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EW SHOW DAILY 38 ASCRS Symposia Sunday, May 7, 2017 In conclusion, he said that monovision remains the most com- mon presbyopia correcting proce- dure. There are excellent outcomes in most cases, but careful selection of patients is necessary. In pseudophakic options, Rich- ard Tipperman, MD, Philadelphia, discussed "Preoperative Testing and Patient Screening for Refractive Lens Exchange: When to Cut and When to Run." There are two parts to an evalua- tion, Dr. Tipperman said. The first is looking at if the patient is a good candidate in terms of health of the eye, and the second is assessing the patient's needs, expectations, and understanding of their vision before and after surgery. Evaluating the health of the eye is something that is done frequently when evaluating patients for cata- ract surgery, he said. A comprehen- sive ophthalmic exam and biometry and keratometry are helpful, he said. But what if the biometry mea- surement vary or disagree? "When- ever things disagree, you should remeasure," he said. We're also more and more aware of looking at higher order aberrations, Dr. Tipperman said. A harder part is evaluating the needs and expectations of the patient. A questionnaire of visual needs and activities is helpful. This allows the surgeon to determine the best approach to visual rehabilita- tion, and it also helps the patient begin to think about different ranges of visual function. Beware of patients who want to be perfect or never want to wear glasses again, Dr. Tipperman warned. He said that's a very high bar, and he usually will not go forward with the surgery if that's the case. He said that when the consult is done, he wants the patient to under- stand and accept that they may still wear spectacles for some activities; that there is the potential for glare, haloes, and unwanted optical im- ages with night driving; and that in rare circumstance, the IOL may need to be removed. EW Editors' note: Dr. Manche has no finan- cial interests related to his comments. Dr. Tipperman has financial interests with Alcon (Fort Worth, Texas). by Ellen Stodola EyeWorld Senior Staff Writer There are a number of caveats to be aware of with monovision, Dr. Manche said. Patients with strong ocular dominance may have reduced intraocular blur suppression and decreased binocular depth of focus that lowers the success rate of mono- vision, he said. Additionally, it's necessary to determine if any tropia or phoria is present and also neces- sary to take a detailed history to rule out previous strabismus or history of strabismus surgery. Dr. Manche said to minimize anisometropia to maintain stereopsis and reduce the chance of decompensated fusion. He recommends targeting no more than 1.5 D of residual myopia to maintain fusion and stereopsis, and he said to do long-term follow-up to monitor for any signs of strabismus. With successful monovision sur- gery, it's essential that the patient's dominant eye sees well at distance. Patient are more sensitive to residual refractive error in the dominant eye. It's important to correct even low levels of residual ametropia in the dominant eye, Dr. Manche said, and there is a higher rate of enhance- ment in the dominant distance eye in patients undergoing refractive surgery for monovision. "When doing monovision, you want to determine ocular dominance," Dr. Manche said. Most monovision patients have the dominant eye set for distance and the non-dominant eye set for near. A small percentage of patients have crossed monovision with the dominant eye set for near and the non-dominant eye for distance. Crossed monovision patients may have lower success rates than con- ventional monovision patients, he noted. There are a number of ways to test for monovision, Dr. Manche said, noting that he likes to use a hole in the card test where patients hold a card extended in front of them and look through a circle at a distance. As they bring the card closer to their eyes, it will become apparent which is the dominant eye. Selecting appropriate power is also important and is determined primarily by the monovision contact lens trial. Dr. Manche highlighted a study on this topic by Daniel Durrie, MD, Overland Park, Kansas, which compared three contact lens powers in emmetropic presbyopes to determine the best solution for monovision. Monovision, corneal inlays, and pseudophakic options were discussed D uring a symposium on the surgical correction of presbyopia, presentations focused on optimizing the available choices. Options in monovision, corneal inlays, and pseudophakic options were covered. Edward Manche, MD, Palo Alto, California, highlighted preop- erative testing and surgical planning in monovision. Monovision is the most fre- quently employed option to manage presbyopia, he said, and it has been used for decades with contact lenses with reported success rates ranging from 70 to 76%. Monovision has also been used with all forms of refractive surgery. With monovision, you want to conduct a contact lens trial to determine if the patient can tolerate it, he said. The contact lens corrects at the corneal plane, so it is a good predictor of potential success with the surgery. Dr. Manche recom- mends a 1- to 2-week contact lens trial to see if the patient can adapt to monovision. Options in presbyopia broken down in symposium Dr. Manche discusses monovision.

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