Presbyopia

1. Presbyopia

2. PRESBYOPIA IS LOSS OF ACCOMODATION INSIDE THE EYE Loss of “auto-focus” Difficult vision at near Need to increase the distance between the objects and the eye Distant vision remains unchanged. PRESBYOPIA DEFINITION

3. Progressive Age-related loss of accommodation Begins early in life Early 40s: Functional vision affected Complete loss of accommodation by 5th to 6th decade Most prevalent ocular affliction 100% of population Presbyopia

4. Lenticular Changes lenticular sclerosis changes in capsular elasticity change in zonular insertion angle Extralenticular Changes Neuromuscular changes Ciliary muscle changes Etiology of Presbyopia Glasser, A et al RSIG 1997

5. THE VISION WITH PRESBYOPIA Distance Intermediate Near

6. Lens makes the auto focus NORMAL YOUNG EYE

7. Increasing Near Point of Accommodation with Age Age (years) Distance (cm) 10 7 20 10 30 14 40 20 50 40

8. Amplitude of Accommodation and Age (Donder’s Table) Age (years) Amplitude (D) Age (years) Amplitude (D) 10 14.00 45 3.50 15 12.00 50 2.50 20 10.00 55 1.75 25 8.50 60 1.00 30 7.00 65 0.50 35 5.50 70 0.25 40 5.00 75 0.00

9. Age Predicted near add 40 45 +1.00 48 +1.25 50 +1.50 52 +1.75 55 +2.00 60 +2.25 63 +2.50 Based on Age

10. Comfortable vision at near uses less than or equal to half of the available amplitude of accommodation Near work becomes difficult when the amplitude of accommodation is less than 5.00D Near Work

11. Working distance at 40 cm requires 2.50D of accommodation Patient A has 5.00D of accommodation He can use up to 2.50D of accommodation comfortably Therefore, he has just enough accommodative power for reading at 40 cm, and no reading glasses are required Patient B has 3.00D of accommodation He can use up to 1.50D of accommodation comfortably Therefore, he needs an additional 1.00D of accommodative power for reading at 40 cm, and +1.00D reading glasses are required Example

12. ADD=Working distance – ½ amplitude

13. Converging or plus lenses for near work only in spectacles or contact lenses Changes in prescriptions are required every two to three years for presbyopia Surgery Management

14. Spectacles Single vision reading glasses Multifocal lenses containing near Add Bifocal lenses Trifocal lenses Progressive addition lenses Management

15. Contact lenses Single vision contact lenses with glasses Monovision contact lenses Bifocal and multifocal contact lenses Modified monovision contact lenses Management

16. Surgery Laser in-situ keratomileusis (LASIK) More for presbyopic hyperopia than presbyopia myopia at the moment Multifocal intraocular lens (IOL) Conductive keratoplasty (monovision) Scleral expansion Management

17. CORNEA SCLERA ANTERIOR CHAMBER LENS SURGERY FOR PRESBYOPIA

18. CORNEAL INLAYS: a) Acufocus : ACI 7000 (Irvine, Cal) b) Presbylens (Revision Optics, Cal) c) FlexiVue microlens ( Presbia Corp. Amsterdam) They are made of Biocompatible material inserted inside the cornea and alter the way light rays enter the eye (Like a Contact Lens) SURGERY IN THE CORNEA

19. Corneal Inlays Waring recently discussed results of the Kamra smallaperture corneal inlay to improve near vision in emmetropic presbyopes . The inlay is 5-μm thick and 3.8 mm in total diameter, with a 1.6-mm central aperture that increases depth of focus and improves near visual acuity by restricting bent light rays from entering the eye similar to the f-stop in a camera.

20. CORNEAL INLAYS: Still not approved by FDA and therefore not available in USA. All of them in Clinical FDA trials. Several advantages: a) Extraocular surgery b) Reversible c) Exchangeable SURGERY IN THE CORNEA

21. The Flexivue Microlens, a corneal inlay treatment for presbyopia, is 3-mm in diameter and about 15 microns thick. The lens is placed about 280-300 microns deep in the cornea of the patient's non-dominant eye through a pocket created using a femtosecond laser.[1] The specific vision-correcting prescription for each patient is incorporated in the outer area of the lens.[2] The procedure lasts about 10 minutes, and after the lens insertion, the pocket self-seals and holds the lens in place. Flexivue Microlens

22. Acufocus

23. Acufocus

24. Flexivue Microlens

25. EXCIMER LASER SURGERY: Monovision: one eye (dominant) for distance and one eye (Non Dominant) for near Only approved Corneal surgery in USA by the FDA. Difficult to tolerate by most of the patients. Loss of Contrast and depth perception by the patients (not suitable for high demanding visual needs) Limited useful time. SURGERY IN THE CORNEA

26. EXCIMER LASER SURGERY: Multifocal Cornea: Excimer Laser reshapes the cornea and alters the way light rays enter the eye. (Like Contact Lenses) Has been named as PRESBYLASIK. Both eyes see near and distance. Several softwares in use by some of the Lasers Manufacturers. Temporary solution for some years Repeatable and/or reversible SURGERY IN THE CORNEA

27. How Does this treatment work if the pupil gets smaller when reading? Frequently Asked Question CREATION OF A PERIPHERAL KNEE

28. Multifocal Cornea

29. HOW THE TREATMENT WORKS WITH A SMALL PUPIL? PREOPERATIVE POSTOPERATIVE The knee

30. Femtosecond Lasers In a prospective, nonrandomized trial, Holzer et al presented early outcomes of Intracor femtosecond laser treatment for presbyopia. The investigators treated the nondominant eye of 25 patients using the Technolas Perfect Vision femtosecond laser (Technolas Perfect Vision GmbH). The procedure involves the creation of five consecutive intrastromal rings around the line of sight. Treatment times were approximately 20 seconds. The mean gain in UCVA was 4.42 lines, with a range of 0 to 9 lines of improvement. The mean loss of distance BCVA was -0.46 ±0.83.9 Similarly, Ruiz et al evaluated 83 eyes of 45 patients with 6- to 12-month follow-up. Of the 83 eyes, 89.2% achieved both J2 and 20/25 or better, and 69.9% achieved a near UCVA of J1. Intracore Femtosecond Laser

31. Femtosecond Lasers

32. It should be noted that, although near vision is better, the quality of distance vision provided by these models is worse than that of a presbyopic emmetropic eye.6 Excimer Lasers and Multifocal Corneal Ablations

33. CONDUCTIVE KERATOPLASTY: A probe touches the cornea with High Radiofrequency and by collagen shrinkage reshapes the cornea. Produces controlled monovision inducing Myopia Only suitable for Hyperopes FDA approved as Monovision Blended Vision Rapid loss of effect is the main problem Its use has decreased in the last years. SURGERY IN THE CORNEA

34. CONDUCTIVE KERATOPLASTY

35. CONDUCTIVE KERATOPLASTY

36. SCLERAL EXPANSION PROCEDURE: Small incisions in the sclera close to the cornea and insertion of a band to create an space for the ciliary muscle to move. Ciliary muscle is the “autofocus” muscle Defensors claim improve accomodation Not FDA approved. Not in use in USA. Its use has declined dramatically due to not consistent results. SURGERY IN THE SCLERA

37. SCLERAL EXPANSION SURGERY

38. Scleral Expansion Surgery

39. PHAKIC MULTIFOCAL INTRAOCULAR LENSES: Lenses inserted inside the eye over the iris (Verizyse-Artisan) or under the iris (Visian ICL) The natural Lens is not removed FDA approved for correction of Myopia not for Presbyopia Still prototypes. Main advantage is reversibility.. SURGERY IN THE ANTERIOR CHAMBER

40. PHAKIC LENS: VERISYSE

41. MULTIFOCAL INTRAOCULAR LENSES ACCOMODATIVE INTRAOCULAR LENSES The natural lens is removed through surgery and replaced by one of those lenses. FDA approved to be used for cataract surgery Off Label used as clear lens exchange (PRELEX) Very popular method internationally Not very commonly used in USA Cristalens Accomodative is number one used in USA SURGERY IN THE LENS

42. Multifocal IOL

43. Multifocal IOL

44. ACCOMODATIVE CRISTALENS

45. MULTIFOCAL INTRAOCULAR LENSES ACCOMODATIVE INTRAOCULAR LENSES Both types still under development and research. Very strong visual symptoms have produced decrease of its use in “young” presbyopes. Not reversible surgery Decreased contrast sensitivity They require a careful selection of candidates and lots of counseling. SURGERY IN THE LENS

46. Hao et al recently introduced data on injectable in situ curable accommodating IOLs. Using functionalized polysiloxane macromonomers, they were able to refill the empty lens capsular bag via an injection. To prevent leakage from the capsular bag, the investigators performed in situ cross-linking of polysiloxane gel using blue light (wavelength, 400-500 nm) at an intensity of 70 mW/cm2. A 3-month in vivo biocompatibility study was performed in rabbits. No iritis, uveitis, retinal detachment. or corneal decompensation was observed. Capsular Bag Refilling

47. Capsular Bag Refilling

48. Capsular Bag Refilling