: spectacle independence for near vision. The unfavorable sides, however, must be communicated to every patient. In a nutshell, the greatest drawback is that the current level of presbyopiacorrecting technologies cannot make one’s eyes behave as they did at age 25. When we treat presbyopia, we create a visual compromise that can create patient dissatisfaction, perception of a failed procedure, and, in the worst cases, hostility. Conversely, patients who enter their surgical procedures with full knowledge and explanation of what compromises they may face can be the most understanding as they undergo surgical recovery and adaptation to their new vision.
Being an early adopter of new surgical treatments for presbyopia and observing firsthand the results of the latest technological advances can be both rewarding and frustrating. This, in part, is because these technologies are not yet perfect, nor are all patients candidates for what we can offer. Gleaned from my experience, the following pearls of successes and failures may sound routine today, yet in the early days they were not.
Success Pearl No. 1: Choosing your patients carefully. Into this category I place the level of understanding that patients show once they are told how postoperative their vision will differ from that of a 25-year-old. Are their expectations reasonable? Is their personality type one that will be frustrated with their choice, or will they be smiling at their new-found visual range? It is often your staff that can best point out these characteristics in your patients.
Success Pearl No. 2: Paying attention to the ocular surface. The first surface with which light interacts as it enters the eye is not the corneal epithelium but the sensitive coating of tears that protects it from the surrounding environment. Still, the epithelium can give us clues regarding the function of the tear film layer. For those who live in arid climates, it comes at perhaps less cost to consider the tear film as part of the eye’s ability to see, but there is no substitute for a well-functioning tear film in order to obtain the best surgical results in the treatment of presbyopia.
Success Pearl No. 3: Paying attention to macular health. Macular irregularities—drusen, retinal epithelial pigment fallout, diabetic changes, and other retinal pathologies—can degrade the perception of light when it strikes the macula, and no amount of presbyopia reversal can correct for that. To avoid patient dissatisfaction, do not perform presbyopia-correction procedures on patients with macular or nerve fiber layer irregularities, including those with any visual field loss from glaucoma. In my experience, preexisting scotomata or visual field loss can appear intensified to patients after presbyopia-correcting lens implantation, whereas vision with a simple monofocal lens is more in line with what they may be accustomed to.
Success Pearl No. 4: Learning to listen to your patients. We have all heard the ophthalmic saying,“ 20/20 does not equal 20/happy.” One after another, my 20/20 and J1 or J2 patients would enter the exam rooms, and I could barely contain my excitement. But the look on my technicians’ faces said it all: Unhappy patient. How could this be? One of the most frustrating realizations may be when your 20/20 J1 patient is utterly disappointed with his or her new vision. A listening ear will go far to uncover patients’ feelings, as opposed to the objective but potentially misleading Snellen chart acuity.
Success Pearl No. 5: Paying attention to the residual refractive error. Besides multifocal lenses, this lesson has perhaps been learned most valuably from patients implanted with the Kamra corneal inlay (AcuFocus, Inc.; Figure 1). In the US Food and Drug Administration (FDA) study for this implant, enrolled patients were emmetropic and within ±0.50 D of plano. Since the study was concluded, results have been far superior when the patient has -0.75 D of sphere in the inlay eye. I decided to undergo the Kamra procedure outside the United States 2 years ago. Before the inlay was implanted, I underwent LASIK to correct my astigmatism, leaving my nondominant eye at -0.75 D. I now enjoy excellent distance and reading vision and have not used glasses for either since undergoing the procedure more than 2 years ago.
Failure Pearl No. 1: Failing to see the importance of personality. In my earliest days, I was so excited to offer my patients presbyopia reversal that I failed to see the importance of their personalities. The clearest example was a gentleman who, immediately upon our introduction, pegged himself as the type of person who enters a room, immediately spots what is not right, and points it out to others. I thought I had the perfect accommodating lens solution for him. Despite his outcome of 20/20 and J2, however, he continued to point out to me what was not right with his vision.
Failure Pearl No. 2: Voicing of too many complaints. My bitterly complaining 78-year-old multifocal patient could see no better than 20/40 and J6. What was wrong? His residual refractive error was within ±0.25 D of plano, and, aside from decreased tear breakup time and a few corneal punctate lesions, all was in good order. Wrong! Even minor ocular surface disease can profoundly deteriorate the visual quality attainable through a multifocal IOL.
Failure Pearl No. 3: Being too enthusiastic about new technology. In the earliest days of multifocal IOLs, I was over-enthusiastic. A 76-year-old patient caught my enthusiasm and agreed to undergo removal of her very dense cataract with implantation of the newly released AcrySof ReStor IOL (Alcon). I could see she had macular drusen, but I had tunnel vision: How could a patient with a very dense cataract not see distance and near after its removal and replacement with a beautiful new multifocal lens, especially with such a strong add power? Even with the few macular drusen that were present, multifocal diffraction would certainly be far better than trying to see through that dense cataract. Or so I thought. Despite successful surgery in both eyes, her dissatisfaction was a terrible disappointment, and I refunded her money. She promised that she would never return to my office nor refer any of her friends to my care.
Failure Pearl No. 4: Showing no empathy. My 48-year-old Tecnis Multifocal IOL (Abbott Medical Optics Inc.; Figure 2) patient with 20/20 and J1 vision was frustrated with his loss of intermediate vision. My description of this as the usual postoperative course did nothing to dissuade him from seeking another opinion. Sure enough, the other surgeon had no experience with multifocal IOLs and told the patient it was the wrong lens for him. Only after much persuasion did the patient return to me. After 18 months of adaptation, he now enjoys much better intermediate acuity. I learned the hard way that time does indeed help, but thorough explanation and empathy for what the patient is going through can help even more.
Failure Pearl No. 5: Underestimating the importance of cylindrical and spherical corrections. This failure pearl has become more of a success, now that I have addressed it. I now routinely have 70- and 80-year-old patients undergo laser vision correction for residual refractive errors. It is amazing to see an 87-year-old patient having LASIK next to a group of 20-year-olds, but the importance of correcting cylinder and sphere cannot be overstated. Be thorough, aggressive, and appropriate in correcting these patients’ residual refractive errors whenever necessary.
Ponce de León never found the Fountain of Youth, and we have carried on his quest with our modern-day expedition to restore youth. Today, at least for vision, we have several presbyopia-correction strategies that can help us to delay the effects of aging. In my own experience, after years of practice, two things seem most evident: (1) We can successfully apply the pearls mentioned above and achieve outstanding results for our patients; and (2) the future will bring us more options, techniques, and procedures to benefit us all.
Robert P. Rivera, MD, is the Director of Clinical Research, Hoopes Vision, Draper, Utah. Dr. Rivera states that he is a consultant to OptiMedica and a consultant to and shareholder in AcuFocus. He may be reached at e-mail: firstname.lastname@example.org.