LASIK for hyperopic astigmatism and presbyopia using micro-monovision with the Carl Zeiss Meditec MEL80 platform

Small Incision Lenticule Extraction (SMILE) for Hyperopia: Optical Zone Centration

PURPOSE

To evaluate optical zone centration of hyperopic small incision lenticule extraction (SMILE).

METHODS

This prospective study of 60 consecutive hyperopic SMILE procedures used the VisuMax femtosecond laser and matched LASIK procedures with the VisuMax and MEL 80 excimer lasers (Carl Zeiss Meditec AG, Jena, Germany). Inclusion criteria were maximum attempted hyperopic meridian of between +1.00 and +7.00 diopters (D) and astigmatism up to 6.00 D. For SMILE, the optical zone was between 6.3 and 6.7 mm, with a 2-mm transition zone. Two LASIK control groups (6.5- and 7-mm optical zone) were generated matched for spherical equivalent treated. In SMILE, the corneal vertex of the coaxially fixating eye was aligned with the vertex of the curved contact glass. In LASIK, the treatment was centered on the coaxially sighted corneal light reflex (first Purkinje image) with the contralateral eye (Seiler method). A tangential (instantaneous) curvature preoperative to 3 months postoperative difference map was generated for each eye. A fixed grid and set of concentric circles were superimposed on the difference map to measure the offset between the optical zone center and corneal vertex (0,0), and vector analysis was used for comparative analysis.

RESULTS

Mean attempted spherical equivalent was +5.61 ± 0.96 D (range: +3.20 to +6.50 D) and mean cylinder was -0.96 ± 0.62 D (range: 0.00 to -2.75 D) in the SMILE group. Mean age was 29 ± 7 years (range: 19 to 52 years) in the SMILE group. Mean centration offset was 0.23 ± 0.15 mm (range: 0 to 0.61 mm) for the SMILE group, 0.33 ± 0.14 mm (range: 0.14 to 0.85 mm) for the 6.5-mm LASIK group, and 0.31 ± 0.19 mm (range: 0.05 to 0.85 mm) for the 7-mm LASIK group. The mean centration offset for SMILE was less than that of both LASIK groups (P < .05).

CONCLUSIONS

Optical zone centration of hyperopic SMILE was found to be similar to eye-tracker-centered hyperopic LASIK with the MEL 80 laser. [J Refract Surg. 2017;33(3):150-156.].

Improved lenticule shape for hyperopic femtosecond lenticule extraction (ReLEx FLEx): a pilot study

The aim of this study is to establish and to prove a new lenticule shape for the treatment of hyperopia using a 500 kHz femtosecond laser and the femtosecond lenticule extraction (ReLEx FLEx) technique. Improved lenticule shapes with a large transition zone of at least 2 mm adjusted to the 5.75 mm optical zone were designed. A prospective pilot study on nine eyes of five patients who underwent an uncomplicated FLEx using VisuMax femtosecond laser (Carl Zeiss Meditec AG) for spherical hyperopia was performed. Patients' mean age was 55.5 years, and the preoperative manifest spherical equivalent (SE) was +1.82 D (range +1.25 to +3.00 D). Because of the presbyopic age and in order to compensate for a possible regression, the treatment was aimed at low myopia (mean target SE was -0.88 D with a mean treatment refraction of +2.69 D). At the last follow-up, after 9 months, 33% were within ±0.50 D and 78% within ±1.00 D of intended correction. Thirty-three percent lost one line, and 11% gained one line corrected distance visual acuity (CDVA). On average, the centre of the optical zone was 0.34 ± 0.17 mm from the corneal vertex. No adverse effects were observed. This pilot study confirms that the improved lenticule's design with a large optical and transition zone can achieve good centration and acceptable results for spherical hyperopia using FLEx. The next steps are to extend the study to spherocylindrical hyperopic treatments and to increase the number of eyes for better assessment of refractive outcome.

Central PresbyLASIK for Hyperopia and Presbyopia Using Micro-monovision With the Technolas 217P Platform and SUPRACOR Algorithm

PURPOSE

To analyze the refractive outcomes and satisfaction of presbyopic hyperopes treated with central presbyopicLASIK (presbyLASIK) with induced micro-monovision.

METHODS

This retrospective study included 74 eyes of 37 patients treated with central presbyLASIK with micro-monovision using the Technolas 217P excimer laser (Technolas Perfect Vision GmbH, Munich, Germany) between June 2011 and March 2014. Study parameters included uncorrected distance visual acuity (UDVA) and uncorrected near visual acuity (UNVA), aberrometry, the central steep zone, and patient satisfaction.

RESULTS

Median age was 54.3±4 years (range: 46 to 63 years). Mean postoperative spherical equivalent refraction was 0.00±0.58 diopters (D) for dominant eyes and -0.51±0.54 D for non-dominant eyes. Mean binocular UDVA was 0.01±0.10 logMAR (Snellen 20/20) at 6 months and -0.01±0.05 logMAR (Snellen 20/19) at 1 year postoperatively. Mean binocular UNVA was 0.18±0.14 logMAR (Parinaud 2) (Jaeger 1) at 6 months and 0.18±0.12 logMAR (Parinaud 2) (Jaeger 1) at 1 year postoperatively. At 6 months, 79.31% of patients achieved 20/25 and could read Parinaud 2 (Jaeger 1) binocularly. At 1 year, 84.21% of patients achieved 20/25 and could read Parinaud 2 (Jaeger 1) binocularly. The mean central steep zone was 2.35±1.00 D. There were significantly more negative spherical aberration and vertical coma in the central 5 mm postoperatively (P<.05). The re-treatment rate was 6.75%. Eighty-three percent of these patients did not need any glasses for distance and near vision.

CONCLUSIONS

This procedure may improve functional near, intermediate, and distance vision in presbyopic patients with low and moderate hyperopia.

PresbyLASIK approach for the correction of presbyopia

PURPOSE OF REVIEW

The aim of this review is to offer a comprehensive overview of the different PresbyLASIK approaches, which have been published in peer-reviewed journals.

RECENT FINDINGS

Comprehensive search was conducted in scopus using keywords presbyLASIK, presbyopia, LASIK, corneal multifocality. We reviewed binocular uncorrected and corrected distance and near visual acuity, and loss of lines of best corrected visual acuity, for presbyopic patients among three different basic treatment modalities.

SUMMARY

Additional trials and standards for reporting results for presbyopic approaches are necessary. Careful patient selection and counseling is imperative in all PresbyLASIK treatments.

A review of the surgical options for the correction of presbyopia

Presbyopia is an age-related eye condition where one of the signs is the reduction in the amplitude of accommodation, resulting in the loss of ability to change the eye's focus from far to near. It is the most common age-related ailments affecting everyone around their mid-40s. Methods for the correction of presbyopia include contact lens and spectacle options but the surgical correction of presbyopia still remains a significant challenge for refractive surgeons. Surgical strategies for dealing with presbyopia may be extraocular (corneal or scleral) or intraocular (removal and replacement of the crystalline lens or some type of treatment on the crystalline lens itself). There are however a number of limitations and considerations that have limited the widespread acceptance of surgical correction of presbyopia. Each surgical strategy presents its own unique set of advantages and disadvantages. For example, lens removal and replacement with an intraocular lens may not be preferable in a young patient with presbyopia without a refractive error. Similarly treatment on the crystalline lens may not be a suitable choice for a patient with early signs of cataract. This article is a review of the options available and those that are in development stages and are likely to be available in the near future for the surgical correction of presbyopia.

[Laser Blended Vision for presbyopia: Results after 3 years]

PURPOSE

Retrospective study of the first 173 patients with presbyopia who underwent LASIK with a non-linear aspheric ablation profile and micro-monovision for the correction of presbyopia with myopia, astigmatism, hyperopia or emmetropia: Laser Blended Vision(®) Program by Carl Zeiss Meditec(®) (Jena, Germany).

METHODS

We retrospectively studied the first consecutive 173 patients with presbyopia who underwent LASIK with the wavefront-guided Laser Blended Vision(®) Program by Zeiss(®) in our Excimer Laser Zeiss Mel-80 by Carl Zeiss Meditec(®) (Jena, Germany) over the last three years in our clinic (Optima Laser Clinic, Valence, Spain). The program has a non-linear aspheric ablation profile that increases the spherical aberration in both eyes. A slight myopia of -1.5 diopters (D) in the non-dominant eye is also programmed. We analysed the results and patient satisfaction. The patients were separated into two groups: less than 50 years old and 50 years or more. Follow-up was from 1 to 28 months. We also separated two groups: follow-up under 12 months and follow-up of 12 months or more. We analysed the efficacy, safety and predictability of the procedure.

RESULTS

Seventy-nine male and 94 female patients between 42 and 69 years old were studied, for a total of 337 eyes. Only eight patients (4.62%) were between 42 and 44; 55 (31.79%) were between 45 and 49; 110 patients (63.58%) were 50 years or more. Nine patients underwent the surgery in the non-dominant eye only. Twelve (6.94%) patients were emmetropic (0.5 or less spherical equivalent), 42 (24.28%) were myopic or myopic astigmatic, and 119 (68.79%) were hyperopic or hyperopic astigmatic. One hundred and thirty-six patients (78.61%) had pre-operative near vision between J4 and J10. One hundred and seventy-one patients (98.84%) had post-operative near vision between J1 and J3; 150 (86.7%) had J1 (efficacy). Post-operative visual acuity without correction for distance was 20/20 or better in 159 patients (91.91%) (binocular). The predictability within 0.5 D was 87.86%. Safety 99.7% (336/337 eyes): one eye of a diabetic patient lost two lines BCVA. A total of 93.64% were satisfied with the procedure, 2.89% used eye-glasses for certain activities, 1.73% reported dry eye, 0.58% reported a nonspecific lack of adaptation, and there were no serious complications; 3.47% did not achieve their expectations. Twenty-four patients (13.87%) needed an enhancement, 18 of them (75.5%) for only one eye, with 88.89% of these being the non-dominant eye. Forty-nine patients (28.32%) had over 12 months follow-up, with 95.92% still satisfied.

CONCLUSIONS

Laser Blended Vision(®) is an excellent option, well tolerated, stable and effective for patients with presbyopia and myopia, astigmatism, hyperopia or emmetropia, also avoiding an intraocular procedure.

[Comparison of two different surgical treatments of presbyopia for hyperopic patients over 55 years old: Presbylasik (Supracor) and Prelex (presbyopic lens exchange)]

INTRODUCTION

The management of presbyopic patients is a medical, surgical and economic issue. We wondered which procedure, whether a Presbylasik technique called Regular Supracor or the intraocular surgery of clear lens replacement by a trifocal diffractive lens (presbyopic lens exchange [Prelex]), provided the best results (in visual acuity and satisfaction) for our hyperopic and presbyopic patients between 55 and 70. The aim of this study was to compare the safety and efficacy of the two techniques (at one week and three months) and to assess patients' quality of life.

METHODS

This study is a retrospective monocentric clinical trial conducted between June 2011 and March 2014, on 21 hyperopic presbyopic patients (mean age 60.9 years), in the "hôpital d'instruction des armées-Percy" (Clamart); 13 patients underwent the corneal treatment of Presbylasik (with the Intralase FS60 femtosecond laser [AMO, USA] and the Technolas 217P excimer laser [Technolas Perfect Vision, GmbH] following the Zyoptix Tissue-Saving algorithm adjusted with a nomogram and the Regular Supracor mode), and 8 patients underwent clear lens extraction (Prelex), through bimanual phacoemulsification and implantation of diffractive trifocal intraocular lenses (Finevision Micro F, PhysIOL(*)).

RESULTS

Mean uncorrected binocular distance and near vision visual acuity in the Supracor group were respectively 0.03 (-0.2-0.1) LogMar and 0.23 (0.06-0.36) one week postoperatively and 0.031 (-0.2-0.1) and 0,166 (0.06-0.36) three months postoperatively. In the Prelex group, the mean uncorrected one week binocular VA was 0.025 (0-0.1) for distance vision and 0.165 (0.06-0.18) for near distance and the three months visual acuity was 0 (-0.1-0.1) and 0.105 (0.06-0.18) for distance and near vision. All Prelex patients were spectacle-free at all distances, whereas 4 Supracor patients required spectacles for near vision postoperatively. Seven of 11 patients in the Supracor group and 100% of the Prelex patients were completely satisfied. Both groups experienced halos, but patients reported more halos in the Prelex group (75%). One eye required intraocular lens exchange and four eyes (16.7%) required a new corneal procedure in the Supracor group.

CONCLUSION

Both surgeries are safe and effective modalities in the management of hyperopic and presbyopic patients. However, the Prelex procedure seems to be more appropriate for patients over 55 years of age.

Artemis very high frequency digital ultrasound-guided femtosecond laser recut after flap complication

Incomplete flaps are a relatively uncommon complication of laser-assisted in situ keratomileusis (LASIK) that occur when creation of the corneal flap is interrupted. Further complications can arise if a second flap is created that intersects the original flap interface, resulting in tissue slivers that can lead to more complications and poor visual outcomes. We report the case of a 56-year-old man who underwent LASIK in which an incomplete flap occurred after 45% completion using a mechanical microkeratome with a 160 µm head. The maximum depth achieved by this incomplete flap was measured by very high-frequency (VHF) digital ultrasound as 182 μm peripherally. Two months later, a second flap was created beneath the incomplete flap, at a depth of 190 μm. The resulting flap had a central thickness of 196 μm and a minimum clearance of 30 μm beneath the incomplete flap. This demonstrates a method for creating secondary flaps that may significantly reduce the risk of flap interface intersection.

Changes to corneal aberrations and vision after Presbylasik refractive surgery using the MEL 80 platform

PURPOSE

To investigate changes to corneal surface aberrations and vision between PresbyLASIK and LASIK for correction of presbyopia using the MEL 80 platform (Carl Zeiss Meditec, Jena, Germany).

METHODS

The retrospective data of 31 patients who underwent PresbyLASIK (the PresbyLASIK group) between January 2009 and November 2011 and 20 matched patients who underwent LASIK (the LASIK group) were analyzed for changes to refraction, corrected distance visual acuity, and corneal surface wavefront aberrations calculated over 4- and 6-mm pupils. Outcomes at the 3-month follow-up visit were compared to data collected immediately prior to surgery and between PresbyLASIK and LASIK correction. Associations between induced corneal aberrations and best spherical equivalent refraction were explored.

RESULTS

PresbyLASIK and LASIK significantly reduced refractive error in both myopes and hyperopes. Residual refractive error was not significantly different between treatment groups, except for spherical equivalent refraction, which was significantly more myopic following LASIK treatment compared to PresbyLASIK in myopes. There was no significant difference in postoperative corrected distance visual acuity between groups. LASIK and PresbyLASIK induced positive spherical aberration in myopes and negative spherical aberration in hyperopes, with significant differences between treatments only apparent in myopes when analyzed over a 4-mm pupil (PresbyLASIK group: 0.07 ± 0.06 µm; LASIK group: 0.03 ± 0.04 µm, P < .05). In hyperopes, induced spherical aberration was more highly associated with refractive change after LASIK (r = 0.82, P < .05) than PresbyLASIK (r = 0.64, P < .001); instead PresbyLASIK led to a more consistent shift of approximately 0.3 µm independent of induced change to refraction.

CONCLUSIONS

PresbyLASIK using the MEL 80 platform induced significant changes in spherical aberration in myopes and hyperopes. PresbyLASIK appears to offer an improved response over LASIK when correcting myopes due to an apparent increase in depth of focus resulting from changes in spherical aberration. For hyperopes, PresbyLASIK provides a more consistent spherical aberration effect independent of refractive change.

Developments in the correction of presbyopia II: surgical approaches

PURPOSE

To discuss the various static and dynamic surgical approaches which attempt to give presbyopes good vision at far, intermediate and near viewing distances.

CONTENT

Static methods broadly adopt the same optical techniques as those used in presbyopic contact lens correction and aim to satisfy the needs of the presbyope by increasing binocular depth-of-focus, often using monovision as well as simultaneous-imagery. Dynamic methods generally attempt to make use of at least some of the still-active elements of the accommodation system. They include procedures which are supposed to modify the relative geometry of the ciliary muscle and lens, or which reduce the stiffness of the presbyopic lens either by replacing it with other natural or man-made material or by subjecting it to femtosecond laser treatment. Alternatively the natural lens may be replaced by some form of intraocular lens which changes power as a result of forces derived from the still-active ciliary muscle, zonule and capsule, or other sources.

CONCLUSIONS

At present, multifocal intraocular lenses appear to offer the most consistent and reliable surgical approach to surgical presbyopic correction. They have obvious advantages in convenience and stability over optically-similar, simultaneous-image presbyopic contact lenses but this must be balanced against their relative inflexibility in cases of patient dissatisfaction. Dynamic methods remain largely experimental. Although some approaches show promise, as yet no method has demonstrated a reliable, long-term ability to correct distance refractive error and to appropriately change ocular power in response to changes in viewing distance over the normal range of interest.

Femtosecond laser-assisted keyhole endokeratophakia: correction of hyperopia by implantation of an allogeneic lenticule obtained by SMILE from a myopic donor

PURPOSE

To describe endokeratophakia in which a small incision lenticule extraction (SMILE) lenticule from a myopic patient is implanted into a recipient eye through a small incision to correct hyperopia.

METHODS

A 23-year-old aphakic woman presented following cataract surgery to remove a childhood congenital cataract with hyperopia of +12.00 -1.50 × 155, corrected distance visual acuity of counting fingers, and exotropia. A SMILE procedure using the VisuMax femto-second laser (Carl Zeiss Meditec, Jena, Germany) was performed on a donor patient with high myopia and the extracted lenticule was stored (power -10.50 diopter sphere, optical zone 5.75 mm, central lenticule thickness 127 μm). In the recipient eye, a pocket lamellar incision was created using the VisuMax SMILE software. The upper interface was separated and the donor lenticule was inserted through the small incision.

RESULTS

One year postoperatively, retinoscopy refraction was +7.50 -3.00 × 150, a spherical equivalent refraction reduction of 5.25 diopters. Mean keratometric power increased by 2.91 diopters. The posterior surface elevation changed significantly with a central bulge into the anterior chamber. Central corneal thickness by Pentacam (Oculus Optikgeräte, Wetzlar, Germany) increased by 121 μm. Central lenticule thickness was 130 μm and central epithelial thickness was 43 μm measured by RTVue OCT (Optovue Inc., Fremont, CA). The cornea remained clear over the 1-year postoperative period.

CONCLUSIONS

Endokeratophakia appears to be a viable procedure for correcting hyperopia on the cornea by implantation of an extracted myopic SMILE lenticule from a donor patient. However, posterior surface changes and epithelial remodeling resulted in only 50% of the intended correction. No adverse side effects were observed following implantation of donor tissue for 1 year.

Presbyopic correction on the cornea

Purpose

The aim of this systematic review was to synthesize and appraise the evidence of the benefits of presbyopic correction on the cornea for visual function.

Summary

Comprehensive search was conducted in MEDLINE using keywords like “presbylasik”, “presbyopic refractive surgery”, “corneal pseudoaccommodation” and “corneal multifocality”. We reviewed corrected and uncorrected visual acuities for distance and near (uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), corrected distance visual acuity (CDVA), distance corrected near visual acuity (DCNVA), corrected near visual acuity (CNVA)), along with the refractive outcomes in spherical equivalent (SE) and astigmatism comparing the differences observed between preoperative myopic and hyperopic patients, as well as among techniques.

Thirty-one studies met the inclusion and quality criteria. Monovision provides excellent distance and near uncorrected acuities, but with a 17% retreatment and a 5% reversal rate. Initial multifocal ablations result in 12% loss of 2 or more lines of CDVA, and a 21% retreatment rate. Laser Blended Vision provides excellent UDVA, but with a 19% retreatment rate. Initial experiences with Supracor show moderate predictability and a 22% retreatment rate. Intracor results in 9% loss of 2 or more lines of CDVA. KAMRA provides excellent UDVA, with only a 1% retreatment rate, but a 6% reversal rate. Initial experiences with PresbyMAX provided excellent UNVA and DCNVA, showing excellent predictability and a 1% reversal rate.

Conclusions

The findings have implications for clinicians and policymakers in the health-care industry and emphasize the need for additional trials examining this important and widely performed clinical procedure.

One-year experience in presbyopia correction with biaspheric multifocal central presbyopia laser in situ keratomileusis

PURPOSE

To analyze simultaneous vision (distance and near) 1-year after biaspheric multifocal central presbyLASIK treatments for hyperopia and myopia with or without astigmatism.

METHODS

Patients were treated to correct distance ametropias and alleviating presbyopic symptoms simultaneously. All patients have been treated in Presby aberration-free mode using FemtoLASIK for Sphere from -7.00 to +3.25 diopters (D), astigmatism up to 3.00 D, and addition up to +2.75 D. No eye had previous corneal refractive surgery. Preoperative corneal curvature ranged between 40 and 48 D, with pachymetry thicker than 500 μm. Preoperative corrected distance visual acuity was 0.1 logarithm of the minimum angle of resolution (logMAR) or better, with near vision of 0.2 logRAD or better with addition up to +2.50 D.

RESULTS

Sixty-six eyes treated bilaterally using PresbyMAX software were reviewed. For 31 patients (94%), 1-year follow-up was completed. At 1 year, 70% of patients achieved uncorrected distance visual acuity 0.1 logMAR or better, 84% patients obtained uncorrected near visual acuity 0.1 logRAD or better, and 83% of eyes were within 0.75 D of defocus. Postoperative mean spherical equivalent refraction was -0.47 ± 0.44 D. Stability was achieved from the 6-week follow-up. Eighty-five percent of patients achieved simultaneously uncorrected distance visual acuity 0.2 logMAR or better and uncorrected near visual acuity 0.2 logRAD or better.

CONCLUSION

Patient selection and expectation management is essential to achieve patient satisfaction. Even though optically the results are predictable and good, some patients find it difficult to adapt to the compromise and others are dissatisfied by the minor loss of distance visual acuity. Certain individuals are best suited for PresbyMAX. A test with multifocal contact lenses or trial frames that creates slightly defocused images can be used to simulate postoperative visual impressions and verify patient acceptance.

Uncorrected binocular performance after biaspheric ablation profile for presbyopic corneal treatment using AMARIS with the PresbyMAX module

PURPOSE

To analyze the uncorrected binocular performance after biaspheric multifocal central presbyopic laser in situ keratomileusis treatments.

DESIGN

Retrospective, interventional case series.

METHODS

setting. Private clinical practice. patient or study population. Three hundred fifty-eight presbyopic patients (43% males, 82 myopic), bilaterally treated, suitable for laser in situ keratomileusis, with monocular corrected distance visual acuity of 20/32 or better. intervention or observation procedure(s). PresbyMAX (Schwind Eye-Tech-Solutions GmbH and Co) biaspheric multifocal ablation. main outcome measures. Binocular uncorrected distance visual acuity (UDVA) and near visual acuity (UNVA) after surgery and their changes compared with corrected distance visual acuity and corrected near visual acuity before surgery.

RESULTS

At 6 months, 76% of patients achieved a UDVA of 0.1 logarithm of the minimal angle of resolution (logMAR; Snellen equivalent, 20/25) or better, 91% of patients obtained a UNVA of 0.1 logarithmic of the reading acuity determination (logRAD) (p3) or better, and 99% of patients were within 1 diopter of defocus. Postoperative mean spherical equivalent was -0.17 ± 0.34 diopter. Ninety-six percent of patients achieved a UDVA of 0.2 logMAR (Snellen equivalent, 20/32) or better and a UNVA of 0.2 logRAD (p4) or better. Mean binocular corrected distance visual acuity degraded from 0.00 ± 0.01 logMAR (Snellen equivalent, 20/20) to a UDVA of 0.09 ± 0.07 logMAR (Snellen equivalent, 20/25). Mean binocular corrected near visual acuity degraded from 0.02 ± 0.01 logRAD (p2) to a UNVA of 0.07 ± 0.07 logRAD (p2).

CONCLUSIONS

Although optically the results are predictable, approximately 17% of the patients did not obtain objectively successful outcomes. In presbyopic patients without symptomatic cataracts, but with refractive errors, the PresbyMAX will decrease the presbyopic symptoms and correct far distance refraction in the same treatment, offering spectacle-free vision in daily life in most of the patients. Further investigation is necessary to evaluate the overall benefit of this procedure.

LASIK for presbyopia correction in emmetropic patients using aspheric ablation profiles and a micro-monovision protocol with the Carl Zeiss Meditec MEL 80 and VisuMax

PURPOSE

To evaluate the monocular and binocular visual outcomes of LASIK with an aspheric micro-mono-vision protocol in emmetropic patients with presbyopia.

METHODS

A retrospective, noncomparative case series included 296 eyes from 148 consecutive emmetropic patients with presbyopia who were treated with LASIK-induced micro-monovision. The CRS-Master software was used to generate ablation profiles for the MEL 80 excimer laser (Carl Zeiss Meditec) and flaps were created using the VisuMax femtosecond laser (Carl Zeiss Meditec). The target refraction was plano for distance eyes (dominant eye) and between -1.00 and -1.88 diopters (D) for near eyes. Patients were followed for 1 year. Emmetropia was defined for inclusion as spherical equivalent refraction ⩾- 0.88 D, sphere ⩽+1.00 D, and cylinder ⩽1.25 D. Median patient age was 55 years (range: 44 to 65 years). Median follow-up was 12.9 months.

RESULTS

Mean deviation from intended correction was +0.02±0.35 D, with 91% within ±0.50 D and 100% within ±1.00 D. Of distance eyes, 95% achieved uncorrected distance visual acuity (UDVA) of 20/20 or better and 100% achieved 20/32 or better. Binocularly, 98% of patients achieved UDVA of 20/20 or better and 100% achieved 20/32 or better; 96% achieved uncorrected near visual acuity of J2 and 99% could read J3 or better. No eyes lost 2 or more lines of corrected distance visual acuity. An average increase of 0.05 logMAR was noted in distance-corrected near visual acuity. A small increase occurred in mesopic contrast sensitivity (CSV-1000, VectorVision Inc) at 3 cycles per degree (cpd) (P=.016) and no change at 6, 12, or 18 cpd.

CONCLUSIONS

This aspheric micro-monovision protocol was a well-tolerated and effective procedure for treating emmetropic patients with presbyopia.

A new method of cornea modulation with excimer laser for simultaneous correction of presbyopia and ametropia

PURPOSE

To investigate the outcomes of simultaneous correction of presbyopia and ametropia by a bi-aspheric cornea modulation technique, based on the creation of a central area hyperpositive for near vision and leaving the pericentral cornea for far vision in hyperopic, emmetropic, and myopic presbyopic patients.

SETTING

Sixty eyes of 30 patients were treated with the PresbyMAX technique by one surgeon (D.U.) at the Eye Hospital Bellevue, Kiel, Germany.

METHODS

Twenty eyes with hyperopic presbyopia, 20 eyes with emmetropic presbyopia, and 20 eyes with myopic presbyopia underwent Femto-Lasik, and were assessed up to 6 months postoperatively. All eyes underwent cornea treatment using the PresbyMAX® software, delivering a bi-aspheric multifocal ablation profile developed by SCHWIND eye-tech-solutions (Kleinostheim, Germany). All flaps were created by Ziemer LDV Femtolaser (Port, Switzerland).

RESULTS

The mean binocular distance of uncorrected visual acuity (DUCVA) improved in the hyperopic group from 0.28 ± 0.29 logMAR to -0.04 ± 0.07 logMAR, in the emmetropic group from -0.05 ± 0.07 logMAR to 0.02 ± 0.11 logMAR, and in the myopic group from 0.78 ± 0.27 logMAR to 0.09 ± 0.08 logMAR. The mean binocular near uncorrected visual acuity (NUCVA) increased in the hyperopic group from 0.86 ± 0.62 logRAD to 0.24 ± 0.23 logRAD, and in the emmetropic group from 0.48 ± 0.14 logRAD to 0.18 ± 0.11 logRAD. The myopic presbyopes showed a decrease of the mean binocular NUCVA from 0.04 ± 0.19 logRAD to 0.12 ± 0.18 logRAD. The mean postoperative spherical equivalent for distance refraction was -0.13 ± 0.61 D for the hyperopic presbyopia, -0.43 ± 0.35 D for the emmetropic presbyopia, and -0.68 ± 0.42 D for the myopic presbyopia group, whereas the software took aim at -0.50 D in all groups.

CONCLUSIONS

In presbyopic patients without symptomatic cataracts, but refractive errors, PresbyMAX® will decrease the presbyopic symptoms and correct far distance refraction in the same treatment, offering spectacle-free vision in daily life in most of the treated patients. Further investigation is necessary to evaluate the overall benefit of this procedure.

Pseudophakic monovision is an important surgical approach to being spectacle-free

There are few studies on pseudophakic monovision even though it is widely applied. We reviewed the published literature on pseudophakic monovision. Surgeons select patients who not only have a strong desire to be free of glasses after surgery, but also fully understand monovision design and its drawbacks. However, other criteria adopted for pseudophakic monovision are very different. Both traditional monovision and cross monovision are used in pseudophakic monovision, and the target binocular anisometropia ranges from -1.0 D to -2.75 D. Postoperative results were acceptable in every study and most patients were satisfied, with vision being improved and presbyopia corrected. Complications were decreased stereopsis, contrast sensitivity, and visual fields, similar to other types of monovision. The term "pseudophakic monovision" should include more than just monocular intraocular lens implantation in two eyes, and further studies are required.

Aspheric wavefront-guided LASIK to treat hyperopic presbyopia: 12-month results with the VISX platform

PURPOSE

To evaluate an aspheric ablation profile to improve near vision in presbyopic patients with hyperopia and to outline the key factors of success.

METHODS

A prospective, nonrandomized, clinical trial of 66 eyes of 33 hyperopic patients who underwent customized bilateral refractive surgery, which included an aspheric presbyopia treatment shape and wavefront-driven hyperopic treatment, was studied. Surgeries were performed using the VISX STAR S4 or STAR S4 IR excimer laser system (Abbott Medical Optics). Mean preoperative refractive error was +1.77 ± 0.56 diopters (D) sphere (range: 0.75 to 3.50 D) with 0.41 ± 0.34 D cylinder (range: 0.00 to 1.50 D). All patients received full distance refractive correction. No patients received monovision or were intentionally left with residual myopia. Patient satisfaction results were evaluated using a questionnaire with a 5-point scale.

RESULTS

Sixty eyes completed 6-month and 50 eyes completed 12-month postoperative follow-up. At 6 months, mean corrected distance visual acuity (CDVA) was 20/20±1 line (range: 20/25 to 20/10). Mean gain in distance-corrected near visual acuity (DCNVA) was 2.7 ± 1.7 lines with a maximum of 6 lines of near. Spectacle dependence for tasks, such as reading and computer use, was reduced. At 12 months, 100% of patients had achieved binocular simultaneous uncorrected vision of 20/25 or better and J3. Refraction was stable over 12 months. Contrast sensitivity reduction was clinically insignificant (1 step or 0.15 logCS). Negative spherical aberration highly correlated with postoperative improvement of DCNVA. Patients who had a larger amount of preoperative hyperopia or a greater decrease of preoperative DCNVA were more likely to have overall satisfaction.

CONCLUSIONS

The aspheric ablation designed to expand near functional vision was effective and stable over 12 months. The wavefront-customized hyperopic treatment significantly reduced spectacle dependence.

Combined corneal topography and corneal wavefront data in the treatment of corneal irregularity and refractive error in LASIK or PRK using the Carl Zeiss Meditec MEL 80 and CRS-Master

PURPOSE

To assess the efficacy, safety, and accuracy of TOSCA II (Topography Supported Custom Ablation) treatments for the correction of high corneal aberrations and refractive error following previous ocular surgery.

METHODS

Forty-eight eyes of 32 patients were included for study. Indications for TOSCA II treatment included small optical zone, decentered ablation, subjective visually significant higher order aberrations, and irregularly irregular astigmatism induced by LASIK, photorefractive keratectomy, radial keratotomy, conductive keratoplasty, cataract surgery, and deep lamellar keratoplasty. An ablation profile based on corneal topography data and corneal wavefront and manifest refraction was created using the CRS-Master software (Carl Zeiss Meditec) to treat corneal irregularity and refractive error simultaneously. Postoperative assessments were performed at 1 week and 1, 2, 3, 6, and 12 months.

RESULTS

Mean attempted spherical equivalent refraction (SE) was -1.12 +/- 1.97 diopters (D) (range: +1.13 to -10.50 D). Mean attempted cylinder correction was 1.34 +/- 1.65 D (range: 0.00 to 7.75 D). Median age was 38 years (range: 19 to 68 years). Median follow-up was 9.4 months. Accuracy: mean deviation from the intended SE correction was -0.19 +/- 0.94 D, 60% of eyes were within +/- 0.50 D and 77% of eyes were within +/- 1.00 D of the intended SE. Cylinder: the correction ratio was 1.49 +/- 0.85 and the error ratio was 0.87 +/- 0.69.

EFFICACY

56% of eyes achieved uncorrected visual acuity of 20/20 or better and 88% achieved 20/40 or better.

SAFETY

34% of eyes gained one or more lines of best spectacle-corrected visual acuity, 15% lost one line, and no eye lost two or more lines. Contrast sensitivity: for the subset of eyes with below normal contrast sensitivity preoperatively, there was a statistically significant improvement in contrast sensitivity at 3 cycles per degree (cpd), 6 cpd, and 12 cpd (P < .05). Stability: the average change in refraction between 3 months and 1year was +0.38 +/- 0.30 D. Higher order aberrations: the average higher order root-mean-square decreased by 21% and the average spherical aberration decreased by 41%.

CONCLUSIONS

The MEL 80 CRS-Master TOSCA II software appears to be an effective treatment for decentrations, optical zone enlargement, and reduction of higher order aberrations. The refractive outcome was satisfactory after one treatment.

Corneal multifocality with excimer laser for presbyopia correction

PURPOSE OF REVIEW

To offer a comprehensive perspective on corneal multifocality created by excimer laser surgery, with the different approaches used for the purpose and its reported outcomes.

RECENT FINDINGS

Three different approaches have been used for corneal multifocality: transitional multifocality, central presbyLasik (center for near) and peripheral presbyLasik (peripheral cornea for near). Although central presbyLasik creates a bifocal cornea, the other techniques increase the depth of focus based on the ablation of the peripheral cornea. Transitional multifocality creates intentionally an increase in coma aberration. According to the reported results, both central and peripheral presbyLasik obtain adequate spectacle independence simultaneously for far and for near. A neuroadaptation process is necessary for peripheral presbyLasik. Transitional techniques have a very limited use and very few outcomes reported.

SUMMARY

The level of scientific evidence from the literature is enough to consider that presbyLasik is a useful tool in the correction of presbyopia. However, most of the techniques are still under development in clinical investigations and further clinical data will validate the outcomes reported for the different techniques.