Presbyopia modern surgical treatments Johan Lønsmann Poulsen, Euroeyes
Presbyopia the earliest treatments Reading stones Emperor Nero (37-68 AD)
Presbyopia design trends c. 1400s c. 1680-1750 c. 1800 1850
Presbyopia surgical approaches 1979 1991 2007 2009
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
Multifocals many attempts First multifocal implants in 1970s Historically - not very successful! Bad optics Postoperative refractive error Poor pre-op biometry / poor surgery
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!
IOL design & type Review of Presbyopic IOLs: Multifocal and Accommodating IOLs Gooi, Patrick MD; Ahmed, Ike K. MD, FRCSC
Monofocal Distance focal point Refractive Near focus Distance focus Diffractive Near focus Distance focus
Multifocal IOLs Refractive v. Diffractive Refractive Diffractive Apodized or non-apodized Not much difference between refractive & diffractive IOLs BUT better UCNVA with dif. IOL
Diffractive vs. Refractive patient satisfaction 95 94 93 92 91 90 89 88 87 86 85 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
Multifocal IOLs Bifocal or Trifocal
Multifocal IOLs Bifocal or Trifocal
Accomodating IOLs Single optic Double optic
Accomodating IOLs The Synchrony (Visiogen) The Tetraflex (Lenstec) The NuLens (NuLens Ltd.) FluidVision accommodating IOL (PowerVision)
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
The femtosecond laser Long wavelength laser Very short pulse Vaporises tissue w. very little heat
Precise, quick & safe
Better surgery the LensX
the LensX the advantages Astigmatic control Predictable results Perfectly sized rhexis Perfectly centered rhexis Less phako energy needed Minimal trauma during surgery Improved safety
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
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
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
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)
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
The optical principle
Depth of field an example SLR camera simulation of vision with a 4.0 mm pupil. Focus @ 7.69 feet, f-stop 5.6 SLR camera simulation of vision with a 1.6 mm pupil. Focus @ 7.69 feet, f-stop 22 Image courtesy of Jack Holladay, MD Image courtesy of Jack Holladay, MD
KAMRA Inlay Design 3.8mm Total diameter 1.6mm Aperture 5 μ Thick
The KAMRA inlay Made from Polyvinylidene Fluoride (PVDF) Highly biocompatible Good mechanical strength Forms consistent thin films
8000 micro-fenestrations Oxygen Glucose Slide courtesy of Stephen D Klyce, PhD
8000 micro-fenestrations Too many / too large holes: degrade vision Light transmission of only 5% Arranged in a pseudo-random pattern to minimise diffraction
Cosmesis
Cosmesis
Broad Application Post-LASIK +0.25 to -0.50 D Cylinder 0.75 D PEK Procedure CLK Procedure
Surgical method
Surgical method
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 = 485 12M N = 479 18M N = 423 24M N = 99 UCNVA Post-Operative Period (Months)
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.
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 = 485 12M N = 479 18M N = 423 24M N = 99 UCIVA Post-Operative Period (Months)
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 = 485 12M N = 479 18M N = 423 24M N = 99 UCDVA Post-Operative Period (Months)
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 10 2012 1808-1816
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
Contrast sensitivity
The near future Multifocal IOLs Trifocals Optics and design Femtosecond assisted surgery Inlays Accomodating IOLs Improvements
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
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