phaco ersatz how and why did it start ? where do we go? frank joseph goes [email protected]...
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PHACO ERSATZ HOW AND WHY DID IT START ? WHERE DO WE GO?
FRANK JOSEPH GOES [email protected] Antwerp-Belgium.
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PHACO ERSATZ WHAT DOES IT MEAN?????
REPLACING THE
NATURAL LENS OF
A 60 YEARS OLD
BY AN ARTIFICIAL
LENS PERFORMING
LIKE A
2O YEARS OLDESCRS 2011
WHY SHOULD WE REPLACE THE NATURAL LENS ? ACCOMODATION AGE
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WHAT IS ACCOMODATION ???
Described by HELMHOLTZ1853. Accommodation is the process by which
the eye changes its refractive power to bring objects of regard at different distances into focus.
During accomodation contraction of the ciliary muscle releases the at rest zonular tension around the lens equator and the lens increases in axial thickness and in anterior and posterior diameter.
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The principle of accommodation was discovered in the 17th century by Scheiner.
The theories for presbyopia are generally addressing the age changes in the lens, the lens capsule and/or within the lens support structures. Recent studies have shown that the stiffness of the lens substance increases with age by a factor 1000 to 10000 over a lifetime.
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. Loss of accommodative amplitude with age. Predicted by lens stiffness changes alone, compared to measured objective accommodative amplitude
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WITH AGE THE LENS CHANGES
the central thickness of the (disaccommodated) lens increases. the equatorial diameter of the (disaccommodated)lens does not change the surface curvatures of the (disaccommodated) lens increase the lens matrix loses its elasticity the mechanical properties of the capsular bag change the thickness of the lens capsule changes. The thickness of the anterior
capsule increases the thickness of the posterior pole shows no change with age and the
posterior peripheral thickness decreases the elasticity of the zonular fibers does not change there is no change in the number of zonular fibers the insertion points of the anterior zonular fibers stay fixed in relation to
the lens center, but shift in reference to the lens equator HENK WEEBER
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/Region Extrapolated Prevalence Population Estimated Used Presbyopia in North America (Extrapolated Statistics) USA 26,428,986 293,655,4051 Canada 2,925,708 WARNING! (Details) 32,507,8742 Mexico 9,446,363 WARNING! (Details) 104,959,5942 Presbyopia in Central America (Extrapolated Statistics) Belize 24,565 WARNING! (Details) 272,9452 Guatemala 1,285,253 WARNING! (Details) 14,280,5962 Nicaragua 482,378 WARNING! (Details) 5,359,7592 Presbyopia in Caribbean (Extrapolated Statistics) Puerto Rico 350,816 WARNING! (Details) 3,897,9602 Presbyopia in South America (Extrapolated Statistics) Brazil 16,569,099 WARNING! (Details) 184,101,1092 Chile 1,424,156 WARNING! (Details) 15,823,9572 Colombia 3,807,969 WARNING! (Details) 42,310,7752 Paraguay 557,223 WARNING! (Details) 6,191,3682 Peru 2,478,987 WARNING! (Details) 27,544,3052 Venezuela 2,251,564 WARNING! (Details) 25,017,3872 Presbyopia in Northern Europe (Extrapolated Statistics) Denmark 487,205 WARNING! (Details) 5,413,3922 Finland 469,306 WARNING! (Details) 5,214,5122 Iceland 26,456 WARNING! (Details) 293,9662 Sweden 808,776 WARNING! (Details) 8,986,4002 Presbyopia in Western Europe (Extrapolated Statistics) Britain (United Kingdom) 5,424,363 WARNING! (Details) 60,270,708 for UK2 Belgium 931,344 WARNING! (Details) 10,348,2762 France 5,438,179 WARNING! (Details) 60,424,2132 Ireland 357,260 WARNING! (Details) 3,969,5582 Luxembourg 41,642 WARNING! (Details) 462,6902 Monaco 2,904 WARNING! (Details) 32,2702 Netherlands (Holland) 1,468,637 WARNING! (Details) 16,318,1992 United Kingdom 5,424,363 WARNING! (Details) 60,270,7082 Wales 262,620 WARNING! (Details) 2,918,0002 Presbyopia in Central Europe (Extrapolated Statistics) Austria 735,728 WARNING! (Details) 8,174,7622 Czech Republic 112,156 WARNING! (Details) 1,0246,1782 Germany 7,418,214 WARNING! (Details) 82,424,6092 Hungary 902,913 WARNING! (Details) 10,032,3752 Liechtenstein 3,009 WARNING! (Details) 33,4362 Poland 3,476,371 WARNING! (Details) 38,626,3492 Slovakia 488,121 WARNING! (Details) 5,423,5672 Slovenia 181,032 WARNING! (Details) 2,011,473 2 Switzerland 670,578 WARNING! (Details) 7,450,8672 Presbyopia in Eastern Europe (Extrapolated Statistics) Belarus 927,946 WARNING! (Details) 10,310,5202 Estonia 120,749 WARNING! (Details) 1,341,6642 Latvia 207,567 WARNING! (Details) 2,306,3062 Lithuania 324,710 WARNING! (Details) 3,607,8992 Russia 12,957,665 WARNING! (Details) 143,974,0592 Ukraine 4,295,887 WARNING! (Details) 47,732,0792 Presbyopia in the Southwestern Europe (Extrapolated Statistics) Azerbaijan 708,154 WARNING! (Details) 7,868,3852 Georgia 422,450 WARNING! (Details) 4,693,8922 Portugal 947,173 WARNING! (Details) 10,524,1452 Spain 3,625,270 WARNING! (Details) 40,280,7802 Presbyopia in Southern Europe (Extrapolated Statistics) Greece 958,277 WARNING! (Details) 10,647,5292 Italy 5,225,172 WARNING! (Details) 58,057,4772 Presbyopia in the Southeastern Europe (Extrapolated Statistics) Albania 319,032 WARNING! (Details) 3,544,8082 Bosnia and Herzegovina 36,684 WARNING! (Details) 407,6082 Bulgaria 676,617 WARNING! (Details) 7,517,9732 Croatia 404,718 WARNING! (Details) 4,496,8692 Macedonia 183,607 WARNING! (Details) 2,040,0852 Romania 2,011,999 WARNING! (Details) 22,355,5512 Serbia and Montenegro 974,331 WARNING! (Details) 10,825,9002 Presbyopia in Northern Asia (Extrapolated Statistics) Mongolia 247,618 WARNING! (Details) 2,751,3142 Presbyopia in Central Asia (Extrapolated Statistics) Kazakhstan 1,362,933 WARNING! (Details) 15,143,7042 Tajikistan 631,040 WARNING! (Details) 7,011,556 2 Uzbekistan 2,376,937 WARNING! (Details) 26,410,4162 Presbyopia in Eastern Asia (Extrapolated Statistics) China 116,896,286 WARNING! (Details) 1,298,847,6242 Hong Kong s.a.r. 616,961 WARNING! (Details) 6,855,1252 Japan 11,459,970 WARNING! (Details) 127,333,0022 Macau s.a.r. 40,075 WARNING! (Details) 445,2862 North Korea 2,042,779 WARNING! (Details) 22,697,5532 South Korea 4,341,038 WARNING! (Details) 48,233,7602 Taiwan 2,047,485 WARNING! (Details) 22,749,8382 Presbyopia in Southwestern Asia (Extrapolated Statistics) Turkey 6,200,452 WARNING! (Details) 68,893,9182 Presbyopia in Southern Asia (Extrapolated Statistics) Afghanistan 2,566,230 WARNING! (Details) 28,513,6772 Bangladesh 12,720,642 WARNING! (Details) 141,340,4762 Bhutan 196,701 WARNING! (Details) 2,185,5692 India 95,856,354 WARNING! (Details) 1,065,070,6072 Pakistan 14,327,670 WARNING! (Details) 159,196,3362 Sri Lanka 1,791,464 WARNING! (Details) 19,905,1652 Presbyopia in Southeastern Asia (Extrapolated Statistics) East Timor 91,732 WARNING! (Details) 1,019,2522 Indonesia 21,460,765 WARNING! (Details) 238,452,9522 Laos 546,130 WARNING! (Details) 6,068,1172 Malaysia 2,117,023 WARNING! (Details) 23,522,4822 Philippines 7,761,752 WARNING! (Details) 86,241,6972 Singapore 391,850 WARNING! (Details) 4,353,8932 Thailand 5,837,897 WARNING! (Details) 64,865,5232 Vietnam 7,439,652 WARNING! (Details) 82,662,8002 Presbyopia in the Middle East (Extrapolated Statistics) Gaza strip 119,249 WARNING! (Details) 1,324,9912 Iran 6,075,288 WARNING! (Details) 67,503,2052 Iraq 2,283,722 WARNING! (Details) 25,374,6912 Israel 557,910 WARNING! (Details) 6,199,0082 Jordan 505,008 WARNING! (Details) 5,611,2022 Kuwait 203,179 WARNING! (Details) 2,257,5492 Lebanon 339,949 WARNING! (Details) 3,777,2182 Saudi Arabia 2,321,634 WARNING! (Details) 25,795,9382 Syria 1,621,518 WARNING! (Details) 18,016,8742 United Arab Emirates 227,152 WARNING! (Details) 2,523,9152 West Bank 208,008 WARNING! (Details) 2,311,2042 Yemen 1,802,238 WARNING! (Details) 20,024,8672 Presbyopia in Northern Africa (Extrapolated Statistics) Egypt 6,850,567 WARNING! (Details) 76,117,4212 Libya 506,842 WARNING! (Details) 5,631,5852 Sudan 3,523,334 WARNING! (Details) 39,148,1622 Presbyopia in Western Africa (Extrapolated Statistics) Congo Brazzaville 269,823 WARNING! (Details) 2,998,0402 Ghana 1,868,132 WARNING! (Details) 20,757,0322 Liberia 305,157 WARNING! (Details) 3,390,6352 Niger 1,022,448 WARNING! (Details) 11,360,5382 Nigeria 1,597,532 WARNING! (Details) 12,5750,3562 Senegal 976,693 WARNING! (Details) 10,852,1472 Sierra leone 529,550 WARNING! (Details) 5,883,8892 Presbyopia in Central Africa (Extrapolated Statistics) Central African Republic 336,823 WARNING! (Details) 3,742,4822 Chad 858,468 WARNING! (Details) 9,538,5442 Congo kinshasa 5,248,532 WARNING! (Details) 58,317,0302 Rwanda 741,480 WARNING! (Details) 8,238,6732 Presbyopia in Eastern Africa (Extrapolated Statistics) Ethiopia 6,420,291 WARNING! (Details) 71,336,5712 Kenya 2,968,389 WARNING! (Details) 32,982,1092 Somalia 747,414 WARNING! (Details) 8,304,6012 Tanzania 3,246,371 WARNING! (Details) 36,070,7992 Uganda 2,375,123 WARNING! (Details) 26,390,2582 Presbyopia in Southern Africa (Extrapolated Statistics) Angola 988,069 WARNING! (Details) 10,978,5522 Botswana 147,530 WARNING! (Details) 1,639,2312 South Africa 4,000,362 WARNING! (Details) 44,448,4702 Swaziland 105,231 WARNING! (Details) 1,169,2412 Zambia 992,312 WARNING! (Details) 11,025,6902 Zimbabwe 330,467 WARNING! (Details) 1,2671,8602 Presbyopia in Oceania (Extrapolated Statistics) Australia 1,792,182 WARNING! (Details) 19,913,1442 New Zealand 359,443 WARNING! (Details) 3,993,8172 Papua New Guinea 487,825 WARNING! (Details) 5,420,2802
About extrapolations of prevalence and incidence statistics Read more at http://www.wrongdiagnosis.com/p/presbyopia/stats-country.htm?ktrack=kcplink Read more at http://www.wrongdiagnosis.com/p/presbyopia/stats-country.htm?ktrack=kcplink
IMPORTANCE !!!!Prevalance Rate for Presbyopia:Approx 1 in 11 = 9.00% or 24.5 M. people in USARead more at http://www.wrongdiagnosis.com/p/presbyopia/stats-country.htm?ktrack=kcplink
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CONCEPTS OF RESTORING ACCOMODATION MONOVISON:not physiological LASER TREATMENT OF THE CORNEA?monovion
multifocality -the problem is not there SCERAL EXPANSION PROCEDURES :doubtful
results ACCOMODATIVE LENSES -DEFORMABLE
ACCOMODATING IOLS Mechanical concepts based on axial shift
principle have very limited accomodative effect
REFILLING THE EMPTY LENS CAPSULE:WITH SOFTER MATERIAL experimantal stage !!!! See later
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HOW TO MAKE A BETTER LENS ?
A more basic treatment should be derived from treating the root cause of presbyopia:
to make the lens substance softer A newer technique - currently proposed -
consists of mechanically softening the lens substance using femto-second laser pulses
Or one can insert an ersatz lens available now
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FUTUREEUROTIMES DOUGH KOCH
IN REFRACTIVE AND CATARACT SURGERY PRESBYOPIA CORRECTION WILL BECOME THE NORM
THE HOLY GRAIL OF ACCOMODATIVE LENSES IS BECOMING CLOSER BUT HOW CLOSE?
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LET US CONCENTRATE ON THE PHACO ERSATZ
HOW TO BRING A NEW ARTIFICAL BETTER FUNCTIONING LENS
IN AN OLDER EYE
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THE EYE IN HISTORY IMPORTANT DISCOVERIES
HOW FAR ARE WE NOW?
HOW SLOW DID IT GO UNTILL NOW !
WHAT WILL THE FUTURE BRING?
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DISCOVERY OF LIGHT
At that time the popular belief was the emanation hypothesis of vision,advanced by Pythagoras (c. 600 B.C.) and accepted by such classical writers as Euclid, Hipparchos and Ptolemy and after them by Galen.
In this hypothesis the visual spirit originating in the brain emanated from the lens (the essential organ of vision) forming a cone of linear
At C
wave–particle duality, described by
Albert Einstein in the early 1900s,
IBN al-Haitham (965-1040
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DISCOVERY OF SPECTACLES
Venice Murano 1270 and 1280. Gutenberg’s invention of the printing press 1450
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DISCOVERY OF ANATOMY AND FUNCTION OF THE EYE
Georg Bartisch(1535-1606) surgeon and oculist of Dresden published the first systematic work on ocular disease
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JACQUES DAVIEL FRANCE 1745FIRST REAL CATARACT SURGERY ECCE
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HAROLD RIDLEYTHE FIRST IOL 1949
Sir Harold Ridley and his wife-medal received at the knighthood ceremony
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CHARLIE KELMAN
receiving presedential award from G.Bush Sr.
Modern Era of cataract surgery 1967
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1987 JEAN MARIE PAREL PHACO ERSATZ
The Ophthalmic Biophysics Center
created in 1970 - Bascom Palmer-
director Dr. Edward Norton and Dr. Parel
WHAT HAPPENED SINCE THEN ????
PERSONAL EXPERIENCE
TRUE VISTA STORZ 3 ZONE DESIGN 1992
3M APODIZED PRINCIPLE 1992 ESCRS 2011
FDA PANEL RECOMMENDS APPROVAL OF 3M MULTIFOCAL INTRAOCULAR LENS ST. PAUL, Minn., Jan. 23 /PRNewswire/ -- The Food and Drug Administration's Ophthalmic Advisory Panel today recommended approval with conditions, of the 3M (NYSE: MMM) brand Multifocal intraocular lens (IOL) for sale in the United States. The conditions are related mainly to labeling. The FDA relies on the clinical expertise of the advisory panels to guide its decisions. Generally, approval to market follows advisory panel recommendation. "The advisory panel's recommendation represents an important step forward in making this advanced lens available to ophthalmologists for treatment of cataract patients in the United States," said Robert B. Bomar, manager, 3M Vision Care. "The lens will be commercially available only after final approval by the FDA," Bomar added. Since 1987, the lens has been implanted in approximately 30,000 cataract patients worldwide. Of those, over 700 were involved in the U.S. study, which is currently under review by the FDA. An individual who undergoes cataract surgery and receives a conventional monofocal lens implant typically needs to wear eyeglasses, usually bifocals, following surgery to achieve acceptable near and far vision. The majority of patients implanted with bilateral 3M Multifocal IOLs, however, do not need to wear bifocals; and about half of these patients function entirely without the aid of eyeglasses. The lens has been available for sale to ophthalmologists in most countries for over two years. In March 1991, the 3M Multifocal intraocular lens was the first multifocal lens to receive commercial marketing approval from Japan's Ministry of Health and Welfare. -0-
01/23/92 ESCRS 2011
DID IT WORK ?DID IT LAST?
YES IT WORKED !! BUT NO SMALL INCISION POSSIBLE
SINCE NO Foldable IOL 6 -6.5 mm. PMMA MATERIAL NEEDED SUTURING CREATED ASTIGMATISM SO IT WAS NOT THE FINAL SOLUTION
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WHERE DO WE GO?
PREDICTION IS VERY DIFFICULT SPECIFICALLY ABOUT THE FUTURE
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Newer succesfull models
ALCON RESTOR/old 3M apodized principle 2001
ABBOTT AMO TECNIS:Ring principle 2003 Later on adapations;
add on near zone
material changes etc.etc.etc.etc.
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Tecnis One Piece ZMBOO
Full diffractive posterior surface
Wavefront-designed aspheric anterior surface
Newest generation Acrylic material
Near addition +4D=3.1 pupil plane
One piece iol :+5.0 D to +34.0 D in 0.5 D increments
Ease of insertion
Performance is Pupil Independent
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New trends EUROTIMES MAY 2011TOO MANY TO BE GOOD
Dual optic Synchrony -iol more effect for less movement-2.5 D pro 1 mm.
Opti-K new form of laser thermal keratoplasty LTK.Adv.it can be repeated
why?because regression Palliklaris group:WIOL-CF accomodative
iol2D of pseudo-accomodation. ??ESCRS 2011
INJECTABLE ACCOMODATIVE LENSES-AN INJECTED GEL LENS
IS NOT A NEW CONCEPT !!!! MATERIAL USED_SILICONE-polyethelene-
poloxamer-monomer mixture-silicone polymer gel
1975-1986-1992-1998-2003 First publ:1964 Kessler J.Arch.ophtahl.
71,412-417 Experiments in refilling the lens.
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SOME MAJOR PROBLEMS REMAIN
CREATING A MINICAPSULORHEXIS<2MM: we need innovative instruments and extensive surgical training
PHACO THROUGH A 1 MM HOLE :innovative approach
SEALING THE MICROCAPSULORHEXIS : to prevent leakage
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SOME MAJOR PROBLEMS REMAIN
POLYMER BIOCOMPATIBILITY: many materials used for iols have passed years of biocompatibility testing.
LENS CAPSULAR VOLUME VARIABILITY:varies among patients-the optimum volume should be controlled for each different eye.
POLYMER REFRACTION:desired refraction will be different for each patient-controlling the amount of gel is a challenge.
PREVENTING PCO: challenge yag has to be avoided because will create leakage of the injected gel
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FACTS
PCO PREVENTION WILL REMAIN THE PROBLEM NR 1
New materials Guthoff Rostock:pure water-methotrexate mtx antimetabolite-Actinomycin AM = antibioticun-Daunomycin-Disulfiram.
Untill now tested:
-Cytostatic drugs:5Fluouracil-Colchicine-Doxoribin-Mitomycin C-Methotrexate-Doxorubicin
Anti-inflammatory: Diclofenac-dexamethasone
Immunological agents:cyclopsorine A
Further Investigations involving non-primates are needed
Cave:Endothelial cells ESCRS 2011
A PARADIGM SHIFT NEEDED?INVENTION OFTrain 1803Bicycle 1839 !!!
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MULTIFOCAL IOLS WILL BE HERE FOR ANOTHER10 -15 YEARS BUT THEY WILL IMPROVE !
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WILL EVENTUALLY THE DREAM OF PHACO ERSATZ COME REALITY ?
PROBABLY YES
BUT WE NEED
MORE TIME
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