Surgical Correction of Surgical Correction of PresbyopiaPresbyopia
Con N. MoshegovSydney
Treatment ModalitiesTreatment Modalities
Glasses Contact lenses Corneal procedures:
• CK, PRK, LASIK, intracorneal inlays Scleral procedures:
• Scleral Expansion Bands• Laser Presbyopia Reversal (LAPR)
Intraocular implants
Conductive KeratoplastyConductive Keratoplasty
Radio frequency energyRadio frequency energy Applied to peripheral corneal stroma via probeApplied to peripheral corneal stroma via probe
CK tmt points
Conductive KeratoplastyConductive Keratoplasty
Induces up to 1.5 to 2.0D of steepeningInduces up to 1.5 to 2.0D of steepening Essentially gives patient a monovision effect Essentially gives patient a monovision effect
CK: good pointsCK: good points
ExtraocularExtraocular Relatively inexpensiveRelatively inexpensive Can be done at the slit lampCan be done at the slit lamp Attractive to non refractive surgeonsAttractive to non refractive surgeons
CK: not so good pointsCK: not so good points
Limited to hyperopes or emmetropes (who accept Limited to hyperopes or emmetropes (who accept monovision)monovision)
Induction of cylinder and irregular astigmatismInduction of cylinder and irregular astigmatism Regression of effectRegression of effect
Not popular as a routine tool in the treatmentNot popular as a routine tool in the treatment
of presbyopiaof presbyopia
PRK and LASIKPRK and LASIK
MonovisionMonovision• dominant: planodominant: plano• non-dominant -0.50D to -2.00Dnon-dominant -0.50D to -2.00D
Aspheric ablationsAspheric ablations
Patterns of Multifocal AblationPatterns of Multifocal Ablation
Near
Far Near
Far
Far
Near
Aspheric Ablations for Aspheric Ablations for Presbyopia CorrectionPresbyopia Correction
Canadian Clinical TrialCanadian Clinical Trial
Monocular Simultaneous Uncorrected Monocular Simultaneous Uncorrected Distance and Near VisionDistance and Near Vision
-0.10
0.10
0.30
0.50
0.70
0.90
1.10
1.30
-0.20 -0.10 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90
Pre-op (n=44 eyes)
6 M (n=44 eyes)
20/25 or better
J3 o
r bett
er
77% of eyes achieve both 20/25 distance and J3 near or better
Aspheric Ablation: good pointsAspheric Ablation: good points
PRK and LASIK are familiar procedures Easily enhanced and reversible
Aspheric Ablation: not so good pointsAspheric Ablation: not so good points
Temporary: as crystalline lens changes with age
Personal experience: distance vision has to be compromised (induced myopia) for the reading to be adequate
Intracorneal InlaysIntracorneal Inlays
Lamellar corneal flap created (8.0mm and 160µm)Lamellar corneal flap created (8.0mm and 160µm) Inlay implanted over pupilInlay implanted over pupil
CURRENT CORNEAL INLAYSCURRENT CORNEAL INLAYS
AcuFocus AcuFocus Hydrogel Hydrogel LensLens®®
Biovision Biovision InvueInvue™™
Intracorneal Intracorneal Microlens Microlens SystemSystem
AcuFocus ACI AcuFocus ACI 70007000®®
ReVision ReVision Optics Optics
PresbyLensPresbyLens®®
ThicknessThickness 0.03 mm to 0.03 mm to 0.006 mm 0.006 mm 20 20 μμmm 10 10 μμmm 10 10 μμmm
DiameterDiameter 1.8 mm to 2.2 1.8 mm to 2.2 mmmm 3.0 mm3.0 mm 3.8 mm3.8 mm 1.5 mm1.5 mm
MaterialMaterial 45% hydrogel 45% hydrogel (Hefilcon-A)(Hefilcon-A)
78% water-78% water-permeable permeable
biocompatible biocompatible hydrogelhydrogel
Kynar (opaque Kynar (opaque polymer) with a polymer) with a
small central small central appertureapperture
Micro-porous Micro-porous hydrogel hydrogel
(Nutrepore) for (Nutrepore) for permeability of permeability of nutrients within nutrients within
the corneathe cornea
AcuFocus ACI 7000® (Bausch & Lomb)
PresbyLens®
ReVision Optics
• B&L has rights• 700 eyes Worldwide• Australian investigators• Likely some reduction in CS under mesopic conditions
Inlay: good pointsInlay: good points
ExtraocularExtraocular Easy to do Easy to do Easy to reverseEasy to reverse
Inlay: not so good pointsInlay: not so good points
Involves visual axisInvolves visual axis Adversely effects distance vision in emmetropes.Adversely effects distance vision in emmetropes. Cases of epithelial ingrowth resulting in thinning Cases of epithelial ingrowth resulting in thinning
and melt of flapand melt of flap
Intracorneal InlayIntracorneal Inlay Correction of hyperopia by intracorneal lenses two year Correction of hyperopia by intracorneal lenses two year
follow-upfollow-upIsmail MIsmail M
J Cataract Refract Surg 2006; 32: 1657-60
• 23 eyes of 21 patients• Hyperopia +2.5D to +6.00D• Permavision (Anamed Inc)• Moria M2 microkeratome• 70% within 0.50D• Lens opacification seen in 5 eyes (21.7%)
Scleral Expansion BandsScleral Expansion Bands
Increase distance between ciliary muscle and Increase distance between ciliary muscle and lens equator by tenting sclera between band lens equator by tenting sclera between band and limbusand limbus
Thus enhancing effect of ciliary muscle Thus enhancing effect of ciliary muscle contractioncontraction
Silicone bands inserted onto 4 scleral tunnelsSilicone bands inserted onto 4 scleral tunnels
SEB: good pointsSEB: good points
ExtraocularExtraocular No adverse effects on quality of visionNo adverse effects on quality of vision
SEB: not so good pointsSEB: not so good points
Surgical time: 40 mins per eyeSurgical time: 40 mins per eye Bloody surgeryBloody surgery Modest gains in near visionModest gains in near visionScleral Expansion Surgery Does Not Restore Accomodation Scleral Expansion Surgery Does Not Restore Accomodation
Ophthalmology 1999; 106: 873-877Ophthalmology 1999; 106: 873-877 Dynamic infrared optometry failed to detect any evidence of Dynamic infrared optometry failed to detect any evidence of
accommodation with effortaccommodation with effort
Laser Assisted Presbyopia Reversal Laser Assisted Presbyopia Reversal (LAPR)(LAPR)
• Infrared Erbium:YAGInfrared Erbium:YAG• Delivered through a fibre and contact tipDelivered through a fibre and contact tip
LAPRLAPR 4 fornix based peritomies Ablations applied in scleral
tissue 0.5mm posterior to the limbus to 80% thickness
Peritomy sites closed with bipolar forceps.
LAPR cosmetic appearanceLAPR cosmetic appearance
1 week
4 months
7 months
LAPR complicationsLAPR complications
MicroperforationsMicroperforations
Conjunctival cystsConjunctival cysts
Iris atrophyIris atrophy
LAPRLAPR
Good: Extraocular procedure Surgically easy No adverse effects on visionNot-so-good: No large studies of efficacy yet Variable benefit to near vision Regression reported in several (non US) centres Expensive laser
MULTIFOCAL IOLs
ACCOMMODATING PSEUDOACCOMMODATING
REFRACTIVE DIFFRACTIVE
Intraocular implantsIntraocular implants
Accommodating IOLsAccommodating IOLs
38
5659
4432
7780 76
15
89 8694
0
20
40
60
80
100
6/6 6/9 6/12
Crystalens Results (Stasiuk n=33)
1 week
1 month3 months
6 months
41444144
565956
65
74
6562
80
26
3538
20
0
10
20
30
40
50
60
70
80
N6 N8 N10 <N12
Crystalens Results (Stasiuk n=33)
1 week1 month3 months6 months
CrystaLens (Stasiuk)CrystaLens (Stasiuk)
PCO requiring YAG: 20 (59%) Posterior vaulting in 6 (18%) Glare and night vision disturbances
CrystaLens: does it really vault?CrystaLens: does it really vault?
Pilocarpine-induced shift of an accommodating intraocular lens: AT-45
Koeppl C, Findl O, Menepace R et al (Vienna)J Cataract Refract Surg 2005; 31: 1290-7 54 eyes Slight backward shift occurred with application of
pilocarpine Polishing capsule had no effect on accommodative
ability Near acuity with distance correction was J4 at 3 months Not statistically different from similarly shaped monofocal
HumanOptics 1CUHumanOptics 1CU
Hydrophilic acrylic foldable IOL Haptics thinner near optic Flexibility allows reversible anterior movement
Human Optics 1CUHuman Optics 1CUEarly visual results with the 1CU accommodating intraocular lensDogru M, Honda R, Omoto M et al (Japan)J Cataract Refract Surg 2005; 31: 895-902 Peak amplitude of accommodation with 1CU was 0.5D (±
0.44D) at 3 months Accommodation declined after 6 months Additional near acuity with 1CU disappeared at 12 months Correlated with increasing opacification of anterior and posterior
capsules
Prospective study comparing the 1CU with a monofocal Prospective study comparing the 1CU with a monofocal non-accomodating IOLnon-accomodating IOL
Minor statistical advantage of half a reading step but not Minor statistical advantage of half a reading step but not predictablepredictable
Tetraflex accommodating IOLTetraflex accommodating IOL 5.75mm acrylic optic5.75mm acrylic optic
Designed to have forward movement for near vision and return to the intended plane in the “flat” position for clear intermediate and distance
Personal results: excellent monofocal characteristics Less than optimal DCNVA
Design Theory vs. Practice Design Theory vs. Practice
1CU, BioComFold and CrystaLens IOLs No study found promising near visual acuity results No study found more than 700micrometres of forward shift of
IOLs with accommodation Some found a backward shift with pilocarpine
MULTIFOCAL IOLs
ACCOMMODATING PSEUDOACCOMMODATING
REFRACTIVE DIFFRACTIVE
The ARRAYThe ARRAY®®IOLIOLRefractiveRefractive Multifocal IOL Design Multifocal IOL Design
Five concentric zones Each zone has a near or
distance weighting Centre is distance weighted
3rd (distance dominant) ring enlarged and moved 3.4mm-3.9mm to 3.45mm-
4.3mm4th (near dominant) ring shifted from
3.9mm-4.6mm to 4.3mm-4.6mm (and thinned out)
AMO ReZoomAMO ReZoom™™
Good:Good: Provides excellent distance vision Provides reasonable intermediate vision Fewer halo and glare problems than the Array
Not-so-good:Not-so-good: Reading ability (near acuity) variable Reading ability is pupil dependent Less tolerable in myopes
MULTIFOCAL IOLs
ACCOMMODATING PSEUDOACCOMMODATING
REFRACTIVE DIFFRACTIVE
AMO Tecnis ZM9000 and Alcon ReSTOR
AMO Tecnis: Full Optic Diffractive
Alcon ReSTOR: Partial Optic Diffractive Alcon ReSTOR: Partial Optic Diffractive ApodizedApodized
Only the central 3.6mm of optic contains diffractive rings with steps of certain height
Now available in aspheric form Step heights get progressively lower from centre to
periphery
AMO Tecnis™ ZM900 Multifocal and Alcon ReSTORGood: Provide excellent distance and near vision Fewer halo and glare problems than the Array Most appreciated by hypermetropes Well tolerated by (higher) myopesNot-so-good: Intermediate vision suboptimal: problem for computer
users Quality of vision not as acute as with a monofocal
(contrast sensitivity suffers)
Average Intermediate Acuity (at 60cm)
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
UCVA BCVA
ReSTOR
Array
ReZoom
ReS
TO
R
ReS
TO
R/A
rray
ReS
TO
R/R
eZO
OM
ReS
TO
R
ReS
TO
R/A
rray
ReS
TO
R/R
eZO
OM
P=0.0144 Array better BCVA than ReSTORP=0.0694 Array better UCVA than ReSTOR
Average Near Acuity (at 30cm)
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
UCVA BCVA
ReSTOR ReSTOR/Array ReSTOR/ReZoom
ReS
TO
R
ReS
TO
R/A
rray
ReS
TO
R/R
eZO
OM
ReS
TO
R
ReS
TO
R/A
rray
ReS
TO
R/R
eZO
OM
And…Spectacle Independence
0
10
20
30
40
50
60
70
80
90
100
Pe
rce
nta
ge
of
Pa
tie
nts
Never Sometimes Always
ReSTOR (n=29)
ReSTOR/Array (n=17)
ReSTOR/ReZoom (n=8)
AcrySofAcrySof®® ReSTOR ReSTOR®® Aspheric IOL Aspheric IOL
SN6AD3•Add Power: +4 D•Spectacle Plane: 3.2 D•Range: +10 D to +34 D •A-Constant: 118.9
SN6AD1•Add Power: +3 D•Spectacle Plane: 2.4 D•Range: +10 D to +34 D •A-Constant: 118.9
Both +4D and +3D have 3.6 mm Apodized Diffractive regionBoth +4D and +3D have 3.6 mm Apodized Diffractive region +4 D central zone diameter = 0.742 mm+4 D central zone diameter = 0.742 mm +3 D central zone diameter = 0.856 mm+3 D central zone diameter = 0.856 mm
+4 D, 12 zones+4 D, 12 zones
+3 D, 9 zones+3 D, 9 zones
Physical ComparisonPhysical Comparison
Mean Distance Corrected Intermediate VAMean Distance Corrected Intermediate VA
0
0.1
0.2
0.3
0.4
50 cm 60 cm 70 cm
LogM
A
ReSTOR® Aspheric +3 D N=138 ReSTOR® Aspheric +4 D N=131
20/25
20/32
VAs are approximately 1.5 lines better for ReSTOR® VAs are approximately 1.5 lines better for ReSTOR® Aspheric +3 D Aspheric +3 D
20/20
20/40
Data on File. Alcon, Inc.
Mean Visual DisturbancesMean Visual Disturbances
0 1 2 3 4 5 6 7
Blurred Far Vision
Blurred Near Vision
Distorted Far Vision
Distorted Near Vision
Double Vision
Glare/Flare
Halos
Problems with ColorPerception
Problems with Night Vision
ReSTOR® Aspheric +3 D N=138 ReSTOR® Aspheric +4 D N=131
MildMild ModerateModerate SevereSevereNoneNone
Data on File. Alcon, Inc.
LASIK used to refine sphere and treat astigmatism
Future IOLsFuture IOLs
Second generation Visiogen Synchrony IOL Two optics linked by a bridge Plus lens in front, minus lens in back Dozens have been implanted
Medennium Smart IOL Completely filling capsular bag Thermodynamic Acrylic material Fills capsular bag and flexes with attempted
accommodation
IOLs likely to be the permanent solution to presbyopia
Presbyopia treatment todayPresbyopia treatment today
Hypermetropic:Hypermetropic:• Monovision: Monovision: LASIK, PRK or IOLLASIK, PRK or IOL• Aspheric laser ablationAspheric laser ablation• Multifocal IOLMultifocal IOL
Highly myopic:Highly myopic:• Monovision Monovision • Multifocal IOL Multifocal IOL
Emmetropic:Emmetropic: monovision only monovision only Low myopes:Low myopes: monovision at best monovision at best