Intraocular accommodative movements in monkeys; relationship to presbyopia

Symptomatic Presbyopia may Develop Earlier in Patients With Glaucoma-A Cross-Sectional Retrospective Cohort Study

Purpose

The purpose of this study was to explore risk factors for symptomatic presbyopia, defined as near add power ≥1.50 diopters, in patients with glaucoma.

Methods

Treated glaucoma (n = 56), untreated glaucoma (n = 21), and control individuals (n = 376), aged 40 to 55 years at first visit, were enrolled in the study, and near add power, retinal thickness, and visual field were examined. The association between near add power and ocular parameters and the odds ratios (ORs) for symptomatic presbyopia were investigated. Survival analysis for symptomatic presbyopia was conducted.

Results

Age, astigmatic power, mean deviation, and ganglion cell complex thickness were associated with near add power. The OR for symptomatic presbyopia was significant for age (OR = 1.51), astigmatism (OR = 1.01), mean deviation (OR = 0.72), ganglion cell complex thickness (OR = 0.98), treated and untreated glaucoma (OR = 2.09), and use of glaucoma eye drops (OR = 3.33). Survival analysis showed that the treated glaucoma group reached the near add power endpoint of ≥1.50 D (symptomatic presbyopia) significantly earlier than the other two groups, and there was no difference between the control and untreated glaucoma groups.

Conclusions

Glaucoma patients treated with eye drops may start near correction earlier.

Translational Relevance

Symptomatic presbyopia may develop earlier in patients with glaucoma, and our findings could further contribute to better management and understanding of presbyopia with glaucoma.

Model of zonular forces on the lens capsule during accommodation

How the human eye focuses for near; i.e. accommodates, is still being evaluated after more than 165 years. The mechanism of accommodation is essential for understanding the etiology and potential treatments for myopia, glaucoma and presbyopia. Presbyopia affects 100% of the population in the fifth decade of life. The lens is encased in a semi-elastic capsule with attached ligaments called zonules that mediate ciliary muscle forces to alter lens shape. The zonules are attached at the lens capsule equator. The fundamental issue is whether during accommodation all the zonules relax causing the central and peripheral lens surfaces to steepen, or the equatorial zonules are under increased tension while the anterior and posterior zonules relax causing the lens surface to peripherally flatten and centrally steepen while maintaining lens stability. Here we show with a balloon capsule zonular force model that increased equatorial zonular tension with relaxation of the anterior and posterior zonules replicates the topographical changes observed during in vivo rhesus and human accommodation of the lens capsule without lens stroma. The zonular forces required to simulate lens capsule configuration during in vivo accommodation are inconsistent with the general belief that all the zonules relax during accommodation.

Finite element analysis of zonular forces

To determine the effect of zonular forces on lens capsule topography, a finite element (FE) analyses of lens capsules with no lens stroma and constant and variable thickness with anterior capsulotomies of 1.5 mm-6.5 mm were evaluated when subjected to equatorial (Ez), anterior (Az) and posterior (Pz) zonular forces. The lens capsule was considered in the unaccommodated state when the total initial zonular force was 0.00075 N or 0.3 N. From the total 0.00075 N zonular force, the Ez force was increased in 0.000125 N steps for a maximum force of 0.03 N and simultaneously the Az plus Pz force was reduced in 0.000125 N steps to zero. In addition, the force of all the zonules was reduced from 0.00075 N and separately from 0.3 N in 0.000125 N steps to zero. Only when Ez force was increased as Az and Pz force was reduced did the capsule topography simulate in vivo observations with the posterior capsule pole bowing posteriorly. The posterior bowing was directly related to Ez force and capsulotomy size. Whether the total force of all the zonules in the unaccommodated state was 0.00075 N or 0.3 N and reduced in steps to zero, the lens capsule topography did not emulate the in vivo observations. The FE analysis demonstrated that Ez tension increases while the Az and Pz tension decreases and that all the zonules do not relax during ciliary muscle contraction.

Accommodative movements of the choroid in the optic nerve head region of human eyes, and their relationship to the lens

The ciliary muscle (CM) powers the accommodative response, and during accommodation the CM pulls the choroid forward in the region of the ora serrata. Our goal was to elucidate the accommodative movements of the choroid in the optic nerve region in humans and to determine whether these movements are related to changes in the lens dimensions that occur with aging, in the unaccommodated and accommodated state. Both eyes of 12 human subjects (aged 18-51 yrs) were studied. Homatropine (1 drop/5%) was used to relax the ciliary muscle (unaccommodated or "resting" eye) and pilocarpine was used to induce the maximum accommodative response (2 drops/4%) (accommodated eye). Images of the fundus and choroid were collected in the region of the optic nerve (ON) via Spectralis OCT (infrared and EDI mode), and choroidal thickness was determined. Ultrasound biomicroscopy (UBM; 50 MHz, 35 MHz) images were collected in the region of the lens/capsule and ciliary body. OCT and UBM images were collected in the resting and accommodated state. The unaccommodated choroidal thickness declined significantly with age (p = 0.0073, r = 0.73) over the entire age range of the subjects studied (18-51 years old). The choroidal thickness was significantly negatively correlated with lens thickness in the accommodated (p = 0.01) and the unaccommodated states (p = 0.005); the thicker the lens the thinner the choroid. Choroid movements around the optic nerve during accommodation were statistically significant; during accommodation the choroid both thinned and moved centrifugally (outward/away from the optic nerve head). The accommodative choroid movements did not decline significantly with age and were not correlated with accommodative amplitude. Measurement of the choroidal thickness is possible with the Spectralis OCT instrument using EDI mode and can be used to determine the accommodative changes in choroidal thickness. The choroidal thickness decreased with age and during accommodation. It may be that age-related choroidal thinning is due to changes in the geometry of the accommodative apparatus to which it is attached (i.e., ciliary muscle/lens complex) such that when the lens is thicker, the choroid is thinner. Accommodative decrease in choroidal thickness and stretch of the retina/choroid may indicate stress/strain forces in the region of the optic nerve during accommodation and may have implications for glaucoma.