This 60 year old patient is seeing you in consultation for cataract surgery. He has a significant posterior subcapsular cataract in each eye and his vision has declined to the point where he cannot drive safely. In our city, Los Angeles, most people require a car for mobility and independence since the city is spread out over a large area and public transportation is not as good as other cities.
For as long as he can remember, he has not worn glasses for most activities. He has been prescribed glasses in the past, but found that he really didn’t wear them much except for driving at night. He is an accountant and spends 8 hours per day on the computer or reading paperwork. His hobby is woodworking.
He has a pair of glasses that are 12 years old and they measure:
- OD: -0.75 -0.25 x 45 giving 20/20 distance vision (at that time)
- OS: -1.75 spherical giving 20/20 distance vision (at that time)
In the pic above you can see that his current refraction is very similar. The printout from our biometer is below:
His surgery should be relatively straightforward and routine, but the difficulty is deciding on the best IOL power and post-op target. What are the options?
- Option A: Plano OU with monofocal IOLs would give the best distance vision, likely better than he has had in many years, but will take away the benefit of his low myopia
- Option B: Plano OU with multifocal IOLs would give good distance and near vision but would produce some level of dysphotopsias, particularly at night
- Option C: Plan OD / -1.75 OS with monofocal IOLs would give better distance vision than he has had and would maintain his near vision, but his is more anisometropia than he is used to
- Option D: -0.75 OD / -1.75 OS with monofocal IOLs would give him about the same refraction that he’s used to, but we lose the opportunity to improve his distance vision
Given these options, which would you choose? Or perhaps there is another option that you prefer? Please give your response in the comment section below.
In case you’re wondering, I have chosen option D with a plan for a +22.0 D IOL OD (-0.75 target) and +23.0 D IOL OS (-1.75 target). My thinking is that this will make him the happiest and it is what he is used to. He does not mind wearing glasses for driving, but wishes to be able to do his computer work and desk work without glasses.