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