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The Best of Both Worlds a Mix of Cornea- and Lens-Based Options for Presbyopia Correction Is Appropriate for Many Practices

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The Best of Both Worlds a Mix of Cornea- and Lens-Based Options for Presbyopia Correction Is Appropriate for Many Practices COVER STORY The Best of Both Worlds A mix of cornea- and lens-based options for presbyopia correction is appropriate for many practices. BY DETLEF HOLLAND, MD he treatment of presbyopia is one of the most challenging frontiers of ophthalmic surgery. For successful surgical treatment of Even with a plethora of corrective options, the goal of restoring accommodation seems presbyopia, it is important to toT be elusive. In Germany, the percentage of patients conduct thorough patient with presbyopic symptoms has increased significantly evaluation and patient counseling due to the aging of the population, and this trend will continue over the next few years. Another factor is that in advance of the procedure. patients are more demanding and ask for more options than just reading glasses or multifocal contact lenses. Accordingly, the number of patients who elect surgery risks of intraocular surgery, including endophthalmitis. for presbyopia correction is on the rise. Today, about Additionally, not all patients are willing to undergo 10% of our patients undergo presbyopia correction at intraocular surgery if other options, such as monovision the Augenklinik Bellevue. LASIK or presbyopic LASIK (presby-LASIK), are available. For successful surgical treatment of presbyopia, it We have performed simultaneous correction of pres- is important to conduct thorough patient evaluation byopia and ametropia using PresbyMax, a biaspheric and patient counseling in advance of the procedure. presby-LASIK technique in which we shape the central Understanding the patient’s expectations is especially cornea for near vision and leave the midperipheral crucial, as unrealistic expectations can lead to an unhap- cornea for far vision. PresbyMax is performed with py patient postoperatively. Clinical diagnostics including the Amaris 750 (Schwind eye-tech-solutions). Initially corneal topography, aberrometry, pupillometry, and an we treated both eyes with the same ablation profile optical coherence tomography (OCT) scan of the mac- for near addition, but we subsequently changed to a ula are mandatory. Macular puckers are often present monovision strategy to improve results for binocular in the eyes of elderly patients, making OCT a must-have distance visual acuity, still using a multifocal ablation assessment before every lens surgery. profile for both eyes. We have seen good results with this technique CORNEA- AND LENS-BASED OPTIONS in both hyperopes and myopes. We do not use At the Augenklinik Bellevue, we feel that both cornea- PresbyMax in near emmetropic patients, and in mod- and lens-based options can be appropriate for presby- erately myopic patients we prefer classical monovision opia correction. At the moment, our strategy of choice with an aberration-free ablation profile. Younger pres- is multifocal IOL implantation. In patients with excessive byopic patients usually do well with PresbyMax, but corneal aberrations, however, we prefer using a monovi- the procedure can also be repeated when presbyopia sion approach. Other treatment options such as corneal progresses. inlays and scleral-expanding systems are alternatives. A multifocal contact lens trial is helpful in making the Any method of presbyopia correction has limitations. final decision. If the patient does not tolerate multifocal- In multifocal IOL implantation, there are the associated ity during the trial, PresbyMax is not an option. 54 CATARACT & REFRACTIVE SURGERY TODAY EUROPE OcTOBER 2013 Figure 1. A limbal relaxing incision created with the Lensar femtosecond laser, 1 week postoperative. MULTIFOCAL IOL IMPLANTATION When implanting multifocal IOLs to treat presbyopia, we use bifocal and trifocal models. We have had good results with the trifocal AT.LISA (Carl Zeiss Meditec) and FineVision (PhysIOL) lenses. Since integrating them into practice, the percentage of bifocal multifocal IOLs we implant has decreased. One reason for the apparent prefer- ence for trifocal lenses is that they provide the best interme- diate visual acuity, which in our world of smartphones and computer work is the biggest factor in favor of these lenses. In the presence of 1.00 D or more of astigmatism, the AT.LISA toric is implanted. The availability of toric multifocal IOLs has allowed us to decrease the number of bioptics procedures and touch-ups we perform. The toric Mplus (Oculentis GmbH), with its individualized torus, is easy to implant because rotation of the lens into the steep axis is not necessary. Because of the possibility for photopic and night driv- ing problems that can occur with all multifocal IOLs, we also have the Mplus and Mplus comfort (Oculentis GmbH) in our portfolio. These lenses provide high levels of patient satisfaction, due to their good results in con- trast sensitivity and reduction of glare and halos. When patients are interested in good intermediate visual acuity and have no objection to using glasses for extended read- ing, the Mplus comfort with its 1.50 D of near addition TAKE-HOME MESSAGE • For successful surgical treatment of presbyopia, understanding the patient’s expectations is crucial, as unrealistic expectations can lead to an unhappy patient postoperatively. • The use of toric multifocal IOLs has the potential to decrease the need for bioptics procedures and postoperative touch-ups. • Multifocal sulcus-fixated supplementary IOLs are an option in pseudophakic patients who want to reduce their spectacle dependence. COVER STORY powers from -3.00 to 4.00 D. Unilateral implantation is often sufficient to provide adequate near vision. The refractive model of the AddOn lens is used to cre- ate standard monovision; however, we prefer the diffrac- tive version. We have seen no postoperative problems such as pigment dispersion or secondary glaucoma after implantation. The multifocal AddOn IOL has enormous potential, but, given that the lens works best in elderly pseudophakic patients, marketing is difficult. PROCEDURES THAT HAVE CAUGHT OUR ATTENTION The next presbyopia-treatment option we want to try is the Raindrop Near Vision inlay (Revision Optics, Inc). We are intrigued by this corneal inlay because it has a similar optical concept to PresbyMax, which is steepening of the central cornea. Also, reversibility is an added bonus. Figure 2. Capsular phimosis after toric multifocal IOL Nevertheless, we are skeptical of corneal implants because implantation. of potential associated complications including corneal scarring. is our first choice. Historically, mix-and-match strategies We are also highly interested in the effect of limbal have not been our choice, but we are considering this relaxing incisions (LRIs) on our refractive results with approach with the Mplus and the Mplus comfort after multifocal IOLs. We have been performing laser-assisted hearing of the impressive results of colleagues including cataract surgery with the Lensar Laser System (Lensar, Inc.) Sunil Shah, MBBS, FRCOphth, FRCS(Ed), FBCLA. since August 2013. We also create LRIs with this platform in patients with 1.50 D or less of astigmatism in the hopes SUPPLEMENTARY IOLs of reducing residual postoperative refractive error and An interesting option in pseudophakic patients who further improving UCVA (Figure 1). To achieve this goal, want to reduce their spectacle dependence is multifocal however, we must create our own nomograms after lon- supplementary IOLs for sulcus implantation. We use a ger follow-up. diffractive model, the AddOn IOL (1stQ), which provides It is likely that other options for presbyopia treatment good centration due to its four flexible haptics. This lens will be born from the use of femtosecond laser technol- has a near addition of 3.50 D and is available in spherical ogy, if studies on lens softening to increase accommoda- tion are successful. This would be a great step forward in presbyopia correction because it is a non- invasive technique treating the cause of presbyopia—the loss of elasticity of the human lens. Nevertheless, there are many good solutions now available to treat presbyopic symptoms in our patients, even though they all rep- resent a reasonable compromise. CASE PRESENTATIONS Because all of our presbyopia- correcting procedures come with compromises, it is not sur- prising that some outcomes are less favorable than others. Below Figure 3. Corneal topography before (top) and after (bottom) PresbyMax micro-monovision. I recount two cases, of which 56 CATARACT & REFRACTIVE SURGERY TODAY EUROPE OcTOBER 2013 COVER STORY one had a rather negative outcome and one a positive outcome. Case No. 1: Capsular fibrosis. A 55-year-old woman with hyperopic astigmatism and presbyopia was treated bilaterally with implantation of toric bifocal plate-haptic IOLs. In both eyes, a capsular tension ring (CTR) was implanted. Intraoperatively, no complica- tions occurred. On day 1 postoperative, near UCVA was reading acuity determination (logRAD) 0.0, and distance UCVA was logMAR 0.1 in both eyes. Six weeks later, the patient presented with severe loss of visual acuity at all distances in both eyes due to mas- sive capsular phimosis (Figure 2). In the left eye, Nd:YAG laser capsulotomy was successful in opening the fibrosis. In the other eye, however, surgical excision was required. Moderate rotation of the lens position in both eyes led to 0.75 D of induced astigmatism, and there was a hyperopic shift of 1.50 D in the right eye and 1.75 D in the left. We prescribed glasses for distance vision, which made the patient relatively satisfied with distance BCVA of logMAR 0.2 and near BCVA of logRAD
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