A review of the surgical options for the correction of presbyopia

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.

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: 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.

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.

Comparison of Early Vision Quality of SBL-2 and SBL-3 Segmented Refractive Lens

PURPOSE

To compare objective quality of vision in patients undergoing phacoemulsification with implantation of a bilateral segmented multifocal intraocular lens (SMIOL).

METHODS

A retro-prospective study included 110 eyes of 55 patients who underwent cataract surgery with bilateral SMIOL implantation. Patients were divided according to the type of implanted intraocular lens into group 1 (SBL-2, 62 eyes) and group 2 (SBL-3, 48 eyes). Postoperatively, monocular and binocular uncorrected distance visual acuity (UCDVA), corrected distance visual acuity (BCDVA), uncorrected intermediate visual acuity (UCIVA, at 66 cm), uncorrected near visual acuity (UCNVA, at 40 cm), corrected near visual acuity (BCNVA) and defocus curve were measured and evaluated. The follow-up period was 6 months.

RESULTS

Mean UCDVA in group 1 (SBL-2) was 0.010 ±0.15 LogMAR monocularly, 0.01 ±0.10 LogMAR binocularly, and in group 2 (SBL-3) was 0.02 ±0.11 LogMAR monocularly and -0.07 ±0.09 LogMAR binocularly. Binocular defocus curves showed that the SBL-3 group performed better than the SBL-2 lens at a vergence of -1.50 D corresponding to 66 cm (center distance), averaging 0.03 ±0.11 LogMAR, while the SBL-2 group averaged 0.12 ±0.14 LogMAR (p = 0.01). The -2.50 D vergence characterizing near vision (40 cm) was achieved by the SBL-2 lens in our study at 0.33 ±0.15 LogMAR and by the SBL-3 lens at 0.00 ±0.11 LogMAR (p = 0.00).

CONCLUSION

Both SMIOLs provided very good vision at all tested distances 6 months postoperatively. The SBL-2 lens performed better in UCIVA, while the SBL-3 lens excelled in UCDVA and UCNVA.

Refractive Outcomes of Cataract Surgery in Patients With Intrastromal Femtosecond Laser Treatment of Presbyopia (INTRACOR)

PURPOSE

To evaluate the outcomes of cataract surgery with intraocular lens (IOL) implantation in patients who underwent intrastromal femtosecond laser treatment of presbyopia (INTRACOR).

METHODS

This was an interventional case series of 8 patients (10 eyes) who presented for cataract surgery 6.1 ± 3.2 years (mean ± standard deviation [SD]) after INTRACOR (Technolas Perfect Vision GmbH) treatment. A monofocal IOL was implanted in 9 eyes (7 patients) and a small-aperture IOL was implanted in 1 eye. The IOL power was calculated without adjustments using biometry obtained after the INTRACOR treatment. For additional calculations, keratometry obtained before the INTRACOR treatment was used. Postoperative examinations included visual acuity testing, manifest refraction, defocus curve, ocular biometry, corneal tomography, aberrometry, anterior segment optical coherence tomography, and slit-lamp examination.

RESULTS

After the cataract surgery, the mean ± SD uncorrected distance visual acuity was 0.37 ± 0.17 logMAR, the corrected distance visual acuity was 0.10 ± 0.10 logMAR, and the manifest refraction spherical equivalent, adjusted to infinity, was +0.39 ± 0.63 diopters (D). Intermediate and near visual acuity, both uncorrected and distance-corrected, and distance-corrected defocus curves varied considerably among patients. Using biometry performed after INTRACOR, the traditional IOL power calculation formulas produced hyperopic outcomes, with the mean ± SD prediction error ranging from +0.72 ± 0.34 to +0.96 ± 0.41 D. Although the mean ± SD prediction error decreased (range: -0.34 ± 0.56 to -0.15 ± 0.53 D) when using keratometry obtained before INTRACOR, the accuracy remained low due to high variability.

CONCLUSIONS

In patients with cataract who had previous INTRACOR treatment, IOL power calculation could be inaccurate, with a tendency toward hyperopic outcomes. These results require confirmation in more extensive studies. [J Refract Surg. 2023;39(10):676-682.].

Spherical aberrations and their role in modern ophthalmology

Spherical aberration is an imperfection of the optical system of the human eye. The role of spherical aberration of the human eye in the quality of vision and pseudoaccommodation is reviewed. Spherical aberration is an imperfection of the optical system of the human eye. In most cases, due to well-developed neuroadaptation, it is insignificant for the perception of the image. Nevertheless, its role in modern ophthalmology is far from straightforward. On the one hand, there are clinical scenarios in which an excess of spherical aberration degrades the retinal image and leads to a high dissatisfaction rate among patients.©Recently, there is a growing interest in the modulation of spherical aberration in the clinical setting. Modern intraocular lenses as well as laser refractive procedures are aimed at interfering with spherical aberrations of the optical system in order to increase range of pseudoaccommodation. Here, we review the role of spherical aberration of the human eye in the quality of vision and pseudoaccommodation.

Bilateral Implantation of Multifocal Intraocular Lenses: 10-Year Follow-Up

PURPOSE

To evaluate and compare the long-term results after bilateral implantation of different multifocal intraocular lenses (MIOLs).

METHODS

This retrospective comparative study included 42 patients who underwent cataract surgery with bilateral MIOL implantation. Patients were divided into 5 groups: Group 1 received a refractive ReZoom NGX1 IOL (AMO), Group 2 a diffractive Acrysof ReSTOR SA60D3 IOL (Alcon), and Group 3 a diffractive Tecnis ZM900 IOL (AMO). Group 4 and Group 5 were implanted using the mix and match approach with refractive ReZoom-diffractive ReSTOR IOL and refractive ReZoom-diffractive Tecnis ZM900 IOL, respectively. Primary outcome measures were distance, near, and intermediate distance visual acuity measured 6 months (T0) and 10 years (T1) after surgery. Secondary outcomes were defocus curves, contrast sensitivity, patients' satisfaction, and spectacle independence.

RESULTS

All patients achieved best-corrected distance visual acuity (BCDVA) greater than 0.11 logMAR and uncorrected distance visual acuity (UCDVA) greater than 0.14 logMAR at both time points. A decrease in contrast sensitivity was evident, particularly at high spatial frequencies; at T1, Group 4 reported statistically higher values than Group 2 at 12 cycles/degree and 18 cycles/degree and statistically higher values than Group 3 at 18 cycles/degree. Great overall satisfaction was reported even in the presence of dysphotopsia. Tecnis ZM900 IOL showed the lowest incidence of posterior capsular opacification.

CONCLUSION

MIOLs could provide adequate functional vision and patient satisfaction, despite the incidence of side effects, in carefully selected patients desiring spectacle independence.

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.

Exploring the Experience of Living With and Managing Presbyopia

SIGNIFICANCE

Presbyopia typically occurs around 40 years of age and affects approximately one-quarter of the global population. Up to October 2021, there were no approved pharmacotherapies for presbyopia and common treatments, such as glasses, can have disadvantages for individuals' health-related quality of life.

PURPOSE

To document the experience of living with and managing presbyopia, identify perspectives on treatment options, and determine whether there is an unmet need in the treatment landscape.

METHODS

Coded transcripts of concept elicitation (CE; N = 20) and cognitive debriefing (CD; N = 20) interviews with presbyopic individuals, originally conducted for development of patient-reported outcome instruments, were reanalyzed to identify salient concepts describing participants' experiences with presbyopia treatments. Qualitative ranking exercises assessed participants' preferences for a potential pharmacotherapy versus existing treatments.

RESULTS

As most concepts were identified with the CE interviews, data reflect CE findings unless otherwise noted. Average age across CE/CD interviews was 49.4 years; a vast majority of participants used glasses for presbyopia treatment. Four themes related to treatment with glasses were identified with the interviews: inconvenience during daily activities, negative physical sensations around the eyes/head, limitations, and undesirable impacts on daily life (e.g., psychosocial). Most commonly, participants reported inconveniences related to forgetting glasses and psychosocial impacts (e.g., feeling/looking older). Strained/tired eyes and limited ability to see at varying distances were also reported. Among participants with near-vision glasses who provided data, two thirds expressed interest in alternative treatments. Additionally, almost three quarters of the participants ranked hypothetical eye drops as their first or second preferred option, versus reading glasses, contact lenses, magnifying glasses, and surgery.

CONCLUSIONS

This study explored the experience of living with and managing presbyopia, identified limitations and negative impacts of current treatments. Pharmacological development (e.g., eye drops) may fulfill an unmet need in the presbyopia treatment landscape.

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.

Near visual acuity and patient-reported outcomes in presbyopic patients after bilateral multifocal aspheric laser in situ keratomileusis excimer laser surgery

PURPOSE

To determine improvement of near visual acuity by bilateral multifocal aspheric laser in situ keratomileusis (LASIK) treatments in presbyopic patients.

SETTING

Goethe-University, Frankfurt, Germany.

DESIGN

Prospective, nonrandomized trial.

METHODS

Thirty presbyopic patients underwent LASIK treatment with a multifocal aspheric ablation profile using an excimer laser (PresbyMAX). The first 15 patients received a multifocal aspheric ablation profile combined with micromonovision. For the consecutive 15 patients, less depth of focus was included on the distance eye (hybrid). Outcome parameters were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected and distance-corrected intermediate visual acuities, uncorrected near visual acuity (UNVA), and distance-corrected near visual acuity (DCNVA); manifest refraction spherical equivalent; subjective quality of vision; and spectacle independence.

RESULTS

The data of 29 patients were analyzed and showed that binocular CDVA changed from -0.16 ± 0.10 logarithm of the minimum angle of resolution (logMAR) preoperatively to 0.05 ± 0.20 logMAR UDVA and -0.06 ± 0.14 logMAR CDVA (P = .000, P = .001) 1 year postoperatively. Near visual acuity improved from 0.47 ± 0.13 logMAR (DCNVA) and 0.48 ± 0.26 logMAR (UNVA) to 0.19 ± 0.19 logMAR (DCNVA, P < .001) and 0.05 ± 0.15 logMAR (UNVA, P < .001). The hybrid and the μ-monovision group did not differ statistically except for a better DCNVA in the µ-monovision patients (0.21 ± 0.15 logMAR vs 0.34 ± 0.17 logMAR, P = .034). Of the hybrid and µ-monovision patients, 21 (72%) and 12 (41%) had a binocular CDVA and UDVA of 20/20 or better, 8 patients (28%) lost 1 line, 3 (10%) lost 2 lines, 4 (14%) lost 3 lines, and 2 (7%) lost 4 lines of CDVA.

CONCLUSIONS

The PresbyMAX laser seemed to satisfy most of the patients, although they experienced a loss of CDVA. The gain of near visual acuity and therefore reported less need of spectacles seemed to compensate for this loss.

Clinical Outcomes After Phacoemulsification With Implantation of Trifocal and Toric Trifocal Intraocular Lenses

PURPOSE

To evaluate the visual and refractive outcomes, visual quality, patient satisfaction, and spectacle independence after phacoemulsification with bilateral implantation of a diffractive trifocal intraocular lens (IOL).

METHODS

The study sample comprised 36 consecutive patients (72 eyes). Twenty-three (64%) patients underwent refractive lens exchange and 13 (36%) underwent cataract surgery. Exclusion criteria included previous ocular surgery, corneal higher order aberrations of greater than 0.4 µm, angle kappa of greater than 0.6 mm, and corneal astigmatism of greater than 5.00 diopters (D). All eyes were targeted for emmetropia. A toric IOL was used in 35 (48.6%%) eyes with corneal astigmatism of greater than 1.00 D. Uncorrected distance visual acuity (UDVA) and distance-corrected visual acuity were measured at 4 m and 80 and 40 cm. Patients underwent routine ophthalmic examination for 6 months postoperatively. Patient satisfaction was assessed with a subjective questionnaire at 6 months postoperatively. A P value of less than .05 was statistically significant.

RESULTS

At 6 months postoperatively, the mean manifest refractive spherical equivalent was -0.01 ± 0.51 D. Binocular UDVA at 4 m and 80 and 40 cm was -0.02 ± 0.10, -0.07 ± 0.11, and 0.08 ± 0.10 logMAR, respectively. Binocular defocus curves presented two peaks of -0.07 and -0.02 logMAR for 0.00 and -2.00 D defocus, respectively. The Objective Scatter Index score decreased significantly in the cataract group and increased significantly in the refractive lens exchange group (P < .05, both cases). All patients were satisfied or very satisfied with the postoperative outcome.

CONCLUSIONS

Bilateral implantation of a diffractive trifocal IOL resulted in good visual performance at all distances with high patient satisfaction and spectacle independence at 6 months postoperatively. [J Refract Surg. 2021;37(6):372-379.].

Long-Term Evaluation of Visual Outcomes and Patient Satisfaction after Binocular Implantation of a Bioanalogic Lens

Purpose

Long-term evaluation of the visual refractive outcomes and the quality of life after implantation of the WIOL-CF (Medicem, Czech Republic) in both eyes.

Design

retrospective, nonrandomized noncomparative case series.

Methods

50 eyes of 25 patients, including 11 women (44%) and 14 men (56%). The age range of the patients was 38 to 77 years (mean age 55.48 ± 10.97 years). All patients underwent bilateral implantation of the WIOL-CF. Exclusion criteria were previous ocular surgeries except for cataract surgery and refractive lens exchange, irregular corneal astigmatism of >1.0 diopter, and ocular pathologies or corneal abnormalities. Postoperative examinations were performed at 14 days and 3, 6, 12 months of surgery; the last follow-up was between 24 and 36 months after the procedure. All exams included manifest refraction, monocular uncorrected visual acuity (UCVA) and distance-corrected visual acuity (DCVA) in 5 m (Snellen), monocular uncorrected visual acuity in 70 cm and 40 cm (Jeager) and binocular UCVA, DCVA in 5 m, 70 cm, and 40 cm, binocular contrast sensitivity (CS) under photopic conditions, binocular defocus curves, high-order aberrations, quality-of-vision VF-14 questionnaire, and spectacle independence.

Results

Significant improvement in monocular visual acuity at all distances was demonstrated; the mean postoperative spherical equivalent was 0.32 ± 0.45D. The postoperative means of binocular distance UCVA and BCVA were also improved (p < .001) and so were the mean uncorrected intermediate VA (2.053 ± 1.268) and near uncorrected VA (2.737 ± 1.447). There was a significant improvement in contrast sensitivity at all spatial frequencies and higher-order aberration, compared to preoperative results.

Conclusions

The evaluation of a WIOL-CF showed good distance, intermediate, and near visual acuity. Contrast sensitivity increased after surgery in all spatial frequencies. Patient satisfaction was high despite some optical phenomena. The rate of postoperative spectacle independence also turned out high. Financial Disclosure. No author has a financial or proprietary interest in any material or method mentioned.

Simulating Outcomes of Cataract Surgery: Important Advances in Ophthalmology

As the human eye ages, the crystalline lens stiffens (presbyopia) and opacifies (cataract), requiring its replacement with an artificial lens [intraocular lens (IOL)]. Cataract surgery is the most frequently performed surgical procedure in the world. The increase in IOL designs has not been paralleled in practice by a sophistication in IOL selection methods, which rely on limited anatomical measurements of the eye and the surgeon's interpretation of the patient's needs and expectations. We propose that the future of IOL selection will be guided by 3D quantitative imaging of the crystalline lens to map lens opacities, anticipate IOL position, and develop fully customized eye models for ray-tracing-based IOL selection. Conversely, visual simulators (in which IOL designs are programmed in active elements) allow patients to experience prospective vision before surgery and to make more informed decisions about which IOL to choose. Quantitative imaging and optical and visual simulations of postsurgery outcomes will allow optimal treatments to be selected for a patient undergoing modern cataract surgery.

One Year Outcome and Satisfaction of Presbyopia Correction Using the PresbyMAX® Monocular Ablation Profile

Purpose: To explore the safety, efficacy, and satisfaction of the PresbyMAX monocular mode for the correction of presbyopia. Methods: Prospective study. Twenty-two patients (mean age 50.6 ± 6.2 years, 11 myopia patients and 11 hyperopia patients) were enrolled. The dominant eye was fully corrected for distance vision; the non-dominant eye was corrected using central PresbyMAX monocular mode. Binocular uncorrected distance visual acuity (BUDVA), near visual acuity (BUNVA), intermediate visual acuity (BUIVA), corrected distance visual acuity (CDVA), and mean spherical equivalent (SE) were tested at 1 day, 1 week, 1 month, 3 months, and 1 year postoperatively. Questionnaire was performed preoperatively, 1 month, 3 months, and 1 year after surgery. Results: At the final visit, the mean safety index was 1.03 ± 0.14. There were 85.7% eyes with the same or better CDVA than the preoperative value, and 17.1% and 2.9% eyes gained 1 line and 2 lines of CDVA, respectively. All treated eyes achieved 20/25 or better BUDVA, and 95.5% achieved 20/32 or better BUNVA, which improved significantly compared with preoperative values (P < 0.001). BUDVA maintained stability from 1 month postoperatively, BUNVA and BUIVA kept stable since 1 week after surgery. Overall satisfaction was 95.5% (21/22) at 3 months visit, and 100% at the last visit. No differences in terms of visual acuity and satisfaction were found between the myopia and hyperopia groups. Conclusion: The PresbyMAX monocular ablation profile was safe and effective in treating presbyopia, with great satisfaction achieved at postoperative 1 year.

A comparative study on early vision quality after implantation of refractive segmental and diffractive multifocal intraocular lens

Objectives:

To compare early subjective and objective vision quality of postoperative patients undergoing phacoemulsification cataract surgery combined with implantation of refractive segmental multifocal intraocular lens (MIOL) SBL-3 and apodized diffractive MIOL SN6AD1.

Methods:

As a prospective study, it enrolled 53 patients (53 eyes) to undergo phacoemulsification cataract surgery combined with MIOL implantation. According to differences in MIOL implanted, patients were divided into a SBL-3 group (25 eyes) and a SN6AD1 group (28 eyes). Ophthalmological evaluation included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, uncorrected intermediate (UIVA) and near (UNVA) visual acuities, distance-corrected intermediate (DCIVA) and near (DCNVA)visual acuities and corrected near(CNVA) visual acuity, contrast sensitivity, modulation transfer function (MTF) and high order aberration (4 mm pupil diameter) at three months postoperatively. Moreover, a questionnaire survey was carried out to assess near spectacle independence, patient satisfaction and symptoms of visual disturbance.

Results:

At three months after surgery, UIVA and UNVA in the SBL-3 group are statistically significantly superior to those of the SN6AD1 group (P>0.05). There was statistical difference in contrast sensitivity at four spatial frequencies (3, 6, 12, 18cycles/degree) under mesopic conditions and mesopic conditions with glare (P>0.05). The total ocular high order aberration, coma and trefoil were statistically significantly larger in the SBL-3 group than in the SN6AD1 group with 4.0 mm pupil diameters (P>0.05). Statistical differences were found in the MTF at spatial frequencies of 5, 10 and 15 cycles/degree between the groups. There were no significant differences in spectacle independence, patient satisfaction and visual disturbance between the groups (P>0.05).

Conclusions:

Both the two multifocal intraocular lens provided an excellent level of quality of vision three months postoperatively. However, the application effect of SBL-3 MIOL is superior to that of SN6AD1 MIOL as far as intermediate vision, near vision and contrast sensitivity are concerned.

A preliminary study on the visual outcomes after LaserACE for presbyopia

Background

To investigate the visual outcomes over 1 year after laser anterior ciliary excision (LaserACE) procedure for presbyopic subjects.

Methods

A prospective, non-randomized, non-comparative study. Eight emmetropic eyes of four patients with presbyopia were included in this study. All eyes were treated with the LaserACE procedure using the VisioLite erbium-YAG laser (Ace Vision Group, USA). Subjects were assessed preoperatively and at 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year postoperatively. Outcome measures included questionnaires, visual acuity, manifest refraction, pupil size, keratometry, reading prescription, and intraocular pressure.

Results

Binocular distance corrected intermediate visual acuity (DCIVA) had improved from 0.33±0.12 logMAR to 0.12±0.12 logMAR after 6 months (P<0.05) and 0.13±0.12 logMAR after 12 months postoperatively (P<0.01). Binocular distance corrected near visual acuity (DCNVA) improved from 0.41±0.10 logMAR to 0.24±0.12 logMAR after 6 months (P<0.05) and 0.26±0.09 log MAR after 12 months postoperatively (P<0.05). An average decrease of 0.91±0.28 D in the reading prescription at a 40 cm reading distance was observed and remained stable over 12 months (P<0.05). There were no significant differences in manifest refraction, uncorrected distance visual acuity (UDVA), corneal curvature, high order aberrations, pupil size compared with preoperative and 6 months as well as 12 months postoperative visits (P>0.05).

Conclusions

The LaserACE procedure is shown to be safe and efficient for presbyopia correction without influencing distance vision or visual quality. However, its mechanism and long-term effects need further validation.

Objective optical quality and visual outcomes after the PresbyMAX monocular ablation profile

AIM

To assess objective visual quality after presbyopia correction using the PresbyMAX monocular mode.

METHODS

This prospective, nonrandomized study included 28 eyes from 18 patients (mean age 50.4±5.6y) who underwent presbyopia correction with the PresbyMAX monocular mode. Monocular and binocular visual acuities were evaluated preoperatively, 1d, 1wk, 1, 3mo, and 1y after surgery. Optical quality was analyzed by Hartmann-Shack wavefront aberration supported cornea ablation. Modulation transfer function (MTF) cutoff frequency, Strehl ratio, and objective scattering index (OSI) were analyzed using an optical quality analysis system.

RESULTS

One year after surgery, 100% and 94.4% of patients achieved binocular uncorrected distance and near visual acuity of 20/25, respectively. At the last visit Spherical aberration and total higher aberration were higher than the corresponding preoperative levels (P<0.001); however, no significant difference was found in MTF, OSI, or Strehl ratio. Transient decreases in OSI and MTF mainly occurred in the nondominant eyes. There was no significant difference in optical quality between the dominant and nondominant eyes, except for spherical aberration and horizontal coma (P<0.05).

CONCLUSION

The PresbyMAX monocular mode is safe and effective for presbyopia correction. It has little effect on optical quality, though short-term degraded optical quality occurred mainly in the bi-aspheric ablated eyes.

Sources of error in clinical measurement of the amplitude of accommodation

Measurement of the amplitude of accommodation is established as a procedure in a routine optometric eye examination. However, clinical methods of measurement of this basic optical function have several sources of error. They are numerous and diverse, and include depth of focus, reaction time, instrument design, specification of the measurement end-point, specification of the reference point of measurement, measurement conditions, consideration of refractive error, and psychological factors. Several of these sources of inaccuracy are composed of multiple sub-sources, and many of the sub-sources influence the common methods of measurement of amplitude of accommodation. Consideration of these sources of measurement error casts doubt on the reliability of the results of measurement, on the validity of established normative values that have been produced using these methods, and on the value of reports of the results of surgery designed to restore accommodation. Clinicians can reduce the effects of some of the sources of error by modifying techniques of measurement with existing methods, but a new method may further improve accuracy.

A 3-year follow-up study of a new corneal inlay: clinical results and outcomes

PURPOSE

Here, we report the results of a 3-year follow-up analysis of the outcomes of the Flexivue Microlens corneal inlay.

PATIENTS

Non-dominant eyes (n=31) of emmetropic presbyopic patients (spherical equivalent: -0.5 to 1.00 dioptre).

METHODS

A Flexivue Microlens corneal inlay was implanted after the creation of a 300 μm deep stromal pocket using a femtosecond laser. Patients were followed up according to a clinical protocol involving refraction, anterior segment imaging analysis (Oculyser), optical quality analysis (OPD-Scan), monocular binocular uncorrected and corrected visual acuity tests, contrast sensitivity measurements (photopic and mesopic), satisfaction questionnaire results and adverse event reporting.

RESULTS

Thirty patients were examined at the 3-year follow-up in this ongoing study. The mean uncorrected near visual acuity improved to Jaeger 1 in 76.9% of eyes treated with the inlays (vs 87.1% at the 1-year follow-up). All eyes improved four lines in all visits, except for four patients for whom the inlay was explanted. Patients reported that their near vision was good or excellent in 73.3% of cases (vs 90.3% in the first year). The UDVA remained stable over time. Three patients were explanted due to blurred vision for near-point and far-point distances. One patient developed a superficial corneal ulcer after 20 months. Two patients underwent cataract removal. Four patients underwent inlay exchange to increase near power correction.

CONCLUSIONS

The Presbia Flexivue Microlens provided presbyopia treatment by improving near vision. Manageable complications may occur over the long term.

CLINICAL TRIAL REGISTRATION NUMBER

U1111-1185-5684 and 0310451200000550.

Presbyopic Excimer Laser Ablation: A Review

PURPOSE

To provide an overview of the efficacy and safety of available presbyopic excimer laser ablation profiles.

METHODS

Literature review.

RESULTS

Monovision with excimer laser traditionally applies near correction to the non-dominant eye. Different excimer laser presbyopic approaches include the increase in depth of focus, through the controlled change of spherical aberration or asphericity, or multifocal ablation patterns with central or peripheral near vision zones. The studies investigating different excimer laser ablation patterns applied in previously myopic eyes revealed high levels of efficacy with all ablation profiles (between 68% and 99% achieving binocular uncorrected distance visual acuity [UDVA] of 20/25 or better, and between 70% and 100% achieving uncorrected near visual acuity [UNVA] presenting J3 or better). In hypermetropic eyes, most of the studies revealed high levels of efficacy with different platforms (between 78% and 100% achieving binocular UDVA of 20/25 or better and between 70% and 100% achieving UNVA presenting J3 or better). Loss of two or more lines of corrected distance visual acuity varied between 0% and 10% in the myopic eyes and between 0% and 14% in the hyperopic eyes.

CONCLUSIONS

There is evidence that excimer laser presbyopic strategies accomplish spectacle independence at reasonable levels. There are reliable and safe options for both myopic and hyperopic eyes with satisfactory outcomes regarding near and distance vision. [J Refract Surg. 2018;34(10):698-710.].

Impact of light conditions on reading ability following multifocal pseudophakic corrections

Purpose

To examine the impact of light intensity and temperature on reading performance following bilateral pseudophakic multifocal presbyopic correction.

Patients and methods

This is a prospective clinic-based trial conducted at the Department of Ophthalmology in the University Hospital of Alexandroupolis, Greece. Three groups of patients were formed (G1: patients with bilateral bifocal implantation, G2: patients with bilateral trifocal implantation, and control group: patients with bilateral pseudophakic monofocal implantation). Reading ability was quantified with the Greek version of MNREAD chart with minimal reading speed at 80 words/min for the following light intensities (25, 50, and 75 Foot-Candles [FC]) and temperatures (3,000, 4,000, and 6,000 K). Preferred light conditions for reading were assessed, as well. ClinicalTrials.gov Identifier: NCT03226561.

Results

Control group demonstrated significantly lower reading ability at all light combinations with maximal ability at 75 FC and 6,000 K (0.58±0.18 logMAR). Bifocal group presented a light-dependent reading ability that ranged from 0.45±0.08 logMAR (25 FC and 3,000 K) to 0.40±0.11 logMAR (75 FC and 4,000 or 6,000 K). Trifocal participants presented the best reading ability that was light intensity-independent; however, their performance was reduced at 6,000 K. G1 and G2 preferred primarily intermediate light temperature, while control participants preferred cold light temperature.

Conclusion

Multifocal pseudophakic corrections improve reading ability; however, they present variable efficacy according to the light conditions.

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.

Safety and satisfaction of myopic small-incision lenticule extraction combined with monovision

Background

To investigate the safety and optical quality of small-incision lenticule extraction (SMILE) combined with monovision, and patient satisfaction with the procedure.

Methods

The present study assessed a non-random case series involving 60 eyes of 30 patients (mean age 45.53 ± 3.20 years [range 41 to 52 years]) treated bilaterally using the VisuMax 500 system (Carl Zeiss Meditec, Jena, Germany) between January and July 2016. The target refraction was plano for the distance eye, and between − 0.5 and − 1.75 diopters (D) for the near eye. Visual acuity, refraction errors, ocular aberrations, and satisfaction questionnaire scores were calculated 1 year after surgery.

Results

All surgeries were uneventful, with a mean safety index of 1.03 and 1.04 in dominant and nondominant eyes, respectively. Binocular uncorrected distance visual acuity of all patients was ≥20/32, while binocular uncorrected near visual acuity was ≥20/40 1 year postoperatively. Higher-order aberration (0.45 ± 0.14, 0.51 ± 0.15 μm), spherical (0.18 ± 0.15, 0.21 ± 0.14 μm) and coma aberration (0.31 ± 0.16, 0.27 ± 0.17 μm) were identical between dominant and nondominant eyes after surgery. The overall satisfaction rate was 86.7% (26/30), with large contributions from age (OR = 1.76 95% CI: 1.03–2.53; P = 0.036). Binocular uncorrected distance visual acuity was related to preoperative spherical diopter (r = − 0.500; P = 0.005).

Conclusions

Monovision appears to be a safe and effective option for myopia patients with presbyopia who are considering the SMILE procedure. Patients with younger age were more satisfied with the procedure.

Monovision LASIK Versus Presbyopia-Correcting IOLs: Comparison of Clinical and Patient-Reported Outcomes

PURPOSE

To compare clinical and quality of life outcomes between patients who underwent monovision LASIK and refractive lens exchange.

METHODS

The study comprised 590 patients with refractive lens exchange and 608 patients with monovision LASIK available for 3-month postoperative clinical visits. All patients with refractive lens exchange had a Tecnis Symfony lens (Johnson & Johnson Vision Care, Inc., Santa Ana, CA) in at least one eye. Patients were divided into four refractive categories: moderate to high myopia, low myopia, plano presbyopia, and hyperopia. Three-month postoperative data were compared between monovision LASIK and refractive lens exchange for each group.

RESULTS

Postoperatively, the percentage of patients with binocular uncorrected distance visual acuity of 20/20 or better, for monovision LASIK and refractive lens exchange, respectively, was as follows: moderate to high myopia: 84.7% vs 90.7% (P = .31), low myopia: 89.4% vs 85.2% (P = .45), plano presbyopia: 90.5% vs 89.9% (P = .90), and hyperopia: 77.5% vs 84.2% (P = .03). For near vision, the percentage with binocular near visual acuity of 20/40 or better (J5) at 40 cm was as follows: moderate to high myopia: 98.9% vs 90.7% (P < .01), low myopia: 100% vs 98.1% (P = .17), plano presbyopia: 96.8% vs 95.8% (P = .34), and hyperopia: 95.6% vs 95.7% (P = .96). There was a statistically significant difference in patient satisfaction in favor of monovision LASIK for moderate to high myopia (94.3% for monovision LASIK vs 79.1% for refractive lens exchange, P <.01). For all other refractive categories, there was no significant difference in patient satisfaction. All myopic patients with refractive lens exchange experienced more postoperative visual phenomena than patients with monovision LASIK. The plano presbyopia group had comparable visual phenomena between the two procedures.

CONCLUSIONS

Monovision LASIK and refractive lens exchange are both reasonable options for presbyopic patients. [J Refract Surg. 2017;33(11):749-758.].

Visual quality assessment after presbyopic laser in-situ keratomileusis

AIM

To assess visual quality after presbyopia correction using an aspheric ablation profile and a micro-monovision protocol.

METHODS

This is a retrospective interventional study. Fifty-four eyes of 27 patients (mean age, 50.2±7.5y) who underwent presbyopia correction with an aspheric micro-monovision protocol were enrolled. The values of modulation transfer function (MTF) cutoff frequency, Strehl ratio, objective scattering index (OSI) and accommodation range were quantitatively assessed using the HD analyzer. Preoperative and postoperative contrast sensitivity (CS) at far (2.5 m) and near (40 cm) distance and higher-order aberrations (HOAs) were analyzed. Subjective visual satisfaction was evaluated by self-reported questionnaire regarding optical visual symptoms.

RESULTS

One year after presbyopia correction, no significant differences were found in the MTF cutoff frequency, Strehl ratio and OSI, however, the HD analyzer accommodation range significantly differed postoperatively (P=0.004). Postoperative CS at 12 and 18 cpd at near showed statistically significant improvement (P=0.020 and 0.008, respectively). Visual performance by self-reported questionnaire revealed satisfactory results in terms of subjective visual quality improvement.

CONCLUSION

Objective optical quality parameters show good visual outcomes. Subjective visual quality assessed by self-reported questionnaire in the presbyopia correction group show satisfactory results.

Scleral surgery for the treatment of presbyopia: where are we today?

Presbyopia corrections traditionally have been approached with attempts to exchange power, either at the cornea or the lens planes, inducing multifocality, or altering asphericity to impact the optical system. Treatments that affect the visual axis, such as spectacle and contact lens correction, refractive surgeries, corneal onlays and inlays, and intraocular lenses are typically unable to restore true accommodation to the presbyopic eye. Their aim is instead to enhance 'pseudoaccommodation' by facilitating an extended depth-of-focus for which vision is sufficient. There is a true lack of technology that approaches presbyopia from a treatment based or therapy based solution, rather than a 'vision correction' solution that compromises other components of the optical system. Scleral surgical procedures seek to restore true accommodation combined with pseudoaccommodation and have several advantages over other more invasive options to treat presbyopia. While the theoretical justification of scleral surgical procedures remains controversial, there has nevertheless been increasing interest and evidence to support scleral surgical and therapeutic approaches to treat presbyopia. Enormous progress in scleral surgery techniques and understanding of the mechanisms of action have been achieved since the 1970s, and this remains an active area of research. In this article, we discuss the historic scleral surgical procedures, the two scleral procedures currently available, as well as an outlook of the future for the scleral surgical space for treating presbyopia.

Correction of presbyopia: An integrated update for the practical surgeon

Presbyopia results from loss or insufficiency of the eye's accommodative ability, and clinically manifests as the inability to focus near objects on the retina. It is one of the most common causes of visual impairment worldwide especially in adults of productive or working age. Various means of compensating for the loss of accommodative ability have been devised from optical tools such as spectacles and contact lenses, to topical medications and to surgical procedures. A comprehensive search on journal articles about topical and surgical correction of presbyopia was undertaken. The various techniques for presbyopia correction, as enumerated in these articles, are discussed in this paper with the addition of our personal experience and perspective on the future of these techniques.

An Italian Translation and Validation of the near Activity Visual Questionnaire (NAVQ)

Purpose

To validate the Near Activity Vision Questionnaire (NAVQ) in Italian to allow the assessment of presbyopia corrections in Italian-speaking patients.

Methods

An Italian version of the NAVQ was arranged through several steps: an initial forward translation (from English to Italian), a backward translation (from Italian to English), and finally a consensual version to check against the original NAVQ. This prospective study enrolled native Italian-speaking presbyopic patients with corrected distance visual acuity of 0.20 logMAR or better in each eye and free of ocular anomalies. Six different groups of patients were asked to complete the questionnaire: emerging presbyopic patients, reading spectacle users, multifocal spectacle users, multifocal contact lens (CL) wearers, monovision CL wearers, and monofocal intraocular lens patients. Subjects were asked to answer the questionnaire again 2 weeks after the first completion.

Results

A total of 207 subjects completed the questionnaire. Data analysis showed good internal consistency (Cronbach α = 0.93) and factorial validity with only one factor explaining 62.0% of the variance. Test-retest reliability was extremely good (ICC = 0.92) as well as discriminatory power of the questionnaire's ability to discriminate between subjects with different forms of presbyopic correction.

Conclusions

The Italian version of the NAVQ matches the properties of the original English version. It is a valid instrument to evaluate near activity visual quality of presbyopic Italian speakers.

Review of Static Approaches to Surgical Correction of Presbyopia

Presbyopia is the primary cause of reduction in the quality of life of people in their 40s, due to dependence on spectacles. Therefore, presbyopia correction has become an evolving and rapidly progressive field in refractive surgery. There are two primary options for presbyopia correction: the dynamic approach uses the residual accommodative capacity of the eye, and the static approach attempts to enhance the depth of focus of the optical system. The dynamic approach attempts to reverse suspected pathophysiologic changes. Dynamic approaches such as accommodative intraocular lenses (IOLs), scleral expansion techniques, refilling, and photodisruption of the crystalline lens have attracted less clinical interest due to inconsistent results and the complexity of the techniques. We have reviewed the most popular static techniques in presbyopia surgery, including multifocal IOLs, PresbyLASIK, and corneal inlays, but we should emphasize that these techniques are very different from the physiologic status of an untouched eye. A systematic PubMed search for the keywords “presbylasik”, “multifocal IOL”, and “presbyopic corneal inlay” revealed 634 articles; 124 were controlled clinical trials, 95 were published in the previous 10 years, and 78 were English with available full text. We reviewed the abstracts and rejected the unrelated articles; other references were included as needed. This narrative review compares different treatments according to available information on the optical basis of each treatment modality, including the clinical outcomes such as near, intermediate, and far visual acuity, spectacles independence, quality of vision, and dysphotopic phenomena.

Comparison of clinical performance between trifocal and bifocal intraocular lenses: A meta-analysis

PURPOSE

To compare the clinical performance between trifocal and bifocal intraocular lenses in bilateral cataract and/or refractive lens exchange (RLE) surgery.

METHODS

A comprehensive literature search of PubMed, EMBASE, Cochrane Controlled Trials Register and Web of Science was performed through October 2016 to identify randomized, controlled trials (RCTs) and comparative cohort studies. The primary outcomes were uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), uncorrected near visual acuity (UNVA), defocus curve, spectacle independence, patient satisfaction and contrast sensitivity. The secondary outcomes were residual sphere, spherical equivalent (SE), cylinder and complications.

RESULTS

Six RCTs and 2 cohort studies including 568 eyes (278 in the trifocal group and 290 in the bifocal group) were identified. There was a statically significant difference between the two groups in UDVA (WMD: -0.03, 95% CI: -0.05 to -0.01, P = 0.005), but the difference (0.03 log MAR) is not clinically significant. Intermediate visual acuity was better in the trifocal IOL group judging from UIVA and defocus curves. There was a statically significant difference between the two groups in residual cylinder (WMD: 0.11, 95% CI: 0.02 to 0.20, P = 0.02), and subgroup AT Lisa tri 839MP trifocal also showed significant better UNVA than bifocal IOLs (WMD: -0.13, 95% CI: -0.17 to -0.08, P<0.00001). However, no significant differences were observed in UNVA (WMD: -0.04, 95% CI: -0.11 to 0.02, P = 0.19), spectacle independence (WMD: 1.27, 95% CI: 0.89 to 18.15, P = 0.07), patient satisfaction (WMD: 4.01, 95% CI: 0.07 to 22.72, P = 0.87), residual sphere (WMD: -0.03, 95% CI: -0.18 to 0.13, P = 0.74), SE (WMD: 0.04, 95% CI: -0.09 to 0.16, P = 0.55) or complications (WMD: 2.08, 95% CI: 0.35 to 12.43, P = 0.42).

CONCLUSIONS

Trifocal IOL technology (especially AT Lisa trifocal 839M trifocal) had a clear advantage over bifocal IOLs in intermediate visual acuity, while both trifocal IOLs and bifocal IOLs showed excellent performance in distance visual acuity. AT Lisa trifocal 839M trifocal could provide better uncorrected near visual acuity than bifocal IOLs. However, more evidence is needed to compare their spectacle independence, higher satisfaction rate, and photic phenomena.

Changes to Corneal Aberrations and Vision After Monovision in Patients With Hyperopia After Using a Customized Aspheric Ablation Profile to Increase Corneal Asphericity (Q-factor)

PURPOSE

To evaluate the visual outcomes and fourth-order Zernike spherical aberrations induced with a customized change in corneal asphericity (ΔQ) correction of presbyopia combined with monovision for hyperopic patients.

METHODS

Consecutive hyperopic patients who underwent presbyopic LASIK between September 2013 and July 2014 were included. For the non-dominant eyes, the aspheric ablation profile associated with a myopic refraction was planned using the Custom-Q nomogram (Alcon Laboratories, Inc., Fort Worth, TX). Uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), spherical equivalent refraction, ΔQ, and change in corneal spherical aberration coefficient (ΔC₄⁰) were analyzed. Postoperative data were collected at 1, 3, and 6 months.

RESULTS

Sixty-five patients were included. The mean age was 56.5 ± 5.7 years (range: 47 to 70 years). At the 6-month follow-up, the spherical equivalent refraction for non-dominant and dominant eyes was -1.07 ± 0.74 and 0.32 ± 0.55 diopters (D), respectively. The mean binocular UDVA was 0.01 ± 0.04 logMAR (range: -0.12 to 0.30 logMAR); 91% of patients achieved 20/20 or better binocular UDVA and 83% of patients had Jaeger 3 (Parinaud 4) or better binocular UNVA. The ΔQ for non-dominant and dominant eyes was -0.61 ± 0.15 and -0.33 ± 0.25, respectively, for a 6-mm pupil diameter and was significantly higher for non-dominant eyes (P < .0001). The achieved ΔC₄⁰ was -0.49 ± 0.23 µm for non-dominant eyes (for a theoretical ideal value of -0.40 µm) and -0.30 ± 0.18 µm for dominant eyes. For non-dominant eyes, the attempted ΔQ (-0.60) was close to the achieved value (-0.61 ± 0.15).

CONCLUSIONS

For hyperopic patients, combining the customized corneal aspheric ablation profile with monovision is safe, effective, and reproducible, inducing intended changes in corneal spherical aberrations. [J Refract Surg. 2016;32(11):734-741.].

Cataracts

An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. With the development of advanced technology in intraocular lenses, the combined treatment of cataract and astigmatism or presbyopia, or both, is possible. Paediatric cataracts have a different pathogenesis, surgical concerns, and postoperative clinical course from those of age-related cataracts, and the visual outcome is multifactorial and dependent on postoperative visual rehabilitation. New developments in cataract surgery will continue to improve the visual, anatomical, and patient-reported outcomes. Future work should focus on promoting the accessibility and quality of cataract surgery in developing countries.

Comparison between bilateral implantation of a trifocal intraocular lens and blended implantation of two bifocal intraocular lenses

Purpose

To compare visual outcomes and performance between bilateral implantation of a diffractive trifocal intraocular lens (IOL) Acrysof^®PanOptix^® TFNT00 and blended implantation of two different near add power bifocal IOLs: Acrysof^® Restor^® SV25T0 in dominant eye and Acrysof^® Restor^® SN6AD1 in the nondominant eye.

Methods

This prospective, nonrandomized, consecutive and comparative study assessed 20 patients (40 eyes) who had bilateral cataract surgery performed using the IOLs described. Patients were divided into groups, bilateral trifocal implant and blended implant. Evaluation included measurement of binocular uncorrected and corrected distance visual acuity at 4 m (UDVA, CDVA) and uncorrected intermediate (60 cm) and near (at 40 cm) visual acuity; contrast sensitivity (CS) and visual defocus curve.

Results

Postoperative CDVA comparison showed no statistical significance between groups. UDVA was significantly better in the trifocal groups. Under photopic conditions, the trifocal group had better CS in higher frequencies with and without glare. The binocular defocus curve demonstrated a trifocal behavior in both groups, with the bilateral trifocal group exhibiting better performance for intermediate vision.

Conclusion

Both lens combinations were able to provide good near, intermediate and distance vision, with the trifocal group showing significantly better performance at intermediate distances and better CS under photopic conditions.

Suppression of presbyopia progression with pirenoxine eye drops: experiments on rats and non-blinded, randomized clinical trial of efficacy

Various methods can correct presbyopia, but all require devices or surgeries. Recently, supplements or warming devices to relieve presbyopic symptoms have been developed, but no eye drops have been developed. We screened certain compounds possibly related to lens degeneration and identified pirenoxine, which has been used for cataracts, as a possible new pharmacologic treatment for presbyopia. We first researched the anti-presbyopic activity of pirenoxine in rats. The lens elasticity significantly (p = 0.028) increased with exposure to tobacco smoke for 12 days, and pirenoxine eye drops significantly (p < 0.001) suppressed lens hardening, which causes presbyopia in humans. In a parallel randomized controlled clinical study of the subjects in their fifth decade of life, the objective accommodative amplitude (AA) decreased significantly (p < 0.01) by 0.16 diopter (D) in the control group, and there was no detectable change in the treatment group after a 6-month treatment period, suggesting that pirenoxine eye drops might prevent progression of presbyopia. Subjects in their sixth decade of life, in whom the AA was already nearly 0 D, did not show similar results. Pirenoxine eye drops might be a new and the first pharmacologic treatment for preventing progression of presbyopia.

Non-lens-based surgical techniques for presbyopia correction

INTRODUCTION

Presbyopia is the most prevalent refractive error. With a progressive aging population, its surgical correction is an important challenge for the ophthalmology community, as well as the millions of patients who suffer from it, and who are increasingly demanding alternatives to its correction with glasses or contact lenses.

MATERIAL AND METHODS

A review is presented with a synthesised discussion on the pathophysiological theories of presbyopia and an updated and analytical description of the non-lens involvement surgical techniques used to treat presbyopia.

RESULTS

Corneal procedures include various types of corneal implants and photo-ablative techniques that generate a multifocal cornea, or monovision. Scleral procedures exert a traction on supralenticular sclera that supposedly would improve the amplitude of accommodation.

CONCLUSIONS

None of the techniques are able to completely eliminate the need for near -vision glasses, but many of them manage to improve the refractive status of the patients. More studies with rigorous and standardised methods and longer follow-up are needed to evaluate the changes in the near vision of the patients, in order to corroborate the real and practical usefulness of many of these techniques.

Visual outcomes 24 months after LaserACE

Background

To evaluate the effects on near and intermediate visual performance after bilateral Laser Anterior Ciliary Excision (LaserACE) procedure.

Methods

LaserACE surgery was performed using the VisioLite 2.94 μm erbium: yttrium–aluminum–garnet (Er:YAG) ophthalmic laser system in 4 oblique quadrants on the sclera over the ciliary muscle in 3 critical zones of physiological importance (over the ciliary muscles and posterior zonules) with the aim to improve natural dynamic accommodative forces. LaserACE was performed on 26 patients (52 eyes). Outcomes were analyzed using visual acuity testing, Randot stereopsis, and the CatQuest 9SF patient survey.

Results

Binocular uncorrected near visual acuity (UNVA) improved from +0.20 ± 0.16 logMAR preoperatively, to +0.12 ± 0.14 logMAR at 24 months postoperatively (p = 0.0014). There was no statistically significant loss in distance corrected near visual acuity (DCNVA). Binocular DCNVA improved from +0.21 ± 0.17 logMAR preoperatively, to +0.11 ± 0.12 logMAR at 24 months postoperatively (p = 0.00026). Stereoacuity improved from 74.8 ± 30.3 s of arc preoperatively, to 58.8 ± 22.9 s of arc at 24 months postoperatively (p = 0.012). There were no complications such as persistent hypotony, cystoid macular edema, or loss of best-corrected visual acuity (BCVA). Patients surveyed indicated reduced difficulty in areas of near vision, and were overall satisfied with the procedure.

Conclusions

Preliminary results of the LaserACE procedure show promising results for restoring visual performance for near and intermediate visual tasks without compromising distance vision and without touching the visual axis. The visual function and visual acuity improvements had clinical significance. Patient satisfaction was high postoperatively and sustained over 24 months.

Trial registration

NCT01491360 (https://clinicaltrials.gov/ct2/show/NCT01491360). Registered 22 November 2011.

Rotationally asymmetric multifocal intraocular lenses: preoperative considerations and postoperative outcomes

PURPOSE OF REVIEW

The manuscript presents a review of recently published studies reporting objective and subjective outcomes and preoperative considerations of asymmetrical multifocal intraocular lenses (IOLs).

RECENT FINDINGS

Current publications suggest that asymmetrical multifocal IOLs provide good, distance, intermediate and near vision for cataract and clear lens extraction patients. The contrast sensitivity achieved is similar to monofocal IOLs. Photopic phenomenon such as glare and halos has been reduced through the use of these IOLs leading to better patient satisfaction. Centration plays a critical role and the lack of a gold standard assessment tool has led to a minority of patients experiencing lower quality of vision and side-effects such as glare and hazy vision. The frequency of dissatisfied patients can be minimized by appropriate patient selection. This is achieved by assessing pupil parameters which guides the surgeon to align the IOL accordingly.

SUMMARY

Asymmetric multifocal IOLs provide the surgeon with an IOL that achieves excellent visual and refractive outcomes enabling patients to see clearly at a range of distances. Subjectively patients report low levels of photopic phenomena and high levels of spectacle independence resulting in high overall patient satisfaction.

Evaluation of activities of daily living following pseudophakic presbyopic correction

Background

Pseudophakic presbyopic correction is among the prevalent methods for regaining near vision capacity. The purpose of this study is to compare the impact of pseudophakic monovision correction and multifocal lens implantation on the performance in a series of activities of daily living (ADL) of presbyopic patients.

Methods

An ADL research framework (10 ADLs) was constructed and validated in a sample of patients divided into three validation groups according to their near visual acuity. Sixty-two participants that underwent mini-monovision (MoG) cataract extraction and 60 that underwent bilateral multifocal lenses implantation (MfG) populated study groups and addressed the ADLs. Binocular uncorrected distant (BdUVA) and near (BnUVA) visual acuity were associated with ADL scores and with subjective satisfaction using the VF-14 questionnaire.

Results

Test-retest reliability [all Intraclass Correlations Coefficients (ICC) >0.90] and construct validity (all p < 0.05) tests indicated sufficient psychometric performance of the ADL framework. Both study groups presented comparable mean ADL scores (p = 0.07) however, MoG patients had lower performance in demanding ADLs (p = 0.02). ADL scores demonstrated significant correlation with BnUVA (r² = −0.67, p < 0.01) VF-14 scores (r² = 0.53, p < 0.01).

Conclusions

Both methods provide sufficient near vision capacity for the majority of activities of daily living. However, only multifocal lens implantation can address demanding near vision tasks.

Trial registration

ClinicalTrials.gov Identifier: NCT02431156.