Blended Vision for Myopia, Hyperopia, and Emmetropia (Non-Linear Aspheric Presbyopic Micro-Monovision LASIK)

Mechanism and outcomes of PRESBYOND

Glenn I Carp MBBCh, FC Ophth (SA)1 Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth FEBO1,2,3,4 Timothy J Archer, MA(Oxon), DipCompSci(Cantab)1

1. London Vision Clinic, London, UK 2. Columbia University Medical Center, New York, USA 3. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France 4. Biomedical Science Research Institute, Ulster University, Coleraine, Northern Ireland

Financial Disclosure

The author (GI Carp) receives travel expenses from Carl Zeiss Meditec AG (Jena, Germany)

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

The author (DZ Reinstein) acknowledges a financial interest in Artemis™ VHF digital ultrasound (ArcScan Inc., Golden, CO)

©DZ Reinstein 2016 [email protected] Objective

PRESBYOND is…. not monovision! not micro/modest monovision! not a multifocal treatment!

It’s PRESBYOND!!!!!

©DZ Reinstein 2016 [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 Brain merges two for near images to see near and far without glasses

©DZ Reinstein 2016 [email protected] Monovision: Challenges

1. Intermediate vision loss 2. Tolerance 3. Distance vision loss

4. Summation loss 5. Stereo acuity loss (unrecoverable)

©DZ Reinstein 2016 [email protected] Modest Monovision

** Pardhan et al., The Effect of Monocular Defocus on Binocular Contrast Sensitivity, Ophthal. Physiol. Opt., 1990, Vol. 10, January Summation Suppression Subtraction

Literature suggests a defocus value of -1.3D delivers the best balance of summation and near acuity

©DZ Reinstein 2016 [email protected] Monovision: Challenges

1. Blur zone at intermediate 2. Anisometropia not 3. Poor distance vision in distances tolerated by many the near eye

Modest Improves on 4. Loss of binocular distance these5. Loss challenges of stereo acuity Monovisionvision (rivalry/suppression) (unrecoverable)

Graham Barrett

©DZ Reinstein 2016 [email protected] Stereoacuity and anisometropia

-1.50 D or more

Up to -1.25 D

Minimal stereopsis impairment for anisometropia <1.5D

©DZ Reinstein 2016 [email protected] Stereoacuity and anisometropia

-1.50 D or more However, near visual acuity is Up to -1.25 D compromised as max -1.25 add!

Minimal stereopsis impairment for anisometropia <1.5D

©DZ Reinstein 2016 [email protected] Monovision: Challenges

1. Intermediate vision loss 2. Tolerance 3. Distance vision loss

Presbyond Improves on all 4. SummationLoss of binocular loss distance of 5.these StereoLoss of acuity stereo loss acuity vision (rivalry/suppression) (unrecoverable)

©DZ Reinstein 2016 [email protected] Increased Depth of Field by controlling Spherical Aberration

• Naturally occurring aberration • Increases with age • Increases during accommodation

Influence of Spherical Aberration on Depth of Field

without spherical aberration

with spherical aberration

courtesy Hartmut Vogelsang, PhD

©DZ Reinstein 2016 [email protected] Influence of Spherical Aberration on Depth of Field

0.00 D -0.50 D -1.00 D -1.50 D -2.00 D without spherical aberration @ 7 mm with spherical aberration @ 7 mm

Slides courtesy Hartmut Vogelsang, PhD

©DZ Reinstein 2016 [email protected] Simulation for -1.50 D defocus

-1.50 D @ 7 mm

Reduce pupil size to 4 mm Add spherical aberration

With spherical aberration and @ 4 mm

Central neural processing

©DZ Reinstein 2016 [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

©DZ Reinstein 2016 [email protected] PRESBYOND Laser Blended Vision for Myopia, Hyperopia, and Emmetropia (Non-linear Aspheric Presbyopic Micro-monovision LASIK)

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 2016 [email protected] Depth of Field by SA: Myopia

Low High High Pre SA

+ve Threshold

0 Spherical Aberration Spherical

-ve

©DZ Reinstein 2016 [email protected] Depth of Field by SA: Hyperopia

Low High

+ve Threshold

0 Spherical Aberration Spherical

-ve Threshold

©DZ Reinstein 2016 [email protected] Depth of Field by SA: Emmetropia

Dist Eye Near Eye

+ve Threshold

0 Spherical Aberration Spherical

-ve Threshold

©DZ Reinstein 2016 [email protected] Laser Blended Vision – Micro-Monovision

Dominant Eye Non-Dominant Eye

Far Distance

D D

Distance DOF 1.50 1.50 DOF DOF 1.50 1.50 DOF “Blend Zone”

Intermediate

Near

©DZ Reinstein 2016 [email protected] Laser Blended Vision – Micro-Monovision

Dominant Eye Non-Dominant Eye

Far Distance

D Nominal Rx: plano Distance

-0.75 D DOF: 1.50 1.50 DOF:

“Blend Zone” D

Intermediate

Nominal Rx: -1.50 D DOF: 1.50 1.50 DOF:

Near -2.25 D

©DZ Reinstein 2016 [email protected] PRESBYOND Laser Blended Vision for Myopia, Hyperopia, and Emmetropia (Non-linear Aspheric Presbyopic Micro-monovision LASIK)

Blended Vision: Methods

Myopia Hyperopia Emmetropia

# Patients 136 111 148

-3.58 ± 1.80 D +2.58 ± 1.17 D +0.25 ± 0.43 D SEQ up to -8.50 D up to +5.75 D -0.88 to +1.00 D -0.83 ± 0.64 D -0.49 ± 0.50 D -0.44 ± 0.31 D Cylinder up to -2.50 D up to -3.25 D up to -1.25 D median 49 yrs median 56 yrs median 55 yrs Age 43 to 63 44 to 66 44 to 65 • >90% follow up at 1 year • Results presented including enhancements

©DZ Reinstein 2016 [email protected] Blended Vision: Enhancement Rate

Myopia Hyperopia Emmetropia -8.50 +5.75

All 19% 22% 12%

Distance eyes 9% 9% 6% (20/25 or worse) Near eyes 8% 9% 7% (J3 or worse)

©DZ Reinstein 2016 [email protected] 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 2016 [email protected] Safety: Laser Blended Vision

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

©DZ Reinstein 2016 [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 2016 [email protected] Monovision: Challenges

1. Intermediate vision loss 2. Tolerance 3. Distance vision loss

4. Summation loss 5. Stereo acuity loss (unrecoverable)

©DZ Reinstein 2016 [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 2013 [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 2013 [email protected] Monovision: Challenges

1. Blur zone at intermediate 2. Anisometropia not 3. Poor distance vision in distances tolerated by many the near eye 

4. Loss of binocular distance 5. Loss of stereo acuity vision (rivalry/suppression) (unrecoverable)

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 Brain merges two for near images to see near and far without glasses

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 Brain merges two for near images to see near and far without glasses

1. Intermediate vision loss 2. Tolerance 3. Distance vision loss  

4. Summation loss 5. Stereo acuity loss (unrecoverable)

-1.50 D refraction n=395 expect 20/80

100%100% 90%90% 80%80% 70%70% 60%60% 50%50% 40%40% 30%30% 20%20% 10%10% 0%

Cumulative Eyes Percentage Cumulative 0%

CumulativePercentage Eyes 20/12.520/12.5 or 20/16 oror 20/20 or 20/25 or 20/32 or 20/40 oror 20/63 or orbetter better better better better better better better NearNear EyesEyes 0.00550961% 0.03305793% 0.146005515% 0.236914624% 0.363636436% 0.44628145% 0.804407780% Distance Eyes 0.0931507 0.4465753 0.9232877 0.9780822 0.9945205 0.9972603 1 Distance Eyes 9% 45% 92% 98% 99% 100% 100% Binocular 0.1315068 0.5342466 0.9616438 0.9808219 1 1 1 Binocular 13% 53% 96% 98% 100% 100% 100% DistanceDistance UCVAUCVA After All Treatments

1. Intermediate vision loss 2. Tolerance 3. Distance vision loss   

4. Summation loss 5. Stereo acuity loss (unrecoverable) 

©DZ Reinstein 2013 [email protected] Stereo Acuity: Efficacy (near-corrected pre vs near-uncorrected post) • 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

1. Intermediate vision loss 2. Tolerance 3. Distance vision loss   

4. Summation loss 5. Stereo acuity loss (unrecoverable)  

©DZ Reinstein 2013 [email protected] Summary • PRESBYOND Laser Blended Vision – Correction of pure presbyopia (distance normal) – Wide range of refractive error: +5.00 to -9.00 – Based on induction of ‘natural aberrations’ – Simultaneous accurate correction of cylinder – Easily enhanced in future if required – Centration on visual axis – Minimal compromise to contrast sensitivity and night vision disturbances – Tolerated by >95% of patients – Functional stereo acuity maintained – Performed as bilateral simultaneous 10 minute procedure with fast recovery

Glenn I Carp MBBCh, FC Ophth (SA)1 Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth FEBO1,2,3,4 Timothy J Archer, MA(Oxon), DipCompSci(Cantab)1

Thank You

So how much compromise in near vision?

≤J4 92%

2.5x >>

Near eye target: -1.00 to -1.50 D Achieved: -0.92 ±0.65

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

Traditional Monovision 20/200

Normal

Blended Vision

20/63 Visual Acuity Visual

20/20 0 30 10 5 5 10 30 Eccentricity (degrees)

Normal

Blended Vision 20/63

Visual Acuity Visual Summation

20/20 30 10 5 0 5 10 30 Eccentricity (degrees)

• Take patient to the slit-lamp in the operating room to redistribute any redundant cap to the periphery • Use Fluorescein stain to review the cap tension • Minor cap adjustment can be carried out at the slit-lamp using a sterile spear-tip sponge if necessary