My first patient this morning at Miami Eye Center was a 50 year old executive who was “tired of wearing my glasses and I would like to be evaluated for LASIK.”  Seemed like he was in the right place until I asked him what he wanted to accomplish.  “I would like to be able to see far objects without my glasses.”  I then preceded to ask him what he did for his near work.  He told me that he took his glasses off to read.  This gentleman was telling me that he is nearsighted and has presbyopia.  I asked him what happens when he wears his glasses and attempts to read; answer: “I can’t see a thing.”  Major caution lights go off!  So if I do a LASIK procedure on this patient and correct his distance vision, he will have to wear glasses all of the time to read.  As it turned out, he did not see this as a reasonable alternative to his present condition.  I went on to tell him that the only other option was to apply the laser to his dominant eye and correct it for distance and leave untouched the fellow eye for near work.  This was also unacceptable at which time we shook hands and went on to other things. 

If the above tale sounds like it’s you then save yourself a LASIK evaluation.  I have written this blog because this scenerio plays out quite often in my office and hopefully this will help someone understand one of the LASIK dilemmas and be resigned to eyeglasses or faking it.

Now that you have a visually significant cataract, that is, a cataract that is interfering with activities that you enjoy doing or those that you must do, the choice is no longer “should you do the surgery,” rather “how should the surgery be done.”  Needless to say, this decision must be made during a consultation with an ophthalmologist with whom you feel  comfortable.  Keep in mind that this is the last and best opportunity to not only remove your cataract but to correct other problems such as nearsightedness, farsightedness presbyopia and astigmatism.

To help with the discussion, the lens options fall into several classes; MONOFOCAL LENSES will deliver good vision at a single point in space, ie, distance or near.  A modern variation on this lens is the ASPHERIC LENS which has a curvature which neutralizes the curvature of the cornea and thus reduces glare and other types of distortion.  A TORIC LENS will correct astigmatism at the same time that it corrects nearsightedness or farsightedness and it has recently been manufactured in an aspheric form.  Then there are the MULTIFOCAL LENSES which are in many instances, aspheric as well.  These lenses correct for distance and near vision.  There is the Restor lens from Alcon Labs, the ReZoom lens and more recently the Tecnis lens from AMO.  In addition, the Crystalens from Bausch and Lomb which is somewhat different from the other lenses but ultimately yields a similar outcome.

The issue is that there are numerous lenses to place in the eye at the time of surgery. The lens must be matched to the patient’s visual needs, not the other way around; one lens does not fit all.  On the one hand, an 80 year old with macular degeneration and cataracts who does not mind wearing reading glasses would fair best with a lens that provides only distance vision and perhaps it should be an ASPHERIC LENS which minimizes glare and maximizes distant vision.  The opposite situation might occur in a 50 year old who needs distance vision, computer vision and reading vision and would be willing to wear reading glasses occassionally.  The latter case would call for a MULTIFOCAL LENS of which there are several. 

It must be said that every style of lens has different advantages and disadvantages and these must be reconciled with the patient; that is my job.  I must find out what you expect and want from the procedure.  What are the tasks that you want to do without glasses and which are you willing to occassionally put the glasses on in order to perform. 

Remember that cataracts come with having birthdays and perhaps this year’s present might be good vision and possibly no glasses to achieve that end.

Patients of all ages ask me what they must do to be free of eyeglasses.  The answer lies in their age and their vision requirements. 

The first group of folks are the younger aged.  These are people who are nearsighted or farsighted with or without astigmatism and who when they have their contacts or glasses on, can read without the need for additional reading glasses.  This group is “pre-presbyopic.”  The approach to getting this group out of glasses or contacts is straight forward.  We must correct the refractive error (nearsightedness, farsightedness or astigmatism) and they are set.  In most cases this is done with LASIK or PRK in individuals who have a refractive error which has stopped changing with age and meet the other criteria for safe refractive surgery. 

Eliminating the need for glasses gets a little more involved in the next group; the presbyopic group.  These people need reading glasses in addition to their contacts or distance glasses correction; this is the group that wears bifocals.  There are several theories as to the mechanism of this progressive need for reading glasses but the bottom line is that the lens of the eye losses its ability to focus at near.  This inability is superimposed upon ones nearsighted or farsighted condition.  This gets confusing because a 48 year old nearsighted individual can see well at near without glasses but once the glasses go on they no longer can see close.  A younger nearsighted person will see well at near with the distance correction.  So what must we do to eliminate glasses?  In my surgical ophthalmology practice there are two ways to do this.  The first is to do LASIK or PRK with the dominant eye corrected for distance and the non-dominant eye for near (monofocal).  While this may sound “wild and crazy,” about 20%-30% of the population is capable of doing this.  When patients inquire about this approach, we fit them with trial contact lenses for the day which simulates the monofocal condition.  In general, people who are not suited for the monofocal correction know immediately after putting the lenses on.  For those who are comfortable we go to LASIK or PRK and permanently correct the refractive error.

The other 80% used to have no option but to wear bifocals.  Now there is an excellent second option; multifocal lenses.  These are acrylic lenses which can be permanently placed inside the eye which give good distance and near vision in each eye.  The lenses create two images at the retina, one for near and one for far.  Depending upon which image your brain wants to see will determine which image it recognizes.   This works similarly to being in a room where there are several conversations going on simultaneously.  Your brain will direct your attention to one of these conversations and you will hear it at the exclusion of the others and in an instant you can switch to another conversation and not hear the first.

In multifocal lens surgery your clear lens is surgically removed and replaced with an acrylic lens which has been calculated to neutralize your refractive error and at the same time correct for near vision.  I prefer the Restor Lens manufactured by Alcon Labs.  The surgery takes about 15 minutes and one eye is operated at a time.  The second eye is operated about 2 weeks later.  There is very little down time as people feel good the next day. 

This surgery is available for those of any age as long as they are presbyopic.  In younger presbyopes we remove the clear lens and instill the multifocal lens.  In those older presbyopes requiring cataract surgery, the same lens is placed with the same benefits. 

I or one of the surgery counselors will be pleased to discuss these options with you.  Give a call.