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The Ebb and Flow of Presbyopic Correction

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The Ebb and Flow of Presbyopic Correction 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 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] 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. ©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- 2,717,203 eyes 57. 65,055 eyes 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
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