Presbyopic patient with hyperopia and moderately steep corneas: December consultation #1.

A 47-year-old woman was referred for refractive surgery evaluation. She has no ocular or medical history. Spectacle dependence is her chief concern. She cannot tolerate contact lens. The corrected near and distance visual acuity (CDVA) are 20/20, easily, in both eyes. The manifest refraction is +3.50 in the right eye and +2.75 in the left eye (dominant eye). The intraocular pressure and the results from a slitlamp examination and a fundus retinoscopy are normal. She has no dry eye and no complaints of halos or glare. She works in an office using a computer most of the day.The Scheimpflug device revealed the thinnest point of corneal thickness to be 497 μm in the right eye and 501 μm in the left eye ( and ). Keratometry (K) values were K1 43.20 diopters (D), K2 45.00 D, and Kmax 45.50 D in the right eye and K1 43.40 D, K2 45.00 D, and Kmax 46.00 D in the left eye. Optical coherence tomography revealed thinnest epithelial thickness of 48 μm in the right eye and 49 μm in the left eye. A Zernike analysis showed low values for coma and spherical aberrations.(Figure is included in full-text article.)(Figure is included in full-text article.)The topographic maps, despite the relative scale, revealed a pattern that seems to truncate in the center, in both eyes, but especially in the right eye. Pachymetric progression indices were within normal limits ().(Figure is included in full-text article.)What kind of surgery (if any) would you recommend to this patient? Would you consider laser in situ keratomileusis (LASIK) with a thin, predictable LASIK flap? And in this case, what are your limits for final, postoperative steep K? How much concern would you have if this patient needed an excimer laser enhancement?Would you offer clear lens extraction (CLE)? And in this case any specific intraocular lens (IOL) model?What data helped you most in making your decision? If you recommend proceeding with surgery, would age have played any significant role in the decision process?