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Multifocal Femto-Presbylasik in Pseudophakic Eyes

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Multifocal Femto-Presbylasik in Pseudophakic Eyes Journal of Clinical Medicine Article Multifocal Femto-PresbyLASIK in Pseudophakic Eyes Bojan Pajic 1,2,3,4,5,* , Horace Massa 3 , Philipp B. Baenninger 6 , Erika Eskina 7,8 , Brigitte Pajic-Eggspuehler 1, Mirko Resan 5 and Zeljka Cvejic 2 1 Eye Clinic Orasis, Swiss Eye Research Foundation, 5734 Reinach, Switzerland; [email protected] 2 Department of Physics, Faculty of Sciences, University of Novi Sad, Trg Dositeja Obradovica 4, 21000 Novi Sad, Serbia; [email protected] 3 Department of Clinical Neurosciences, Division of Ophthalmology, Geneva University Hospitals, 1205 Geneva, Switzerland; [email protected] 4 Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland 5 Faculty of Medicine of the Military Medical Academy, University of Defense, 11000 Belgrade, Serbia; [email protected] 6 Cantonal Hospital of Lucerne, Department of Ophthalmology, 6006 Lucerne, Switzerland; [email protected] 7 Ophthalmological Department of Academy of Postgraduate Education FSBF FRCC of the FMBA of Russia, 125310 Moscow, Russia; [email protected] 8 Laser Surgery Clinic “SPHERE”, 117628 Moscow, Russia * Correspondence: [email protected]; Tel.: +41-62-765-60-80 Abstract: Background: Presbyopia treatment in pseudophakic patients with a monofocal IOL is challenging. This study investigates the refractive results of femto-PresbyLASIK and analyzes presbyopia treatment in pseudophakic eyes. Methods: 14 patients with 28 pseudophakic eyes were treated with femto-PresbyLASIK. The dominant eye was targeted at a distance and the non-dominant eye at −0.5 D. The presbyopic algorithm creates a steepness in the cornea center by using an excimer Citation: Pajic, B.; Massa, H.; laser that leads to corneal multifocality. Results: 6 months after surgery a refraction of −0.11 ± Baenninger, P.B.; Eskina, E.; 0.13 D (p = 0.001), an uncorrected distance visual acuity of 0.05 ± 1.0 logMAR (p < 0.001) and an Pajic-Eggspuehler, B.; Resan, M.; uncorrected near visual acuity of 0.15 ± 0.89 logMAR (p = 0.001) were achieved in the dominant eye. Cvejic, Z. Multifocal For the non-dominant eye, the refraction was −0.28 ± 0.22 D (p = 0.002), the uncorrected distance Femto-PresbyLASIK in Pseudophakic of visual acuity was 0.1 ± 1.49 logMAR, and the uncorrected near visual acuity was 0.11 ± 0.80 Eyes. J. Clin. Med. 2021, 10, 2282. logMAR (p < 0.001). Spherical aberrations (Z400) were reduced by 0.21–0.3 µm in 32% of eyes, and https://doi.org/10.3390/jcm10112282 by 0.31–0.4 µm in 26% of eyes. Conclusion: By steepening the central cornea while maintaining spherical aberrations within acceptable limits, PresbyLASIK created a corneal multifocality that Academic Editor: Kazuno Negishi safely improved near vision in both eyes. Thus, femto-PresbyLASIK can be used to treat presbyopia Received: 11 April 2021 in pseudophakic eyes without performing intraocular surgery. Accepted: 21 May 2021 Published: 25 May 2021 Keywords: presbyLASIK; excimer laser; multifocality; pseudophakic Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- 1. Introduction iations. While patients are increasingly aware of the possibility that they do not need to wear spectacles after cataract surgery, if they have a simultaneous multifocal intraocular lens (IOL) placed, few patients are benefiting from this advanced technology. Indeed, the vast majority of patients are choosing a monofocal IOL. Limitations to the wider use of Copyright: © 2021 by the authors. multifocal IOL might be their high cost, the careful patient selection that is required for Licensee MDPI, Basel, Switzerland. good outcomes, or the patients’ fear of side effects. Monofocal IOL placement after cataract This article is an open access article surgery allows perfect vision, but only at one focal distance. This monovision can lead distributed under the terms and to patient dissatisfaction, and a desire to regain multifocality without corrective lenses. conditions of the Creative Commons Unfortunately, solutions to restore multifocality remain scarce and poorly explored. Attribution (CC BY) license (https:// There are different ways to reach multifocality. The goal is to achieve the best possible creativecommons.org/licenses/by/ visual outcome while maintaining a low level of optical disturbance. There are only 3 4.0/). J. Clin. Med. 2021, 10, 2282. https://doi.org/10.3390/jcm10112282 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 2282 2 of 14 surgical options to treat presbyopia [1]. One option is to exchange the monofocal lens with a multifocal one, but this remains challenging, as treated eyes might be weakened by the first surgery. Thus, this does not have a high level of safety [2]. A second option would be the implantation of a multifocal add-on IOL [3], but this has several limitations. The power calculations of lenses are not as precise as with a laser. Deposits in the interface between the IOL in the bag and the add-on IOL might also disturb the vision. The rubbing of the add-on IOL against the iris tissues might induce ocular inflammation [4], or a pigment dispersion syndrome that risks elevated intraocular pressure and glaucoma. Lastly, this is an intraocular procedure that poses a certain amount of complication risk. The third option is to obtain multifocality at the corneal level. The concept of multifocal PresbyLASIK is an attractive correction method, because the surgical technique is based on the LASIK method. In contrast to a multifocal IOL implantation, minimal invasive surgery is necessary, because the eye does not need to be opened up. PresbyLASIK involves two steps. The first step is to correct ametropia for distance vision, and the second step is to make an addition for near vision. In multifocality, the central part of the cornea is most often adjusted for proximity, and the middle periphery is corrected for distance [5–10]. A conventional PresbyLASIK always represents a compromise between distance and near vision, since it creates unwanted aberrations, especially spherical aberrations in the central pupillary region. To minimize unwanted aberrations, today’s PresbyLASIK treatment algorithms are wavefront-guided. Compared to the well-established treatment of presbyopia with a multifocal IOL, PresbyLASIK is a newer surgical technique, but it has the advantage of being less invasive than implanting an IOL, because the eye does not need to be opened up. On the other hand, the use of PresbyLASIK is much more demanding. Patient selection and the interpretation of objective preoperative topographic and wavefront analyses are challenging. In particular, decisions based on the Zernike polynomial analysis of the cornea have a high influence on the surgical result. It is not sufficient to use the general LASIK criteria for PresbyLASIK application. The lack of encouraging treatment results of PresbyLASIK to date is likely because the indication for surgery was on LASIK criteria, and corresponding refraction and other parameters from the wavefront analysis were not taken into account [11]. Moreover, even if wavefront analysis is done perfectly, it must be adapted to pupillary diameter in the mesopic condition [12]. The PresbyLASIK, in particular the Supracor algorithm, was already successfully used with presbyopic phakic eyes [11,13,14]. Therefore, in this retrospective study, we assessed refractive outcomes after PresbyLASIK in pseudophakic patients. 2. Materials and Methods We included 14 patients with 28 pseudophakic eyes in this retrospective case series. The same surgeon performed all surgical procedures. The study was approved by the Ethics Committee in Novi Sad (34–08.18). This study was conducted in accordance with the Protocol, the Declaration of Helsinki, and all applicable regulatory requirements. In the following Table1, all significant preoperative PresbyLASIK data were listed of all 14 patients, such as mean age, UDVA, CDVA, UNVA, CNVA for the dominant and non-dominant eye, as well as the refraction preoperative levels for the dominant and non- dominant eyes. The mean period between cataract surgery and presbyopia was 8.93 ± 3.82 (range 6–16) months (Table1). J. Clin. Med. 2021, 10, 2282 3 of 14 Table 1. Details regarding preoperative data prior to PresbyLASIK, inclusive preoperative refraction, visual acuity in logMAR, and time elapsed since cataract surgery in months. Mean + SD Range Age 55.9 ± 13.1 Years (Range 37–74) UDVA before: Dominant eye 0.42 ± 1.13 0.3–0.5 CDVA before: Dominant eye 0.10 ± 0.87 0.0–0.2 UNVA before: Dominant eye 0.45 ± 1.0 0.7–0.3 CNVA before: Dominant eye 0.19 ± 0.81 0.3–0.1 UDVA before: Non-dominant eye 0.33 ± 0.83 0.5–0.2 CDVA before: Non-dominant eye 0.11 ± 0.85 0.2–0.0 UNVA before: Non-dominant eye 0.53 ± 1.2 0.7–0.4 CNVA before: Non-dominant eye 0.20 ± 0.83 0.3–0.1 −1.14 ± 0.73 sph −2.0–−0.25 Preoperative refraction: dominant eye −0.96 ± 0.77 cyl −2.0–0 −1.62 ± 1.03 sph aquiv −3.0–−0.5 −0.59 ± 0.81 sph −1.75–±0.25 Preoperative refraction: non-dominant eye −1.23 ± 0.67 cyl −2.0–−0.25 −1.23 ± 1.03 sph aquiv −2.63–0.13 Time elapsed since the cataract surgery (months) 8.93 ± 3.82 6–16 Inclusion criteria were a dissatisfaction with myopic refraction obtained with a monofocal IOL with manifest refraction spherical equivalent (MRSE) between −0.5 and −4.0 diopters (D), astigmatism of 2.50 D or less, mean keratometry between 41.00 and 46.00 D, a central corneal thickness of 540 µm or more, a mesopic pupil diameter between 4 and 6 mm, and a kappa angle of less than 6◦. Exclusion criteria were the presence of ocular surface disease, clinically significant corneal opacity, posterior segment ocular pathologies, and abnormal corneal topography.
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