The mechanism of presbyopia

Consolidating multiple evolutionary theories of ageing suggests a need for new approaches to study genetic contributions to ageing decline

Understanding mechanisms of ageing remains a complex challenge for biogerontologists, but recent adaptations of evolutionary ageing theories offer a compelling lens in which to view both age-related molecular and physiological deterioration. Ageing is commonly associated with progressive declines in biochemical and molecular processes resulting from damage accumulation, yet the role of continued developmental gene activation is less appreciated. Natural selection pressures are at their highest in youthful periods to modify gene expression towards maximising reproductive capacity. After sexual maturation, selective pressure diminishes, subjecting individuals to maladaptive pleiotropic gene functions that were once beneficial for developmental growth but become pathogenic later in life. Due to this selective 'shadowing' in ageing, mechanisms to counter such hyper/hypofunctional genes are unlikely to evolve. Interventions aimed at targeting gene hyper/hypofunction during ageing might, therefore, represent an attractive therapeutic strategy. The nematode Caenorhabditis elegans offers a strong model for post-reproductive mechanistic and therapeutic investigations, yet studies examining the mechanisms of, and countermeasures against, ageing decline largely intervene from larval stages onwards. Importantly, however, lifespan extending conditions frequently impair early-life fitness and fail to correspondingly increase healthspan. Here, we consolidate multiple evolutionary theories of ageing and discuss data supporting hyper/hypofunctional changes at a global molecular and functional level in C. elegans, and how classical lifespan-extension mutations alter these dynamics. The relevance of such mutant models for exploring mechanisms of ageing are discussed, highlighting that post-reproductive gene optimisation represents a more translatable approach for C. elegans research that is not constrained by evolutionary trade-offs. Where some genetic mutations in C. elegans that promote late-life health map accordingly with healthy ageing in humans, other widely used genetic mutations that extend worm lifespan are associated with life-limiting pathologies in people. Lifespan has also become the gold standard for quantifying 'ageing', but we argue that gerospan compression (i.e., 'healthier' ageing) is an appropriate goal for anti-ageing research, the mechanisms of which appear distinct from those regulating lifespan alone. There is, therefore, an evident need to re-evaluate experimental approaches to study the role of hyper/hypofunctional genes in ageing in C. elegans.

Mendelian randomization implicates causal association between epigenetic age acceleration and age-related eye diseases or glaucoma endophenotypes

BACKGROUND

Age-related eye diseases (AREDs) have become increasingly prevalent with the aging population, serving as the leading causes of visual impairment worldwide. Epigenetic clocks are generated based on DNA methylation (DNAm) levels and are considered one of the most promising predictors of biological age. This study aimed to investigate the bidirectional causal association between epigenetic clocks and common AREDs or glaucoma endophenotypes.

METHODS

Instrumental variables for epigenetic clocks, AREDs, and glaucoma endophenotypes were obtained from corresponding genome-wide association study data of European descent. Bidirectional two-sample Mendelian randomization (MR) was employed to explore the causal relationship between epigenetic clocks and AREDs or glaucoma endophenotypes. Multivariable MR (MVMR) was used to determine whether glaucoma endophenotypes mediated the association of epigenetic clocks with glaucoma. Multiple sensitivity analyses were conducted to confirm the robustness of MR estimates.

RESULTS

The results showed that an increased intrinsic epigenetic age acceleration (HorvathAge) was significantly associated with an increased risk of primary open-angle glaucoma (OR = 1.04, 95% CI 1.02 to 1.06, P = 6.1E-04). The epigenetic age acceleration (EEA) of HannumAge was related to a decreased risk of primary angle-closure glaucoma (OR = 0.92, 95% CI 0.86 to 0.99, P = 0.035). Reverse MR analysis showed that age-related cataract was linked to decreased HannumAge (β = -0.190 year, 95% CI -0.374 to -0.008, P = 0.041). The EEA of HannumAge (β = -0.85 μm, 95% CI -1.57 to -0.14, P = 0.019) and HorvathAge (β = -0.63 μm, 95% CI -1.18 to -0.08, P = 0.024) were associated with decreased central corneal thickness (CCT). PhenoAge was related to an increased retinal nerve fiber layer thickness (β = 0.06 μm, 95% CI 0.01 to 0.11, P = 0.027). MVMR analysis found no mediation effect of CCT in the association of HannumAge and HorvathAge with glaucoma. DNAm-based granulocyte proportions were significantly associated with presbyopia, rhegmatogenous retinal detachment, and intraocular pressure (P < 0.05). DNAm-based plasminogen activator inhibitor-1 levels were significantly related to age-related macular degeneration and intraocular pressure (P < 0.05).

CONCLUSION

The present study revealed a causal association between epigenetic clocks and AREDs. More research is warranted to clarify the potential mechanisms of the biological aging process in AREDs.

Optical coherence tomography quantifies gradient refractive index and mechanical stiffness gradient across the human lens

BACKGROUND

As a key element of ocular accommodation, the inherent mechanical stiffness gradient and the gradient refractive index (GRIN) of the crystalline lens determine its deformability and optical functionality. Quantifying the GRIN profile and deformation characteristics in the lens has the potential to improve the diagnosis and follow-up of lenticular disorders and guide refractive interventions in the future.

METHODS

Here, we present a type of optical coherence elastography able to examine the mechanical characteristics of the human crystalline lens and the GRIN distribution in vivo. The concept is demonstrated in a case series of 12 persons through lens displacement and strain measurements in an age-mixed group of human subjects in response to an external (ambient pressure modulation) and an intrinsic (micro-fluctuations of accommodation) mechanical deformation stimulus.

RESULTS

Here we show an excellent agreement between the high-resolution strain map retrieved during steady-state micro-fluctuations and earlier reports on lens stiffness in the cortex and nucleus suggesting a 2.0 to 2.3 times stiffer cortex than the nucleus in young lenses and a 1.0 to 7.0 times stiffer nucleus than the cortex in the old lenses.

CONCLUSIONS

Optical coherence tomography is suitable to quantify the internal stiffness and refractive index distribution of the crystalline lens in vivo and thus might contribute to reveal its inner working mechanism. Our methodology provides new routes for ophthalmic pre-surgical examinations and basic research.

BCLA CLEAR presbyopia: Mechanism and optics

With over a billion adults worldwide currently affected, presbyopia remains a ubiquitous, global problem. Despite over a century of study, the precise mechanism of ocular accommodation and presbyopia progression remains a topic of debate. Accordingly, this narrative review outlines the lenticular and extralenticular components of accommodation together with the impact of age on the accommodative apparatus, neural control of accommodation, models of accommodation, the impact of presbyopia on retinal image quality, and both historic and contemporary theories of presbyopia.

Pharmacological treatments for the correction of presbyopia

Presbyopia affects between 1.7 and 2 billion people worldwide. Presbyopia significantly impacts productivity and quality of life in both developed and developing countries. During accommodation, the human eye changes its dioptric power by altering the shape of the lens, but the exact nature of this change has not been fully explained. Recently, topical treatments have been marketed for the treatment of presbyopia and others are under investigation. In order to prepare a review of these novel therapies, we searched the major biomedical search engines. We found 15 randomized clinical trials and 12 reviews that met our review criteria. There are two different strategies for this purpose, the pinhole effect that increases depth of focus and "crystalline lens relaxation" for which parasympathetic mimetics and lens oxidation intermediates have been used. The results are generally favorable in terms of improvement of near visual acuity, although the follow-up period of the studies is short. These are novel strategies in the early stages of research that could be useful in the treatment of presbyopia.

BCLA CLEAR Presbyopia: Evaluation and diagnosis

It is important to be able to measure the range of clear focus in clinical practice to advise on presbyopia correction techniques and to optimise the correction power. Both subjective and objective techniques are necessary: subjective techniques (such as patient reported outcome questionnaires and defocus curves) assess the impact of presbyopia on a patient and how the combination of residual objective accommodation and their natural DoF work for them; objective techniques (such as autorefraction, corneal topography and lens imaging) allow the clinician to understand how well a technique is working optically and whether it is the right choice or how adjustments can be made to optimise performance. Techniques to assess visual performance and adverse effects must be carefully conducted to gain a reliable end-point, considering the target size, contrast and illumination. Objective techniques are generally more reliable, can help to explain unexpected subjective results and imaging can be a powerful communication tool with patients. A clear diagnosis, excluding factors such as binocular vision issues or digital eye strain that can also cause similar symptoms, is critical for the patient to understand and adapt to presbyopia. Some corrective options are more permanent, such as implanted inlays / intraocular lenses or laser refractive surgery, so the optics can be trialled with contact lenses in advance (including differences between the eyes) to better communicate with the patient how the optics will work for them so they can make an informed choice.

Dynamic refraction and anterior segment OCT biometry during accommodation

Accommodation is the process by which the eye changes focus. These changes are the result of changes to the shape of the crystalline lens. Few prior studies have quantified the relation between lens shape and ocular accommodation, primarily at discrete static accommodation states. We present an instrument that enables measurements of the relation between changes in lens shape and changes in optical power continuously during accommodation. The system combines an autorefractor to measure ocular power, a visual fixation target to stimulate accommodation, and an optical coherence tomography (OCT) system to image the anterior segment and measure ocular distances. Measurements of ocular dimensions and refraction acquired dynamically on three human subjects are presented. The individual accommodative responses are analyzed to correlate the ocular power changes with changes in ocular dimensions.

Compound Acoustic Radiation Force Impulse Imaging of Bovine Eye by Using Phase-Inverted Ultrasound Transducer

In general, it is difficult to visualize internal ocular structure and detect a lesion such as a cataract or glaucoma using the current ultrasound brightness-mode (B-mode) imaging. This is because the internal structure of the eye is rich in moisture, resulting in a lack of contrast between tissues in the B-mode image, and the penetration depth is low due to the attenuation of the ultrasound wave. In this study, the entire internal ocular structure of a bovine eye was visualized in an ex vivo environment using the compound acoustic radiation force impulse (CARFI) imaging scheme based on the phase-inverted ultrasound transducer (PIUT). In the proposed method, the aperture of the PIUT is divided into four sections, and the PIUT is driven by the out-of-phase input signal capable of generating split-focusing at the same time. Subsequently, the compound imaging technique was employed to increase signal-to-noise ratio (SNR) and to reduce displacement error. The experimental results demonstrated that the proposed technique could provide an acoustic radiation force impulse (ARFI) image of the bovine eye with a broader depth-of-field (DOF) and about 80% increased SNR compared to the conventional ARFI image obtained using the in-phase input signal. Therefore, the proposed technique can be one of the useful techniques capable of providing the image of the entire ocular structure to diagnose various eye diseases.

Simulation of daily soft multifocal contact lenses using SimVis Gekko: from in-vitro and computational characterization to clinical validation

Multifocal contact lenses (MCLs) are one of the solutions to correct presbyopia, but their adoption is not widespread. To address this situation, visual simulators can be used to refine the adaptation process. This study aims to obtain accurate simulations for a visual simulator (SimVis Gekko; 2EyesVision) of daily soft MCL designs from four manufacturers. In-vitro characterization of these MCLs-several powers and additions- was obtained using NIMO TR-1504. From the averaged relative power profiles across powers, phase maps were reconstructed and the Through-Focus Visual Strehl metric was calculated for each MCL design. The SimVis Gekko simulation corresponding to each MCL design was obtained computationally and bench-validated. Finally, the MCL simulations were clinically validated involving presbyopic patients. The clinical validation results show a good agreement between the SimVis Gekko simulations and the real MCLs for through-focus visual acuity (TF-VA) curves and VA at three real distances. All MCL designs showed a partial correlation higher than 0.90 and a Root Mean Square Error below 0.07 logMAR between the TF-VA of simulations and Real MCLs across subjects. The validity of the simulation approach using SimVis Gekko and in-vitro measurements was confirmed in this study, opening the possibility to accelerate the adaptation of MCLs.

Assessment of the ciliary muscle and scleral anterior thickness in high myopia by optical coherence tomography

PURPOSE

To assess ciliary muscle (CM) and anterior scleral thickness (AST) dimensions in vivo in high myopia using swept-source optical coherence tomography (SS-OCT) and to compare with emmetropic and hyperopic subjects.

METHODS

Cross-sectional study that included 34 high myopic patients (≥ -6 diopters [D]), 90 emmetropes (-1 to +1 D) and 38 hyperopic patients (≥ +3.5 D). CM thickness (CMT) and AST were measured in the temporal and nasal quadrants at 1, 2, and 3 mm from the scleral spur using SS-OCT. In addition, the length of the CM (CML) was evaluated.

RESULTS

The dimensions of the CML and the CMT at any of their measurement points were greater in high myopes and emmetropes than in hyperopes, both in the nasal and temporal quadrants (P < .001). However, there were no differences between high myopes and emmetropes for any of the parameters (P ≥ .076) except for the CMT at 3 mm in the temporal quadrant (P < .001). There were no differences in the AST between high myopes, emmetropes and hyperopes, in any of the measurement points or quadrants studied (P > .05).

CONCLUSIONS

The SS-OCT allows to measure the CM in vivo, not observing differences in its dimensions between high myopes and emmetropes, but they were smaller in hyperopes. In the measurement of the anterior sclera, no differences were observed between the three groups analyzed according to refraction.

The effect of age on the hearing-related quality of life in normal-hearing adults

INTRODUCTION

Recently, a new holistic Patient Reported Outcome Measure (PROM) to assess hearing-related quality of life was developed, named the hearing-related quality of life questionnaire for Auditory-VIsual, COgnitive and Psychosocial functioning (hAVICOP). The purpose of the current study was to evaluate if the hAVICOP is sufficiently sensitive to detect an age effect in the hearing-related quality of life.

METHODS

One-hundred thirteen normal-hearing participants (mean age: 42.13; range: 19 to 69 years) filled in the entire hAVICOP questionnaire online through the Research Electronic Data Capture surface. The hAVICOP consists of 27 statements, across three major subdomains (auditory-visual, cognitive, and psychosocial functioning), which have to be rated on a visual analogue scale ranging from 0 (rarely to never) to 100 (almost always). Mean scores were calculated for each subdomain separately as well as combined within a total score; the worse one's hearing-related quality of life, the lower the score. Linear regression models were run to predict the hAVICOP total as well as the three subdomain scores from age and sex.

RESULTS

A significant main effect of age was observed for the total hAVICOP and all three subdomain scores, indicating a decrease in hearing-related quality of life with increasing age. For none of the analyses, a significant sex effect was found.

CONCLUSION

The hAVICOP is sufficiently sensitive to detect an age effect in the hearing-related quality of life within a large group of normal-hearing adults, emphasizing its clinical utility. This age effect on the hearing-related quality of life might be related to the interplay of age-related changes in the bottom-up and top-down processes involved during speech processing.

Effect of Contact Lens Design on Objective Visual Acuity-Based Parameters in Pre-Presbyopic Patients in Photopic and Mesopic Lighting Conditions

Presbyopia is often corrected by progressive soft contact lenses (CL), and the resulting visual acuity-based parameters can be affected by the lens design and pupil size under different lighting conditions. In this study, we examined the effect of CL design (spheric vs. aspheric) on objective parameters of visual acuity-based parameters under mesopic vs. photopic lighting conditions. In a prospective, double-blind study, pre-presbyopic and presbyopic patients were fitted with spheric (Dispo Silk; 8.6 base curve, 14.2 diameter) and aspheric (Dispo Aspheric; 8.4 base curve, 14.4 diameter) CLs. The low contrast (10%) and high contrast (100%) visual acuity (VA), amplitude of accommodation (AA) (push-away method, Diopters) and distance contrast sensitivity (CS) (FACT chart, cycles per degree (CPD)) were measured with both types of CLs under mesopic and photopic lighting conditions. The eye with the better visual acuity was tested and analyzed. Thirteen patients (age range: 38-45 years) were included. The mean CS was significantly better with spheric compared to aspheric lenses for low spatial frequencies (3 CPD: 81.69 ± 7.86, 67.62 ± 5.67, respectively; p < 0.05), though there was no significant difference for lower or higher spatial frequencies (1.5, 6, 12, 18 CPD). The low-contrast (10%) and high-contrast (100%) VAs were not different between the two lens designs. However, there were significant differences between near VA, distance low-contrast VA and AA obtained under mesopic (dim) vs. photopic (bright) conditions with the aspheric design correction modality. In conclusion, photopic lighting conditions improved both the visual acuity and measured amplitude of accommodation with both lens designs, though the amplitude of accommodation was significantly higher with aspheric lenses. However, contrast sensitivity demonstrated the superiority of the spheric lens at a 3 CPD spatial frequency. This suggests that the ideal lens differs from patient to patient, depending on the visual demands.

Ageing as a software design flaw

Ageing is inherent to all human beings, yet why we age remains a hotly contested topic. Most mechanistic explanations of ageing posit that ageing is caused by the accumulation of one or more forms of molecular damage. Here, I propose that we age not because of inevitable damage to the hardware but rather because of intrinsic design flaws in the software, defined as the DNA code that orchestrates how a single cell develops into an adult organism. As the developmental software runs, its sequence of events is reflected in shifting cellular epigenetic states. Overall, I suggest that to understand ageing we need to decode our software and the flow of epigenetic information throughout the life course.

Lens structure segmentation from AS-OCT images via shape-based learning

BACKGROUND AND OBJECTIVES

The lens is one of the important refractive media in the eyeball. Abnormality of the nucleus or cortex in the lens can lead to ocular disorders such as cataracts and presbyopia. To achieve an accurate diagnosis, segmentation of these ocular structures from anterior segment optical coherence tomography (AS-OCT) is essential. However, weak-contrast boundaries of the object in the images present a challenge for accurate segmentation. The state-of-the-art (SOTA) methods, such as U-Net, treat segmentation as a binary classification of pixels, which cannot handle pixels on weak-contrast boundaries well.

METHODS

In this paper, we propose to incorporate shape prior into a deep learning framework for accurate nucleus and cortex segmentation. Specifically, we propose to learn a level set function, whose zero-level set represents the object boundary, through a convolutional neural network. Moreover, we design a novel shape-based loss function, where the shape prior knowledge can be naturally embedded into the learning procedure, leading to improvement in performance. We collect a high-quality AS-OCT image dataset with precise annotations to train our model.

RESULTS

Abundant experiments are conducted to verify the effectiveness of the proposed framework and the novel shape-based loss. The mean Intersection over Unions (MIoUs) of the proposed method for lens nucleus and cortex segmentation are 0.946 and 0.957, and the mean Euclidean Distance (MED) measure, which can reflect the accuracy of the segmentation boundary, are 6.746 and 2.045 pixels. In addition, the proposed shape-based loss improves the SOTA models on the nucleus and cortex segmentation tasks by an average of 0.0156 and 0.0078 in the MIoU metric and 1.394 and 0.134 pixels in the MED metric.

CONCLUSION

We transform the segmentation from a classification task to a regression task by making the model learn the level set function, and embed shape information in deep learning by designing loss functions. This allows the proposed method to be more efficient in the segmentation of the object with weak-contrast boundaries.

CONCISE ABSTRACT

We propose to incorporate shape priors into a deep learning framework for accurate nucleus and cortex segmentation from AS-OCT images. Specifically, we propose to learn a level set function, where the zero-level set represents the boundary of the target. Meanwhile, we design a novel shape-based loss function in which additional convex shape prior can be embedded in the learning process, leading to an improvement in performance. The IOUs for nucleus and cortex segmentation are 0.946 and 0.957, while the MED that reflects the accuracy of the boundary are 6.746 and 2.045 pixels. The proposed shape-based loss improves the SOTA model for nucleus and cortex segmentation by an average of 0.0156 and 0.0078 in IOU, and 1.394 and 0.134 pixels in MED. We transform segmentation from classification to regression by making the model learn a level set function, resulting in improved performance at the boundary with weak contrast.

Adaptive optical two-photon fluorescence microscopy probes cellular organization of ocular lenses in vivo

The mammalian ocular lens is an avascular multicellular organ that grows continuously throughout life. Traditionally, its cellular organization is investigated using dissected lenses, which eliminates in vivo environmental and structural support. Here, we demonstrated that two-photon fluorescence microscopy (2PFM) can visualize lens cells in vivo. To maintain subcellular resolution at depth, we employed adaptive optics (AO) to correct aberrations due to ocular and lens tissues, which led to substantial signal and resolution improvements. Imaging lens cells up to 980 μm deep, we observed novel cellular organizations including suture-associated voids, enlarged vacuoles, and large cavities, contrary to the conventional view of a highly ordered organization. We tracked these features longitudinally over weeks and observed the incorporation of new cells during growth. Taken together, non-invasive longitudinal in vivo imaging of lens morphology using AO 2PFM will allow us to directly observe the development or alterations of lens cellular organization in living animals.

Characterization of Femtosecond Laser and Porcine Crystalline Lens Interactions by Optical Microscopy

The use of ultrafast laser pulses for eye anterior segment surgery has seen a tremendous growth of interest as the technique has revolutionized the field, from the treatment of myopia, hyperopia, and presbyopia in the cornea to laser-assisted cataract surgery of the crystalline lens. For the latter, a comprehensive understanding of the laser-tissue interaction has yet to be achieved, mainly because of the challenge of observing the interaction zone in situ with sufficient spatial and temporal resolution in the complex and multi-layered tissue of the crystalline lens. We report here on the dedicated characterization results of the laser-tissue interaction zone in the ex vivo porcine lens using three different methods: in situ and real-time microscopy, wide-field optical imaging, and phase-contrast microscopy of the histological cross sections. These complementary approaches together revealed new physical and biological consequences of laser irradiation: a low-energy interaction regime (pulse energy below ~1 µJ) with very limited cavitation effects and a stronger photo-disruption regime (pulse energy above 1 µJ) with a long cavitation duration from seconds to minutes, resulting in elongated spots. These advances in the understanding of the ultrafast laser's interactions with the lens are of the utmost importance for the preparation of the next-generation treatments that will be applied to the lens.

An AFM Approach Applied in a Study of α-Crystallin Membrane Association: New Insights into Lens Hardening and Presbyopia Development

The lens of the eye loses elasticity with age, while α-crystallin association with the lens membrane increases with age. It is unclear whether there is any correlation between α-crystallin association with the lens membrane and loss in lens elasticity. This research investigated α-crystallin membrane association using atomic force microscopy (AFM) for the first time to study topographical images and mechanical properties (breakthrough force and membrane area compressibility modulus (K_A), as measures of elasticity) of the membrane. α-Crystallin extracted from the bovine lens cortex was incubated with a supported lipid membrane (SLM) prepared on a flat mica surface. The AFM images showed the time-dependent interaction of α-crystallin with the SLM. Force spectroscopy revealed the presence of breakthrough events in the force curves obtained in the membrane regions where no α-crystallin was associated, which suggests that the membrane’s elasticity was maintained. The force curves in the α-crystallin submerged region and the close vicinity of the α-crystallin associated region in the membrane showed no breakthrough event within the defined peak force threshold, indicating loss of membrane elasticity. Our results showed that the association of α-crystallin with the membrane deteriorates membrane elasticity, providing new insights into understanding the molecular basis of lens hardening and presbyopia.

Pharmacological Treatment in Presbyopia

Pharmacological treatment of presbyopia may be an alternative for those who want a spectacle-free scenario and an easy-to-use method with lower risk of irreversible ocular adverse events. There are two main agents, miotics and lens softeners, investigated as agents for the pharmacological treatment. Miotic agents treat presbyopia by creating a pinhole effect which may increase the depth of focus at all working distances. The miotic agents have been studied for application to only one eye for monovision or both eyes. Their effect is temporary with common adverse events, such as headache and dim vision at nighttime, with no known long-term safety and efficacy. There have been studies on the miotic agents in combination with other agents for additive treatment effects or lessening adverse events, however, these combination effects are not clear. Lens softeners increase the elasticity of the lens, which is targeted at one of the etiologic mechanisms of presbyopia. There is only one lens softener being investigated in only a few trials. The results were inconclusive. The recent approval of 1.25% pilocarpine for treatment of presbyopia by the US FDA may be an important milestone for investigation of real-world data of pharmacological treatment of presbyopia.

Force of lifelong crystalline lens growth: chronic traumatic mechanical insult to the choroid

PURPOSE

To calculate the forces applied to the uvea and retina as a result of lifelong crystalline lens growth.

DESIGN

Retrospective study.

SETTING

MRI Research, Inc., Middleburg Heights, Ohio; Institute of Ophthalmology and Visual Science UMDNJ-New Jersey Medical School, Newark, New Jersey; USC Psychology University of Southern California, Los Angeles.

METHODS

Magnetic resonance images were acquired from 15 phakic/pseudophakic eye pairs in patients with cataract (ages 46 to 83 years). Choroidal lengths were measured. The forces required to produce differences between phakic/pseudophakic choroidal lengths were calculated.

RESULTS

The length of the choroid is greater in the phakic eye compared with the corresponding pseudophakic eye (n = 15), and this difference increases with age (P = .00006; power = 0.99). The corresponding choroidal strain also increases with age (P = .00003, power = 0.99) as do the forces required to produce such a change in choroidal length (P = .000008, power = 0.99).

CONCLUSIONS

The authors theorize that lifelong crystalline lens growth applies a chronic, traumatic, mechanical insult to the uvea and retina. This previously unknown, ever-increasing, force appears to stretch the choroidal tissue and may be an intraocular pressure-independent modifiable risk factor for retinal disease. Implications exist for understanding the pathophysiology of retinal diseases in the aging eye that are often comorbid with cataracts, for example, glaucoma, macular degeneration, and diabetic retinopathy.

The hyperfunction theory: An emerging paradigm for the biology of aging

The process of senescence (aging) is predominantly determined by the action of wild-type genes. For most organisms, this does not reflect any adaptive function that senescence serves, but rather evolutionary effects of declining selection against genes with deleterious effects later in life. To understand aging requires an account of how evolutionary mechanisms give rise to pathogenic gene action and late-life disease, that integrates evolutionary (ultimate) and mechanistic (proximate) causes into a single explanation. A well-supported evolutionary explanation by G.C. Williams argues that senescence can evolve due to pleiotropic effects of alleles with antagonistic effects on fitness and late-life health (antagonistic pleiotropy, AP). What has remained unclear is how gene action gives rise to late-life disease pathophysiology. One ultimate-proximate account is T.B.L. Kirkwood's disposable soma theory. Based on the hypothesis that stochastic molecular damage causes senescence, this reasons that aging is coupled to reproductive fitness due to preferential investment of resources into reproduction, rather than somatic maintenance. An alternative and more recent ultimate-proximate theory argues that aging is largely caused by programmatic, developmental-type mechanisms. Here ideas about AP and programmatic aging are reviewed, particularly those of M.V. Blagosklonny (the hyperfunction theory) and J.P. de Magalhães (the developmental theory), and their capacity to make sense of diverse experimental findings is assessed.

The Relationship Between Age and the Morphology of the Crystalline Lens, Ciliary Muscle, Trabecular Meshwork, and Schlemm's Canal: An in vivo Swept-Source Optical Coherence Tomography Study

Purpose: To evaluate the effects of age on the morphologies of the crystalline lens, ciliary muscle (CM), Schlemm’s canal (SC), and trabecular meshwork (TM) using swept-source optical coherence tomography (SS-OCT).

Methods: Images of the crystalline lens and iridocorneal angle were obtained in healthy participants’ eyes using SS-OCT. Morphological parameters of the crystalline lens, CM, and TM/SC were measured, and the relationship between these parameters and age was evaluated.

Results: A total of 62 healthy participants were enrolled, with an age range of 7–79 years. With adjustments for the effects of axial length and sex, both the nasal and temporal SC cross-sectional areas (CSA) and the cross-sectional area of the CM (CMA), distance from the scleral spur to the inner apex of the ciliary muscle (IA-SS), and nasal SC volume were negatively correlated with age (P ≤ 0.041). Meanwhile, the lens thickness (LT) (P < 0.001) and lens vault (LV) (P < 0.001) were positively correlated with age, and the radius of the curvature of the anterior lens (ALR) was negatively correlated with age (P < 0.001).

Conclusion: Increasing age was associated with a thicker crystalline lens, a steeper anterior lens curvature, an anteriorly located and smaller CM, and a narrower SC.

Clinical Trial Registration:https://register.clinicaltrials.gov/prs/app/action/Select Protocol?sid=S000A3JZ&selectaction=Edit&uid=U00019K7&ts=4&cx=-c5xxp8, identifier [NCT04576884].

Correcting Presbyopia With Autofocusing Liquid-Lens Eyeglasses

OBJECTIVE

Presbyopia, an age-related ocular disorder, is characterized by the loss in the accommodative abilities of the human eye. Conventional methods of correcting presbyopia divide the field of view, thereby resulting in significant vision impairment. We demonstrate the design, assembly and evaluation of autofocusing eyeglasses for restoration of accommodation without dividing the field of view.

METHODS

The adaptive optics eyeglasses comprise of two variable-focus liquid lenses, a time-of-flight range sensor and low-power, dual microprocessor control electronics, housed within an ergonomic frame. Subject-specific accommodation deficiency models were utilized to demonstrate high-fidelity accommodative correction. The abilities of this system to reduce accommodation deficiency, its power consumption, response time, optical performance and MTF were evaluated.

RESULTS

Average corrected accommodation deficiencies for 5 subjects ranged from -0.021 D to 0.016 D. Each accommodation correction calculation was performed in ∼67 ms which consumed 4.86 mJ of energy. The optical resolution of the system was 10.5 cycles/degree, and featured a restorative accommodative range of 4.3 D. This system was capable of running for up to 19 hours between charge cycles and weighed ∼132 g.

CONCLUSION

The design, assembly and performance of an autofocusing eyeglasses system to restore accommodation in presbyopes has been demonstrated.

SIGNIFICANCE

The new autofocusing eyeglasses system presented in this article has the potential to restore pre-presbyopic levels of accommodation in subjects diagnosed with presbyopia.

Diagnostic imaging of the ciliary body: Technologies, outcomes, and future perspectives

The ciliary body (CB) is part of the uvea and is a complex, highly specialized structure with multiple functions and significant relationships with nearby structures. Its functions include the aqueous humor (AH) production in the ciliary processes, the regulation of the AH output through the uveoscleral pathway, and accommodation, which depends on the ciliary muscle. Also, the CB is an important determinant of angle width as it forms part of the ciliary sulcus. Until recently, knowledge of the CB was based on histological studies. However, this structure can currently be assessed in vivo using imaging techniques such as ultrasound biomicroscopy (UBM) and optical coherence tomography (OCT). Both techniques have shown good reproducibility of their measurements allowing for quantification of CB dimensions and their localization. In effect, studies have shown a larger CB in myopia and its diminishing size with age. Swept-source OCT devices offer fast, non-invasive high-resolution imaging allowing the identification of multiple structures. UBM requires contact and is uncomfortable for the patient. However, this technique offers deeper imaging and therefore remains the gold standard for assessing the posterior chamber, ciliary processes, or zonula. The clinical utility of CB imaging includes its assessment in different types of glaucoma such as angle-closure, malignant or plateau iris. Diagnostic CB imaging is also invaluable for the assessment of ciliochoroidal detachment when suspected, the position after the implantation of a pre-crystalline or sulcus-sutured lenses, diagnosis or monitoring of cysts or tumors, sclerotomies after retinal surgery, intermediate uveitis, or accommodation.

IMI Accommodation and Binocular Vision in Myopia Development and Progression

The role of accommodation in myopia development and progression has been debated for decades. More recently, the understanding of the mechanisms involved in accommodation and the consequent alterations in ocular parameters has expanded. This International Myopia Institute white paper reviews the variations in ocular parameters that occur with accommodation and the mechanisms involved in accommodation and myopia development and progression. Convergence is synergistically linked with accommodation and the impact of this on myopia has also been critiqued. Specific topics reviewed included accommodation and myopia, role of spatial frequency, and contrast of the task of objects in the near environment, color cues to accommodation, lag of accommodation, accommodative-convergence ratio, and near phoria status. Aspects of retinal blur from the lag of accommodation, the impact of spatial frequency at near and a short working distance may all be implicated in myopia development and progression. The response of the ciliary body and its links with changes in the choroid remain to be explored. Further research is critical to understanding the factors underlying accommodative and binocular mechanisms for myopia development and its progression and to guide recommendations for targeted interventions to slow myopia progression.

Polymeric Materials for Eye Surface and Intraocular Applications

Ocular applications of polymeric materials have been widely investigated for medical diagnostics, treatment, and vision improvement. The human eye is a vital organ that connects us to the outside world so when the eye is injured, infected, or impaired, it needs immediate medical treatment to maintain clear vision and quality of life. Moreover, several essential parts of the eye lose their functions upon aging, causing diminished vision. Modern polymer science and polymeric materials offer various alternatives, such as corneal and scleral implants, artificial ocular lenses, and vitreous substitutes, to replace the damaged parts of the eye. In addition to the use of polymers for medical treatment, polymeric contact lenses can provide not only vision correction, but they can also be used as wearable electronics. In this Review, we highlight the evolution of polymeric materials for specific ocular applications such as intraocular lenses and current state-of-the-art polymeric systems with unique properties for contact lens, corneal, scleral, and vitreous body applications. We organize this Review paper by following the path of light as it travels through the eye. Starting from the outside of the eye (contact lenses), we move onto the eye's surface (cornea and sclera) and conclude with intraocular applications (intraocular lens and vitreous body) of mostly synthetic polymers and several biopolymers. Initially, we briefly describe the anatomy and physiology of the eye as a reminder of the eye parts and their functions. The rest of the Review provides an overview of recent advancements in next-generation contact lenses and contact lens sensors, corneal and scleral implants, solid and injectable intraocular lenses, and artificial vitreous body. Current limitations for future improvements are also briefly discussed.

Thermal Psychophysics and Associated Brain Activation Patterns Along a Continuum of Healthy Aging

OBJECTIVE

To examine psychophysical and brain activation patterns to innocuous and painful thermal stimulation along a continuum of healthy older adults.

DESIGN

Single center, cross-sectional, within-subjects design.

METHODS

Thermal perceptual psychophysics (warmth, mild, and moderate pain) were tested in 37 healthy older adults (65-97 years, median = 73 years). Percept thresholds (oC) and unpleasantness ratings (0-20 scale) were obtained and then applied during functional magnetic resonance imaging scanning. General linear modeling assessed effects of age on psychophysical results. Multiple linear regressions were used to test the main and interaction effects of brain activation against age and psychophysical reports. Specifically, differential age effects were examined by comparing percent-signal change slopes between those above/below age 73 (a median split).

RESULTS

Advancing age was associated with greater thresholds for thermal perception (z = 2.09, P = 0.037), which was driven by age and warmth detection correlation (r = 0.33, P = 0.048). Greater warmth detection thresholds were associated with reduced hippocampal activation in "older" vs "younger" individuals (>/<73 years; beta < 0.40, P < 0.01). Advancing age, in general, was correlated with greater activation of the middle cingulate gyrus (beta > 0.44, P < 0.01) during mild pain. Differential age effects were found for prefrontal activation during moderate pain. In "older" individuals, higher moderate pain thresholds and greater degrees of moderate pain unpleasantness correlated with lesser prefrontal activation (anterolateral prefrontal cortex and middle-frontal operculum; beta < -0.39, P < 0.009); the opposite pattern was found in "younger" individuals.

CONCLUSIONS

Advancing age may lead to altered thermal sensation and (in some circumstances) altered pain perception secondary to age-related changes in attention/novelty detection and cognitive functions.

Fear of falling avoidance behavior affects the inter-relationship between vision impairment and diminished mobility in community-dwelling older adults

BACKGROUND

Age-related decline in vision may contribute to the development of fear of falling (FOF) behavior and reduced mobility, which are related to increased fall risk in older adults.

PURPOSE

To investigate the inter-relationship between vision impairment, physical mobility performance, and FOF behavior in community-dwelling older adults.

METHODS

A total of 400 participants from community centers (267 females; age = 74.8 (6.4), range = 65-97 years) participated in this cross-sectional study. Presence of age-related eye diseases (e.g. macular degeneration, cataracts, glaucoma, and retinopathy) and visual acuity (VA) was assessed. Physical mobility and FOF avoidance behavior were assessed using the Timed Up-and-Go (TUG) test and the Fear of Falling Avoidance Behavior Questionnaire (FFABQ). The inter-relationships between parameters were analyzed using mediation model analysis.

RESULTS

Significant decreases in mobility performance were observed in those with eye disease (eye disease = 9.56 [5.2] sec, no eye disease = 8.54 [2.75] sec; p = .037) and FOF avoidance behavior (avoiders = 12.87 [6.04] sec, non-avoiders = 8.51 [3.56] sec; p < .001). Furthermore, FOF behavior was found to significantly influence the inter-relationship between presence of eye disease and TUG performance (p = .004). VA alone had no significant effect on mobility (p = .69).

CONCLUSION

The presence of eye disease and the associated FOF behavior was related to decreased mobility and potentially increased fall risk. We recommend clinicians to inquire about the presence of eye disease and FOF behavior to identify risk factors related to falls in older adults.

Ciliary muscle dimensions by swept-source optical coherence tomography and correlation study in a large population

PURPOSE

To examine ciliary muscle (CM) dimensions in vivo by swept-source optical coherence tomography (SS-OCT) in a large healthy population. To assess the reproducibility of CM measurements and correlations with different parameters.

METHODS

In this cross-sectional study, the following CM measurements were made in 495 eyes of 495 subjects in the temporal and nasal quadrants: length (CML), area (CMA) and thickness at distances of 1000 μm (CMT1), 2000 μm (CMT2) and 3000 μm (CMT3) from the scleral spur using the SS-OCT DRI-Triton^® (Topcon, Tokyo, Japan). These dimensions were then assessed for correlations with the factors age, gender, refractive error, anterior chamber angle (ACA) and intraocular pressure (IOP). The reproducibility of CM measurements was determined in 85 of the participants.

RESULTS

Mean age was 41.4 ± 17.5 years (range 5-83). The following means were recorded as follows: CML = 4.57 ± 0.73 mm (range 2.16-6.97), CMA = 1.35 ± 0.31 mm² (2.04-5.45), CMT1 = 558 ± 98 μm (299-891), CMT2 = 366 ± 100 μm (89-629) and CMT3 = 210 ± 75 μm (36-655). Negative correlation was detected between CML/CMA and age (R = -0.516/R = -0.404; p < 0.001) and refractive error (R = -0.519/R = -0.538; p < 0.001). No gender differences were observed (p ≥ 0.150). Both CML and CMA were correlated with ACA (R = 0.498 and 0.546; p < 0.001) and slightly with IOP (R = -0.175; p < 0.001). The reproducibility of the CM measurements was excellent (intraclass correlation coefficient ≥0.878).

CONCLUSIONS

Swept-source optical coherence tomography is a valid tool for in vivo CM measurements. Our data indicate a larger CM in myopes and its diminishing size with age.

Presbyopia: Effectiveness of correction strategies

Presbyopia is a global problem affecting over a billion people worldwide. The prevalence of unmanaged presbyopia is as high as 50% of those over 50 years of age in developing world populations, due to a lack of awareness and accessibility to affordable treatment, and is even as high as 34% in developed countries. Definitions of presbyopia are inconsistent and varied, so we propose a redefinition that states "presbyopia occurs when the physiologically normal age-related reduction in the eye's focusing range reaches a point, when optimally corrected for distance vision, that the clarity of vision at near is insufficient to satisfy an individual's requirements". Strategies for correcting presbyopia include separate optical devices located in front of the visual system (reading glasses) or a change in the direction of gaze to view through optical zones of different optical powers (bifocal, trifocal or progressive addition spectacle lenses), monovision (with contact lenses, intraocular lenses, laser refractive surgery and corneal collagen shrinkage), simultaneous images (with contact lenses, intraocular lenses and corneal inlays), pinhole depth of focus expansion (with intraocular lenses, corneal inlays and pharmaceuticals), crystalline lens softening (with lasers or pharmaceuticals) or restored dynamics (with 'accommodating' intraocular lenses, scleral expansion techniques and ciliary muscle electrostimulation); these strategies may be applied differently to the two eyes to optimise the range of clear focus for an individual's task requirements and minimise adverse visual effects. However, none fully overcome presbyopia in all patients. While the restoration of natural accommodation or an equivalent remains elusive, guidance is given on presbyopic correction evaluation techniques.

Optical Coherence Tomography Reveals Sigmoidal Crystalline Lens Changes during Accommodation

This study aimed to quantify biometric modifications of the anterior segment (AS) during accommodation and to compare them against changes in both accommodative demand and response. Thirty adults, aged 18–25 years were rendered functionally emmetropic with contact lenses. AS optical coherence tomography (AS-OCT) images were captured along the 180° meridian (Visante, Zeiss Meditec, Jena, Germany) under stimulated accommodative demands (0–4 D). Images were analysed and lens thickness (LT) was measured, applying a refractive index correction of 1.00. Accommodative responses were also measured sequentially through a Badal optical system fitted to an autorefractor (Shin Nippon NVision-K 5001, Rexxam, Japan). Data were compared with Dubbelman schematic eye calculations. Significant changes occurred in LT, anterior chamber depth (ACD), lens centroid (i.e., ACD + LT/2), and AS length (ASL = ACD + LT) with accommodation (all p < 0.01). There was no significant change in CT with accommodation (p = 0.81). Measured CT, ACD, and lens centroid values were similar to Dubbelman modelled parameters, however AS-OCT overestimated LT and ASL. As expected, the accommodative response was less than the demand. Interestingly, up until approximately 1.5 D of response (2.0 D demand), the anterior crystalline lens surface appears to be the primary correlate. Beyond this point, the posterior lens surface moves posteriorly resulting in an over-all sigmoidal trajectory. he posterior crystalline lens surface demonstrates a sigmoidal response with increasing accommodative effort.

The importance of parameter choice in modelling dynamics of the eye lens

The lens provides refractive power to the eye and is capable of altering ocular focus in response to visual demand. This capacity diminishes with age. Current biomedical technologies, which seek to design an implant lens capable of replicating the function of the biological lens, are unable as yet to provide such an implant with the requisite optical quality or ability to change the focussing power of the eye. This is because the mechanism of altering focus, termed accommodation, is not fully understood and seemingly conflicting theories require experimental support which is difficult to obtain from the living eye. This investigation presents finite element models of the eye lens based on data from human lenses aged 16 and 35 years that consider the influence of various modelling parameters, including material properties, a wide range of angles of force application and capsular thickness. Results from axisymmetric models show that the anterior and posterior zonules may have a greater impact on shape change than the equatorial zonule and that choice of capsular thickness values can influence the results from modelled simulations.

Semiautomatic procedure to assess changes in the eye accommodative system

PURPOSE

The aim of this pilot study was to evaluate a new semiautomatic procedure to assess in vivo changes in the crystalline lens and ciliary muscle during accommodation.

METHODS

A total of 14 subjects were divided into two groups, young (aged between 20 and 25 years) and adult (aged between 35 and 40 years), and measured with an anterior segment optical coherence tomography. A semiautomatic procedure was implemented to measure the central lens thickness (CLT), anterior lens radius (ALR) and the ciliary muscle area (CMA) for the unaccommodated eye and for a vergence of - 3.00 D.

RESULTS

The CLT increase for each population group was smaller than 5%, and the dispersion of each group was similar between them. Contrariwise, the reduction in the ALR was about 30% for both groups, although the young one showed the largest variability. The CMA increase was smaller than 30% for both groups, and the dispersion was similar between them. For each metric, differences between both groups were not statistically significant.

CONCLUSIONS

The semiautomatic procedure seems to be useful for the in vivo analysis of the accommodative system. Additionally, the results obtained showed that changes in the CLT were much smaller compared to those obtained for the ALR or CMA.

Accommodating Intraocular Lenses

With an explosive increase in the worldwide prevalence of presbyopia, development of an accommodating intraocular lens (IOL) with expansive accommodative amplitude remains the holy grail in lens-based refractive surgery. A dynamic change in the dioptric power of the eye can be accomplished by various strategies alone or in combination, including changes in the position, shape, or refractive index of a single- or dual- optic IOL. This article reviews the cumulative advances in these various lens designs, along with clinical outcomes and complications of those that have been implanted. The challenges that remain in each cat-egory are also highlighted.

Photoperiodic regime influences onset of lens opacities in a non-human primate

Background

Opacities of the lens are typical age-related phenomena which have a high influence on photoreception and consequently circadian rhythm. In mouse lemurs, a small bodied non-human primate, a high incidence (more than 50% when >seven years) of cataracts has been previously described during aging. Previous studies showed that photoperiodically induced accelerated annual rhythms alter some of mouse lemurs’ life history traits. Whether a modification of photoperiod also affects the onset of age dependent lens opacities has not been investigated so far. The aim of this study was therefore to characterise the type of opacity and the mouse lemurs’ age at its onset in two colonies with different photoperiodic regimen.

Methods

Two of the largest mouse lemur colonies in Europe were investigated: Colony 1 having a natural annual photoperiodic regime and Colony 2 with an induced accelerated annual cycle. A slit-lamp was used to determine opacities in the lens. Furthermore, a subset of all animals which showed no opacities in the lens nucleus in the first examination but developed first changes in the following examination were further examined to estimate the age at onset of opacities. In total, 387 animals were examined and 57 represented the subset for age at onset estimation.

Results

The first and most commonly observable opacity in the lens was nuclear sclerosis. Mouse lemurs from Colony 1 showed a delayed onset of nuclear sclerosis compared to mouse lemurs from Colony 2 (4.35 ± 1.50 years vs. 2.75 ± 0.99 years). For colony 1, the chronological age was equivalent to the number of seasonal cycles experienced by the mouse lemurs. For colony 2, in which seasonal cycles were accelerated by a factor of 1.5, mouse lemurs had experienced 4.13 ± 1.50 seasonal cycles in 2.75 ± 0.99 chronological years.

Discussion

Our study showed clear differences in age at the onset of nuclear sclerosis formation between lemurs kept under different photoperiodic regimes. Instead of measuring the chronological age, the number of seasonal cycles (N = four) experienced by a mouse lemur can be used to estimate the risk of beginning nuclear sclerosis formation. Ophthalmological examinations should be taken into account when animals older than 5–6 seasonal cycles are used for experiments in which unrestricted visual ability has to be ensured. This study is the first to assess and demonstrate the influence of annual photoperiod regime on the incidence of lens opacities in a non-human primate.

Does transient increase in axial length during accommodation attenuate with age?

Background

The aim was to profile transient accommodative axial length changes from early adulthood to advanced presbyopia and to determine whether any differences exist between the responses of myopic and emmetropic individuals.

Methods

Ocular biometry was measured by the LenStar biometer (Haag‐Streit, Switzerland) in response to zero, 3.00 and 4.50 D accommodative stimuli in 35 emmetropes and 37 myopes, aged 18 to 60 years. All results were corrected to reduce errors arising from the increase in crystalline lens thickness with accommodation. Accommodative responses were measured sequentially by the WAM 5500 Auto Ref/Keratometer (Grand Seiko, Hiroshima, Japan).

Results

Axial length increased significantly with accommodation (p < 0.001), with a mean corrected increase in axial length of 2 ± 18 µm and 8 ± 16 µm observed at 3.00 and 4.50 D, respectively. The magnitude of accommodative change in axial length was not dependent on refractive error classification (p = 0.959); however, a significant reduction in the magnitude and variance of axial length change was evident after 43 to 44 years of age (p < 0.002).

Conclusion

The negative association between transient increase in axial length and age, in combination with reduced variance of data after age 43 to 44 years, is consistent with a significant increase in posterior ocular rigidity, which may be influential in the development of presbyopia.

Evaluating relaxed ciliary muscle tone in presbyopic eyes

PURPOSE

Studies of age-related changes in ciliary muscle (CM) morphology and contractility have variously reported that CM weakens or strengthens with age. In response, the aim of this study was to evaluate relaxed CM tone in vivo in pre-presbyopic and presbyopic patients using a predictor value (P_CM).

METHODS

Two groups of eyes-40 eyes of 40 healthy volunteers with a mean age of 28.1 ± 5.8 years and 40 eyes of 40 healthy volunteers with a mean age of 56.6 ± 7.3 years-formed the sample for this prospective, observational cross-sectional study. Used to evaluate relaxed CM tone, P_CM was calculated as the difference between the change in mean anterior chamber depth (ACD) and lens thickness (LT) before and after cycloplegia, as measured with swept-source optical biometry.

RESULTS

The P_CM for relaxed CM tone was 0.04 ± 0.04 mm in pre-presbyopic participants, 0.06 ± 0.03 mm in presbyopic ones, and significantly greater in presbyopic patients (p = .018).

CONCLUSION

The statistical significance of P_CM between pre-presbyopic and presbyopic eyes might not signify clinical significance, since the difference was close to the repeatability limits for swept-source optical biometry. When relaxed, CM tone does not diminish with presbyopia according to changes in anterior chamber parameters due to cycloplegia.

Prevalence, Correlates, and Impact of Uncorrected Presbyopia in a Multiethnic Asian Population

PURPOSE

To examine the prevalence, correlates, and impact of uncorrected presbyopia on vision-specific functioning (VF) in a multiethnic Asian population.

DESIGN

Population-based cross-sectional study.

METHODS

We included 7890 presbyopic subjects (3909 female; age range, 40-86 years) of Malay, Indian, and Chinese ethnicities from the Singapore Epidemiology of Eye Disease study. Presbyopia was classified as corrected and uncorrected based on self-reported near correction use. VF was assessed with the VF-11 questionnaire validated using Rasch analysis. Multivariable logistic and linear regression models were used to investigate the associations of sociodemographic and clinical parameters with uncorrected presbyopia, and its impact on VF, respectively. As myopia may mitigate the impact of noncorrection, we performed a subgroup analysis on myopic subjects only (n = 2742).

RESULTS

In total, 2678 of 7890 subjects (33.9%) had uncorrected presbyopia. In multivariable models, younger age, male sex, Malay and Indian ethnicities, presenting distance visual impairment (any eye), and lower education and income levels were associated with higher odds of uncorrected presbyopia (all P < .05). Compared with corrected presbyopia, noncorrection was associated with worse overall VF and reduced ability to perform individual near and distance vision-specific tasks even after adjusting for distance VA and other confounders (all P < .05). Results were very similar for myopic individuals.

CONCLUSION

One-third of presbyopic Singaporean adults did not have near correction. Given its detrimental impact on both near and distance VF, public health strategies to increase uptake of presbyopic correction in younger individuals, male individuals, and those of Malay and Indian ethnicities are needed.

Clinical utility of the KAMRA corneal inlay

The treatment of presbyopia has been the focus of much scientific and clinical research over recent years, not least due to an increasingly aging population but also the desire for spectacle independence. Many lens and nonlens-based approaches have been investigated, and with advances in biomaterials and improved surgical methods, removable corneal inlays have been developed. One such development is the KAMRA™ inlay where a small entrance pupil is exploited to create a pinhole-type effect that increases the depth of focus and enables improvement in near visual acuity. Short- and long-term clinical studies have all reported significant improvement in near and intermediate vision compared to preoperative measures following monocular implantation (nondominant eye), with a large proportion of patients achieving Jaeger (J) 2 to J1 (~0.00 logMAR to ~0.10 logMAR) at the final follow-up. Although distance acuity is reduced slightly in the treated eye, binocular visual acuity and function remain very good (mean 0.10 logMAR or better). The safety of the inlay is well established and easily removable, and although some patients have developed corneal changes, these are clinically insignificant and the incidence appears to reduce markedly with advancements in KAMRA design, implantation technique, and femtosecond laser technology. This review aims to summarize the currently published peer-reviewed studies on the safety and efficacy of the KAMRA inlay and discusses the surgical and clinical outcomes with respect to the patient’s visual function.

Quantification of the ciliary muscle and crystalline lens interaction during accommodation with synchronous OCT imaging

Two SD-OCT systems and a dual channel accommodation target were combined and precisely synchronized to simultaneously image the anterior segment and the ciliary muscle during dynamic accommodation. The imaging system simultaneously generates two synchronized OCT image sequences of the anterior segment and ciliary muscle with an imaging speed of 13 frames per second. The system was used to acquire OCT image sequences of a non-presbyopic and a pre-presbyopic subject accommodating in response to step changes in vergence. The image sequences were processed to extract dynamic morphological data from the crystalline lens and the ciliary muscle. The synchronization between the OCT systems allowed the precise correlation of anatomical changes occurring in the crystalline lens and ciliary muscle at identical time points during accommodation. To describe the dynamic interaction between the crystalline lens and ciliary muscle, we introduce accommodation state diagrams that display the relation between anatomical changes occurring in the accommodating crystalline lens and ciliary muscle.

Measurement of Crystalline Lens Volume During Accommodation in a Lens Stretcher

PURPOSE

To determine if the lens volume changes during accommodation.

METHODS

The study used data acquired on 36 cynomolgus monkey lenses that were stretched in a stepwise fashion to simulate disaccommodation. At each step, stretching force and dioptric power were measured and a cross-sectional image of the lens was acquired using an optical coherence tomography system. Images were corrected for refractive distortions and lens volume was calculated assuming rotational symmetry. The average change in lens volume was calculated and the relation between volume change and power change, and between volume change and stretching force, were quantified. Linear regressions of volume-power and volume-force plots were calculated.

RESULTS

The mean (± SD) volume in the unstretched (accommodated) state was 97 ± 8 mm3. On average, there was a small but statistically significant (P = 0.002) increase in measured lens volume with stretching. The mean change in lens volume was +0.8 ± 1.3 mm3. The mean volume-power and volume-load slopes were -0.018 ± 0.058 mm3/D and +0.16 ± 0.40 mm3/g.

CONCLUSIONS

Lens volume remains effectively constant during accommodation, with changes that are less than 1% on average. This result supports a hypothesis that the change in lens shape with accommodation is accompanied by a redistribution of tissue within the capsular bag without significant compression of the lens contents or fluid exchange through the capsule.

Age-related changes in the anterior segment biometry during accommodation

PURPOSE

We investigated the dynamic response of human accommodative elements as a function of age during accommodation using synchronized spectral domain optical coherence tomography devices (SD-OCT).

METHODS

We enrolled 33 left eyes from 33 healthy subjects (age range, 20-39 years, 17 males and 16 females). Two SD-OCT devices were synchronized to simultaneously image the anterior segment through pupil and the ciliary muscle during 6.00 diopter (D) accommodation for approximately 3.7 seconds in two repeated measurements. The anterior segment parameters included the lens thickness (LT), radius of curvature of the lens anterior surface (LAC), maximum thickness of ciliary muscle (CMTMAX), and anterior length of the ciliary muscle (CMAL). A first-order exponential equation was used to fit the dynamic changes during accommodation. The age-related changes in the dynamic response and their relationship were calculated and compared.

RESULTS

The amplitude (r = -0.40 and 0.53 for LT and LAC, respectively) and peak velocity (r = -0.65 and 0.71 for LT and LAC, respectively) of the changes in LT and LAC significantly decreased with age (P < 0.05), whereas the parameters of the ciliary muscle remained unchanged (P > 0.05), except for the peak velocity of the CMAL (r = 0.44, P = 0.01). The difference in the time constant between the lens reshaping (LT and LAC) and CMTMAX increased with age (r = 0.46 and 0.57 for LT and LAC, respectively, P < 0.01). The changes in LT and LAC per millimeter of CMTMAX change decreased with age (r = -0.52 and -0.34, respectively, P < 0.05). The ciliary muscle forward movement correlated with the lens deformation (r = -0.35 and 0.40 for amplitude, while r = 0.36 and 0.58 for time constant, respectively, P < 0.05).

CONCLUSIONS

Age-related changes in the lens reshaping and ciliary muscle forward movement were found. Lens reshaping was much slower than the contraction of the ciliary muscle, especially in aging eyes, and this process required the ciliary muscle to contract more to reach a given response.