Refractive surgery for myopia vs presbyopia: Tailoring the approach for the individual

When it comes to refractive surgery, not all patients are created equal. A 28-year-old patient with myopia desiring to be free of glasses is different from a 52-year-old patient with presbyopia looking to minimize dependence on reading glasses. Understanding these differences is essential for creating realistic expectations and recommending the right procedure for the right patient.

Refractive surgery for myopia: Freedom with LASIK, SMILE, PRK, and ICL

For patients with myopia, the refractive surgery conversation is often straightforward. These patients are primarily concerned with seeing clearly without spectacles or contact lenses, and their motivation is high. The procedures we commonly consider are LASIK, small incision lenticule extraction (SMILE), photorefractive keratectomy (PRK), and phakic intraocular lenses (IOLs) such as implantable collamer lenses (ICLs).

LASIK remains the workhorse for mild to moderate myopia. Patients appreciate the quick recovery, minimal discomfort, and immediate visual improvement. The predictability is high, especially for patients with stable refractions. The procedure is simple to explain: flap creation, laser ablation, and visual freedom.

It is also a widely performed procedure with high success rates. Findings from a study by Chua et al in 2019 reported that over 94% of eyes achieved within ± 1.0 D of target refraction and at least 70% achieved within ± 0.50 D.¹

SMILE has gained popularity for patients with myopia, especially those with higher prescriptions or thinner corneas, because it is minimally invasive and maintains corneal biomechanics better than LASIK. Although the visual recovery can be slightly slower, patients often experience less dry eye and fewer flap-related complications.²

PRK is less commonly performed today but is still valuable for thin corneas or patients at higher risk for trauma, such as athletes. Findings from a study by Tananuvat et al in 2021 demonstrated that PRK provides excellent refractive outcomes and is safe, even for high-myopia corrections.³ Visual recovery is longer, but the long-term outcomes are excellent.

ICLs have been gaining in popularity as a great option for high myopia, particularly for patients outside the safe limits for corneal laser procedures. They offer excellent visual quality and are reversible. Findings from the EVO ICL study by Packer et al in 2022 reported that 94.5% of eyes achieved uncorrected distance visual acuity (UDVA) of 20/20 or better.⁴

The takeaway for patients with myopia is that options are abundant, outcomes are predictable, and the trade-offs are minimal, especially compared with older adults. Because the procedures are relatively more straightforward compared with presbyopic correction, these patients are often easier to counsel, more motivated, and quicker to commit.

Refractive surgery for presbyopia: Navigating complexity and expectations

Patients with presbyopia present a different challenge. By definition, presbyopia reduces near vision, and although distance vision might be adequate, the patient now wants both. Couple this with the fact that presbyopia is a continuous process, and we are left trying to correct a moving target, one where accommodation continues to decline over time and visual demands evolve with it. This makes refractive surgery more nuanced because we are not correcting one plane of focus but attempting to create functional vision across distances. The current options include the following:

Monovision LASIK, SMILE, PRK, or refractive lens exchange (RLE): Monovision has been around for decades and can be highly effective in the right patient. However, some patients may struggle with depth perception or neuroadaptation, particularly those in visually demanding professions. This is why preoperative testing with a contact lens trial is imperative. The beauty of monovision is that it leverages familiar technology, and in many cases, patients are already comfortable wearing monovision contact lenses. A systematic review by Kelava et al in 2017 found that monovision can be effective, but patient satisfaction varies depending on individual adaptation.⁵

RLE with extended depth-of-focus (EDOF) or multifocal IOLs: Here, the natural lens is removed and an IOL is implanted to restore both near and distance vision. With newer technologies, such as EDOF lenses and trifocals, visual quality is significantly improved compared with earlier multifocal designs. Patients often experience good intermediate vision and functional near vision with minimal dependence on glasses. Findings from a study by Schnider et al in 2024 discussed strategies to minimize the impact of presbyopia with IOLs, including mixing and matching lenses between the eyes.⁶

The challenge with presbyopia is that there are more trade-offs and that more complex counseling is required. Multifocal IOLs can introduce glare, halos, or reduced contrast sensitivity. EDOF lenses provide excellent intermediate vision but may not fully eliminate the need for reading glasses. Monovision, although effective, requires neuroadaptation and may not be suitable for everyone. Unlike younger patients with myopia, those with presbyopia need more education about what success looks like and may take longer to decide. The understanding is that although the near vision will be better, the natural accommodation cannot be restored with current technology and vision will not be what it was when they were younger. However, once they understand the functional benefits and are willing to accept minor compromises, satisfaction can be high.

Motivation and likelihood to proceed: Myopia vs presbyopia

From a psychological standpoint, patients with myopia are often easier to manage when it comes to refractive surgery. Their goals are clear: spectacle and contact lens independence at distance. They are younger, generally healthier, and less concerned about subtle trade-offs such as halos or contrast changes. Younger patients with myopia also tend to have fewer comorbidities, making surgical planning simpler.

Patients with presbyopia, in contrast, are motivated more by quality-of-life improvements rather than sheer convenience. They may already be accustomed to reading glasses or contacts and may approach surgery cautiously. Financial considerations, risk tolerance, and realistic expectations play a larger role. Although the motivation is there, it is tempered by careful consideration of trade-offs. As a result, patients with presbyopia may take longer to commit and require multiple consultations.

Conclusion

Refractive surgery is much simpler for patients with myopia: LASIK, SMILE, PRK, or ICL implantation offer predictable results, minimal trade-offs, and immediate lifestyle benefits. Patients with presbyopia, however, require a more nuanced approach, balancing monovision, multifocal IOLs, EDOF lenses, or refractive lens exchange. Modern technologies have improved outcomes, but counseling, expectation management, and lifestyle considerations are crucial.

In short, patients with myopia are often easier to convert to patients for surgery because the goal is clear and achievable whereas those with presbyopia require careful discussion, but when approached correctly, they can achieve remarkable functional vision and, ultimately, high satisfaction. Understanding these differences allows surgeons and optometrists to provide patient-centered care and help each individual achieve their personal visual goals.

References:

1. Chua D, Htoon HM, Lim L, et al. Eighteen-year prospective audit of LASIK outcomes for myopia in 53 731 eyes. Br J Ophthalmol. 2019;103(9):1228-1234. doi:10.1136/bjophthalmol-2018-312587

2. Nair S, Kaur M, Sharma N, Titiyal JS. Refractive surgery and dry eye - an update. Indian J Ophthalmol. 2023;71(4):1105-1114. doi:10.4103/IJO.IJO_3406_22

3. Tananuvat N, Winaikosol P, Niparugs M, Chaidaroon W, Tangmonkongvoragul C, Ausayakhun S. Twelve-month outcomes of the wavefront-optimized photorefractive keratectomy for high myopic correction compared with low-to-moderate myopia. Clin Ophthalmol. 2021;15:4775-4785. doi:10.2147/OPTH.S346992

4. Packer M. The EVO ICL for moderate myopia: results from the US FDA clinical trial. Clin Ophthalmol. 2022;16:3981-3991. doi:10.2147/OPTH.S393422

5. Kelava L, Barić H, Bušić M, Čima I, Trkulja V. Monovision versus multifocality for presbyopia: systematic review and meta-analysis of randomized controlled trials. Adv Ther. 2017;34(8):1815-1839. doi:10.1007/s12325-017-0579-7

6. Schnider C, Yuen L, Rampat R, et al. BCLA CLEAR presbyopia: management with intraocular lenses. Cont Lens Anterior Eye. 2024;47(4):102253. doi:10.1016/j.clae.2024.102253