Presbyopia: Effectiveness of correction strategies

Impact of Refractive Status on Presbyopia Progression among Patients with Presbyopia

PURPOSE

To explore the impact of refractive status on presbyopia progression among patients with presbyopia.

METHODS

This retrospective observational study included patients with presbyopia who visited the Seventh Affiliated Hospital of Sun Yat-sen University and Shenzhen Polytechnic Medical College between May 2018 and August 2022. The amplitude of accommodation (AMP) and near addition power (ADD) at 6 months and 1 year were collected.

RESULTS

A total of 103 patients with presbyopia were included in this study: 42 patients with myopia, 23 patients with emmetropia, and 38 patients with hyperopia. There were significant differences in ΔAMP(6-month) and ΔADD(6-month) among patients with different refractive statuses, and the values of emmetropic patients and hyperopic patients were higher than in myopic patients (all P < 0.001). The ΔAMP(1-year) and ΔADD(1-year) of hyperopic patients were significantly higher than in emmetropic patients and myopic patients (all P < 0.001). The ΔADD(1-year) of emmetropic patients was greater than in myopic patients (P = 0.045), but there were no significant differences in ΔAMP(1-year) between patients with emmetropia and myopia (P = 0.090).

CONCLUSIONS

The progression of presbyopia in hyperopic patients was relatively more significant than for emmetropia, followed by myopia. The prescription of presbyopia glasses might need to be replaced more frequently in patients with hyperopia.

Outcomes of Corneal Compound Hyperopic Astigmatism With Presbyopia by Zeiss PRESBYOND Laser Blended Vision LASIK Using Default Custom Refractive Software Master Target Refractions for Reduced Anisometropia

PURPOSE

To evaluate the effectiveness, safety, and stability of a modified PRESBYOND Laser Blended Vision protocol (Carl Zeiss Meditec AG) for correcting hyperopic astigmatism and presbyopia, using Custom Refractive Software Master (CRSM) targeting over a 6-month period.

METHODS

A total of 636 eyes of 318 patients with a mean age of 51.05 ± 4.71 years (range: 40 to 60 years) met the inclusion and exclusion criteria. All patients completed a 6-month follow-up. CRSM software was used to generate ablation profiles for the MEL90 excimer laser (Carl Zeiss Meditec AG). The target refraction was emmetropic for the dominant eyes and between -0.75 and -1.12 diopters (D) for the near eyes.

RESULTS

Visual and refractive results were studied separately by the dominant and non-dominant eyes. The mean attempt to correct for spherical equivalent refraction was +2.17 ± 1.16 D (range: -1.00 to +5.37 D). The mean attempted cylinder was -0.60 ± 0.75 D (range: -4.00 to 0.00 D). All eyes monocularly achieved uncorrected distance visual acuity (UDVA) of 20/25 or better after refractive treatment and 88% achieved 20/20. Binocularly all eyes achieved UDVA of 20/25 or better and 96.54% achieved 20/20. Ninety-eight percent of the patients maintained their corrected distance visual acuity before surgery and UDVA 6 months after surgery.

CONCLUSIONS

This hyperopic micro-anisometropia protocol with PRESBYOND Laser Blended Vision was an effective, safe, and well-tolerated refractive treatment. It was an effective procedure with excellent results for UDVA and uncorrected near visual acuity and demonstrates that binocular summation exists. [ J Refract Surg. 2024;40(7):e480-e489.].

BCLA CLEAR Presbyopia: Management with corneal techniques

Corneal techniques for enhancing near and intermediate vision to correct presbyopia include surgical and contact lens treatment modalities. Broad approaches used independently or in combination include correcting one eye for distant and the other for near or intermediate vision, (termed monovision or mini-monovision depending on the degree of anisometropia) and/or extending the eye's depth of focus [1]. This report provides an overview of the evidence for the treatment profile, safety, and efficacy of the range of corneal techniques currently available for managing presbyopia. The visual needs and expectations of the patient, their ocular characteristics, and prior history of surgery are critical considerations for patient selection and preoperative evaluation. Contraindications to refractive surgery include unstable refraction, corneal abnormalities, inadequate corneal thickness for the proposed ablation depth, ocular and systemic co-morbidities, uncontrolled mental health issues and unrealistic patient expectations. Laser refractive options for monovision include surface/stromal ablation techniques and keratorefractive lenticule extraction. Alteration of spherical aberration and multifocal ablation profiles are the primary means for increasing ocular depth of focus, using surface and non-surface laser refractive techniques. Corneal inlays use either small aperture optics to increase depth of field or modify the anterior corneal curvature to induce corneal multifocality. Presbyopia correction by conductive keratoplasty involves application of radiofrequency energy to the mid-peripheral corneal stroma which leads to mid-peripheral corneal shrinkage, inducing central corneal steepening. Hyperopic orthokeratology lens fitting can induce spherical aberration and correct some level of presbyopia. Postoperative management, and consideration of potential complications, varies according to technique applied and the time to restore corneal stability, but a minimum of 3 months of follow-up is recommended after corneal refractive procedures. Ongoing follow-up is important in orthokeratology and longer-term follow-up may be required in the event of late complications following corneal inlay surgery.

Modulation transfer function of implantable phakic intraocular contact lens (IPCL) for myopia and presbyopia

PURPOSE

This study aimed to assess the optical quality of myopic and presbyopic IPCLs with different additional powers, and to investigate the effects of pupil size on the optical quality of these IPCLs using an in-vitro modulation transfer function (MTF) measurement system.

METHODS

Linear scatter functions (LSFs) were recorded using the OPAL Vector system and an eye phantom consisting of wet cells filled with a balanced salt solution. A myopic IPCL or a presbyopic IPCL was placed in the posterior chamber of this model. The MTF was calculated from the LSF using the fast Fourier transform techniques. The effective apertures were set at 2.0 to 5.0 mm in 1.0 mm steps.

RESULTS

The in-focus MTF values of the myopic IPCL and presbyopic IPCL with additional powers of + 2.0 and + 4.0 diopters at 100 cycles/mm for an effective aperture of 3.0 mm were 43%, 27%, and 24%, respectively. The in-focus MTF value of both myopic and presbyopic IPCLs was the highest when the effective aperture was set at 3.0 mm, and it gradually worsened when the effective aperture became larger than 3.0 mm at 20, 60, and 100 cycles/mm.

CONCLUSIONS

Both myopic and presbyopic IPCLs provided excellent MTF values, but the additional power profile can deteriorate optical performance in presbyopic IPCL-implanted eyes, even with a low additional power. Pupil size can influence visual quality in IPCL-implanted eyes for both myopia and presbyopia.

Gaze and behavioural metrics in the refractive correction of presbyopia

PURPOSE

To investigate gaze and behavioural metrics at different viewing distances with multifocal contact lenses (MFCLs), single vision contact lenses (SVCLs) and progressive addition lenses (PALs).

METHODS

Fifteen presbyopic contact lens wearers participated over five separate study visits. At each visit, participants were randomly assigned to wear one of five refractive corrections: habitual PAL spectacles, delefilcon A (Alcon Inc.) MFCLs and three separate pairs of delefilcon A single vision lenses worn as distance, intermediate and near corrections. Participants wore a Pupil Core headset to record eye and head movements while performing three visual tasks: reading, visual search and scene observation. Data were investigated using linear regression and post-hoc testing. Parameters of interest included gaze (fixation duration, head movement) and behavioural (reading speed, reading accuracy, visual search time) metrics.

RESULTS

Reading speed in SVCLs was significantly faster than in MFCLs and PAL spectacles (F = 16.3, p < 0.0001). Refractive correction worn did not influence visual search times (F = 0.16, p = 0.85). Fixation duration was significantly affected by the type of visual task (F = 60.2, p < 0.001), and an interaction effect was observed between viewing distance and refractive correction (F = 4.3, p = 0.002). There was significantly more horizontal and vertical head movement (F = 3.2, p = 0.01 and F = 3.3, p = 0.01, respectively) during visual search tasks when wearing PAL spectacles compared to SVCLs or MFCLs.

CONCLUSION

This work showed that the type of refractive correction affects behavioural metrics such as reading speed and gaze behaviour by affecting horizontal and vertical head movements. The findings of this study suggest that under certain conditions, wearers of MFCLs make fewer head movements compared to PAL spectacles. Gaze behaviour metrics offer a new approach to compare and understand contact lens and spectacle performance, with potential applications including peripheral optical designs for myopia management.

Cortical dynamics in visual areas induced by the first use of multifocal contact lenses in presbyopes

A common non-spectacle strategy to correct presbyopia is to provide simultaneous images with multifocal optical designs. Understanding the neuroadaptation mechanisms behind multifocal devices usage would have important clinical implications, such as predicting whether patients will be able to tolerate multifocal optics. The aim of this study was to evaluate the brain correlates during the initial wear of multifocal contact lenses (CLs) using high-density visual evoked potential (VEP) measures. Fifteen presbyopes (mean age 51.8 ± 2.6 years) who had previously not used multifocal CLs were enrolled. VEP measures were achieved while participants looked at arrays of 0.5 logMAR Sloan letters in three different optical conditions arranged with CLs: monofocal condition with the optical power appropriate for the distance viewing; multifocal correction with medium addition; and multifocal correction with low addition. An ANOVA for repeated measures showed that the amplitude of the C1 and N1 components significantly dropped with both multifocal low and medium addition CL conditions compared to monofocal CLs. The P1 and P2 components showed opposite behavior with an increase in amplitudes for multifocal compared to monofocal conditions. VEP data indicated that multifocal presbyopia corrections produce a loss of feedforward activity in the primary visual cortex that is compensated by extra feedback activity in extrastriate areas only, in both early and late visual processing.

Comparison of Barrett TK Universal II and Barrett Universal II TCRP Formulas in Power Calculations for 3 Presbyopia-Correcting Intraocular Lenses

Purpose

To compare Barrett TK Universal II and Barrett Universal II TCRP calculations in the power calculations for 3 presbyopia-correcting intraocular lenses (PC-IOL).

Methods

This observational study involved 64 eyes from 64 patients who prepared to undergo extraction of crystalline lenses combined with PC-IOL (Symfony ZXR00, PanOptix TFNT00, or AT LISA tri 839MP) implantation. All eyes underwent ocular biometric measurements with IOLMaster 700 and Pentacam HR, and the interdevice agreement of measurements including total keratometry (TK, IOLMaster 700) and total corneal refractive power (TCRP, Pentacam HR) was evaluated. IOL power calculations were performed using TK-based Barrett TK Universal II and TCRP-based Barrett Universal II calculations, respectively.

Results

Paired t-tests showed that the differences in white-to-white diameter, central corneal thickness, anterior chamber depth, and mean TK between IOLMaster 700 and Pentacam HR were slight but significant (all P<0.05), and the differences in recommended IOL power for emmetropia between two Barrett calculations were also significant in 3 PC-IOLs (all P<0.05). The ROC curve showed that the AUC was 0.917 (95% CI, 0.820-0.971) for the absolute value of the difference between TK and TCRP in discriminating the difference of ≥ ±0.5 D in predicted IOL power with best cutoff values of 0.4 D.

Conclusion

The novel Barrett TK Universal II formula built in IOLMaster 700 is comparable to TCRP-based Barrett Universal II calculation for IOL power calculation of PC-IOLs, and the convenience of using the Barrett TK Universal II formula should be founded on measurement consistency between devices.

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.

Outcomes of Corneal Compound Myopic Astigmatism with Presbyopia by Zeiss PRESBYOND® Laser Blended Vision LASIK Using Default CRS-Master® Target Refractions for Reduced Anisometropia

Background/Objectives: Presbyopia, a common age-related refractive error, affects over a billion people globally and significantly impacts daily life. Methods: This retrospective study analyzed 288 eyes of 144 patients undergoing LBV PRESBYOND® treatment for myopic presbyopia with astigmatism, aiming to evaluate precision, efficacy, safety, and stability over six months. Results: Key findings include high efficacy, with 99% of distance-eyes achieving uncorrected distance visual acuity (UDVA) of 20/25 or better, and 85% of near-eyes achieving UDVA of 20/32 or better. The results show excellent refractive outcomes, with 99% of long-sighted eyes and 97% of near-sighted eyes having a postoperative spherical equivalent within ±1.00 D. Safety was demonstrated by no loss of two or more Snellen lines after treatment, with 94% of patients maintaining corrected distance visual acuity (CDVA) before and after surgery. Conclusions: Overall, LBV PRESBYOND® proved effective, safe, and well tolerated for myopic presbyopia correction, offering satisfactory visual outcomes and potential spectacle independence for various distances. This study underscores the importance of individualized treatment based on patient age, highlighting the positive impact of binocular summation on visual function. This study contributes to the growing body of evidence supporting LBV PRESBYOND® as a viable option for addressing presbyopic myopia, offering insights into its efficacy and safety profile. Further research could explore postoperative stereopsis and long-term outcomes to enhance understanding and refine treatment protocols.

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.

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.

BCLA CLEAR Presbyopia: Management with contact lenses and spectacles

This paper seeks to outline the history, market situation, clinical management and product performance related to the correction of presbyopia with both contact lenses and spectacles. The history of the development of various optical forms of presbyopic correction are reviewed, and an overview is presented of the current market status of contact lenses and spectacles. Clinical considerations in the fitting and aftercare of presbyopic contact lens and spectacle lens wearers are presented, with general recommendations for best practice. Current options for contact lens correction of presbyopia include soft simultaneous, rigid translating and rigid simultaneous designs, in addition to monovision. Spectacle options include single vision lenses, bifocal lenses and a range of progressive addition lenses. The comparative performance of both contact lens and spectacle lens options is presented. With a significant proportion of the global population now being presbyopic, this overview is particularly timely and is designed to act as a guide for researchers, industry and eyecare practitioners alike.

BCLA CLEAR Presbyopia: Definitions

Presbyopia is often the first sign of ageing experienced by humans. Standardising terminology and adopting it across the BCLA CLEAR Presbyopia reports, improves consistency in the communication of the evidence-based understanding of this universal physiological process. Presbyopia can be functionally and psychologically debilitating, especially for those with poor access to eyecare. Presbyopia was defined as occurring when the physiologically normal age-related reduction in the eye's focusing range reaches a point that, when optimally corrected for far vision, the clarity of vision at near is insufficient to satisfy an individual's requirements. Accommodation is the change in optical power of the eye due to a change in crystalline lens shape and position, whereas pseudo-accommodation is the attainment of functional near vision in an emmetropic or far-corrected eye without changing the refractive power of the eye. Other definitions specific to vision and lenses for presbyopia were also defined. It is recommended that these definitions be consistently adopted in order to standardise future research, clinical evaluations and education.

Psychometric evaluation of the near activity visual questionnaire presbyopia (NAVQ-P) and additional patient-reported outcome items

BACKGROUND

The Near Visual Acuity Questionnaire Presbyopia (NAVQ-P) is a patient-reported outcome (PRO) measure that was developed in a phakic presbyopia population to assess near vision function impacts. The study refined and explored the psychometric properties and score interpretability of the NAVQ-P and additional PRO items assessing near vision correction independence (NVCI), near vision satisfaction (NVS), and near vision correction preference (NVCP).

METHODS

This was a psychometric validation study conducted using PRO data collected as part of a Phase IIb clinical trial (CUN8R44 A2202) consisting of 235 randomized adults with presbyopia from the US, Japan, Australia, and Canada. Data collected at baseline, week 2, and months 1, 2, and 3 during the 3-month trial treatment period were included in the analyses to assess item (question) properties, NAVQ-P dimensionality and scoring, reliability, validity, and score interpretation.

RESULTS

Item responses were distributed across the full response scale for most NAVQ-P and additional PRO items. Confirmatory factor analysis supported the pre-defined unidimensional structure and calculation of a NAVQ-P total score as a measure of near vision function. Item deletion informed by item response distributions, dimensionality analyses, item response theory, and previous qualitative findings, including clinical input, supported retention of 14 NAVQ-P items. The 14-item NAVQ-P total score had excellent internal consistency (α = 0.979) and high test-retest reliability (Intraclass Correlation Coefficients > = 0.898). There was good evidence of construct-related validity for all PROs supported by strong correlations with concurrent measures. Excellent results for known-groups validity and ability to detect change analyses were also demonstrated. Anchor-based and distribution-based methods supported interpretation of scores through generation of group-level and within-individual estimates of meaningful change thresholds. A meaningful within-patient change in the range of 8-15-point improvement on the NAVQ-P total score (score range 0-42) was recommended, including a more specific responder definition of 10-point improvement.

CONCLUSIONS

The NAVQ-P, NVCI, and NVS are valid and reliable instruments which have the ability to detect change over time. Findings strongly support the use of these measures as outcome assessments in clinical/research studies and in clinical practice in the presbyopia population.

BCLA CLEAR Presbyopia: Epidemiology and impact

The global all-ages prevalence of epidemiologically-measured 'functional' presbyopia was estimated at 24.9% in 2015, affecting 1.8 billion people. This prevalence was projected to stabilise at 24.1% in 2030 due to increasing myopia, but to affect more people (2.1 billion) due to population dynamics. Factors affecting the prevalence of presbyopia include age, geographic location, urban versus rural location, sex, and, to a lesser extent, socioeconomic status, literacy and education, health literacy and inequality. Risk factors for early onset of presbyopia included environmental factors, nutrition, near demands, refractive error, accommodative dysfunction, medications, certain health conditions and sleep. Presbyopia was found to impact on quality-of-life, in particular quality of vision, labour force participation, work productivity and financial burden, mental health, social wellbeing and physical health. Current understanding makes it clear that presbyopia is a very common age-related condition that has significant impacts on both patient-reported outcome measures and economics. However, there are complexities in defining presbyopia for epidemiological and impact studies. Standardisation of definitions will assist future synthesis, pattern analysis and sense-making between studies.

Visual Quality Assessment After FS-LASIK Using Customized Aspheric Ablation Profile for Age-Related Accommodation Deficiency Compensation

PURPOSE

To evaluate clinical outcomes and visual quality 12 months after femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) performed with the Custom-Q algorithm for correction of myopia with or without astigmatism and compensate for age-related accommodation deficiency.

METHODS

Patients who had Custom-Q FS-LASIK for myopia and myopic astigmatism with age-related accommodation deficiency were included in this retrospective study. Distance, intermediate, and near visual acuities, objective and subjective refractions, Q-factor, corneal higher order aberrations (HOAs), accommodation function, defocus curve, contrast sensitivity, and a subjective questionnaire assessing visual quality were evaluated 12 months postoperatively.

RESULTS

Clinical data of 43 cases were analyzed. The mean age was 42.02 ± 1.85 years (range: 40 to 48 years). At the 12-month follow-up visit, there were 43 (100%), 42 (97%), and 33 (77%) patients who achieved a binocular uncorrected distance, intermediate, and near visual acuity, respectively, better than 20/20 separately. Defocus curves revealed better distance vision in the dominant eyes, and the nondominant eyes performed better at intermediate and near vergence (P < .001). The Q-value and corneal spherical aberration coefficient were more positive in the dominant eyes than those in the nondominant eyes (P < .001). The accommodative amplitude and relative accommodation improved binocularly (P < .001). The questionnaire demonstrated high patient satisfaction with near vision, and no one reported having severe visual disturbance.

CONCLUSIONS

For myopic patients with age-related accommodation deficiency, the Custom-Q algorithm proved to be an effective way to achieve acceptable near vision without compromising distance vision. [J Refract Surg. 2024;40(4):e245-e252.].

Bilateral Femtosecond Laser-Assisted Clear Lens Extraction with Trifocal Intraocular Lens Implantation for Presbyopia Correction: A Short-Term Observational Study in Chinese Adults

Purpose

To observe the outcome of bilateral femtosecond laser-assisted clear lens extraction with trifocal intraocular lens (IOL) implantation for presbyopia correction and evaluate its feasibility in early presbyopic adults.

Methods

Prospective case series of eyes with clear crystalline lenses that underwent femtosecond laser-assisted lens extraction and trifocal IOL (Acrysof IQ PanOptix, Model TFNT00, Alcon) implantation between 2021 and 2023 were followed up for at least 3 months after surgery. Outcome measures included monocular uncorrected visual acuity at near (UNVA, 40 cm), intermediate (UIVA, 60 cm), and distance (UDVA, 5 m), monocular manifest refraction, corrected distance visual acuity (CDVA), defocus curve assessment, and spectacle independence at both near and distance.

Results

A total of 60 eyes from 30 consecutive patients were included, and their mean age was 50.4±6.5 years. After surgery, the mean UNVA (LogMAR) increased from 0.28±0.16 to 0.08±0.07, UIVA increased from 0.25±0.12 to 0.09±0.06, and UDVA increased from 0.27±0.21 to 0.01±0.08. The enhancements of UNVA, UIVA and UDVA were all significant (P < 0.05). The optometric results showed that the mean postoperative spherical equivalent (SE) was -0.21±0.24 D, and the mean postoperative CDVA (LogMAR) was -0.00±0.06. The preoperative spectacle independences at near and distance were 46.7% (14/30) and 56.7% (17/30), respectively, and both increased to 100% at 3 months after surgery.

Conclusion

Satisfactory visual outcomes and safe surgical procedures were observed in this study, which demonstrate that bilateral femtosecond laser-assisted clear lens extraction with PanOptix IOL implantation could be a feasible approach for presbyopia correction in working-age Chinese patients.

Effects of Miosis on the Visual Acuity Space under Varying Conditions of Contrast and Ambient Luminance in Presbyopia

Background: Presbyopia is an age-related ocular condition, typically affecting individuals aged over 40 years, characterized by a gradual and irreversible decline in the eye's ability to focus on nearby objects. Correction methods for presbyopia encompass the use of corrective lenses, surgical interventions (corneal or lens based), and, more recently, the FDA-approved topical administration of 1.25% pilocarpine. While prior research has demonstrated the efficacy of daily pilocarpine eye drop application in enhancing near visual acuity by increasing the depth of focus leveraging the pinhole effect, limited knowledge exists regarding its influence on visual acuity under varying conditions of contrast and ambient luminance. Methods: This study aims to investigate the impact of these variables on visual acuity, employing the VA-CAL test, among 11 emmetropic and 11 presbyopic volunteers who reported subjective difficulties with near vision. This study includes evaluations under natural conditions with a pinhole occluder (diameter of 2 mm), and subsequent administration of 1% pilocarpine (Pilomann, Bausch + Lomb, Laval, Canada). Results: The VA-CAL results demonstrate the expected, statistically significant effects of contrast and ambient luminance on visual acuity in both emmetropic and presbyopic volunteers. Furthermore, in emmetropic individuals, the application of pilocarpine resulted in a statistically significant reduction in visual acuity. In contrast, presbyopes did not exhibit statistically significant differences in the visual acuity space under either the pinhole or pilocarpine conditions when compared to natural conditions. Conclusions: The pharmacological treatment of presbyopia with pilocarpine eye drops, intended to enhance near vision, does not adversely affect visual acuity in presbyopes. This suggests that pilocarpine may offer a viable alternative for individuals averse to wearing corrective eyewear.

Visual quality assessment and comparison of two multifocal scleral lens designs

PURPOSE

To analyze the visual quality of a new multifocal scleral lens with a customized decentred optic zone compared to a conventional design by measuring visual acuity, contrast sensitivity function, stereopsis, subjective vision and comfort after one month of wear.

METHODS

Nineteen presbyopic subjects were fitted with two multifocal scleral lens designs: a conventional multifocal and a customized decentred optical zone design. All subjects wore both scleral lens designs for one month with a two-week washout period. The main variables evaluated included high and low-contrast visual acuity under photopic and mesopic light conditions, binocular defocus curves, contrast sensitivity function and a visual analogue scale (VAS) for subjective vision and comfort.

RESULTS

Comparing the two scleral lens designs, statistically significant differences in visual acuity were found, highlighting the improvement in more than one chart line (6 letters) for low contrast near tests under photopic light conditions with the decentred optics lens design. VAS questionnaire scores also showed a significant improvement in distance and overall subjective vision with the decentred optics lenses. Contrast sensitivity function showed an improvement with decentred multifocal lenses at all spatial frequencies measured, being statistically significant for 12 cycles per degree. No differences in stereoacuity were found.

CONCLUSION

Multifocal scleral lenses with a customized decentred optical zone proved to be a promising refractive correction in presbyopic subjects after one month of wear, offering good comfort and visual quality under photopic and mesopic light conditions.

A new look at an old problem: 3D modeling of accommodation reveals how age-related biomechanical changes contribute to dysfunction in presbyopia

Presbyopia is an age-related ocular disorder where accommodative ability declines so that an individual's focusing range is insufficient to provide visual clarity for near and distance vision tasks without corrective measures. With age, the eye exhibits changes in biomechanical properties of many components involved in accommodation, including the lens, sclera, and ciliary muscle. Changes occur at different rates, affecting accommodative biomechanics differently, but individual contributions to presbyopia are unknown. We used a finite element model (FEM) of the accommodative mechanism to simulate age-related changes in lens stiffness, scleral stiffness, and ciliary contraction to predict differences in accommodative function. The FEM predicts how ciliary muscle action leads to lens displacement by initializing a tensioned unaccommodated lens (Phase 0) then simulating ciliary muscle contraction in accommodation (Phase 1). Model inputs were calibrated to replicate experimentally measured lens and ciliary muscle in 30-year-old eyes. Predictions of accommodative lens deformation were verified with additional imaging studies. Model variations were created with altered lens component stiffnesses, scleral stiffness, or ciliary muscle section activations, representing fifteen-year incremental age-related changes. Model variations predict significant changes in accommodative function with age-related biomechanical property changes. Lens changes only significantly altered lens thickening with advanced age (46% decrease at 75 years old) while sclera changes produced progressive dysfunction with increasing age (23%, 36%, 49% decrease at 45, 60, and 75 years old). Ciliary muscle changes effected lens position modulation. Model predictions identified potential mechanisms of presbyopia that likely work in combination to reduce accommodative function and could indicate effectiveness of treatment strategies and their dependency on patient age or relative ocular mechanical properties.

Efficacy and Safety of CSF-1 (0.4% Pilocarpine Hydrochloride) in Presbyopia: Pooled Results of the NEAR Phase 3 Randomized, Clinical Trials

PURPOSE

This study was undertaken to evaluate the safety and efficacy of CSF-1 (0.4% pilocarpine hydrochloride ophthalmic solution) for use in individuals with presbyopia.

METHODS

Two Phase 3 multicenter, randomized, double-masked, vehicle-controlled, parallel-group clinical trials were conducted in 35 private ophthalmology clinics in the United States from October 2020 to February 2022. Key inclusion criteria were the following: (1) age 45-64 years, (2) distance-corrected near visual acuity (DCNVA) at 40 cm ≥0.40 and ≤0.90 logarithm of the minimum angle of resolution (logMAR, approximately 20/50-20/160 Snellen) in at least 1 eye, (3) manifest refraction (MR) between -4.50 and +2.00 diopter (D) sphere in each eye with ≤2.00D difference between eyes, (4) <2.00D of cylinder MR in each eye, (5) ≤0.04 logMAR (20/20-2 or better) corrected distance visual acuity (CDVA) at 4 m in each eye. Key exclusion criteria were the following: (1) >0.14 logMAR (7 letters) improvement in post-vehicle treatment in monocular DCNVA in either eye at visit 1, (2) introcular pressure (IOP) <9 or >22 mm Hg, (3) average dark-adapted pupillometry <3.5 mm in either eye, (4) prior refractive surgery or intraocular lens (IOL) implantation. Participants applied CSF-1 or vehicle twice per day for 2 weeks. Efficacy and safety assessments were performed at several times on days 1, 8, and 15. Response was defined as ≥3-line gain in DCNVA without loss of ≥1-line in CDVA in the study eye under mesopic room lighting conditions. The primary efficacy endpoint was measured 1 hour post-dose 1 on day 8. Key secondary endpoints were 2 hours post-dose 1, and 1 and 2 hours post-dose 2, also on day 8. Safety endpoints were ocular and non-ocular treatment-related adverse events (TRAE), conjunctival redness, drop comfort, slit-lamp biomicroscopy, intraocular pressure, indirect fundoscopy, and CDVA at 4 m.

FINDINGS

Six hundred thirteen participants were randomized to CSF-1 (n = 309) or vehicle (n = 304). Participants were predominantly White (80.8%) and female (62.0%), with mean age (standard deviation) of 54.7 (4.8). CSF-1 met the primary and key secondary endpoints. At the primary endpoint, 40.1% of the CSF-1 group achieved response versus 19.1% of the vehicle group (P < 0.0001). The percentage of responders was significantly greater in CSF-1 compared with vehicle at all tested times. Changes from baseline in all safety endpoints were comparable between groups. Most adverse events (AEs) were mild and transient. Neither serious nor severe AEs were reported with CSF-1.

IMPLICATIONS

CSF-1, a low-dose pilocarpine ophthalmic solution, demonstrated superiority to vehicle in improving near vision in individuals with presbyopia without compromising distance vision. CSF-1 demonstrated a favorable safety profile.

CLINICALTRIALS

gov identifier: NCT04599933 (NEAR-1), NCT04599972 (NEAR-2).

Patient Perception and Self-Reported Outcomes with Presbyopia-Correcting Intraocular Lenses (PCIOLs): A Social Media Listening Study

INTRODUCTION

Presbyopia-correcting intraocular lens (PCIOL) implantation is a popular treatment option for cataract surgery patients who desire spectacle independence. This study aimed to understand patient perception and outcomes with PCIOLs by analyzing patient social media posts.

METHODS

This was a non-interventional retrospective study that used predefined search strings to identify publicly available social media data discussing patient perceptions and outcomes with seven PCIOLs (three trifocal, one multifocal with continuous range of vision, and three extended depth-of-focus [EDOF] PCIOLs). Relevant posts were searched from Reddit, YouTube, and Facebook and patient forums Patient.info, Medicine.net, Optiker-Forum, and Medizin Forum from September 2020 to October 2022 in four languages (English, German, French, and Spanish).

RESULTS

A total of 2237 posts were included, all in English, with 68% of posts identified on Patient.info. The themes most discussed by patients were quality of vision (69% of total posts), patient experience after PCIOL implantation (30%), patient perception before PCIOL implantation (26%), and visual disturbances (24%). Most discussed PCIOLs were Vivity® (58% of total posts), PanOptix® (38%), Synergy® (26%), and Symfony® (13%). Patient perception of PCIOLs was most frequently influenced by healthcare professionals, online reading, and online videos (31%, 18%, and 15% of posts, respectively). A total of 215 posts (10% of total) discussed glasses use after PCIOL surgery: for EDOF and trifocal/multifocal PCIOLs, 37% and 56% of posts discussing glasses use stated being glasses free, respectively. A total of 537 posts discussed visual disturbances: halos/rings (66%) and starbursts (36%) were the most discussed visual disturbances for all lens types. Being glasses free after PCIOL implantation appeared to be a key driver of patient satisfaction.

CONCLUSION

Social media provides a rich source of information on patient perception, experience, and overall satisfaction of PCIOLs that can be used to complement and guide the collection of further evidence generated through controlled trials.

2022 Glenn A. Fry Award lecture: Enhancing clinical assessment for improved ophthalmic management

ABSTRACT

Detailed clinical assessment is critical to allow sensitive evaluation of the eye and its management. As technology advances, these assessment techniques can be adapted and refined to improve the detection of pathological changes of ocular tissue and their impact on visual function. Enhancements in optical medical devices including spectacle, contact, and intraocular lenses have allowed for a better understanding of the mechanism and amelioration of presbyopia and myopia control. Advancements in imaging technology have enabled improved quantification of the tear film and ocular surface, informing diagnosis and treatment strategies. Miniaturized electronics, large processing power, and in-built sensors in smartphones and tablets capacitate more portable assessment tools for clinicians, facilitate self-monitoring and treatment compliance, and aid communication with patients. This article gives an overview of how technology has been used in many areas of eye care to improve assessments and treatment and provides a snapshot of some of my studies validating and using technology to inform better evidence-based patient management.

Applications of the pinhole effect in clinical vision science

The pinhole effect is commonly used to discriminate uncorrected refractive error from ocular diseases. A small aperture limits the width of light beams entering the eye, thus increasing the depth of focus. The pinhole effect has also been used in spectacles, contact lenses, corneal inlays, and intraocular lenses (IOLs) to improve reading by compensating for loss of accommodative function. Pinhole spectacles improve near visual acuity, but reduce reading speed, increase interblink interval, and decrease tear break-up time. For contact lenses and IOLs, pinhole devices are usually used in the nondominant eye, which allow compensation of various refractive errors and decrease spectacle dependence. Pinhole corneal inlays are implanted during laser in situ keratomileusis or as a separate procedure. Pinhole IOLs are gaining popularity, particularly as they do not bring a risk of a local inflammatory reaction as corneal inlays do. Disadvantages of using the pinhole effect include high susceptibility to decentration, decrease in retinal luminance levels, and difficulties in performing fundus examinations or surgery in eyes with implanted devices. There are also concerns regarding perceptive issues with different retinal illuminances in the 2 eyes (the Pulfrich effect).

Visual Quality Assessment and Comparison of Monofocal and Multifocal Scleral Lens Designs: A Pilot Study

PURPOSE

To compare visual quality, contrast sensitivity, stereopsis, subjective vision, and comfort between monofocal and multifocal scleral lens (SL) designs.

METHODS

An experimental, cross over and short-term pilot study has been performed. Nineteen presbyopic patients (51.9±3.8 years) with regular corneas participated voluntarily in the study and Onefit MED monofocal and multifocal SL designs were fitted bilaterally. Subjective vision and comfort, contrast sensitivity function, stereopsis, high- and low-contrast visual acuity (VA) at 4 m and 40 cm under photopic and mesopic conditions, and defocus curves were measured. Data analysis was performed with nonparametric tests. P<0.05 was considered as statistically significant.

RESULTS

Mean addition power of the prescribed lenses was 1.72±0.38 diopters. Multifocal design showed a statistically significant improvement for intermediate and near vision in the defocus curve under photopic and mesopic conditions (P<0.05), however, worsening in stereopsis (P<0.05) and contrast sensitivity for high spatial frequencies (P<0.05). Distance visual acuity (VA) showed significantly lower values under mesopic conditions for high- and low-contrast tests (P<0.05), and on low-contrast test under photopic conditions (P<0.001) with the multifocal design.

CONCLUSION

Multifocal SLs showed better visual performance at intermediate and near distances without compromising distance vision under photopic conditions for a high-contrast test when compared with monofocal design.

Visual performance of new affordable and auto-adherent lenses for presbyopia correction

Presbyopia is a visual condition that affects all of us, evolving with time, reducing the range of accommodation and the ability to work at near. Reading glasses, bifocals or multifocal lenses are the most common solutions. In this work, we demonstrate the near visual performance of new elastomeric auto-adherent lenses developed for the correction of presbyopia. Visual acuity and contrast sensitivity were measured in 10 presbyopic subjects. The results showed that wearing either conventional trial ophthalmic lenses or the new elastomeric lenses provided similar visual quality. These elastomeric lenses can be placed in, or removed from the distance-vision spectacles of the wearers, providing an affordable solution for correcting presbyopia at its clinical onset, which might be especially useful in subjects with different refractive error in each eye and for those with astigmatism.

Factors influencing the need and willingness for presbyopic correction: a cross sectional study from south India

Presbyopia is an age-related physiological phenomenon in which eye gradually losses its ability to accommodate. It is one of the leading causes of visual impairment worldwide, especially in adults above the age of 40. If uncorrected, it can significantly impair a patient's quality of life. This study aims to evaluate the factors which affects patient's need and willingness to accept presbyopic correction. This cross-sectional analytical study was carried out in a semi urban tertiary care hospital from Jan 2021 to June 2022 among patients aged 40 and above who presented to Outpatient department (OPD). Demographic details, medical history, presenting ocular complaints pertaining to presbyopia, spectacle use and decision regarding using near vision correction were noted. Ocular examination included refraction and ocular biometry. Factors that may have influenced complaints of presbyopia or willingness to accept presbyopic correction were analysed. Three hundred and forty two patients with a mean age of 48.55 ± 6.68 years were included. Of these, 262 (76.61%) patients presented with chief complaints related to presbyopia. Those with higher educational qualification (p = 0.031), hypermetropia (p = 0.021), shallower AC depth (p = 0.028) and on medications for systemic ailments (p = 0.01), were more likely to present with chief complaints attributable to presbyopia. Among them, those with higher educational qualifications (p = 0.02) and skilled workers were more likely to accept near vision glasses (p = 0.02), while those with lower Hb (p = 0.01) and myopia (p = 0.01) were less likely to accept correction for presbyopia. Among the 80 patients without chief complaints related to presbyopia, 35 (43.75%) were not willing to accept near vision glasses. Those with higher BMI (p = 0.04) and hypermetropes (p = 0.05) were more willing to accept presbyopic correction. Presbyopia constitutes a significant reason for patients above the age of 40 visiting eye care facility. Multiple socio-economic, systemic and ocular factors influenced both the chief complaints related to presbyopia and willingness to accept presbyopic correction.

Vehicle Headlight Halo Simulation of Presbyopia-Correcting Intraocular Lenses

Purpose

This optical bench study was designed to evaluate and compare the halos generated by presbyopia-correcting intraocular lenses (PCIOLs) and monofocal intraocular lenses (IOLs), with or without lens decentration, using an optical bench to simulate the headlight of a distant vehicle in mesopic conditions.

Methods

Halos generated by six nondiffractive and 10 diffractive IOLs with different dioptric add powers were evaluated using a high dynamic range bench system. Halo intensities were compared by assessing the area under the measured intensity profile curve to compute the relative halo magnitude (RHM).

Results

Nondiffractive PCIOLs produced smaller and less intense bench halo images than diffractive ones. RHM measurements ranged from 964 to 1896. Monofocal IOLs produced lower RHM values, whereas diffractive PCIOLs generated higher ones. When decentered by 0.5 mm with respect to the system aperture, more obviously asymmetric halo image profiles were observed in diffractive compared with nondiffractive PCIOLs.

Conclusions

Simulated bench halos of nondiffractive PCIOLs are smaller and less intense than those of diffractive PCIOLs. Additional clinical studies assessing standardized patient-reported outcomes measures are required to correlate these bench results with patient satisfaction.

Translational Relevance

This study contrasts the design-related simulated bench halos of nondiffractive and diffractive PCIOLs, aiming to elucidate their impact on halo perception.

Temporal fluctuations in defocus may reverse the acuity loss encountered with induced refractive errors

A recent template-matching model hypothesized that simulated visual acuity loss with uncorrected refractive errors may be recovered by adding temporal defocus fluctuations up to the magnitude of the refractive error. Acuity recovery saturates or gets attenuated beyond this magnitude. These predictions were confirmed for monocular high-contrast visual acuity of 10 young, cyclopleged adults with 0.5-2.0D of induced myopia combined with the same range of temporal defocus fluctuations at 4.0 Hz frequency. The outcomes reinforce that spatial resolution may be optimized by averaging time-varying defocus over the entire stimulus presentation epoch or around the point of least defocus within this epoch.

IRIS® Registry (Intelligent Research In Sight) Analysis of the Incidence of Monovision in Cataract Patients with Bilateral Monofocal Intraocular Lens Implantation

Purpose

To determine the incidence of pseudophakic monovision among patients bilaterally implanted with monofocal intraocular lenses (IOLs) and to characterize the distribution of myopic offsets achieved.

Patients and Methods

This retrospective database study included data on patients receiving care from ophthalmologists who contributed to the Academy IRIS® (Intelligent Research In Sight) Registry. Anonymized data were collected, including patient age, ethnicity, procedure data (CPT code, date, laterality), and postoperative manifest refractive spherical equivalent (MRSE) in both eyes implanted with monofocal or monofocal toric IOLs. No data regarding IOL manufacturer, model, or power were collected. One primary outcome measure was the percentage of patients achieving monovision (defined as emmetropia within ±0.25 diopters [D] in one eye and a myopic offset of ≥0.50 D in the fellow eye) among all patients receiving bilateral monofocal IOLs at the time of cataract surgery between January 1, 2016, and September 1, 2019, with at least 90 days of follow-up. Other primary outcomes included the distribution and frequency of myopic offsets (anisometropia) between eyes.

Results

Of the 16,765 people receiving bilateral monofocal IOLs within the study period, 4796 (28.6%) achieved emmetropia in at least one eye, as defined by an MRSE within ± 0.25 D. The incidence of monovision among these patients was 34.2% (1638/4796). One-quarter (24.7%; 405/1638) of patients who achieved monovision had a myopic offset between 0.50 and 0.74 D, with more than one-third (35.2%; 576/1638) falling within 0.75-1.24 D and 18.0% within 1.25-1.74 D. A myopic offset ≥1.75 D was observed in 22.1% (362/1638) of patients who achieved monovision.

Conclusion

Pseudophakic monovision for presbyopia correction was achieved in ~34% of patients in the IRIS Registry bilaterally implanted with monofocal IOLs, with myopic offsets typically ranging from 0.5 to 1.24 D.

Increasing depth of focus with allogeneic presbyopic inlays: 3-year results

PURPOSE

To demonstrate the safety and efficacy of allogenic corneal inlays designed to increase the depth of focus (DoF) in treated eyes.

SETTINGS

Medipol University Hospital, Istanbul, Turkey.

DESIGN

Prospective case series.

METHODS

This study includes 50 eyes of 25 patients with a follow-up of 3 years. Emmetropic patients with presbyopia had implantation of allogenic corneal inlays in the nondominant eye. The uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and uncorrected near visual acuity (UNVA) were evaluated in all eyes. A subjective visual acuity test system (Multifocal Lens Analyzer 3.0 application) was used to analyze the DoF by measuring the defocus curves.

RESULTS

No significant difference between the treated and fellow eyes in UDVA and CDVA was found, whereas UNVA was significantly better in the treated eyes ( P = .20, P = .07, P < .01, respectively). Comparing to the preoperative CDVA, there was a 1-line decrease in CDVA in 6 (%24) patients. The mean defocus curves reveal a DoF of 1.1 diopters (D) for the untreated eye at the logMAR = 0.2 threshold. By contrast, the mean DoF of the treated eye and binocularly was 2.8 D. The areas under the curve were significantly better in the near, intermediate, and total distances in the treated eyes, whereas it was better for the far distances in the untreated eyes. All values were significant ( P = .023 total, P < .01 others).

CONCLUSIONS

Allogenic presbyopic inlay implantation may be safe and provided a clinically and statistically significant increase in the DoF leading to good far, intermediate, and near-visual acuity in emmetropic presbyopic patients.

Comparison of binocular visual quality in six treatment protocols for bilateral cataract surgery with presbyopia correction: a prospective two-center single-blinded cohort study

OBJECTIVE

To compare the postoperative binocular visual quality in six treatment protocols for bilateral age-related cataract surgery with presbyopia correction for clinical decisions.

MATERIALS AND METHODS

In this prospective two-center single-blinded cohort study, participants from North or South China who underwent bilateral phacoemulsification and intraocular lens implantation were divided into six protocols: monovision, diffractive bifocal, mixed, refractive bifocal, trifocal, and micro-monovision extended range of vision (EROV). Binocular visual quality was evaluated at 3 months postoperatively, including binocular uncorrected full-range visual acuity, binocular defocus curves (depth of focus [DoF] and area under the curve [AUC]), binocular visual function (fusion function and stereopsis), binocular subjective spectacle independence rates, visual analog scale (VAS) of overall satisfaction, 25-item visual function questionnaire (VFQ-25), and binocular dysphotopsia symptoms.

RESULTS

Of the 300 enrolled patients, 272 (90.7%; 544 eyes) were analyzed. The trifocal protocol showed excellent binocular full-range visual acuity and the best performance for most DoFs and AUCs. The monovision protocol presented the worst binocular visual quality in most perspectives, especially in convergence, distance, and near stereopsis (p < 0.001). The full-range subjective spectacle independence rates were sorted from highest to lowest as follows: trifocal (84.8%), refractive bifocal (80.9%), EROV (80.0%), mixed (73.3%), diffractive bifocal (65.2%), and monovision (32.6%) protocols, with no statistically significant differences between the former five protocols (p > 0.05). The EROV protocol achieved the highest VAS and VFQ-25 scores. The incidence of postoperative binocular dysphotopsia symptoms was comparable in all protocols.

CONCLUSIONS

The trifocal protocol showed the best performance, and the monovision protocol presented the worst performance in most perspectives of binocular visual quality for presbyopia correction. The refractive bifocal, mixed, or EROV protocols can provide an approximate performance as a trifocal protocol. Ophthalmologists can customize therapies using different protocols.

Surgical Technique to Treat Presbyopic Inlay-Associated Corneal Haze With Sequential Excimer Photoablation: A Case Series

PURPOSE

To describe an approach using sequential excimer laser ablation of the stromal surface of the corneal flap with or without subsequent excimer ablation to the stromal bed to reduce presbyopic inlay-associated corneal haze.

METHODS

Twelve patients who underwent KAMRA inlay (Acufocus) explantation due to corneal haze were included. The mean interval between explantation and the primary surgery (phototherapeutic keratotomy [PTK] to corneal flap) was 16.2 ± 29.7 months (range = 1 to 83 months). The corneal flap was lifted and laid on an evisceration spoon and an excimer laser was used to ablate the flap stroma by 30 to 40 µm depth. Subsequently, an excimer laser was used to ablate and treat the stromal bed following a second flap lift according to the manifest refraction, leaving a minimal residual stromal bed thickness of greater than 300 µm. For both procedures, mitomycin C 0.02% was applied to the stromal bed before the flap was replaced and a bandage contact lens applied.

RESULTS

Reductions in corneal haze were observed, following PTK to the corneal flap with or without photorefractive keratectomy (PRK) to the stromal bed, both clinically and on imaging. No significant changes in uncorrected distance visual acuity (P = .442) and corrected distance visual acuity (P = .565) were observed. Improvements were observed for both spherical equivalent refractive errors (P = .036) and corneal light backscatter (P = .019). There were significant improvements in spherical aberrations (P = .014) but no changes in total lower and higher order aberrations.

CONCLUSIONS

PTK to the corneal flap with or without subsequent stromal bed PRK is an effective technique in treating corneal haze following presbyopic inlay explantation. [J Refract Surg. 2023;39(9):639-646.].

Assessment of Visual Quality Improvement as a Result of Spectacle Personalization

Personalized spectacles customized according to an individual's facial anatomy were developed to provide enhanced visual performance and overall comfort when compared to standard spectacles. In this comparative crossover trial, each subject was randomly assigned to wear either personalized spectacles or standard spectacles for two weeks and then tried the second pair for another two weeks. Visual acuity and reading speed were measured, and visual quality and comfort were assessed using specific questionnaires. The correlation of the wearing parameters with the subjects' satisfaction was calculated. According to our results, the subjects wearing personalized glasses reported significantly less experience of swaying and significantly higher overall satisfaction compared to those wearing the control spectacles. At the end of the study, 62% of subjects preferred the personalized spectacles, and visual quality was the primary reason for their spectacle preference followed by wearing comfort. The difference from the ideal cornea-vertex distance was significantly lower when wearing the personalized spectacles compared to the control frames. In addition, the absolute value of the difference from the ideal cornea-vertex distance was significantly correlated with patient satisfaction. These results suggest that personalized spectacles, customized according to an individual's facial anatomy for the ideal wearing parameters, result in both visual and comfort advantages for wearers.

Presbyopia correction with multifocal contact lenses: Evaluation of silent reading performance using eye movements analysis

PURPOSE

Many activities of daily living rely on reading, thus is not surprising that complaints from presbyopes originate in reading difficulties rather in visual acuity. Here, the effectiveness of presbyopia correction with multifocal contact lenses (CLs) is evaluated using an eye-fixation based method of silent reading performance. ΜETHODS: Visual performance of thirty presbyopic volunteers (age: 50 ± 5 yrs) was assessed monocularly and binocularly following 15 days of wear of monthly disposable CLs (AIR OPTIX™ plus HydraGlyde™, Alcon Laboratories) with: (a) single vision (SV) lenses - uncorrected for near (b) aspheric multifocal (MF) CLs. LogMAR acuity was measured with ETDRS charts. Reading performance was evaluated using standard IReST paragraphs displayed on a screen (0.4 logMAR print size at 40 cm distance). Eye movements were monitored with an infrared eyetracker (Eye-Link II, SR Research Ltd). Data analysis included computation of reading speed, fixation duration, fixations per word and percentage of regressions.

RESULTS

Average reading speed was 250 ± 68 and 235 ± 70 wpm, binocularly and monocularly, with SV CLs, improving statistically significantly to 280 ± 67 (p = 0.002) and 260 ± 59 wpm (p = 0.01), respectively, with MF CLs. Moreover, fixation duration, fixations per word and ex-Gaussian parameter of fixation duration, μ, showed a statistically significant improvement when reading with MF CLs, with fixation duration exhibiting the stronger correlation (r = 0.79, p < 0.001) with improvement in reading speed. The correlation between improvement in VA and reading speed was moderate (r = 0.46, p = 0.016), as was the correlation between VA and any eye fixation parameter.

CONCLUSION

Average silent reading speed in a presbyopic population was found improved with MF compared to SV CL correction and was faster with binocular compared to monocular viewing: this was mainly due to the faster average fixation duration and the lower number of fixations. Evaluating reading performance using eye fixation analysis could offer a reliable outcome of functional vision in presbyopia correction.

Visual satisfaction with progressive addition lenses prescribed with novel foveal fixation axis measurements

Progressive addition lens (PAL) prescription is usually conducted using the pupillary centre as a reference, which in general does not coincide with the visual axis (kappa distance), and this difference could induce undesired prismatic effects in far and near vision distances and adaptation problems. This study aimed to assess the impact on subjects' visual satisfaction with PALs prescribed based on foveal fixation axis (FFA) measurements. Two different PALs (LifeStyle 3i, Hoya Lens Iberia) were randomly prescribed [one with a customized inset (the difference between the FFA measurements (Ergofocus®, Lentitech, Spain) at far and near distances and the second with a standard inset (2.5 mm)] to be used by 71 healthy presbyopic volunteers in a prospective double-masked crossover clinical study involving one month of use of each PAL. Patients were self-classified into four groups according to their previous experience with PALs: neophyte, PAL users, PAL drop-out, and uncomfortable PAL users. Visual function and overall satisfaction with each PAL were collected and compared. Ninety-seven percent (95% CI 93-100%) of participants successfully adapted to PALs prescribed with FFA without significant differences (P = 0.26) among the study groups (100% neophyte and uncomfortable PAL users (95% CI 100% in both groups), 89% (95% CI 67-100%) PAL users and 94% (95% CI 82-100%) PAL drop-out group). There were no statistically significant differences in visual function (P > 0.05) between customized and standard inset PALs. Customized and standard inset lenses showed similar satisfaction (P > 0.42) that increased significantly (P < 0.01 without any carry-over effect) after 30 days of wear. PALs prescribed with FFA measurements showed high visual satisfaction, suggesting that these measurements are suitable for prescribing PAL adaptation processes. Additional research is necessary to assess differences in PAL users' performance with different prescription methods and lens designs.

Refractive lens exchange - who is getting it, what are they getting, how are they doing?

PURPOSE OF REVIEW

The purpose of this article is to provide a review of the literature on refractive lens exchange and present a retrospective analysis of 55 patients who underwent refractive lens exchange at a single practice.

RECENT FINDINGS

Our study substantiates refractive lens exchange as an important option for presbyopic patients, hyperopic patients or patients with extremely high refractive error who desire spectacle independence.

SUMMARY

Our study reveals that the refractive lens exchange population is younger than the average cataract population and their primary motivations are to resolve hyperopic or myopic refractive errors, gain spectacle independence, and address near vision loss. A variety of presbyopia-addressing intraocular lens options are available and we present our experience with multifocal, extended depth-of-focus, light-adjustable, and monofocal lenses.

Factors Affecting Unmet Need for Presbyopia Correction Among School Teachers in Debre Tabor Town, Northwest Ethiopia

Background

Uncorrected presbyopia is the leading cause of near visual impairment among working-age adults in the world. In Ethiopia, there was limited evidence on the magnitude of uncorrected presbyopia and its associated factors among school teachers. Therefore, this study aimed to determine the magnitude of untreated presbyopia and its associated factors among school teachers in Debre Tabor town, Northwest Ethiopia.

Methods

An institution-based cross-sectional study was conducted on 448 school teachers at Debre Tabor town using a simple random sampling technique. The data were collected using a face-to-face interview and a comprehensive ocular examination. A binary multivariable logistic regression model was conducted to identify associated factors of the uncorrected presbyopia.

Results

Generally, the prevalence of uncorrected presbyopia among school teachers was 63.62% (95% CI: 59.2-67.9). Age (35-45) (AOR: 4.56, 95% CI: 1.74, 11.91), female gender (AOR: 3.03, 95% CI: 1.75, 5.26), unaware of presbyopia (AOR: 2.35, 95% CI: 1.30, 4.25), unaware of refraction site (AOR: 4.21, 95% CI: 2.42, 7.33), no eye checkup history (AOR: 2.76, 95% CI: 1.52, 5.01), and no family history of spectacle use (AOR: 2.61, 95% 4.67) were significantly associated with uncorrected presbyopia.

Conclusion

In the current study, the magnitude of uncorrected presbyopia was high. Age below 45 years, female gender, lack of awareness of presbyopia and refraction site, lack of history of eye checkups, and family spectacle use were significantly associated with uncorrected presbyopia. The early correction of presbyopia, health education on presbyopia, and the provision of affordable spectacle corrections for school teachers were recommended.

Patient reported outcomes after implementation of an enhanced depth of focus intraocular lens with low postoperative myopia

Background

Enhanced depth-of- focus intraocular lenses (EDOF IOL) have filled the gap between monofocal and multifocal intraocular implants with optical qualities of monofocal lenses and usually minor dysphotopsias typical for multifocal lenses. The purpose of this study was to evaluate visual outcomes after bilateral implantation of a new EDOF IOL in patients with requirements for perfect near and intermediate vision.

Methods

The study included 15 patients (29 eyes as one was amblyopic) with bilateral implantation of LUXSMART EDOF IOL (Bausch & Lomb) with a targeted myopia (between -0.25 and -0.50D) in both eyes. Monocular corrected and uncorrected visual acuity for far, intermediate and near as well as refractive outcomes were evaluated at 1, 3, 6 and 12 months after the surgery. Additionally, binocular visual acuity, contrast sensitivity and defocus curve were measured at the final follow-up visit. At 12 months' visit patients completed a questionnaire evaluating patient satisfaction, spectacle independence and presence of dysphotopsias.

Results

Binocular uncorrected visual acuities at 12 month's visit were 0.13 ​± ​0.16, 0.06 ​± ​0.08, 0.07 ​± ​0.09 and 0.15 ​± ​0.09 logMAR for far distance, 80 ​cm, 66 ​cm and 40 ​cm respectively. Corrected binocular visual acuities at 12 months were 0.00 ​± ​0.00, 0.05 ​± ​0.07, 0.05 ​± ​0.06, 0.13 ​± ​0.16 respectively for distance, 80 ​cm, 66 ​cm and 40 ​cm. Automated refraction spherical equivalent at 12 months' visit stood at -0.70 ​± ​0.48D, which was 0.46D less than calculated biometric target, however spherical equivalent of subjective refraction at 12 months equaled -0.49 ​± ​0.46D, which was closer to preoperative biometric target. Defocus curve had gentle shape without peaks typical for monofocal IOLs. Binocular contrast sensitivity results were superior to average results for that age group and equaled 1.78 ​± ​0.16 logMAR without correction and 1.81 ​± ​0.13 logMAR with correction. Spectacle independence for near and intermediate distances was achieved in all patients and for far distance in 73.3% of patients. Burdensome dysphotopsias were not reported in any case.

Conclusions

EDOF IOLs targeted bilaterally at low myopia can provide excellent near and intermediate visual acuity and independence of any optical correction in majority of cases. This approach can be used in selected patients who are focused on stationary activities.

Burden of near vision loss in China: findings from the Global Burden of Disease Study 2019

PURPOSE

To investigate the burden of near vision loss (NVL) in China by year, age and gender from 1990 to 2019.

METHODS

We used estimates from the Global Burden of Disease (GBD) 2019 study to report the prevalence and disability-adjusted life-years (DALYs) due to NVL in China. Estimates of crude counts and age-standardised rates per 100 000 population are accompanied by 95% uncertainty intervals (UIs). We summarised the age-specific and sex-specific patterns and trends regarding the burden of NVL in China, compared with seven neighbouring countries.

RESULTS

From 1990 to 2019, the all-age number and rate for NVL prevalence and DALYs increased significantly in China (all p<0.001). The age-standardised rate decreased from 7538.1 (95% UI 6946.3 to 8075.1) to 7392.9 (95% UI 6855.8 to 7890.5) per 100 000 population for NVL prevalence (p=0.107), and from 74.9 (95% UI 69.6 to 79.9) to 73.8 (95% UI 70.6 to 80.1) per 100 000 population for DALYs (p=0.388). Women had higher NVL prevalence (t=170.1, p<0.001) and DALYs (t=192.5, p<0.001) than men. Higher disease burden of NVL was observed in the middle-aged and elderly population. The age-standardised prevalence and DALY rate attributable to NVL in China were lower than in India, North Korea, Pakistan (all p<0.001), but higher than Russia, South Korea, Singapore and Japan (all p<0.001).

CONCLUSIONS

Despite a small decrease in age-standardised prevalence and DALYs due to NVL in China in the past two decades, the existing burden is still considerable and significantly higher compared with neighbouring developed countries. An approach that includes all stakeholders is needed to further reduce this burden.

Comparison of Literature Review, Social Media Listening, and Qualitative Interview Research Methods in Generating Patient-Reported Symptom and Functional Impact Concepts of Presbyopia

INTRODUCTION

To compare the insights obtained about the experience of individuals with presbyopia (age-related impaired near vision) across three different sources of qualitative data: a structured targeted literature review, a social media listening (SML) review, and qualitative concept elicitation (CE) interviews with individuals with presbyopia and healthcare professionals (HCPs). The number of concepts identified, depth of data, cost and time implications, and value of the patient insights generated were explored and compared for each method.

METHODS

Keyword searches in bibliographic databases and review of abstracts identified 120 relevant publications; in-depth targeted literature review of the qualitative studies identified key symptoms/functioning concepts. SML was conducted using publicly accessible social media sources with focus on ophthalmologic diseases using a pre-defined search string. Relevant posts from individuals with presbyopia (n = 270) were analysed and key concepts identified. Semi-structured CE interviews were conducted with individuals with presbyopia (US n = 30, Germany n = 10, France n = 10), and HCPs (US = 3, France n = 2, Germany n = 1, Japan n = 1) who were experienced in treating presbyopia. Verbatim transcripts were coded using thematic analysis. A conceptual model summarised concepts identified across sources RESULTS: Out of the total of 158 concepts identified across the three sources, qualitative CE interviews yielded the highest number of concepts (n = 151/158, 96%), with SML yielding a third of the concepts (n = 51/158, 32%) and the literature review yielding the fewest concepts (n = 33/158, 21%). Qualitative CE interviews provided greater depth of data than SML and literature reviews. SML and literature reviews were less costly and quicker to run than qualitative CE interviews and also were less burdensome for participants.

CONCLUSION

Qualitative CE interviews are considered the gold standard in providing greater depth of understanding of the patient experience, and more robust data. However, research requirements, budget, and available time should be considered when choosing the most appropriate research method. More time and cost-effective SML and literature review methods can be used to supplement qualitative CE interview data and provide early identification of measurement concepts. More research and regulatory guidance into less traditional qualitative methods, however, are needed to increase the value of SML and literature review data.

Pharmacological Treatments for Presbyopia

Accommodation is the change in dioptric power of the eye. It is a dynamic process that allows focusing on an object at all distances. In order to focus sharply, three physiological responses, known as the triad of accommodation, are produced by a change in pupil size, a change in shape and position of the lens, and ocular convergence. This is modulated by the autonomic nervous system, mainly the parasympathetic nervous system. Presbyopia is a refractive condition that occurs with aging, usually manifesting around 40-50 years of age, and is a result of the loss of accommodation in the eye, causing loss of visual performance when focusing on objects placed at different distances, starting with near vision. Glasses, contact lenses, surgical approaches and now pharmacological treatments are accepted methods of treating presbyopia. Pharmacological treatment is a promising new noninvasive option for treating presbyopia. Currently there are three pharmacological approaches to the treatment of presbyopia. The first one aims to produce miosis and, from a pinhole effect, increase depth of focus, and therefore improve uncorrected near visual acuity (UNVA). The second one addresses rehabilitating accommodation in a binocular way, allowing good vision at all distances. Finally, the third strategy uses lipoic acid to restore the lost elasticity of the lens. All of these pharmacological treatments are topical non-invasive eyedrops, with no serious adverse effects having been reported with any of the strategies, and require the right patient selection process to fulfill expectations and needs. The aim of this article is to provide an update on recent advances in this field.

Complications of Small Aperture Intracorneal Inlays: A Literature Review

Presbyopia can be defined as the refractive state of the eye in which, due to a physiological decrease in the ability to accommodate, it is not possible to sustain vision without fatigue in a prolonged manner, along with difficulty focusing near vision. It is estimated that its prevalence in 2030 will be approximately 2.1 billion people. Corneal inlays are an alternative in the correction of presbyopia. They are implanted beneath a laser-assisted in situ keratomileusis (LASIK) flap or in a pocket in the center of the cornea of the non-dominant eye. The purpose of this review is to provide information about intraoperative and postoperative KAMRA inlay complications in the available scientific literature. A search was conducted on PubMed, Web of Science, and Scopus with the following search strategy: ("KAMRA inlay" OR "KAMRA" OR "corneal inlay pinhole" OR "pinhole effect intracorneal" OR "SAICI" OR "small aperture intracorneal inlay") AND ("complication" OR "explantation" OR "explanted" OR "retired"). The bibliography consulted shows that the insertion of a KAMRA inlay is an effective procedure that improves near vision with a slight decrease in distance vision. However, postoperative complications such as corneal fibrosis, epithelial iron deposits, and stromal haze are described.

Presbyopia: What We Do Know and What We Do Not Know in 2022

The subject of presbyopia has accompanied clinical ophthalmic practices around the world for centuries [...].

New insights in presbyopia: impact of correction strategies

Presbyopia occurs when the physiologically normal age-related reduction in the eyes 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. Hence, it is more about the impact it has on an individual’s visual ability to function in their environment to maintain their lifestyle than a measured loss of focusing ability. Presbyopia has a significant impact on an individual’s quality of life and emotional state. While a range of amelioration strategies exist, they are often difficult to access in the developing world and prescribing is generally not optimal even in developed countries. This review identified the need for a standardised definition of presbyopia to be adopted. An appropriate battery of tests should be applied in evaluating presbyopic management options and the results of clinical trials should be published (even if unsuccessful) to accelerate the provision of better outcomes for presbyopes.

Interdevice agreement in the measurement of physiognomy parameters and frame angles to prescribe progressive addition lenses

CLINICAL RELEVANCE

Ophthalmic lens adaptation requires accurate measurements of physiognomy parameters and frame angles, with a great impact on subject vision, especially when personalised progressive addition lenses are prescribed.

BACKGROUND

The aim of this study is to describe interdevice agreement between different methods and traditional methods (frame ruler).

METHODS

The agreement of the interpupillary distance, nasopupillary distance and fitting point height measured with four devices (PD-5, OptiCenter, Visioffice and a frame ruler) and of pantoscopic and frame wrap angles measured with three devices (OptiCenter, Visioffice and Essilor standard ruler) was assessed in 21 healthy volunteers, by a Bland-Altman analysis; mean difference and limits of agreement (LoA) were calculated.

RESULTS

Frame ruler nasopupillary distance measurements showed limited agreement with PD-5 [-0.38 ± 1.03 (LoA -2.40 to 1.64) and 0.44 ± 1.02 (LoA -1.72 to 2.61)] and Visioffice [0.62 ± 1.24 (LoA -1.81 to 3.05) and -0.16 ± 1.72 (LoA -3.54 to 3.22)] measurements for the right and left eyes, respectively. Poor agreement was found for interpupillary distances (PD-5 [0.21 ± 1.47 (LoA -2.67 to 3.09)], OptiCenter [-0.05 ± 1.16 (LoA -2.32 to 2.22)] and Visioffice [0.46 ± 1.95 (LoA -3.36 to 4.28)]), fitting point height (OptiCenter [-1.27 ± 2.56 (LoA -6.27 to 3.75) and -0.92 ± 2.77 (LoA -6.35 to 4.51)] and Visioffice [-5.88 ± 6.21 (LoA -18.05 to 6.29) and -5.98 ± 6.12 (LoA -17.98 to 6.02)] for the right and left eyes, respectively) and pantoscopic and frame wrap angles (OptiCenter [-4.13 ± 3.75 (LoA -11.48 to 3.22) and -1.09 ± 0.60 (LoA -2.27 to 0.09)] and Visioffice [-6.18 ± 3.53 (LoA -13.10 to 0.74) and -1.93 ± 3.49 (LoA -8.77 to 4.91)], respectively).

CONCLUSIONS

These results suggest that measurements of physiognomy and frame angles are not interchangeable between assessed devices and that these differences could induce lens centration errors with a large impact on progressive addition lens prescriptions.

Adaptive optics visual simulators: a review of recent optical designs and applications [Invited]

In their pioneering work demonstrating measurement and full correction of the eye's optical aberrations, Liang, Williams and Miller, [JOSA A14, 2884 (1997)10.1364/JOSAA.14.002884] showed improvement in visual performance using adaptive optics (AO). Since then, AO visual simulators have been developed to explore the spatial limits to human vision and as platforms to test non-invasively optical corrections for presbyopia, myopia, or corneal irregularities. These applications have allowed new psychophysics bypassing the optics of the eye, ranging from studying the impact of the interactions of monochromatic and chromatic aberrations on vision to neural adaptation. Other applications address new paradigms of lens designs and corrections of ocular errors. The current paper describes a series of AO visual simulators developed in laboratories around the world, key applications, and current trends and challenges. As the field moves into its second quarter century, new available technologies and a solid reception by the clinical community promise a vigorous and expanding use of AO simulation in years to come.