Adolescence

Refractive procedures are not recommended for prepubertal and pubescent teenagers. Currently, some surgeons are evaluating refractive surgery for adolescents with strabismus, but it is too early to generally recommend this option.

Preoperative Considerations

• general ocular health
  
• progression of refractive error
  
• refractive stability
  
• visual demands and working distances
  
• accommodation
  
• need for extreme caution with patients in late adolescence (refraction often unstable)

Adulthood

Refractive targets for adults vary widely from full-distance correction for young adults to monovision considerations with presbyopic patients.

PREPRESBYOPIC ADULTS Prepresbyopic adults are usually 20 to 40 years of age.

Preoperative Considerations

• patient education about the effects and progression of presbyopia and mechanisms of correction (reading glasses, monovision with contact lenses, surgically induced monovision, multifocal* options)
  
• refractive stability
  
• progression of refractive error secondary to high demand for near tasks
  
• occupational and recreational visual demands (e.g., sufficiency of accommodation for near tasks, need for binocularity)
  
• speed of progressive loss of accommodation from hyperopia (in patient’s mid 30s) to emmetropia (in patient’s early 40s) to myopia (in patient’s mid to late 40s)
  
• ocular health (early cataracts, trauma, or ocular surface disease)

PRESBYOPIC ADULTS Presbyopia usually begins to affect adults in their early to mid 40s.

Preoperative Considerations

• refractive stability (more stable unless active ocular disease is present)
  
• speed and progressive nature of loss of accommodation
  
• absolute presbyopia by age 65
  
• patient education about the effects and progression of presbyopia and mechanisms of correction (reading glasses, monovision with contact lenses, surgically induced monovision, multifocal options)
  
• patient education (about need for reading glasses if bilateral distance refraction is the target)
  
• patient willingness to sacrifice bilateral acute distance vision for functional vision without correction at multiple distances
  
• adaptability to monovision
  
• increased frequency of ocular diseases in older age groups, including cataracts and age-related macular degeneration

Determination of the refractive target may be the most important part of the presurgical patient examination. Discussion of various target options follows.

Bilateral Distance Target

Preoperative Considerations

• ocular dominance (less critical because both eyes are corrected for distance)
  
• desire for optimal binocular distance vision (the reason most young adults and many presbyopic adults choose surgery)
  
• visual recreational and occupational demands (especially important in prepresbyopic and presbyopic individuals)
  
• evaluation of binocular status to rule out binocular abnormality and avoid patient expectation of no longer needing to wear eyeglasses
  
• possibility of diplopia in some patients with anisometropia and compensatory suppression in those with mild to moderate phorias or an alternating tropia (may require full-time prismatic correction postoperatively)
  
• documentation of possible postoperative effects on binocular vision if binocular abnormality found at preoperative assessment
  
• patient education about the advantages and disadvantages of binocular distance vision to prevent the surprise of decreased postoperative near visual acuity
  
• demonstration of patient’s postoperative vision with trial frames or contact lenses to show the effect of distance correction on near vision
  
• addition of a 1- to 1.5-D myopic lens in both eyes to simulate loss of accommodative reserve, especially for prepresbyopic patients

Bilateral Near or Intermediate Target

Though less frequently pursued, some individuals choose to have bilateral near or intermediate targets. Bilateral near or intermediate vision may be useful for certain occupations that require prolonged near-vision tasks (e.g., a computer programmer or professional pianist).

Preoperative Considerations

• demonstration of less than optimal distance vision using trial frames or contact lenses to create proper patient expectations
  
• patient education about the need for distance prescription eye-glasses or part-time contact lens wear to maximize distance acuity for driving and other distance tasks (verbal acknowledgment by the patient and chart documentation are essential)

Monovision

For decades contact lens wearers have utilized monovision to achieve functional vision at variable distances.

Preoperative Considerations

Although not currently the standard method of refractive surgery, the use of intraocular multifocal lenses also warrants discussion.

Advantages

• marked decrease in need for any form of additional optical correction
  
• potential for inducing mild blur at all distances and glare from the transitional component of the intraocular lens (IOL)
  
• extensive interest in the refractive community in multifocal IOLs with cataract extraction and clear lens extraction

Disadvantages

• requirement of extensive education to educate patients about potential complications with these lenses
  
  
  
  • loss of best corrected acuity
    
  • loss of contrast sensitivity
    
  • disabling night glare

Demers PE, Wu HK, Steinert RF. Refractive error. In: Wu HK, Thompson VM, Steinert RF, Slade SD, Hersh PS, eds. Refractive Surgery. New York: Thieme; 1999:3-39.