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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
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