Tools to Guide Treatment Choices

When examining a new patient with presbyopia, using objective tests to predict quality of vision and subjective tools to align expectations and tolerance are both essential. According to Erik L Mertens MD, FEBOS-CR, it is important to transfer all of this into a shortlist and to have a plan B ready.

The first step to consider is the modern patient’s journey through the digital sphere and the front desk, he said. There is only one chance for a first impression, and it is important to make it count. The second step is for optometrists and technicians to actually speak and listen to the patient, considering their motivations and frustrations about their vision, collecting useful data on their lifestyle, work, and hobbies, and understanding their expectations.

The subjective tools available in the clinical armamentarium are the basic quality of vision questionnaire and an interview focused on patients’ top three daily tasks, assessing their needs, their level of spectacle tolerance, and whether they are perfectionists or easy-going. The interview should be no longer than five minutes to avoid annoying the patient too much, he noted.

Another important subjective tool is the simulation/trial phase, in which Dr Mertens includes a monovision trial and explains dysphotopsia and what to expect from plan B to the patient. When the patient is going to receive a multifocal IOL, dysphotopsia needs to be explained honestly from the outset, he emphasised. The patient needs to be informed that halos and glare can be experienced for up to six months. Moreover, he pointed out, the surgeon should always discuss what is going to happen if the first surgery is not successful.

The third step is a full examination using the objective tools. Dr Mertens explained a full examination includes checking the ocular surface and considering a thorough preoperative treatment, performing an OCT evaluation of the macula, measuring astigmatism, and examining the cornea looking for conditions such as Cogan dystrophy or map-dot-fingerprint dystrophy as well as the risk of ectasia. It is also important to look for coma, trefoil, and spherical aberration, he said.

The pupil also needs to be analysed in scotopic, mesopic, and photopic circumstances, with evaluation of the angle kappa and alpha.

The fourth step is where the surgeon becomes directly involved. Once all the subjective and objective data have been gathered, Dr Mertens analyses the whole picture, determining the options for each candidate. He then decides which of those options will come closest to the patient’s expectations without exceeding the level of tolerance they are willing to accept.

“I [form a plan in] my mind [about] what I will do with the patient. By step five, I only make one specific recommendation to the patient—because when you give more options, you create doubt,” he concluded.

Dr Mertens presented at the 2026 ESCRS Winter Meeting in Helsinki.

Erik L Mertens MD, FEBO, PCEO, FWCRS, FEBOS-CR is Director, Founder, and Ophthalmic Surgeon of Medipolis, Antwerp, Belgium. E.Mertens@Medipolis.be