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Inside Eyetube.net | Feb 2014

Distance Acuity, Near Vision, and My Old Reading Glasses

In this “patient,” the Kamra inlay has been rewarding for every aspect of visual function.

Currently, I am sitting in a hotel room far from my home, typing in 11-point font on a 13-inch laptop screen while watching the evening news on television. As I do this, my range of vision from near to far is completely seamless, and I have not owned a pair of reading glasses for nearly 3 years now. I continue to enjoy 20/15 distance acuity, J1 or J1+ near vision, and excellent stereopsis; I drive at night on both dark, unlit roads and in heavy traffic with headlights full blast in my face. Oh yes—and I also perform refractive surgery, both on the corneal surface and in the anterior chamber, with no difference in the quality of vision in either eye as I do this. Modern technology is amazing.

My age dictates that I should need a 2.25 D add over whatever my distance correction is, and yet 100% of the time I need neither distance nor near correction. Not having been born with superhuman or even near-perfect vision, my road to enjoying this level of visual function entailed considering a range of surgical options to see if any of them was right for me. My final decision came down to the Kamra inlay (AcuFocus, Inc.), which is currently in use internationally but not yet approved by the US Food and Drug Administration (FDA). It has been an exceptionally fulfilling and rewarding experience for every aspect of my visual function.


What led to my desire for surgical intervention was the natural aging process of my eyes. A functional emmetrope blessed to have enough with-the-rule corneal astigmatism to act as a natural and sufficient add power into my 50s, I did not have to wear eyeglasses while explaining to my patients why they might consider eliminating theirs. At 52, that began to change, and over-the-counter readers began to appear throughout my environment, strategically placed at various locations around the house, on my forehead, in the glove box of my car, and in the locker room.

Rather suddenly, my worst nightmare became the realization that, if I forgot to bring that one appliance to bail me out, I would be hopeless whenever I had to read anything smaller than a newspaper headline. I may be overstating the case, but I seriously felt that patients’ confidence in me as their surgeon would begin to wane as I would fish my readers out of my pocket, carefully place them on my face so as to appear intelligent (a more difficult proposition than you may know), and wait for the inevitable question: “Doctor, why do you wear glasses?” No explanation I ever gave could overcome the image of my own eyes visibly failing to the point of needing corrective eyewear, while trying to represent to my patients our ability to rid them of theirs.

Although I was an early adopter of many techniques for vision correction surgery, I had not yet seen a perfect surgical solution for presbyopia, and I was fully aware of the concept of compromise. I would have to give something up in order to achieve something else. This is best demonstrated with monovision, in which we correct one eye for distance vision and treat the fellow eye for near. This approach gives excellent monocular results, but I was unwilling to sacrifice distance vision in one of my own eyes, especially given my love of outdoor sports, in which I feel binocular vision is mandatory. Monovision was definitely out.

Apart from presbyopia and the slight degradation of distance acuity from 1.00 D of corneal cylinder in each eye, I had normal, healthy eyes. I thought I could undergo refractive lensectomy with a multifocal IOL, but my crystalline lenses were crystal clear. Although I am not afraid of surgery, the concept of removing my clear lenses did not ring true. I would personally rather wait until I have at least a hint of cataract formation before undergoing lensectomy.


This reasoning led me to investigate the notion of undergoing a surgical procedure that would entail no loss of distance vision (binocularity is important), would provide excellent near acuity (get rid of the readers), would be minimal in nature (my eyes are healthy and my lenses are clear), would not degrade my visual quality (I am an eye surgeon), and could be removed without inducing permanent visual loss (just in case). Likewise, if there were to be any compromise, it had to be minimal enough not to affect my night driving, nor should it bother my use of the slit lamp or operating microscope. With the Kamra inlay, I felt that I could go down the column and place a checkmark on each of these requirements and that it would require less compromise than any alternative.

In July 2011, I traveled to Japan to undergo my procedure. Minoru Tomita, MD, PhD, of Shinagawa LASIK Center in Tokyo, had kindly accepted me as his patient. Dr. Tomita first performed LASIK on both eyes, with 100-μm flaps created with a femtosecond laser (Femto LDV; Ziemer Ophthalmic Systems), not only to eliminate my astigmatism but also, importantly, to bring my Kamra eye to a -0.75 D target. This placed me in the group with the highest statistical probability of achieving 20/15 distance and near. I used no sedative at all, just so I could tell my more squeamish patients that it is really not bad. After a couple of days, I went back to the LASIK suite, where Dr. Tomita completed the procedure with a 200-μm–deep femstosecond-created pocket in my left eye (100 μm deeper than the LASIK flap), followed immediately by implantation of the Kamra. That night, I sat up reading my iPad (Apple Inc.) with no glasses, and I since have eliminated them entirely from my life.


Complications or compromises? I had two episodes of epithelial ingrowth under the LASIK flap in my left eye, which were successfully treated and resolved. I occasionally notice blurred near vision in my left eye, which resolves with artificial tears. My night vision in the Kamra eye becomes slightly blurry with a bit of halo and starburst, but driving at night is never an issue.

Would I have this surgery done again? Absolutely. On a scale of 1 to 10, how satisfied am I? 10+. On a scale of 1 to 10, how much do I miss my readers? Negative zero!

Robert P. Rivera, MD, is the Director of Clinical Research at Hoopes Vision in Draper, Utah. Dr. Rivera states that he is a consultant to AcuFocus. He may be reached at e-mail: rpriveramd@aol.com.