PresbyLASIK: the LASIK surgery for presbyopia

PresbyLASIK in hyperopic presbyopic patients

Patients with mild to moderate hyperopia often do not require optical correction until around age 40, when they first need glasses for intermediate and near vision. By age 50, they may need progressive lenses for all distances, including distance vision. This shift is often difficult for patients who were previously independent of glasses.

These patients are the most likely to seek surgery to eliminate the need for glasses at the age of presbyopia.

Several techniques are available, and the choice depends on the patient’s lifestyle, occupation, hobbies, and sports. These factors, along with clinical examination findings, help prioritize distance, intermediate, or near vision. Generally, in hyperopic patients, good distance vision should always be prioritized postoperatively.

SUPRACOR is a reference technique that combines micro-monovision with corneal multifocality centered on near vision using the excimer laser. The principle is to correct the patient’s hyperopia and any associated astigmatism, and to create a central corneal “bump” that enables good near vision without compromising distance vision.

When focusing on near objects, the pupil constricts, and light rays pass through the central cornea, which is optimized for near vision. For distance vision, the pupil dilates, allowing rays to pass through the entire corneal zone, enabling clear distance vision.

Other solutions are based on modulating corneal asphericity (Q-factor) to achieve corneal multifocality.

PresbyLASIK in emmetropic presbyopic patients

Patients with no distance vision defects typically need reading glasses around age 45 and glasses for intermediate (computer) work around age 50. For these patients, it is crucial to preserve the good distance vision they have always enjoyed.

A possible approach is to perform PresbyLASIK on the non-dominant eye to provide good near vision, while leaving the dominant eye untouched to maintain natural distance vision.

PresbyLASIK in myopic presbyopic patients

Myopic patients wear glasses for distance vision and, around age 40, find it more comfortable to remove their glasses to read small print up close. Most will switch to progressive lenses to avoid constantly removing their correction for near tasks, but this depends on individual visual needs. Others may prefer to keep correction only for distance and remove it for near vision.

There are two solutions—both in glasses and contact lenses—to correct myopia and presbyopia:

Monovision (“blended vision”)

Each person has a dominant eye for distance vision and a non-dominant eye for near vision. Monovision in myopic patients involves fully correcting the dominant eye for distance and under-correcting the non-dominant eye to retain some myopia for near vision.

This method is commonly used with contact lenses in presbyopic myopes and can also be applied in refractive surgery. It is not a multifocal solution; each eye is corrected for a single focal point (distance for the dominant eye, near for the non-dominant eye).

Advantages of monovision in myopes

• Simple treatment that preserves excellent visual quality, often better tolerated by myopes than multifocality.
• Simplifies calculation of the optimal intraocular lens for future cataract surgery.

For successful monovision adaptation

• Always perform a contact lens trial before surgery to ensure good adaptation.
• Do not under-correct the non-dominant eye by more than 1.5 diopters.
• Advise the patient not to alternately cover each eye to “test” which sees near or far, as this hinders neuroadaptation.

Multifocality

For low myopes, multifocality is a useful solution, based on the same principle as for hyperopes. It is reserved as a second-line option for low myopic patients who do not tolerate monovision. Multifocality requires excellent macular sensitivity (the center of the retina), which is necessary to interpret the multifocal wavefront. In moderate to high myopes, macular sensitivity is often compromised, so multifocality is not used; monovision is preferred and yields excellent results.

What Is the postoperative course after PresbyLASIK?

PresbyLASIK is not a painful procedure; simple analgesics are sufficient for postoperative comfort. However, it is very common to experience discomfort, as if a foreign body were present in the operated eye.

For one week, eye drops must be used strictly as prescribed, as their antibiotic and anti-inflammatory effects are essential to prevent complications. Mechanical protection of the eye is also crucial: protective shields should be worn during sleep and replaced with glasses during the day. The patient must avoid rubbing the eyes.

Since the procedure is not covered by public health insurance, no official medical leave is provided. Nevertheless, rest is important for at least 3 to 4 days, avoiding physical exertion.

Resuming physical activities depends on their nature. For one month, activities that pose a risk of eye trauma should be avoided. For the first two weeks, the patient must not immerse their head in water.

How does a PresbyLASIK procedure take place?

As with all refractive surgery, the quality of the preoperative assessment is paramount. It ensures there are no contraindications and confirms that PresbyLASIK is the most appropriate solution. Sometimes, depending on age, clear lens extraction may be preferable, especially if cataract formation has begun or is imminent.

Practically, PresbyLASIK is performed under local anesthesia by instilling lidocaine drops in the eye to be operated. Both eyes can be treated on the same day, and even then, the procedure never exceeds thirty minutes.

This is an outpatient procedure, and the patient can return home the same day.