The advent of premium lens technologies (such as enhanced depth of focus or multifocal IOLs) coupled with the introduction of corneal inlay technologies for the treatment of presbyopia has shifted our emphasis to finding the right patients for these technologies and managing their expectations appropriately. Careful patient selection is critical for postoperative patient satisfaction.

We can administer umpteen lifestyle questionnaires and have multiple discussions with our potential premium technology patients about what they should expect postoperatively, but gaps will still remain. We may overwhelm them with talk about the technology, or they may fall prey to selective hearing about what each procedure can and cannot do. We have found multiple conversations to narrow decisions are a key component but simulating the potential visual outcomes after surgery is by far the most productive way to deliver our messages.

We like using computer programs (such as the AcrySof IOL Vision Simulation App) that try to help a patient visualize postoperative outcomes, but we also realize individual neuroadaptation processes can affect timing and may not be appropriate for every potential surgical candidate. ReVision Optics (Lake Forest, CA) recommends a multifocal contact-lens trial in the non-dominant eye for patients who are interested in corneal inlay technology and meet the criteria for implantation.

OUR PROCESS

We use a plano, high-add multifocal contact lens — typically the PureVision (Bausch + Lomb, Bridgewater, N.J.) — as we believe that a contact lens best simulates the potential visual outcomes of the Raindrop near vision inlay. We have found a multifocal contact lens can aid the patient in realizing the potential improvements in near and intermediate vision while minimizing the loss of distance vision in the implanted eye. Emphasizing the improvement helps patients appreciate the potential of their new vision. (See Figure 1 on page 50 for our process.)

During the Raindrop clinical trials, potential study enrollees were required to undergo a multifocal contact lens trial for five days to assess their potential optimal vision outcomes.¹ The investigators believed using this type of contact lens trial could help further refine those who would succeed postoperatively and achieve higher levels of satisfaction with their vision. The PureVision lens is comprised of silicone hydrogel and features an aspheric center-near design, which closely mimics the results that the Raindrop can provide. As it turns out, the contact lens trial was a great screening tool, but also led to the primary reason potential candidates were excluded from the study itself.

Emmetropic presbyopes have typically never used contact lenses, and the sensation of a foreign body may be quite uncomfortable, especially since they need to wear the lens for five days. Contact lenses can rotate, which can be off-putting to people unfamiliar with lens wear and the potential for vision fluctuation.

Subjects were asked about satisfaction with glasses, contact lenses, magnifiers, or any other type of correction preoperatively, and were graded on the National Eye Institute’s Refractive Error Quality of Life questionnaire.² Before surgery, the mean satisfaction score was 56 (on a scale of 0-100), and potential inlay candidates tended to make this judgment based on their habitual preoperative correction (predominantly readers).¹ Patient satisfaction with vision after the surgery was much higher — 88% at two years. This is also expected, as patients were able to substantially reduce their reliance upon readers.

In the clinical setting, however, five days is often considered too lengthy and cumbersome for most emmetropic presbyopes. In our practice, we have modified the procedure to perform an express version that still gives us the benefit of assessing accurately the potential patient satisfaction with the Raindrop.

Presuming patients meet all other criteria for Raindrop implantation, our modified trial begins with having patients read a near card or their cell phone with no correction. To direct the conversation with patients on the potential visual outcome rather than the sensation of a contact lens, we place numbing drops on the nondominant eye and then insert the contact lens. Patients are then asked to reread the same material they had before the lens was inserted. (Most are immediately pleased with the improvement in near and intermediate vision, and we have found anecdotally that this mimics the patient’s ability to neuro-adapt to the Raindrop.)

We evaluate binocular distance vision at 20/40 on the Snellen chart—if the distance vision is even better post-Raindrop implantation then expectations are exceeded and we become heroes. If a patient needs correction in the dominant eye—as many do—we use a phoropter to adjust the refraction and have patients re-evaluate their binocular distance vision. Most patients are pleased with their newfound vision — even more so when the contact lens is removed. We’ve heard patients say the contact lens trial was like a magic trick, and they are enthused there is a permanent solution that can reduce or eliminate their reliance on readers.

Having an option to simulate vision prior to surgery improves outcomes, but it has to work for both the patients and the practice. OM

REFERENCES

1. Whitman J, Dougherty PJ, Parkhurst GD, et al. Treatment of presbyopia in emmetropes using a shape-changing corneal inlay: one-year clinical outcomes. Ophthalmology 2016;123:466-75.
2. Hays RD, Spritzer K. National Eye Institute Refractive Error Quality of Life Instrument-42: A Manual for use and scoring. Available at: https://www.nei.nih.gov/faqs/resources-neis-refractive-error-quality-life-instrument-nei-rql-42 . Accessed June 22, 2017.

About the Authors

Shilpa Rose, MD and Mark Whitten, MD are in private practice at Whitten Laser Eye in Washington, DC. They are consultants to ReVision Optics.