Presbyopia modern surgical treatments. Johan Lønsmann Poulsen, Euroeyes

Transcription

1 Presbyopia modern surgical treatments Johan Lønsmann Poulsen, Euroeyes

2 Presbyopia the earliest treatments Reading stones Emperor Nero (37-68 AD)

3 Presbyopia design trends c. 1400s c c

4 Presbyopia surgical approaches

5 Presbyopic correction - the options Intraocular approaches Presbyopic IOLs Monovision (LASIK/PRK) no binocularity! Corneal reshaping for multifocality PresbyLASIK / INTRACOR Corneal approach: onlays - experimental Corneal approach: Inlays

6 Multifocals many attempts First multifocal implants in 1970s Historically - not very successful! Bad optics Postoperative refractive error Poor pre-op biometry / poor surgery

7 What is different now? Great advances in IOL design / optics Refractive & diffractive techniques Pre-operative and post-operative refractive error optimisation Accurate biometry (eg. IOLmaster) Accurate keratometry (eg. Orbscan, Pentacam) Small incision cataract approach LASIK!

8 IOL design & type Review of Presbyopic IOLs: Multifocal and Accommodating IOLs Gooi, Patrick MD; Ahmed, Ike K. MD, FRCSC

9 Monofocal Distance focal point Refractive Near focus Distance focus Diffractive Near focus Distance focus

10 Multifocal IOLs Refractive v. Diffractive Refractive Diffractive Apodized or non-apodized Not much difference between refractive & diffractive IOLs BUT better UCNVA with dif. IOL

11 Diffractive vs. Refractive patient satisfaction Diffractive Refractive Distance Near Intermediate Aspheric Diffractive Versus Refractive Multifocal IOLs: Comparison of Visual Prognosis and Patient Satisfaction. Eltutar, Kadir; Akcetin, Tulay A.; Ozcelik, N. Demet

12 Multifocal IOLs Bifocal or Trifocal

13 Multifocal IOLs Bifocal or Trifocal

14 Accomodating IOLs Single optic Double optic

15 Accomodating IOLs The Synchrony (Visiogen) The Tetraflex (Lenstec) The NuLens (NuLens Ltd.) FluidVision accommodating IOL (PowerVision)

16 More than just the IOL Optimal surgery the challenges: Multifocal IOLs are very unforgiving Small amount of refractive error can be significant IOL must be perfectly centered High requirement on surgeon

17 The femtosecond laser Long wavelength laser Very short pulse Vaporises tissue w. very little heat

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20 Precise, quick & safe

21 Better surgery the LensX

22 the LensX the advantages Astigmatic control Predictable results Perfectly sized rhexis Perfectly centered rhexis Less phako energy needed Minimal trauma during surgery Improved safety

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24 Good outcomes: Chose the right patient not just the right lens Ideal patient: - Previous user of contact lenses / glasses - Self-motivated - Doesn t mind sometimes having to wear glasses Caution: - Mild myopes who wear glasses for distance - Overly critical or analytical, unrealistic expectations - Night time driving occupations - Pilots - Amblyopia & pathology

25 Corneal reshaping - PresbyLASIK LASIK creates multifocal cornea Issues with quality of vision Upto 20% lose two lines of BCDA Upto 50% lose two lines of BCNA Less than half achieve 1.0 UCVA PresbyLASIK Enhancements possible Reversible if cornea permitting

26 Corneal reshaping - IntraCor FemtoSecond laser creates multifocal cornea For +0.5 to +1.5 Newer procedure than PresbyLASIK Upto 80% gain 4 lines of UCNA IntraCor Upto 30% lose 2 lines of UCDA Enhancements NOT possible Irreversible

27 Corneal inlays The KAMRA inlay Acufocus a privately held company First launched 2002 CE certification in 2005 Currently an investigational device in the U.S. (IDE trial)

28 How the KAMRA Inlay Works The small aperture: Reduces blur when viewing near objects Increases depth of focus Minimally affects distance vision Blocks unfocused light Allows focused light into the eye

29 The optical principle

30 Depth of field an example SLR camera simulation of vision with a 4.0 mm pupil feet, f-stop 5.6 SLR camera simulation of vision with a 1.6 mm pupil feet, f-stop 22 Image courtesy of Jack Holladay, MD Image courtesy of Jack Holladay, MD

31 KAMRA Inlay Design 3.8mm Total diameter 1.6mm Aperture 5 μ Thick

32 The KAMRA inlay Made from Polyvinylidene Fluoride (PVDF) Highly biocompatible Good mechanical strength Forms consistent thin films

33 8000 micro-fenestrations Oxygen Glucose Slide courtesy of Stephen D Klyce, PhD

34 8000 micro-fenestrations Too many / too large holes: degrade vision Light transmission of only 5% Arranged in a pseudo-random pattern to minimise diffraction

35 Cosmesis

36 Cosmesis

37 Broad Application Post-LASIK to D Cylinder 0.75 D PEK Procedure CLK Procedure

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41 Surgical method

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43 Surgical method

44 Uncorrected Near Visual Acuity (Implanted Eye) Subjects gain on average 3.5 lines of near acuity in the inlay eye, which remains stable out to 24 months. Visual Acuity J2 Pre N = 508 1M N = 505 3M N = 500 6M N = 499 9M N = M N = M N = M N = 99 UCNVA Post-Operative Period (Months)

45 Uncorrected Near Visual Acuity (Implanted Eye) after 3 years Subjects gain on average 4 lines of near acuity in the inlay eye, which remains stable out to 36 months.

46 Uncorrected Intermediate Visual Acuity (Implanted Eye) Mean uncorrected intermediate visual acuity improved 1 line to 20/25 in the inlay implanted eye. Visual Acuity 20/25 Pre N = 508 1M N = 505 3M N = 500 6M N = 499 9M N = M N = M N = M N = 99 UCIVA Post-Operative Period (Months)

47 Uncorrected Distance Visual Acuity (Implanted Eye) In the inlay eye, mean uncorrected distance visual acuity remains stable at 20/20 out to 24 months. Visual Acuity 20/20 Pre N = 508 1M N = 505 3M N = 500 6M N = 499 9M N = M N = M N = M N = 99 UCDVA Post-Operative Period (Months)

48 Scores for visual tasks Reading performance and patient satisfaction after corneal inlay implantation for presbyopia correction: Two-year follow-up Alois K. Dexl, Orang Seyeddain, Wolfgang Riha, Theresa Ruckl, Alexander Bachernegg, Martin Emesz, Josef Ruc... Journal of Cataract & Refractive Surgery Volume 38, Issue

49 Summary of Global Results Near vision of J2 achieved on average Distance vision is minimally affected Long-term data shows maintained visual gain High patient satisfaction Inlay may be implanted in: Naturally occurring emmetropes Simultaneous to a LASIK procedure Safe and reversible

50 Contrast sensitivity

51 The near future Multifocal IOLs Trifocals Optics and design Femtosecond assisted surgery Inlays Accomodating IOLs Improvements

52 The future 10 to 20 years Laser treatment of crystalline lens Reversal of lens aging Very experimental, but promising Fluid/silicone filling of lens capsule Technically challenging Development will benefit from FS surgery

53 Thank you