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AsphericityAsphericity and Q Adjustments in and Q Adjustments in Treating Treating PresbyopiaPresbyopia
Mounir KhalifaMounir KhalifaProf. of Ophthalmology, Tanta UniversityProf. of Ophthalmology, Tanta University
Horus Vision Correction CenterHorus Vision Correction CenterAlexandria, EgyptAlexandria, Egypt
The Mechanism of Accommodation
The Optics of Accommodation
The loss of accommodation leads to presbyopia
Presbyopia
Duane measured Duane measured the amplitude of the amplitude of accommodation in accommodation in 1500 subjects using 1500 subjects using the subjective the subjective ““push uppush up””technique (Duane, technique (Duane, 1912).1912).
Depth of Focus
Looking closer to Presbyopia
NearNear reflexreflex(Nervus (Nervus occulomotoriusocculomotorius))
3.3. MiosisMiosis withwith ageage
2.2. ConvergenceConvergence withwith ageage
1.1. AccommodationAccommodation withwith ageage
withwith accommodationaccommodation
0
5
10
15
20
25
30
35
40
45
-0,9
-0,8
-0,7
-0,6
-0,5
-0,4
-0,3
-0,2
-0,1 0 0,1 0,2 0,3 0,4 0,5
Q-Value
Num
ber
of E
yes (
n=17
6)
The mean shape of the human cornea P.M. Kiely, G. Smith and L.G. CarneyOptica Acta, 1982, Vol.29, No. 8, 1027-1040
Most Corneas are Negatively Aspheric (Prolate)
Population Distribution of Q-Values
Prolate OblateProlate Oblate
Q = 0Q = 0 (Spherical)(Spherical)
Corneal AsphericityCorneal Asphericity
Minimizes Spherical Aberration
Hyper-Prolate Enhances Depth of Focus (DoF)
IROC, Curtesy Prof. Dr. M. Mrochen
DoFDoF Increases with Negative QIncreases with Negative Q
The depth of focus curve (blue curve) strongly increased (up to The depth of focus curve (blue curve) strongly increased (up to 2D), but 2D), but therethere are a maximum before a decrease for strong values (0.9are a maximum before a decrease for strong values (0.9µµm).m).
Mean Spherical Aberration vs. Depth of Focusm
agni
tude
-D
OF
magnitude spherical aberration (SA)
negative SAnegative SA positive SApositive SA
DoF Increases with Negative SADoF Increases with Negative SA
The combination of mono-vision (central rays are focused in front of the retina) and a hyper-prolate shape of the cornea (peripheral rays are focused behind the central rays) creates a larger depth of field.
≈ -1.50D
Advanced Mini Mono-Vision HyperHyper--Prolate Aspheric CorneaProlate Aspheric Cornea
When the eye focuses on the near field (accommodation) the pupil constricts (miosis).
Miosis caused by Nervus occulomotorius HyperHyper--Prolate for Near EyeProlate for Near Eye
Taking benefit of the miosis for advanced monovision procedure, by excluding the peripheral rays of light, only the central rays are now focused on the retina. Miosis will limit the depth of field to close.
Miosis supporting accommodationHyperHyper--Prolate for Near EyeProlate for Near Eye
Inducing SA on Presbyopic Subjects with AOCourtesy Prof. Dr. Ronald Krueger
Using Imagine Eyes Mirror at U of Rochester
Large StrokeDeformableMirror
WavefrontSensor
VisualAcuity
PhoroptorSLD
Eye
ContrastSensitivity
NearBeyond ∞ Distance
SA Increases Depth of Focus
beyond infinity Defocus (D) near
Through Focus Retinal Image Quality
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2No Spherical Aberration
0.5 D
Courtesy Prof. Dr. Ronald Krueger
SA Increases Depth of Focus
NearBeyond ∞ Distance
Through Focus Retinal Image Quality
beyond infinity Defocus (D) near
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2
+SA
No aberration
Positive Spherical Aberration
~2 D
Courtesy Prof. Dr. Ronald Krueger
SA Increases Depth of Focus
NearBeyond ∞ Distance
Through Focus Retinal Image Quality
beyond infinity Defocus (D) near
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2
-SA
+SA
No aberration
Negative Spherical Aberration
~2 D
Courtesy Prof. Dr. Ronald Krueger
1 2 3 4 5 6 7refractive difference / dpt
difference in size of the retinal image
2%
4%
6%
8%
100%100%
50%50%
0%0%
fusionfusion
Courtesy of T. Seiler
The global optimum shape of the cornea is not a The global optimum shape of the cornea is not a multifocal cornea but an aspheric corneamultifocal cornea but an aspheric cornea
It does not produce 2 foci and the brain selects the It does not produce 2 foci and the brain selects the appropriate image like in bifocal appropriate image like in bifocal IOLsIOLs
The driving force is the pupil diameter that shifts The driving force is the pupil diameter that shifts the focus of the opticsthe focus of the optics
PresbyLASIK and Asphericity
The global optimum has the advantages that The global optimum has the advantages that additional reading glasses can help and that the additional reading glasses can help and that the profile is forgiving regarding profile is forgiving regarding decentrationdecentration
DecentrationDecentration0.0 mm 0.3 mm 0.5 mm0.0 mm 0.3 mm 0.5 mm
Distant vision with CSIDistant vision with CSI
Disadvantage of CSI
Mounir KhalifaMounir KhalifaProf. of Ophthalmology, Tanta UniversityProf. of Ophthalmology, Tanta University
Horus Vision Correction CenterHorus Vision Correction CenterAlexandria, EgyptAlexandria, Egypt
Your Name
Evaluation of Aspheric Ablation Profile and Evaluation of Aspheric Ablation Profile and CustomCustom--Q Adjustments in Treating PresbyopiaQ Adjustments in Treating Presbyopia
OBJECTIVEOBJECTIVE
Evaluation of modifying the corneal Evaluation of modifying the corneal asphericityasphericity and and monovisionmonovision correction in myopia and correction in myopia and hyperopiahyperopia with with the aspheric ablation profile and customthe aspheric ablation profile and custom--Q Q adjustments in correction of adjustments in correction of presbyopiapresbyopia..
Mechanism of action
• Increasing prolatness ( negative Q -value )increasing –ve spherical
aberration increasing depth of focus.
• Modified monovision ( < -1.5 D ).
Mechanism of action
• Applying myopic ablation with certain amount ( e.g. -1.5 D), then applying hyperopic ablation with the same amount ( +1.5 D) will create negative Q-value according to the certain amount used.
• That is why shifting Q-value to negative side overcorrects myopia and undercorrects hyperopia, and the reverse in the resulted Q-value; it undertargets in myopia and overtargets in hyperopia.
Material & MethodsMaterial & Methods
Hyperopia (n=32)Hyperopia (n=32)Group AGroup A
Myopia (n=24)Myopia (n=24)Group BGroup B
Mean ageMean age 46. 3746. 37 49.6749.67
Mean MRSEMean MRSE +2.67D +2.67D ±±1.87 D1.87 D --3.87 D 3.87 D ±±2.57 D2.57 D
Mean cylinderMean cylinder --1.37D D 1.37D D ±±1.167D1.167D --1.87 D 1.87 D ±± --1.37 D1.37 D
Mean add for nearMean add for near +1.67 D+1.67 D±±0.62 D0.62 D +1.75D +1.75D ±± 0.75D0.75D
Material & MethodsMaterial & Methods
•• All cases had LASIK with All cases had LASIK with MoriaMoria microkeratommicrokeratom M2 M2 and Allegretto Eyeand Allegretto Eye--Q FQ F--CAT profile with QCAT profile with Q--adjustment (Wave Light).adjustment (Wave Light).
•• NonNon--dominant eye (NDE) was targeted with more dominant eye (NDE) was targeted with more negative Q value and myopic defocus in relation to negative Q value and myopic defocus in relation to dominant eye (DE).dominant eye (DE).
• We followed :Defocus Diff. -1.25 D. in NDEQ-value Diff. -0.2 in NDE
Material & MethodsMaterial & Methods
Preoperative and postoperative UCDVA, BCDVA, DCNVA, Preoperative and postoperative UCDVA, BCDVA, DCNVA, UCNVA, and BCNVA were evaluated, monocular and binocular, UCNVA, and BCNVA were evaluated, monocular and binocular, mesopicmesopic contrast sensitivity ( CSV 1000), and contrast sensitivity ( CSV 1000), and HOAHOA’’ss..
•• Patient satisfaction (visual functionPatient satisfaction (visual function--14) regarding glasses 14) regarding glasses independence was evaluated. independence was evaluated.
•• Follow up to 3 months was recorded.Follow up to 3 months was recorded.
Results of VAResults of VA
HyperopeHyperopePreopPreopDE NDEDE NDE
HyperopeHyperopePostopPostopDE NDEDE NDE
MyopeMyopePreopPreopDE NDEDE NDE
MyopeMyopePostopPostopDE NDEDE NDE
UCDVAUCDVAUCDVA AOUCDVA AO
0.5 0.30.5 0.30.60.6
0.9 0.50.9 0.50.90.9
0.4 0.30.4 0.30.50.5
0.9 0.60.9 0.60.90.9
BCDVABCDVABCDVA AOBCDVA AO
0.9 0.70.9 0.70.90.9
0.9 0.80.9 0.80.90.9
1.0 0.91.0 0.91.01.0
0.9 0.70.9 0.70.90.9
DCNVADCNVADCNVA AODCNVA AO
0.6 0.50.6 0.50.60.6
0.8 0.70.8 0.70.80.8
0.6 0.50.6 0.50.70.7
0.5 0.40.5 0.40.60.6
UCNVAUCNVAUCNVA AOUCNVA AO
0.4 0.30.4 0.30.40.4
0.8 0.90.8 0.91.01.0
0.8 0.80.8 0.80.90.9
0.7 0.80.7 0.80.80.8
BCNVABCNVABCNVA AOBCNVA AO
0.8 0.70.8 0.70.80.8
0.8 0.90.8 0.91.01.0
1.0 0.91.0 0.91.01.0
0.9 0.80.9 0.80.90.9
In myopes, 3(6%) eyes lost 2 lines and 8 (16%) eyes lost 1 line of BCDVA. No loss of lines in hyperopic eyes.
ResultsResults
HyperopeHyperopePreopPreopDE NDEDE NDE
HyperopeHyperopePostopPostopDE NDEDE NDE
MyopeMyopePreopPreopDE NDEDE NDE
MyopeMyopePostopPostopDE NDEDE NDE
Mean of Mean of MRSEMRSE
+2.2 +3.12+2.2 +3.12 +0.24 +0.24 --1.121.12 --3.37 3.37 --4.54.5 --.68 .68 --1.411.41
Mean of Q Mean of Q 0.02 0.040.02 0.04 --0.9 0.9 --1.21.2Overtarget**Overtarget**
--0.1 0.1 --0.060.06 --0.54 0.54 --0.620.62Undertarget*Undertarget*
Mean of Mean of HOAHOA
0.53 0.53 0.480.48 0.320.32 0.350.35
Mean of Mean of Sph. AbSph. Ab
0.430.43 --0.060.06 0.260.26 --0.180.18
No significant change
Significant shift to negative side
*Undertarget mean 0.31
** Overtarget mean -0.19
ResultsResults
•• Patient satisfaction for binocular farPatient satisfaction for binocular far--and near and near different visual activities (using Visual Function VFdifferent visual activities (using Visual Function VF--14) was 86% in 14) was 86% in myopesmyopes and 100% in and 100% in hyperopeshyperopes. .
MesopicMesopic Contrast SensitivityContrast Sensitivity
Group AGroup A
0.5
1.0
1.5
2.0
2.5
3 6 12 18
Cycles Per Degree
LogM
AR
PreopPostop
Dim light with Glare
Bright light no Glare
Group BGroup B
0.5
1.0
1.5
2.0
2.5
12 18
Cycles Per Degree
LogM
AR
PreopPostop
Dim light with Glare
Bright light no Glare
Hyperopic- Group A
Myopic- Group B
*
Treatment plan inTreatment plan inhypermetropichypermetropic casescases
•• ASSIS ASSIS nomogramnomogram: Add +0.16 spherical adjustment : Add +0.16 spherical adjustment for each 0.1 change in Q value.for each 0.1 change in Q value.
•• Target QTarget Q: DE : DE --0.80.8NDE NDE --1.01.0
•• Target MRSETarget MRSE: DE : DE planoplanoNDE NDE --1.251.25
HypermetropicHypermetropic casecase
•• Female 46 yearsFemale 46 years•• PreopPreop: : OD +4.0 OD +4.0 --0.25 NDE0.25 NDE
UCDVA 0.3 BCDVA 0.7UCDVA 0.3 BCDVA 0.7OS +3.0 OS +3.0 --0.75 DE0.75 DEUCDVA 0.4 BCDVA 0.8UCDVA 0.4 BCDVA 0.8
•• PostopPostop: : OD OD --1.25 1.25 UCDVA 0.5 BCDVA 0.7UCDVA 0.5 BCDVA 0.7OS +0.25OS +0.25UCDVA 0.9 BCDVA 0.9UCDVA 0.9 BCDVA 0.9
OA UCDVA 0.9 UCNVA 0.9OA UCDVA 0.9 UCNVA 0.9
HypermetropicHypermetropic casecase-- DEDE
Hyperopic case-DE
Hyperopic case-DE
HypermetropicHypermetropic casecase-- NDENDE
Hyperopic case-NDE
Hyperopic case-NDE
Treatment plan inTreatment plan inmyopic casesmyopic cases
•• ASSIS ASSIS nomogramnomogram: Spherical adjustment factor per 0.1 change in Q: Spherical adjustment factor per 0.1 change in Q--value:value:
<<--2.0 +0.202.0 +0.20--2.0 +0.202.0 +0.20--3.0 +0.273.0 +0.27--4.0 +0.254.0 +0.25
•• Target QTarget Q--valuevalue: DE : DE --0.80.8NDE NDE --1.01.0
•• Target MRSETarget MRSE: DE : DE planoplanoNDE NDE --1.251.25
Myopic caseMyopic case
•• Female 44 years Female 44 years •• PreopPreop: : OD OD --1.75 1.75 --2.0X25 DE2.0X25 DE
UCDVA 0.4 BCDVA 0.9UCDVA 0.4 BCDVA 0.9
OS OS --2.5 2.5 --1.25 X 180 NDE1.25 X 180 NDEUCDVA 0.3 BCDVA 0.8UCDVA 0.3 BCDVA 0.8
•• PostopPostop: : OD +0.75 OD +0.75 --0.5X45 0.5X45 UCDVA 0.8 / BCDVA 0.9UCDVA 0.8 / BCDVA 0.9
OS OS --0.250.25UCDVA 0.9 BCDVA 0.9UCDVA 0.9 BCDVA 0.9
OA UCDVA 0.9 UCNVA 0.8OA UCDVA 0.9 UCNVA 0.8
Myopic-NDE
Myopic-NDE
Myopic-NDE
Myopic-DE
Myopic-DE
Myopic-DE
Recommended QRecommended Q--value targetvalue target
•• In In HyperopiaHyperopia::DE: DE: --0.4 NDE: 0.4 NDE: --0.60.6( Augmented effect by ablation pattern)( Augmented effect by ablation pattern)
•• In Myopia:In Myopia:DE: DE: --0.8 NDE: 0.8 NDE: --1.01.0( Reduced effect by ablation pattern)( Reduced effect by ablation pattern)
HypermetropicHypermetropic case with modified case with modified nomogramnomogram
•• Female 48 yearsFemale 48 years•• PreopPreop: : OD +1.25 OD +1.25 --0.75 X 120 DE0.75 X 120 DE
UCDVA 0.5 BCDVA 0.9UCDVA 0.5 BCDVA 0.9OS +2.0 OS +2.0 --1.0 X 60 NDE1.0 X 60 NDEUCDVA 0.4 BCDVA 0.8UCDVA 0.4 BCDVA 0.8
•• PostopPostop: : OD +0.25 OD +0.25 --0.25 X 180 0.25 X 180 UCDVA 0.9 BCDVA 0.9UCDVA 0.9 BCDVA 0.9OS OS --1.251.25UCDVA 0.6 BCDVA 0.9UCDVA 0.6 BCDVA 0.9
OA UCDVA 0.9 UCNVA 0.9OA UCDVA 0.9 UCNVA 0.9
Hyperopic case with modified nomogram-DE
Hyperopic case with modified nomogram-DE
Hyperopic case with modified nomogram-DE
Hyperopic case with modified nomogram-NDE
Hyperopic case with modified nomogram-NDE
Hyperopic case with modified nomogram-NDE
CONCLUSIONSCONCLUSIONS
•• An adequate uncorrected far and near vision can be An adequate uncorrected far and near vision can be achieved with an increase of depth of field with Qachieved with an increase of depth of field with Q--adjustment and adjustment and monovisionmonovision. Q. Q--adjustment with adjustment with monovisionmonovision is safe and effective in correcting is safe and effective in correcting presbyopiapresbyopia ..
•• Shifting QShifting Q--value to negative side:value to negative side:* Overcorrect in * Overcorrect in myopesmyopes and and undercorrectundercorrect in in
hyperopeshyperopes ( as ( as AssisAssis, user, user’’s meeting 2009).s meeting 2009).* Resulting Q* Resulting Q--value is value is undertargetundertarget in in myopesmyopes and and
overtargetovertarget in in hyperopeshyperopes. .
Course in AAO 2010, ChicagoPresbyopia, Corneal Approach: State of the
Art
Moderator: Mounir Khalifa, MD, PhDFaculty: Ronald Krueger, MD
Gustavo Tamayo, MDTarek A. Wahab, MDJorge Alio, MD, PhD
THANK YOU