Surgical Treatment of Presbyopia

Dr. Andrew CrothersEye Specialty Group

Memphis, TN

Presbyopia

Presbyopia: “Old Man Eyes”

Presbyopia: Historically

• 100 AD Plutarch – proposes several explanations for the cause of Presbyopia

• 1855 Herman von Helmholtz– Presbyopia proposed to be the result of the loss in elasticity of

the lens as a result of sclerotic changes with advancing age

• Ronald A. Schachar– Presbyopia proposed to occur due to the increase in equatorial

diameter of the lens with age. This effectively decreases the distance from the ciliary muscle to lens equator prevents sufficient contraction and accomodation

Presbyopia: Now and in the Future

• Over 1 Billion people worldwide Presbyopic in 2005 according to the WHO

• Projected to be over 2 Billion by 2020

• Over 100 million Presbyopes in the U.S. which is expected to increase to 125 million by 2020

Treatment Options for Presbyopia

If Your Patient is interested in Surgical Presbyopia Treatments what options currently are available in the U.S.A.

• Mono-Vision– Laser based (LASIK vs. PRK)

• Corneal Inlays– Small Aperture Inlay– Corneal Reshaping Inlays

• Lens Technologies– Accomodative IOLs– Multifocal IOLs– Extended Depth of Focus IOLs

Monovision via Excimer Laser Ablation

Monovision

• Advantages

– Near and Distance Vision without lenses

• Disadvantages

– Loss of Stereoacuity

– Possability of Glare and Halo at night

– Some people just do not like it

Monovision via Excimer Laser Ablation

LASIK

• Advantages– Quick visual recovery

– Improved comfort

• Disadvantages– Deeper procedure

– Increased dry eye

– Risk of flap complications

PRK

• Advantages– Able to be performed on

thinner corneas

– Less dry eye

• Disadvantages– Longer recovery

– More pain and discomfort

– Risk of haze

Perioperative Care

LASIK

• Testing

• Medications

• Restrictions

• Dry Eye Care

PRK

• Testing

• Medications

• Restrictions

Corneal Inlays

Cornea Inlays

• Advantages– Retain depth perception and distance vision– Able to be removed if necessary– Does not remove corneal tissue (less risk of ectasia)– Can be combined with LASIK or PRK– Not intraocular

• Disadvantages– Neuro adaptation– Halo, glare– Dry Eye– Need Specialized equipment for precise centration

Small Aperture Corneal InlayPolyvinylidene Fluoride

(PVFD)

Small Aperture Corneal Inlay

• Indications

– Patient age 45-60

– Refractive Error

• Cycloplegic refractive spherical equivalent of +0.50 D to -0.75 D with less than or equal to 0.75 D of refractive cylinder

• Do not use correction for distance vision but do require +1.00 to +2.50 correction for near vision

– Cornea Thickness greater than 500 microns

Corneal Reshaping Inlays

Cornea Reshaping Inlays

• Indications– Patient age 41-65

– Refractive Error• Manifest refractive spherical equivalent of +1.00 D to

-0.50 D with less than or equal to 0.75 D of refractive cylinder

• Do not use correction for distance vision but do require +1.50 to +2.50 correction for near vision

– Cornea Thickness to allow at least 300 microns of residual corneal bed below surgical flap

Combined LASIK and Corneal Inlay Procedure

Checking Centration

Immediate Post Inlay Exam

Corneal Inlay

• Perioperative Care

– Preoperative evaluation

– Medications

– Restrictions

– Follow up

Lens Based Treatment(Refractive Lens Exchange or Cataract Surgery)

• Benefits– “permanent” solution

– Can treat patients who are not candidates for LASIK or PRK• Thin corneas

• Large Refractive Error

– Options beyond monovision-• Accomodative IOLs

• Multifocal IOLs

• Negatives– Intraocular surgery

• Carries risks such as endophthalmitis that other options do not have

– Not as easily “reversible”

– Requires bilateral surgery

Intraocular Lens Technology(Cataract vs. RLE)

Multifocal IOL Accomodative IOL

Accomodative IOLs

• Advantages

– More forgiving of retinal or corneal disease

– Less concern of neuro adaptation

– Available with increased astigmatism correction

• Disadvantages

– Less predictable near vision

– Risk of decentration, z-axis shifts

Multifocal IOLs

Advantages-larger functional depth of focus

-different strengths available- can “titrate” effect

Disadvantages-neuro adaptation

-risk of glare, halo, ghosting

-some multifocal lenses are not available in TORIC powers

-Not recommended for patients with macular or corneal disease

Extended Depth of Focus IOLs

Advantages-Less glare, halo and ghosting as compared to Multifocals

-Available in Toric options for patients with more astigmatism

-Achromatic (corrects for chromatic aberration improving contrast)

Disadvantages-still some neuro adaptation

-still does have risk of glare, halo, ghosting

-may not be ideal for patients with macular or corneal disease

Monofocal vs. Multifocal vs. Extended

Implantation of Toric Extended Depth of Focus Lens

Perioperative Care for Refractive Lens Exchange

Essentially the same as for cataract surgery

• Restrictions

• Medications

• Expectations

Of course…..

Don’t Forget Monovision with IOLs

Whatever Happened to…..

Conductive Keratoplasty

Conductive Keratoplasty

Conductive Keratoplasty

Benefits

• Non-penetrating

• No loss of tissue

• Can be repeated

Negatives

• Effect is only short lived– As a result this has become a

dying procedure

Case Study 1

• 53 Year old Lady. History of LASIK OU, but would like to get out of reading glasses. She has tried monovision in contact lenses but did not like it. Has mild dry eye that she treats with occasional artificial tears.

• Visual Acuity • OD +0.25 -0.50 x 125 20/20• OS -0.25 -0.25 x 95 20/20

• No significant glare on testing

• Corneal Pachymetry ~515 OU

– Options?

Case Study 1

• After full refractive evaluation patient elected to proceed with small aperture corneal inlay

– POST OP at 3 months

• VA – OD 20/20 UCDVA J7 UCNVA

– OS 20/25 UCDVA J1 UCNVA

Case Study 2

• 58 year old woman presents for corneal inlay evaluation. Wears bifocal glasses but sometimes removes them to read. Some complaints of glare.

– Manifest• OD -3.00 -1.75 x 75 20/25

• OS -4.25 -0.75 x 70 20/20

• Glare 20/50 OU

• 2+ nuclear sclerotic and 2+ cortical cataract OU on exam

Case Study 2

• Patient elected to proceed with Femtosecond Laser Cataract Surgery using Extended Depth of Focus IOLs

– 1 month S/P Surgery OU

• OD UCDVA 20/20 UCIVA J2 UCNVAJ2

• OS UCDVA 20/20 UCIVA J3 UCNVAJ1

Case Study 3

• 55 year old man who presents for LASIK evaluation.

• Manifest • OD +2.00 -0.75 x 165 20/15

• OS +1.50 -0.25 x 164 20/15

• No significant glare

• Exam Unremarkable

• Recommendations?

Case Study 3

• After full Refractive Evaluation Patient elected to Proceed with LASIK OU and possible Corneal Inlay in future

• 1 Month Postop– OD DUCVA 20/25 NUCVA J1+

– OS DUCVA 20/20 NUCVA J1+

Future Technologies?

• Scleral Implants

Future Technologies?

• PresbyLASIK

Future Technologies?

• Refractive Index Changing Corneal Inlays

Thank You!

Mechanism of Accomodation

Helmhotz Theory Vs. Schachar Mechanism