presbyopia abolfazl kashfi md isfahan medical university
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Presbyopia
Abolfazl Kashfi MDIsfahan Medical University
Monovision
Definition :One eye for far full correction, one eye for near (33 cm) or intermediate (50 cm) correction
Patient selection :Patient’s needs: Suitable for those need far and near vision intermittently. Dominant eye: Dominant eye for far Tolerance: Contact lens trial , strong sighting preference , history of monovision Sex: Females less likely to reject monovision
Monovision
Methods: contact lens (since 1958,Westsmith) corneal surgery IOL surgery
Usually 1.25-2.00 D at most 3.00 D
Monovision
Advantages Limitations
Spectacle freeHigh level of satisfactionAcceptable stereopsisStable VFPhysician friendlyLess susceptible to decentrationLess halo or glare VS multifocal IOLsEasy glasses correction
Decreased contrast sensitivityBlurred vision while night drivingBlurred intermediate VF defect(?)Challenging preop in cataract
MonovisionLASIK
Garcia-Gonzalez et al 2010
Reinstein DZ et al 2010
Reinstein DZ et al 2009
Levinger E et al 2006
Reilly CD et al 2006
Miranda D, Krueger RR 2004
Goldberg DB 2003
0.97 D difference monovision LASIK correction is a valid and good method
The non-linear aspheric myopic micro-monovision protocol (Carl Zeiss Meditec CRS-Master software and MEL 80 excimer) is well-tolerated, stable, and effective (presbyopia in moderate to high myopic astigmatism) (1-1.5 D difference)
Hyperopic micro-monovision protocol (micro-monovision with the Carl Zeiss Meditec MEL80 platform) was a well-tolerated and effective procedure for treating patients with presbyopia in moderate to high hyperopia (1-1.5 D difference)
Monovision LASIK is valuable but be cautious for patients in whom night driving and/or reading are an essential part of their life
patient satisfaction is good after monovision LASIK but a contact lens trial is advisable
monovision is a valuable option for pre-presbyopic and presbyopic patients considering refractive surgery
Hyperopic monovision was a viable but more problematic solution to correcting presbyopia than myopic monovision
MonovisionIOL
Hayashi et al 2010
Stanojcic et al 2010
Ito M, Shimizu K 2009
Ito M et al 2009
Finkelman YM et al 2009
Marques FF et al 2009
Evans BJ 2007
Greenbaum S 2002
1.5 D difference has a 20/20 far and acceptable near and stereo acuity
VF defects are of interest in far-dominant eye (UK driving license criteria)
The monovision method group had better reading ability than MF IOL group
Pseudophakic monovision is effective after cataract surgery in patients older than 60 years (2.27 D mean difference)
Monovision with modest refractive targets achieved good visual function and patient satisfaction (1-1.5 D difference)
A viable technique for correction of near, intermediate and distant vision on cataract surgery with high rate of satisfaction (2 D difference)
The main limitations are problems with suppressing the blurred image when driving at night and the need for a third focal length, for example with computer screens at intermediate distances. Stereopsis is impaired in monovision, but most patients do not seem to notice this (literature review)
Pseudophakic monovision provided a high level of satisfaction
PresbyLasik
Definition: Making cornea multifocal using excimer laserNormal human cornea is aspheric instead of multifocal
Three approaches : 1 Multifocal transitional 2 Peripheral PresbyLasik (Center for distance and midperipheral for near)3Central PresbyLasik (Hyperpositive center for near and leaving periphery for far)
PresbyLasikMultifocal transitional
An intentionally decentered Hyperopic ablation to produce a transitional vertical multifocality ,inducing a significant vertical coma
An old technic / Very few publications /Not generally accepted and now abandoned because of doubtful quality of vision
PresbyLasikperipheral presbyLasik
Center left for distance and the periphary ablate in a manner which produces a negative aspherisity and a 3 diopter pseudoaccommodation in 4mm pupil VISX, Zeiss, Nidek, Wave light-Allegrato
A good DOF but There is an interaction with myopic correctionMost studies done in hyperopes 8/10 to 10/10 far vision and J2 for near6 month neuroadaptation required
PresbyLasikCentral presbyLasik
A central hyperpositive area for near and periphery left for far
Much prolate cornea much depth of field (KC)
Can perform in myopes , hyperopes or emmetropes ,even previous LASIK Minimal tissue ablation8/10 to 10/10 far vision and J2 for near
Pupil dependentCentration is very important ,it is up to induce coma aberration
Femtosecond assisted Intracor
First introduced by Ruiz et al in 2009 (83 eyes)followed by Holzer et al in 2009 (25 non dominant eyes)They used TECHNOLAS femtosecond platform to make a series of concentric intrastromal cuts for presbyopic emetrrops/hyperops .They made some intrastromal radial cuts to treat distance vision of presbyopic myops.The produced Hyperprolate cornea will give a better near vision while distance vision is preserved.(negative shift of primery spherical aberrations and positive shift of secondary aberrations)
Video from www.technolaspv.com
The strongest lamellae of cornea are in the anterior one third of cornea ;during INTRACOR anterior cornea remains intact to avoid uncontrolled ecstasia
• INTRACOR1.avi
Femtosecond assisted Intracor
AdvantagesPainless ,high level of satisfaction Minimally invasive (Epithelium, Bowman, descemet and endothelium are intact)/ minimal risk of infectionShort treatment time Significant and rapid near vision improvement Improves depth of focus Minimal changes of CDVAMinimal myopic shift (0.3 D)Minimal endothelial changeStable corneal thicknessstable contrast sensitivityStable total and higher order aberrations
Femtosecond assisted Intracor
Disadvantages:Few patients loss 1 to 2 lines of CDVASymptomatic halo (30% day one , 3% after one year)Not suitable for scotopic pupil > 6.5 mmMany unknowns ? Centering ? Retreatment
Corneal inlaysFlexivue microlens
A 3mm hydrophilic lens with 15 microns thickness under aFemtosecond made corneal pocket to correct 2.5 D to 3.5 D presbyopia of non dominant eyes
Reported by Pallikaris 2010One year follow up100% improvement 92% Nea spectacle freeMean UCNVA after 3 month 20/25Mean UCDVA after 6 month 20/30It has CE but not FDA approval
Corneal inlaysKAMRA inlay
A 3.8 mm 10 microns thickness implant with a 1.6 mm central hole under a femtosecond made corneal flap to correct vision via pinhole effect
Polyvinylidine flouride polymer with 1600 nutritional holesFormerly AcuFocusReported by Durrie 201036 months follow upMean distance vision 20/20Mean near vision J1It has CE but not FDA approval (there is an ongoing 504 patients study in US)
Corneal inlaysKAMRA inlay
Thanks