The Ebb and Flow of Presbyopic Correction

Dan Z Reinstein, MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO1,2,3 Ryan S Vida, OD, FAAO1 Timothy J Archer, MA(Oxon), DipCompSci(Cantab), PhD1

1. London Vision Clinic, London UK 2. Columbia University Medical Center, New York, NY, USA 3. Sorbonne Université, Paris, France 4. Biomedical Science Research Institute, Ulster University, Coleraine, UK Financial Disclosure

• The author (DZ Reinstein) is a consultant for Carl Zeiss Meditec AG (Jena, Germany)

• The author (DZ Reinstein) acknowledges a financial interest in Insight 100 VHF digital ultrasound (ArcScan Inc, Golden, CO)

©DZ Reinstein 2019 [email protected] Presbyopic Correction: Cornea & Lens

Multifocal Sph Ab EDoF Monovision

©DZ Reinstein 2019 [email protected] Trends in presbyopic correction

Full multifocality Reduced Extended DoF + Reduced Full Monovision multifocality µ-anisometropia Monovision OD OS OD OS OD OS OD OS OD OS Distance Challenges Intermediate Monovision Maximise Range of Vision Improve SafetyTolerance & Poor Safety / Low Tolerance Low / Safety Poor Near

©DZ Reinstein 2019 [email protected] Trends in presbyopic correction: Multifocality

Full multifocality Reduced Extended DoF + CornealReduced Full Monovision multifocality µ-anisometropia Monovision OD OS OD OS OD OS OD OS OD OS Distance “Multi-focality attempts to substitute the loss of a dynamic system (accommodation) with a static system (multiple foci Challenges in one eye)”

Intermediate John Marshall, AECOS 2013 Monovision Maximise Range of Vision Improve SafetyTolerance & Poor Safety / Low Tolerance Low / Safety Poor Near

©DZ Reinstein 2019 [email protected] Biaspheric Multifocal Ablation

Full multifocality Reduced multifocality Extended DoF + µ-anisometropia Biaspheric Multifocal Ablation Biaspheric Multifocal Biaspheric Multifocal + µ-anisometropiavision Hybrid Ø Target -0.50 D both eyes Ø Target -0.12 DE, -0.88 NDE Ø Target -0.12 DE, -0.88 NDE Ø Add: 2.25 D Ø Add: 1.75 D Ø Add: 0.88 DE, 1.75 NDE Ø Same Add both eyes Ø Same Add both eyes Ø Half Add in DE

Ø Good near vision Loss of 2 lines: 12% Ø Unacceptable loss CDVA, but not Loss of 2 lines: 0% predictable

Loss of 2 lines: 5% Loss of 2 lines: 12%

Loss of 2 lines: 3-8%

©DZ Reinstein 2019 [email protected] Trends in presbyopic correction: Spherical Aberration EDoF

Traditional Treatment Options PRESBYOND Laser Blended Vision Multifocal cornea PRESBYOND - LBV

Monovision

Modified Binocular L R Vision

©DZ Reinstein 2019 [email protected] Trends in presbyopic correction

©DZ Reinstein 2019 [email protected] Increased Depth of Field with Spherical Aberration

• Naturally occurring aberration • Increases with age • Increases during accommodation • NOT a Multifocal Ablation Influence of SA on Depth of Field

without spherical aberration

with spherical aberration

Slides courtesy Hartmut Vogelsang, PhD

©DZ Reinstein 2019 [email protected] Influence of SA on Depth of Field

Dominant

Non-dominant

Slides courtesy Hartmut Vogelsang, PhD

©DZ Reinstein 2019 [email protected] Influence of SA on Depth of Field

Dominant

Non-dominant

Slides courtesy Hartmut Vogelsang, PhD

©DZ Reinstein 2019 [email protected] Spherical Aberration Increases Depth of Field: Confirmed by Adaptive Optics Spherical Aberration Increases Depth of Field

Depth of field increases with both negative and positive spherical aberration Toxic Therapeutic Toxic

©DZ Reinstein 2019 [email protected] Current Possible Depth of Field Increase

Right Eye Left Eye Far Distance

Distance 1.50 D 1.50 D

Intermediate

Loss of contrast

Near

©DZ Reinstein 2019 [email protected] Laser Blended Vision – Micro Monovision

Dominant Eye Non-Dominant Eye Far Distance

Distance DOF 1.50 D DOF 1.50 D “Blend Zone”

Intermediate

Near

©DZ Reinstein 2019 [email protected] Laser Blended Vision – Micro Monovision

Dominant Eye Non-Dominant Eye Far Distance

Nominal Rx: plano Distance

-0.75 D DOF: 1.50 D “Blend Zone”

Intermediate Nominal Rx: -1.50 D DOF: 1.50 D

Near -2.25 D

©DZ Reinstein 2019 [email protected] Monovision Challenges

Tolerance Distance vision loss Stereo acuity loss (unrecoverable) Sph Ab EDoF Modified Improves on all of these BinocularSummation loss Intermediate vision loss Vision

©DZ Reinstein 2019 [email protected] Presbyopic Correction: Cornea & Lens

Multifocal Sph Ab EDoF Monovision

©DZ Reinstein 2019 [email protected] Monovision Disadvantages: Low Tolerance

Evans BJ. Monovision: a review. Ophthalmic Physiol Opt. 2007;27:417-439.

Dominant eye: 59-67% mainly corrected Patients Tolerate for distance

Non-dominant eye: mainly corrected for Brain merges two images near to see near and far without glasses

©DZ Reinstein 2019 [email protected] Laser Blended Vision: Modified BINOCULAR

Reinstein DZ et al. LASIK for Hyperopic Astigmatism and Presbyopia Using Micro-monovision With the Carl Zeiss Meditec MEL80. JRS. 2009;25(1):87-93

Dominant eye: ~97% mainly corrected Patients Tolerate for distance

Non-dominant eye: mainly corrected for Brain merges two images near to see near and far without glasses

©DZ Reinstein 2019 [email protected] Stereo Acuity: Efficacy

• All eyes retained uncorrected stereo acuity of 400 arcsec or better post-operatively

100% 97% 100%100%100% 100% 94% 89% 90% 80% 71% 70% 66% 60% Emmetropes 50% Myopes 40% Hyperopes 30% 20% 10% 0% ≤100 sec ≤200 sec ≤400 sec

©DZ Reinstein 2019 [email protected] PRESBYOND LBV for Myopia, Hyperopia, and Emmetropia Laser Blended Vision: Results

upto -8.50 D upto +5.75 D -0.88 to +0.88 D

20/20 J2 J5 Myopia to -8.50D Hyperopia to +5.75 D Emmetropia 20/20 & J2 20/20 & J2 20/20 & J2 95% 77% 95%

©DZ Reinstein 2019 [email protected] Intermediate Vision: Myopic Patients

• 238 Patients • Age: 40 to 70 years • SEQ: up to -12.00 D • Follow-up: 3 mo to 5 yrs

Computer font size 12

©DZ Reinstein 2019 [email protected] Intermediate Vision: Hyperopic Patients

• 334 Patients • Age: 40 to 70 years • SEQ: up to +6.00 D • Follow-up: 3 mo to 5 yrs

Computer font size 12

©DZ Reinstein 2019 [email protected] Laser Blended Vision: Safety

All 395 Patients: Range: -8.50 D – plano – +5.75 D

©DZ Reinstein 2019 [email protected] Laser Blended Vision: Contrast Sensitivity

Myopia Hyperopia Emmetropia Upto -8.50D, n=272 Upto -8.50D, n=222 n=292

* * * * * *

Statistically significant improvement (p<0.05)

©DZ Reinstein 2019 [email protected] Laser Blended Vision: Outcomes

©DZ Reinstein 2019 [email protected] Presbyopic Correction: Cornea & Lens

Multifocal Sph Ab EDoF Monovision

©DZ Reinstein 2019 [email protected] Presbyopic Correction: Cornea & Lens

Cornea Lens

©DZ Reinstein 2019 [email protected] Presbyopic Correction: Cornea & Lens

Multifocal Sph Ab EDoF Monovision

Cornea

Lens

©DZ Reinstein 2019 [email protected] EXTRA ocular treatment

Extend the DOF while avoiding the risks associated with an intraocular procedure

CME ICL PCO

RD PDS

©DZ Reinstein 2019 [email protected] Higher Risk for Younger Patients Retinal Detachment Risk: 1.5-2.2% (high myopia) Neuhann IM, Neuhann TF, Heimann H, Schmickler S, Gerl RH, Foerster MH. Retinal detachment after phacoemulsification in high myopia: analysis of 2356 cases. J Cataract Refract Surg. 2008 Oct;34(10):1644-57.

Young Old Risk: 1.9% Burg MA, Taqui AM. Frequency of retinal detachment and other complications after neodymium:Yag laser capsulotomy. J Pak Med Assoc. 2008 Oct;58(10):550-2.

Risk: 1.9% Burg MA, Taqui AM. Frequency of retinal detachment and other complications after neodymium:Yag laser capsulotomy. J Pak Med Assoc. 2008 Oct;58(10):550-2. Young Old Retinal detachment after cataract surgery (5 year risk)

2.5 1.99 2.0 1.51 1.5 1.0 0.75 0.33 0.5 0.11 0.0 80> 70-79 60-69 50-59 <50

©DZ Reinstein 2019 [email protected] Age Distribution

©DZ Reinstein 2019 [email protected] Target Population: Presbyopes

Multifocal IOL: ~85% % Light Transmission Light %

©DZ Reinstein 2019 [email protected] Target Population: Presbyopes

Multifocal IOL: ~85% % Light Transmission Light % Age

©DZ Reinstein 2019 [email protected] Age Distribution

30%

10-15%

©DZ Reinstein 2019 [email protected] Target Population: Presbyopes % Light Transmission Light % Age

©DZ Reinstein 2019 [email protected] My Uncorrected Vision Now UDVA 20/10 UIVA J3 UNVA J1

Plano -1.75 D

20/10 20/50

40 secs

©DZ Reinstein 2019 [email protected] Cataract After LBV?

LBV: 96-93%

Multifocal IOL: ~85%

Monofocal IOL % Light Transmission Light % Age

©DZ Reinstein 2019 [email protected] Cataract After LBV Sph Ab EDoF? • Monofocal IOL • Multifocal IOL – Low PCO rate – High PCO rate – 100% transmission – 85% transmission – DoF on the cornea – Risk of NVDs (rings) on Visual Axis

©DZ Reinstein 2019 [email protected] Worldwide Trends: Parallel Universe What is the most common presbyopic procedure offered to patients?

LASIK Monovision

Clear Lens Exchange (Multifocal or monovision)

Lens based Treatment

Cornea based Influencing Factors

©DZ Reinstein 2019 [email protected] Worldwide Trends: Parallel Universe What is the most common presbyopic procedure chosen by surgeons for their own eyes?

LASIK Monovision

Clear Lens Exchange (Multifocal or monovision)

©DZ Reinstein 2019 [email protected] Worldwide Trends: Parallel Universe What is the most common presbyopic procedure chosen by surgeons for their own eyes?

LASIK Monovision

Clear Lens Exchange (Multifocal or monovision)

Dan Z Reinstein, MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO1,2,3 Ryan S Vida, OD, FAAO1 Timothy J Archer, MA(Oxon), DipCompSci(Cantab), PhD1

1. London Vision Clinic, London UK 2. Columbia University Medical Center, New York, NY, USA 3. Sorbonne Université, Paris, France Thank You 4. Biomedical Science Research Institute, Ulster University, Coleraine, UK Summary: Sph Ab EDoF on the cornea

Modified Binocular Vision by Sph Ab EDoF 1. Correction of plano presbyopia 2. Wide range of refractive error: +5.00 to -9.00 3. Simultaneous accurate correction of cylinder 4. Based on induction of ‘natural aberrations’ 5. Centration on visual axis 6. Easily enhanced in future if required 7. Minimal compromise to contrast sensitivity and night vision disturbances 8. Tolerated by >95% of patients 9. Functional stereo acuity maintained 10. Bilateral simultaneous 10 minute procedure with fast recovery ©DZ Reinstein 2019 [email protected] PRESBYOND / Monovision Crossover

QoV Symptoms

DoF Benefit Postop Spherical AberrationSpherical Postop

PRESBYOND Monovision

©DZ Reinstein 2019 [email protected] Assessment by HD Analyser (OQAS) OSI • 70 yo female • LBV LASIK 12 years before • Presbyopic progression • Retreatment performed • OSI still good quality optics

Wertheim T. Uber die indirekte Sehschärfe, Z. Pyschol 7:172, 1894 20/63

20/200

20/63

20/200 20/200

20/20

20/200

20/200 20/200 20/63 - 20/20

Neural Suppression

20/200 20/200 20/63 20/63 20/20

20/200 20/200 20/63 20/63 + 20/20

Neural Summation

Traditional Monovision 20/200 Normal

Blended Vision

20/63 VisualAcuity

20/20

30 10 5 0 5 10 30 Eccentricity (degrees)

Traditional Monovision 20/200 Normal

Blended Vision

20/63 VisualAcuity Summation

20/20

30 10 5 0 5 10 30 Eccentricity (degrees)

n=395 -1.50 D refraction expect 20/80 100%

90%100% 80% 90% 70%80% 60%70% 50%60% 40%50% Eyes 30%40% 20%30% 10%20% 0% 10% 20/12.5 20/16 20/20 20/25 20/32 20/40 20/63 Cumulative Percentage 0% or or or or or or or

Cumulative Percentage Eyes Percentage Cumulative 20/12.5 or 20/16 or 20/20 or 20/25 or 20/32 or 20/40 or 20/63 or betterbetter betterbetter betterbetter betterbetter betterbetter betterbetter betterbetter NearNear Eyes Eyes 0.005511% 0.0330583% 0.14600615% 0.23691524% 0.36363636% 0.44628145% 0.80440880% DistanceDistance Eyes Eyes 0.0931519% 0.44657545% 0.92328892% 0.97808298% 0.99452199% 0.99726100% 100%1 BinocularBinocular 0.13150713% 0.534247Distance53% 0.96164496% UCVA0.980822 98%After All100%1 Treatments100%1 100%1 Distance UCVA After All Treatments ©DZ Reinstein 2019 [email protected] Stereo Acuity: Patients & Methods

• 22 myopes, 38 hyperopes, 16 emmetropes

• Stereo acuity measurements (4-dot test) – Pre-op: near-corrected – Post-op: near-corrected – Post-op: uncorrected # Patients 76 -0.40 ± 2.69 D SEQ • Analysis -7.13 to +3.75 D – Safety: post-op near corrected – pre-op near -0.73 ± 0.54 D Cylinder corrected up to -2.25 D – Efficacy: post-op uncorrected – pre-op near median 57 yrs corrected Age 45 to 69