She is a soft contact lens user with high myopia of about −9.0 D, and first visited us for cataract consultation because both distance and near were hard to see. Both eyes had nuclear cataracts of about grade 3 plus cortical opacity, and measured total astigmatism in the right eye exceeded 4.0 D.
Corneal topography showed about 1.0 D of against-the-rule corneal astigmatism, so by calculation the remaining 3.0 D of lenticular astigmatism from the cataract could be removed by cataract surgery alone. However, she wanted to reduce her dependence on contact lenses and glasses and wished for a trifocal multifocal lens, so to bring out the full effect of the multifocal lens, we recommended the toric PanOptix Toric.
She had the zonular weakness typical of high myopia, but the surgery was completed without problems; uncorrected distance vision, 0.05 / 0.08 before surgery, improved greatly to 1.2 in both eyes, and as she wished, uncorrected near vision was also good at 1.2, so she was very satisfied to be able to live without contact lenses. Incidentally, as a surgeon, nothing pleases me more than being told that peeling off the surgical drape (adhesive) hurt more than the surgery itself.
Colleagues sometimes ask me what target refraction to set for people with high myopia, and here again staged implants (deciding the target power for one eye based on the result in the other) and matching the patient's personal wishes seem important. She works looking at detailed drawings and wished for near dominance, so we first set the right eye slightly toward near, about −0.5 D; she then wanted the other eye to see a little nearer still, so we chose −0.75 to −1.0 D, considerably near-dominant and not usually chosen. As a result, measured postoperative refraction was myopic at −0.625 D right and −0.875 D left, but besides near vision, uncorrected distance vision reached 1.2 in both eyes, with subjective refraction of −0.375 in both.
It does not apply to everyone, but in high myopia like this there are quite a few cases with a considerable difference between objective and subjective refraction. To provide the best visual function for each patient, it seems essential to take subjective refraction into account when setting the target refraction and to accommodate individual lifestyles through detailed interviews.