Transcript

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Trust your eyes.

Presbyopic treatment methods on the cornea

PresbyMAX®– The Principle

PresbyMAX® – Expectations and Key Factors

PresbyMAX®– Upcoming Software Features

PresbyMAX®– Decision criteria and patient’s acceptance

Directory

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0 1 2 3 4 5 6 7 8

Object distance (m)

Vis

ual A

cuity

(%

)

Emmetrope 25yo

Emmetrope 45yo

Emmetrope 55yo

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0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00

Object distance (m)

Vis

ual A

cuity

(%

)

Emmetrope 25yo

Emmetrope 45yo

Emmetrope 55yo

Introduction and Basics:Visual Acuity and Object Distance related to Age

The average distance (more than 1 m) visual acuity in emmetropes until 45 years of age is high, the senior population shows diminished performance.

The average near (less than 1 m) visual acuity in emmetropes until 40 years of age is ok, the senior population shows diminished performance.

Advantage/Comfort Disadvantage/Discomfort

Introduction and Basics:Monovision

Clear focus, i.e. sharp retinal image Anisometropia (more than 1 D)

Highly accept in patients and physicians Loss in stereopsis

Independent from pupil size

near

intermediate

farDE

NDE

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Advantage/Comfort Disadvantage/Discomfort

Introduction and Basics:Bi-Focality

Clear foci; i.e. two sharp images on the retinaDisturbing vision because of „steps“ between zones

Does typically not cover the whole distance range, especially not the intermediate part

Pupil size critically dependent

near

intermediate

far

OR

DE

NDE

Advantage/Comfort Disadvantage/Discomfort

Introduction and Basics:Q-value adjusted

Extended depth-of-focusThe Q-value is no predictor for visual performance

The Q-value describes the shape between the cornea centre and periphery

Influenced by the change in radius of curvature (dioptric power); i.e. kind of unpredicted

Unilateral (non-dominant eye)

near

intermediate

far

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Advantage/Comfort Disadvantage/Discomfort

Introduction and Basics:Multifocality

Covers the whole distance range due to different foci for distance, intermediate, near

Pupil size dependent

Typically bilateral which keeps stereopsis Time of (neural) adaptation

Possibly reduced contrast sensitivity

near

intermediate

far

OR

DE

NDE

micro-monovision (ZEiSS) Aspheric (Nidek) PresbyM AX PresbyMAX µ-monovision

DominantEye

Non-dominantEye

near

far

near

far

near

far

near

far

SCHWIND PresbyMAX®

vs. Competing Multifocal Technologies

near

intermediate

far

near

far

near

far

far

near

far

near

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Near(40cm)

Intermediate(70cm)Far (>5m)

MonovisionDENDE

AMO VISXCustomVue Presbyopia

DENDE

Technolas PVSupracor

DENDE

NidekPAC Aspheric

DENDE

ZEiSSLaser Blended Vision

DENDE

Alcon WavelightQ-value adjusted

DENDE

SCHWIND PresbyMAX

DENDE

SCHWIND PresbyMAX µ-

monovision

DENDE

SCHWIND PresbyMAX®

vs. Competing Technologies

Alternative Presbyopic Solutions:IntraCOR

Advantage/Comfort Disadvantage/Discomfort

No refractive correction procedure, i.e. for „emmetropes“ only Fast visual recovery

No reverse application or re-treatmentMinimally invasive

Difficulties in post-LASIK patients exist

Intrastromal presbyopia treatment using photodisruption with the Technolas femtosecond

• Five rings (1.8, 2.2, 2.6, 3.0 and 3.4 mm in diameter) are created

• Cutting design and stromal depth based on refractive error

• A shift towards myopia exists due to central corneal steepening (hyper-prolate shape)

Difficulties for LASIK post-IntraCOR

No tissue removal

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Alternative Presbyopic Solutions:Corneal Inlay

Advantage/Comfort Disadvantage/Discomfort

Easily removed or replacedNo refractive correction procedure, i.e. for „emmetropes“ only

Increased depth-of-focus without tissue removal

Really fast recovery

Intracorneal inlays have been designed to create a small aperture effect or central steepening.The implant is intended to be placed intra-stromally either under a corneal flap or into a cornealpocket. Placement of the CI will be centered over the pupil, typically in the non-dominant eye.

I. The AcuFocus Kamra corneal inlay (US): Ø 3.8 mm, 10 µm thick, central opening of Ø 1.6 mm, thousands of small laser openings for good corneal nutrition transport

II. Flexivue Micro-Lens (NL): clear circular implant of Ø 1.5 mm, 10 µm thick in the periphery, increase of 24 to 40 µm to the centre, out of hydrogel (hydrophilic polymer)

III. PresbyLens (US): clear circular implant of Ø 2 mm – like a tiny contact lens – out of hydrogel

Before PresbyMAX ® With PresbyMAX ®

Presbyopia software that offersa broad treatment spectrum for different indications:

Treatment of emmetropic, myopic,hyperopic, and astigmatic eyes

Correction of these visual defects can beperformed as “Aberration-Free” or“Customized” treatments

Any treatment method possible:PRK, TransPRK, LASEK, LASIK and FemtoLASIK

Limited treatment range

e.g. only hyperopic patients

e.g. only patients with minor astigmatism

e.g. no presbyopia treatment ofemmetropic or myopic patients

e.g. only in combination with standardtreatments

e.g. only in combination with wavefrontguided treatments

PresbyMAX® - Unique Treatment Range

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extendeddepth-of-focus

PresbyMAX®

pseudo-far-point

PresbyMAX®

pseudo-near-point

foveola

PresbyMAX®

multiaspheric cornea

PresbyMAX® - The Principle

Introduction and Basics:Visual Acuity Scales

Near Visual Acuity Scales

logRAD(40 cm)

Revised Jaeger(35 cm)

Nieden(40 cm)

-0.2 - -

-0.1 - N1

0.0 J1: = 1.00 N2

0.1 J2: = 0.80 N3

0.2 J4: = 0.63 N4

0.3 J5: = 0.50 N5

0.4 J6: = 0.40 N6

0.5 J8: = 0.32 N7

0.6 J9: = 0.25 N8

0.7 J10: = 0.20 N9

0.8 J12: = 0.16 N10

0.9 J13: = 0.13 N11

1.0 J14: = 0.10 N12

Distance Visual Acuity Scales

logMAR feet20/

decimal

-0.2 10 1.60

-0.1 12.5 1.25

0.0 20 1.00

0.1 25 0.80

0.2 32 0.63

0.3 40 0.50

0.4 50 0.40

0.5 63 0.32

0.6 80 0.25

0.7 100 0.20

0.8 125 0.16

0.9 160 0.13

1.0 200 0.10

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PresbyMAX® - ExpectationsReading Acuity vs. Print Size

» 0.4 logRAD (J6; 20/50) ≡ 10 Pt @ 40 cm

» 0.5 logRAD (J8; 20/63) ≡ 12 Pt @ 40 cm

» 0.7 logRAD (J10; 20/100) ≡ 18 Pt @ 40 cm

» 0.8 logRAD (J12; 20/125) ≡ 20 Pt @ 40 cm

» 0.2 logRAD (J4; 20/30) ≡ 6 Pt @ 40 cm

normally suffices to clearly recognize newspaper print in well lit conditions

Pupil ∅ 3.0 mm 3.8 mm 4.5 mm 5.5 mm

Far

(6 m)

Far Intermediate

(1.5 m)

Intermediate

(70 cm)

Near

(40 cm)

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Visual Acuity as a function of the object distance

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Object distance (m)

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cuity

(%

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PresbyMAX V2 +3D (6 mm)

PresbyMAX V2 +3D (3,8 mm)

PresbyMAX V2 +3D (2 mm)

Visual Acuity as a function of the object distance

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0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00

Object distance (m)

Vis

ual A

cuity

(%

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PresbyMAX V2 +3D (6 mm)

PresbyMAX V2 +3D (3,8 mm)

PresbyMAX V2 +3D (2 mm)

Visual Acuity after PresbyMAX®

related to different Pupil Sizes

Visual Acuity as a function of the object distance

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60%

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100%

120%

0 1 2 3 4 5 6 7 8

Object distance (m)

Vis

ual A

cuity

(%

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Emmetrope (55 yo)

PresbyMAX V2 +2D (50 yo)

PresbyMAX V2 +3D (60 yo)

Visual Acuity as a function of the object distance

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0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00

Object distance (m)

Vis

ual A

cuity

(%

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Emmetrope (55 yo)

PresbyMAX V2 +2D (50 yo)

PresbyMAX V2 +3D (60 yo)

As a compromise between multifocality, distance and near UCVAs, consider planning additions between 1.25 D to 2.50 D

Visual Acuity after PresbyMAX®

related to different Additions

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PresbyMAX® - ExpectationsUncorrected Visual Acuity over time

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15

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25

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400 1 2 3 4 5 6 7 8 9 10 11 12

Follow-up time (months)

DU

CV

A (20

/n)

1

2

3

NU

CV

A (Jm

)

DUCVA (20/n)NUCVA (Jm)

The postoperative progress behaves in all refraction types similar but the acceptance patient by patient may differ.

PresbyMAX® - Key Factors for Success

Patients with positive thinking preoperatively knowing that reduced distance vision postoperatively (DBCVA pre-op vs. UCVA post-op) may occur.

Trial with multifocal contact lenses (centre for near, periphery for distance) could be done prior to surgery or easier, even if no influence/effect in multifocality (SphAb) can be demonstrated, simulate a vision of 1 to 2 lines less than BSCVA and ask for the postoperative acceptance (e.g. simulate distance refraction 0.25 to 0.50 D less than BCVA to the patient; simulate near refraction with addition +0.25 to +0.50 less than BCVA to the patient).

Most satisfied patients are hyperopes, then high as tigmatics, then high myopes, then emmetropes, then low myopes .

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PresbyMAX® - a possible Trial Contact LensCibaVision AirOptix Aqua Multifocal

aus AirOptix® Kontaktlinsen Broschüre

PresbyMAX® - Key Factors for Success

Exports are done for selected OZ

» between 5.8 and 6.3 mm (~6.0 mm) in presbyopic myopia,

» between 6.2 and 6.7 mm (~6.5 mm) in presbyopic hyperopia,

» between 6.5 and 7.0 mm (~6.8 mm) in presbyopic astigmatism dominance

Make sure the ablation map is large enough for the scotopic pupil size.

Do both eyes simultaneously since otherwise the binocular vision will suffer from the multifocality on only 1 eye (anisometropia and aniseikonia).

Perform treatments on the corneal vertex to reduce induction of coma aberrations disturbing vision at all distances.

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PresbyMAX® - The PrinciplesTargets for the Central and Mid-Peripheral Areas

∆ 0.0D

Dominant Eye Non-dominant Eye

-0.5D

∆ 0.75D-0.125D

-1.75D -1.75D

-0.875D

-0.5D

-1.0D -1.75D

with µ-monovision

PresbyMAX

PresbyMAX®

The Software Solution V4.4: Hyp.Astigmatism

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PresbyMAX®

The Software Solution V4.4: Myo.Astigmatism

PresbyMAX® with µ-monovisionThe Software Solution V4.4: Hyp.Astigmatism

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Addition as a function of age

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0,50

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2,50

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3,50

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25 30 35 40 45 50 55 60 65 70 75

Age (years old)

Add

ition

(D

)

Addition

Model

PresbyMAX

PresbyMAX® - The Presbyopic Compensation

SCHWIND PresbyMAX® proposes a presbyopiccompensation based on the age of the patient.

PresbyMAX® - GuideSCHWIND Recommendation Document

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Re-treatment Options

PresbyMAX® can be repeated if reading-spectacles demands renew.

PresbyMAX® can be repeated if reading quality (multifocality) is not sufficient but distance vision is satisfying.

Aberration-Free treatment (with equal optical zone size to previous PresbyMAX® procedure) can be performed on top for improved distance correction if reading quality (multifocality) is satisfying.

PresbyMAX® Reversal option with distance best corrected refraction included can be performed if the patient does not accept the PresbyMAX® concept at all (too much compromise for the individual).

Due to healing process and neuronal adaptation, a r e-treatment procedure shall not be performed prior 6 months aft er surgery.

PresbyMAX® – The Reversal Concept

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PresbyMAX® after Previous Refractive Surgery

Previous Corneal Refractive Surgery (with the aim of emmetropic distance vision)

Decision shall be equal to patients with virgin corneae.Futhermore, the SCHWIND decision tree for Aberration-Free, Corneal and Ocular Wavefront treatments might be considered

Previous cataract surgery (natural lens exchange)

Multifocal enhancement can be performed on the patient’s cornea.

Intraocular Surgery after PresbyMAX®

Aspheric IntraOcular Lenses:

Properly calculated aspheric lenses (in the sense of aberration-neutral) after PresbyMAX provide the best quality of vision without compromising the already achieved pseudoaccommodation. (No decentration and tilting of the IOL and correct IOL power assumed)

Spheric IntraOcular Lenses:

Spheric Ienses induce positive spherical aberration and thus would remove in part or in total the already achieved pseudo-accommodation.

Multifocal IntraOcular Lenses:

Multifocal (refractive, diffractive, or accommodative) lenses induce negative spherical aberration and multiple foci and thus would enhance the already achieved pseudoaccommodation. But centration issues of the lenses become critical and may induce large amounts of coma from the misalignment between the PresbyMAX® multifocal cornea and the multifocal IOL.

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SCHWIND eye-tech-solutionsfon: +49(0)6027 / 5 08-0fax: +49(0)6027 / 5 08-208email: [email protected]: www.eye-tech-solutions.com

SCHWIND eye-tech-solutions GmbH & Co. KG · Mainparkstrasse 6-10 · 63801 Kleinostheim · Germany

Thank you very much for your kind attention!Vielen Dank für Ihre Aufmerksamkeit!¡Muchas gracias por su amable atención!


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