Presbyopia

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Presbyopia Correction - Dr James Beatty

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  • Electron micrograph ciliary body
  • Ant chamber OCT
  • Became frustrated switching gls, combined distance and near in one pair of glasses
  • Though spec corrections have long dominated the options for presbyopia correction recent technological innovations have vaulted the management of presbyopia into the surgical arena Internet, advice, enhance practice N01 is still gls and cl
  • Though spec corrections have long dominated the options for presbyopia correction recent technological innovations have vaulted the management of presbyopia into the surgical arena Internet, advice, enhance practice N01 is still gls and cl
  • Topographical map showing before and after
  • Very
  • Need to be centered carefully Easily reversabile
  • After monovision lasik and iol replacement the next most common surgical option
  • Because of the
  • Problem with this type of lens is that its pupil size dependent
  • Pt comes with a whole lot of expectations
  • Jack holliday
  • Presbyopia

    1. 1. Presbyopia correction 2011 Dr James Beatty
    2. 2. The Answer?
    3. 3. Why is it important? • 1.3 billion presbyopes world wide • Like death and taxes it is relentless and predictable • Cost implications • Productivity and functional implications
    4. 4. Why is it important? • “Baby boomers” – Generation with high expectations – High levels of activity – Do not want to accept limitations with vision
    5. 5. Anatomy of Accommodation: the ciliary muscle
    6. 6. Accommodation according to Helmholtz • Ciliary muscle contracts ant lens becomes more convex due to slackening of zonules
    7. 7. Accommodation according to Schachar • Directly contrasts Helmholtz • Zonular tension is increased- rather than decreased- with ciliary body contraction
    8. 8. Accommodation Accommodated o Unaccommodated Ciliary muscle
    9. 9. Amplitude of accommodation - From 1 mth old. - More regular by 2-3 mths. - Almost adult-like by 6 mths. - Falls from maximum of 18D at 10yrs - To zero by 70 yrs
    10. 10. 24 22 20 18 16 14 12 10 8 6 4 2 0 0 10 20 30 40 50 60 70 80 90 Age (yrs)
    11. 11. Young Old Increased sclerosis of lens leads to loss of flexibility and inability to change shape Presbyopia: the common view
    12. 12. …. embryologically the lens is derived from surface ectoderm….. …and keeps growing throughout life!
    13. 13. Treatment options 1784 Benjamin Franklin
    14. 14. Treatment options • Glasses and contact lenses – Still no.1 – Recent technological innovations vaulted management of presbyopia into the surgical arena – Internet has educated patients – Advise patients on options – Can enhance your practice
    15. 15. Treatment options • Surgery – Corneal based surgery • Laser correction (lasik) • Conductive keratoplasty • Corneal inlays – Scleral expansion and anterior ciliary sclerotomy – Lens based surgery • Mulitfocal intraocular lenses • Accommodating intraocular lenses
    16. 16. Monovision • Well established presbyopia therapy • Achieved through contact lenses or surgically at the corneal or lenticular plane.
    17. 17. Monovision • Mild myopia –0.5 to –1.5D in non- dominant eye (avoid anisometropia no more than 2D diff between the eyes) • Need to be able to suppress blurred image • Only a mild decrease in distance, good stereo, very good intermediate
    18. 18. Monovision • Not for patients with high visual requirements for near or distance • Glasses for driving or detailed near tasks • Monovision with contact lenses success rate of 80% • Monovision excimer laser ablation with lasik or PRK still the most commonly performed surgical correction of presbyopia
    19. 19. Corneal based surgery • Lasik • Conductive keratoplasty • Corneal inlays
    20. 20. Lasik • Creating a multi-focal cornea • Various possible ablation patterns – Central near, midperiphery distance – Inferior near, rest distance – Central distance intermediate near • Data limited but so far good • Often compromises distance vision • Induce abberations
    21. 21. Lasik
    22. 22. Conductive keratoplasty
    23. 23. Conductive keratoplasty • Probe delivers radiofrequency energy to the cornea that heats up the collagen and causes it to shrink • Performed in the midperiphery with resultant corneal flattening and central steepening • Amt. of steepening depends on the no. of spots and the no. of rings • Non-dominant eye corrected for near(monovision)
    24. 24. Conductive keratoplasty
    25. 25. Conductive keratoplasty • Safe and easy to perform • Can only be performed on emmetropes and hypermetropes • Less popular because prone to slow regression towards hyperopia • Corneal scaring • Unpredictable
    26. 26. Corneal inlays
    27. 27. Corneal inlays • Biocompatible device placed in a pocket created with a microkeratome or intralase flap • Designed for use in emmetropic or hypermetropic eyes • Aperture 1.6mm, outer rim 3.8mm • Pin hole effect increases depth of focus • Micro pores for nutrients
    28. 28. Corneal inlays
    29. 29. Scleral surgery • Scleral expansion • Anterior ciliary sclerotomy
    30. 30. Scleral surgery • Objective of increasing zonular tension by weakening or altering the sclera over the CB in order to allow for passive expansion • Based on Schachar theory
    31. 31. Doesn’t work, therefore theory probably wrong
    32. 32. Scleral surgery
    33. 33. Lens based surgery • Multifocal intraocular lenses • Accommodating intraocular lenses
    34. 34. Presbyopic correcting IOL’s • Because of recent advances in lens technology the future of presbyopia correction is rapidly moving towards lens- based surgical options • Multiple designs by different companies • Goal is to minimize the dependence on spectacles or contact lenses after cataract or clear lens surgery
    35. 35. Multifocal IOL design • Multiple- zone IOLs ; 3 zones • Central and outer for distance ( distance for large and small pupils ) • Inner annulus for near ( near for moderately small pupils )
    36. 36. • Diffractive multifocal IOL : • Uses geometric optics and diffraction optics • Overall spherical shape of anterior surface produces image for distance vision • Posterior surface has stepped structure (like Fresnel prism) • Diffraction from these multiple rings produces a second image with an effective add
    37. 37. Presbyopic correcting IOL’s • By design all of these lenses present more than one image to the retina at the same time • This leads to reduction in contrast • Abberrations such as glare and halos • Pupil size may be an issue
    38. 38. Presbyopic correcting IOL’s • Array(AMO) – 50% glare and halos • Rezoom(AMO) – smoothing over zones – light dependent – poor intermediate
    39. 39. Presbyopic correcting IOL’s • Technis(AMO) – aspheric, diffractive – poor intermediate • Restore(Alcon) – diffractive, aspheric – +4 and +3
    40. 40. Presbyopic correcting IOL’s
    41. 41. Rezoom
    42. 42. Technis
    43. 43. Restor
    44. 44. Restor
    45. 45. Accommodating IOL’s • Ideal accommodating lens would mimic a juvenile lens that changes in shape and dioptic power when the ciliary muscle contracts
    46. 46. Accommodating IOL’s • Lens refilling – Surgical technique – Material (volume and shape) – Optics – PCO • Lens softening • IOL that moves in the bag
    47. 47. Accommodating IOL’s • Potential to correct near, intermediate and distance without glasses • Potentially less side effects • Designed to sit posteriorly in the bag • With contraction of the ciliary muscle the lens shifts anteriorly allowing “accommodation”
    48. 48. Accommodating IOL’s • Mechanism – has hinges at the lens-haptic juncture • There is only one focal length but it shifts • 1D power generated for near • Increased depth of focus due to it’s posterior positioning • There is a learning curve, the patient needs to learn how to accommodate with this lens in place
    49. 49. Crystal lens
    50. 50. Crystal lens
    51. 51. Crystal lens
    52. 52. • Patient walks into your office, wants to know if they are a candidate for this type of surgery
    53. 53. Patient expectations • Excellent vision • Immediate results • Pain free • Without side effects • Do not want to get older
    54. 54. Patient discussions • Expectations • Alternatives • Financial implications • Side effects • Bilateral need for surgery • Neuro adaptation – may take months
    55. 55. Patient selection • Pre-operative exclusion criteria – Hypercritical patients – Patients with unrealistic expectations – Occupational - night drivers, pilots – Unmotivated patients
    56. 56. Patient selection • Pre-operative exclusion criteria – No eye pathology – Excelent visual potential – Astigmatism <1.5D (Toric IOL’s, LRI’s) – Presbyopic hypermetropes do the best
    57. 57. Pre operative evaluations • Meticulous biometry measurements required • IOL Master • Immersion ultrasonography • Topographic analysis/ multiple keratometry readings • Multiple IOL formulas
    58. 58. Post operative considerations • Astigmatism • Post capsule opacities - yag • Glare and halos - brimonidine • Neural adaptation - 6months • Enhancement • Explantation
    59. 59. Discussion • 10% of cataract surgery in the USA is now done with multifocal lenses • Large studies have shown that 45 % of patients still use glasses (near, distance, computer, driving) • Light adjustable lenses
    60. 60. Thanks

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