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Advances in presbyopia treatment

Perfect Vision's Dr Con Moshegov presentation on: Advances in presbyopia treatment

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Advances in presbyopia treatment

  1. 1. Surgical Correction of Presbyopia Con N. Moshegov Sydney
  2. 2. Treatment Modalities <ul><li>Glasses </li></ul><ul><li>Contact lenses </li></ul><ul><li>Corneal procedures: </li></ul><ul><ul><li>CK, PRK, LASIK, intracorneal inlays </li></ul></ul><ul><li>Scleral procedures: </li></ul><ul><ul><li>Scleral Expansion Bands </li></ul></ul><ul><ul><li>Laser Presbyopia Reversal (LAPR) </li></ul></ul><ul><li>Intraocular implants </li></ul>
  3. 3. Conductive Keratoplasty <ul><li>Radio frequency energy </li></ul><ul><li>Applied to peripheral corneal stroma via probe </li></ul>CK tmt points
  4. 4. Conductive Keratoplasty <ul><li>Induces up to 1.5 to 2.0D of steepening </li></ul><ul><li>Essentially gives patient a monovision effect </li></ul>
  5. 5. CK: good points <ul><li>Extraocular </li></ul><ul><li>Relatively inexpensive </li></ul><ul><li>Can be done at the slit lamp </li></ul><ul><li>Attractive to non refractive surgeons </li></ul>
  6. 6. CK: not so good points <ul><li>Limited to hyperopes or emmetropes (who accept monovision) </li></ul><ul><li>Induction of cylinder and irregular astigmatism </li></ul><ul><li>Regression of effect </li></ul><ul><li>Not popular as a routine tool in the treatment </li></ul><ul><li>of presbyopia </li></ul>
  7. 7. PRK and LASIK <ul><li>Monovision </li></ul><ul><ul><li>dominant: plano </li></ul></ul><ul><ul><li>non-dominant -0.50D to -2.00D </li></ul></ul><ul><li>Aspheric ablations </li></ul>
  8. 8. Patterns of Multifocal Ablation Near Far Near Far Far Near
  9. 9. Aspheric Ablations for Presbyopia Correction Canadian Clinical Trial
  10. 10. Monocular Simultaneous Uncorrected Distance and Near Vision 20/25 or better J3 or better 77% of eyes achieve both 20/25 distance and J3 near or better
  11. 11. Aspheric Ablation: good points <ul><li>PRK and LASIK are familiar procedures </li></ul><ul><li>Easily enhanced and reversible </li></ul>
  12. 12. Aspheric Ablation: not so good points <ul><li>Temporary: as crystalline lens changes with age </li></ul><ul><li>Personal experience: distance vision has to be compromised (induced myopia) for the reading to be adequate </li></ul>
  13. 13. Intracorneal Inlays <ul><li>Lamellar corneal flap created (8.0mm and 160µm) </li></ul><ul><li>Inlay implanted over pupil </li></ul>
  14. 14. CURRENT CORNEAL INLAYS Micro-porous hydrogel (Nutrepore) for permeability of nutrients within the cornea Kynar (opaque polymer) with a small central apperture 78% water-permeable biocompatible hydrogel 45% hydrogel (Hefilcon-A) Material 1.5 mm 3.8 mm 3.0 mm 1.8 mm to 2.2 mm Diameter 10 μ m 10 μ m 20 μ m 0.03 mm to 0.006 mm Thickness ReVision Optics PresbyLens ® AcuFocus ACI 7000 ® Biovision Invue ™ Intracorneal Microlens System AcuFocus Hydrogel Lens ®
  15. 15. AcuFocus ACI 7000 ® (Bausch & Lomb) PresbyLens ® ReVision Optics
  16. 18. <ul><li>B&L has rights </li></ul><ul><li>700 eyes Worldwide </li></ul><ul><li>Australian investigators </li></ul><ul><li>Likely some reduction in CS under mesopic conditions </li></ul>
  17. 19. Inlay: good points <ul><li>Extraocular </li></ul><ul><li>Easy to do </li></ul><ul><li>Easy to reverse </li></ul>
  18. 20. Inlay: not so good points <ul><li>Involves visual axis </li></ul><ul><li>Adversely effects distance vision in emmetropes. </li></ul><ul><li>Cases of epithelial ingrowth resulting in thinning and melt of flap </li></ul>
  19. 21. Intracorneal Inlay <ul><li>Correction of hyperopia by intracorneal lenses two year follow-up Ismail M </li></ul><ul><li>J Cataract Refract Surg 2006; 32: 1657-60 </li></ul><ul><li>23 eyes of 21 patients </li></ul><ul><li>Hyperopia +2.5D to +6.00D </li></ul><ul><li>Permavision (Anamed Inc) </li></ul><ul><li>Moria M2 microkeratome </li></ul><ul><li>70% within 0.50D </li></ul><ul><li>Lens opacification seen in 5 eyes (21.7%) </li></ul>
  20. 22. Scleral Expansion Bands <ul><li>Increase distance between ciliary muscle and lens equator by tenting sclera between band and limbus </li></ul><ul><li>Thus enhancing effect of ciliary muscle contraction </li></ul><ul><li>Silicone bands inserted onto 4 scleral tunnels </li></ul>
  21. 23. SEB: good points <ul><li>Extraocular </li></ul><ul><li>No adverse effects on quality of vision </li></ul>
  22. 24. SEB: not so good points <ul><li>Surgical time: 40 mins per eye </li></ul><ul><li>Bloody surgery </li></ul><ul><li>Modest gains in near vision </li></ul><ul><li>Scleral Expansion Surgery Does Not Restore Accomodation </li></ul><ul><li>Ophthalmology 1999; 106: 873-877 </li></ul><ul><li>Dynamic infrared optometry failed to detect any evidence of accommodation with effort </li></ul>
  23. 25. Laser Assisted Presbyopia Reversal (LAPR) <ul><li>Infrared Erbium:YAG </li></ul><ul><li>Delivered through a fibre and contact tip </li></ul>
  24. 26. LAPR <ul><li>4 fornix based peritomies </li></ul><ul><li>Ablations applied in scleral tissue 0.5mm posterior to the limbus to 80% thickness </li></ul><ul><li>Peritomy sites closed with bipolar forceps. </li></ul>
  25. 27. LAPR cosmetic appearance 1 week 4 months 7 months
  26. 28. LAPR complications <ul><li>Microperforations </li></ul><ul><li>Conjunctival cysts </li></ul><ul><li>Iris atrophy </li></ul>
  27. 29. LAPR <ul><li>Good: </li></ul><ul><li>Extraocular procedure </li></ul><ul><li>Surgically easy </li></ul><ul><li>No adverse effects on vision </li></ul><ul><li>Not-so-good: </li></ul><ul><li>No large studies of efficacy yet </li></ul><ul><li>Variable benefit to near vision </li></ul><ul><li>Regression reported in several (non US) centres </li></ul><ul><li>Expensive laser </li></ul>
  28. 30. <ul><li> MULTIFOCAL IOLs </li></ul><ul><li>ACCOMMODATING PSEUDOACCOMMODATING </li></ul><ul><li>REFRACTIVE DIFFRACTIVE </li></ul>Intraocular implants
  29. 31. Accommodating IOLs
  30. 34. CrystaLens (Stasiuk) <ul><li>PCO requiring YAG: 20 (59%) </li></ul><ul><li>Posterior vaulting in 6 (18%) </li></ul><ul><li>Glare and night vision disturbances </li></ul>
  31. 35. CrystaLens: does it really vault? <ul><li>Pilocarpine-induced shift of an accommodating intraocular lens: AT-45 </li></ul><ul><li>Koeppl C, Findl O, Menepace R et al (Vienna) </li></ul><ul><li>J Cataract Refract Surg 2005; 31: 1290-7 </li></ul><ul><li>54 eyes </li></ul><ul><li>Slight backward shift occurred with application of pilocarpine </li></ul><ul><li>Polishing capsule had no effect on accommodative ability </li></ul><ul><li>Near acuity with distance correction was J4 at 3 months </li></ul><ul><li>Not statistically different from similarly shaped monofocal </li></ul>
  32. 36. HumanOptics 1CU <ul><li>Hydrophilic acrylic foldable IOL </li></ul><ul><li>Haptics thinner near optic </li></ul><ul><li>Flexibility allows reversible anterior movement </li></ul>
  33. 37. Human Optics 1CU <ul><li>Early visual results with the 1CU accommodating intraocular lens </li></ul><ul><li>Dogru M, Honda R, Omoto M et al (Japan) </li></ul><ul><li>J Cataract Refract Surg 2005; 31: 895-902 </li></ul><ul><li>Peak amplitude of accommodation with 1CU was 0.5D ( ± 0.44D) at 3 months </li></ul><ul><li>Accommodation declined after 6 months </li></ul><ul><li>Additional near acuity with 1CU disappeared at 12 months </li></ul><ul><li>Correlated with increasing opacification of anterior and posterior capsules </li></ul>
  34. 38. <ul><li>Prospective study comparing the 1CU with a monofocal non-accomodating IOL </li></ul><ul><li>Minor statistical advantage of half a reading step but not predictable </li></ul>
  35. 39. <ul><li>Tetraflex accommodating IOL </li></ul><ul><li>5.75mm acrylic optic </li></ul>
  36. 40. <ul><li>Designed to have forward movement for near vision and return to the intended plane in the “flat” position for clear intermediate and distance </li></ul><ul><li>Personal results: excellent monofocal characteristics </li></ul><ul><li>Less than optimal DCNVA </li></ul>Design Theory vs. Practice
  37. 41. <ul><li>1CU, BioComFold and CrystaLens IOLs </li></ul><ul><li>No study found promising near visual acuity results </li></ul><ul><li>No study found more than 700micrometres of forward shift of IOLs with accommodation </li></ul><ul><li>Some found a backward shift with pilocarpine </li></ul>
  38. 42. <ul><li> MULTIFOCAL IOLs </li></ul><ul><li>ACCOMMODATING PSEUDOACCOMMODATING </li></ul><ul><li>REFRACTIVE DIFFRACTIVE </li></ul>
  39. 43. The ARRAY ® IOL Refractive Multifocal IOL Design <ul><li>Five concentric zones </li></ul><ul><li>Each zone has a near or distance weighting </li></ul><ul><li>Centre is distance weighted </li></ul>
  40. 44. 3 rd (distance dominant) ring enlarged and moved 3.4mm-3.9mm to 3.45mm-4.3mm 4 th (near dominant) ring shifted from 3.9mm-4.6mm to 4.3mm-4.6mm (and thinned out)
  41. 45. AMO ReZoom ™ <ul><li>Good: </li></ul><ul><li>Provides excellent distance vision </li></ul><ul><li>Provides reasonable intermediate vision </li></ul><ul><li>Fewer halo and glare problems than the Array </li></ul><ul><li>Not-so-good: </li></ul><ul><li>Reading ability (near acuity) variable </li></ul><ul><li>Reading ability is pupil dependent </li></ul><ul><li>Less tolerable in myopes </li></ul>
  42. 46. <ul><li> MULTIFOCAL IOLs </li></ul><ul><li>ACCOMMODATING PSEUDOACCOMMODATING </li></ul><ul><li>REFRACTIVE DIFFRACTIVE </li></ul>
  43. 47. AMO Tecnis ZM9000 and Alcon ReSTOR
  44. 48. AMO Tecnis: Full Optic Diffractive
  45. 49. Alcon ReSTOR: Partial Optic Diffractive Apodized <ul><li>Only the central 3.6mm of optic contains diffractive rings with steps of certain height </li></ul><ul><li>Now available in aspheric form </li></ul><ul><li>Step heights get progressively lower from centre to periphery </li></ul>
  46. 50. <ul><li>AMO Tecnis ™ ZM900 Multifocal and Alcon ReSTOR </li></ul><ul><li>Good: </li></ul><ul><li>Provide excellent distance and near vision </li></ul><ul><li>Fewer halo and glare problems than the Array </li></ul><ul><li>Most appreciated by hypermetropes </li></ul><ul><li>Well tolerated by (higher) myopes </li></ul><ul><li>Not-so-good: </li></ul><ul><li>Intermediate vision suboptimal: problem for computer users </li></ul><ul><li>Quality of vision not as acute as with a monofocal (contrast sensitivity suffers) </li></ul>
  47. 51. Average Intermediate Acuity (at 60cm) ReSTOR ReSTOR/Array ReSTOR/ReZOOM ReSTOR ReSTOR/Array ReSTOR/ReZOOM P=0.0144 Array better BCVA than ReSTOR P=0.0694 Array better UCVA than ReSTOR
  48. 52. Average Near Acuity (at 30cm) ReSTOR ReSTOR/Array ReSTOR/ReZOOM ReSTOR ReSTOR/Array ReSTOR/ReZOOM
  49. 53. And…Spectacle Independence
  50. 54. AcrySof ® ReSTOR ® Aspheric IOL <ul><li>SN6AD3 </li></ul><ul><li>Add Power: +4 D </li></ul><ul><li>Spectacle Plane: 3.2 D </li></ul><ul><li>Range: +10 D to +34 D </li></ul><ul><li>A-Constant: 118.9 </li></ul><ul><li>SN6AD1 </li></ul><ul><li>Add Power: +3 D </li></ul><ul><li>Spectacle Plane: 2.4 D </li></ul><ul><li>Range: +10 D to +34 D </li></ul><ul><li>A-Constant: 118.9 </li></ul>
  51. 55. Physical Comparison <ul><li>Both +4D and +3D have 3.6 mm Apodized Diffractive region </li></ul><ul><li>+4 D central zone diameter = 0.742 mm </li></ul><ul><li>+3 D central zone diameter = 0.856 mm </li></ul>+4 D, 12 zones +3 D, 9 zones
  52. 56. Mean Distance Corrected Intermediate VA 20/25 20/32 VAs are approximately 1.5 lines better for ReSTOR® Aspheric +3 D 20/20 20/40 Data on File. Alcon, Inc.
  53. 57. Mean Visual Disturbances Data on File. Alcon, Inc. Mild Moderate Severe None
  54. 58. <ul><li>LASIK used to refine sphere and treat astigmatism </li></ul>
  55. 59. Future IOLs <ul><li>Second generation Visiogen Synchrony IOL </li></ul><ul><li>Two optics linked by a bridge </li></ul><ul><li>Plus lens in front, minus lens in back </li></ul><ul><li>Dozens have been implanted </li></ul><ul><li>Medennium Smart IOL </li></ul><ul><li>Completely filling capsular bag </li></ul><ul><li>Thermodynamic Acrylic material </li></ul><ul><li>Fills capsular bag and flexes with attempted accommodation </li></ul><ul><li>IOLs likely to be the permanent solution to presbyopia </li></ul>
  56. 60. Presbyopia treatment today <ul><li>Hypermetropic: </li></ul><ul><ul><li>Monovision: LASIK, PRK or IOL </li></ul></ul><ul><ul><li>Aspheric laser ablation </li></ul></ul><ul><ul><li>Multifocal IOL </li></ul></ul><ul><li>Highly myopic: </li></ul><ul><ul><li>Monovision </li></ul></ul><ul><ul><li>Multifocal IOL </li></ul></ul><ul><li>Emmetropic: monovision only </li></ul><ul><li>Low myopes: monovision at best </li></ul>

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