Wellington Eye Clinic in General Media

This is a question often put to me by patients seeking eye laser correction in their later years. Needless to say, many, but not all, older patients are ideal candidates for laser surgery. Recent advances in laser technology have spilled over into other areas of ophthalmology and alternatives to laser vision correction (LVC) have evolved. So, the answer to this question today would be: “No, in fact age is not a limiting factor, you will never be too old.”

Laser eye treatment has had a life-changing impact on people of all ages, particularly among younger patients and those “baby boomers” who were willing to embrace the treatment.

More conservative boomers that have sat on the fence for years are now coming forward in their mid-50s and 60s, eager to benefit and achieve the same excellent results as their children, friends and colleagues. Members of this group are older, and all are presbyopic, needing reading glasses or bifocals/varifocals for near vision.

LVC has one disadvantage in over-40-year-olds, as laser treatment cannot fully compensate for loss of accommodation. An excellent compromise with Lasik/Lasek is created utilizing monovision techniques. This can affect binocularity and depth perception, particularly in poor contrast situations. Alternatively, the laser can fashion a multifocal cornea I both eyes, thereby retaining binocularity but potentially inducing degrading optical aberrations. Both situations can create more problems should cataracts develop in later years.

Some older patients often present with early cataracts at their Lasik evaluation. Cataracts remain the most common cause of reversible blindness in the world today. Cataract surgery has been available for decades; restoring sight to millions of people in the developed and developing worlds alike – intraocular lenses ensure these patients continue to lead productive lives.

The level of surgical sophistication has improved exponentially recently, with newer and more accurate diagnostics, torsional phacoemulsification, advances in laser Wavefront technology and nanotechnology being incorporated into intraocular lens (IOL) implant design. Modern surgical techniques make the operation safer. Wounds are microincisional and infection is rare today given the injection of intraocular antibiotics at surgery. All of these factors are synergistic. Today, our patients have the potential to see better at all distances and without the need for spectacles. This is indeed an important watershed scenario.

In comparison to their refractive laser colleagues, cataract surgeons have often achieved a lower level of accuracy in unaided visual outcomes, as many lack direct access to a laser, which can be prohibitively expensive to own and maintain. Unlike post-Lasik patients who are predominantly spectacle-free, most cataract patients traditionally have needed glasses after surgery for one reason or another.

Eye surgeons now have the capability to change that and achieve excellent visual results without need of a laser in patients with cataracts and patients with normal lenses but frustrated with presbyopia (generally aged 40 years plus). New IOL implants collectively called premium lenses help achieve this.

So what is so special about these premium lenses? Premium lenses offer a solution for presbyopia and astigmatism not seen previously and can give their patients excellent vision for both distance and near in both eyes. Indeed, such is the level of interest, that the topic of “refractive lens exchange” now holds a permanent session at most international ophthalmology congresses and was the subject of the keynote address at the Mater International Refractive Congress, which was held in Croke Park in October.

These IOLs are extremely biocompatible. They are foldable, enabling insertion via injectors through very small wounds. They incorporate an aspheric designed learned from Wavefront lasers, which improve visual function in low contrast. Some accurately compensate for various levels of astigmatism. Others tackle the issue of presbyopia using refractive or diffractive technology, and in the ALCON Restore multifocal implant, a combination of both.

This lens is a masterpiece of nanotechnology and an exciting addition to the ALCON range. Patended “apodisation” of the diffractive segments in the Alcon Restore lens sets it apart from its competitors and improves distribution of light from distant and near objects at various pupil apertures. It also reduces unwanted haloes and glare when the pupil is more dilated, as with night driving. It is an extremely efficient multifocal IOL to replace an ageing natural lens or a cataractous lens.

Not everyone would agree with this claim, though. Some would argue it is not an optimum implant as its blue light blocking feature, multifocality and biocompatibility issues may reduce visual function in poor contrast situations, especially in older people. Others argue that multifocals are still far from ideal. Implant technology is improving constantly. Yet, despite this, there is no single perfect premium IOL. We are, however, getting close.

To date, most patients are happy with these newer implants. They are not standard IOLs and patients need special counseling regarding visual expectations, possible side-effects and complications at the time of their evaluation. Careful patient selection by the surgeon is paramount to a successful visual outcome. Certain patients with, or at risk of, macular degeneration, glaucoma or diabetic eye disease would be unsuitable. Preoperative consultations will by necessity take longer when premium IOLs are considered. It takes time to explain complications and side effects. Patients with high expectations may be disappointed.

Minimal astigmatism and emmetropia (neutral refraction) post-operatively are prerequisite for success. This requires skill as a surgeon and accurate diagnostics. Even in the best hands, up to 10 per cent of patients may require additional fine tuning using a laser. Knowledge of refractive surgery principles and delivering on patients high expectations are already part of the armamentarium of a successful Lasik surgeon, but will present new challenges to a traditional cataract surgeon.

Inevitably, most premium IOL implants do, and all newer generation IOLs in development will, cost more. This will create a difficult scenario in cash-strapped health budgets around the world. In Ireland, premium IOL implants may not become standard in public hospitals or to patients with a medical card.

Finally, wider demand for these implants is being experienced globally as patients compare notes with their peers and hail the benefits. With greater Internet access today, there will be opinion sought from GPs and optometrists. Make sure you are prepared to answer the question: “Am I not too old, Doc?”

References available on request

Dr Richard Corkin
Consultant Ophthalmologist
Wellington Eye Clinic and UMPC Beacon Hospital

Dr Corkin has no financial interest in Alcon Laboratories or any other pharmaceutical enterprise

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Irish Medical News Monday 14th December 2009

“Am I too old to have my eyes fixed, doctor?” Age is not a limiting factor for laser eye surgery, writes Dr Richard Corkin

References available on request

Irish Medical News
Monday 14th December 2009