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Trust your eyes.
Presbyopic treatment methods on the cornea
PresbyMAX®– The Principle
PresbyMAX® – Expectations and Key Factors
PresbyMAX®– Upcoming Software Features
PresbyMAX®– Decision criteria and patient’s acceptance
Directory
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0%
20%
40%
60%
80%
100%
120%
0 1 2 3 4 5 6 7 8
Object distance (m)
Vis
ual A
cuity
(%
)
Emmetrope 25yo
Emmetrope 45yo
Emmetrope 55yo
0%
20%
40%
60%
80%
100%
120%
0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00
Object distance (m)
Vis
ual A
cuity
(%
)
Emmetrope 25yo
Emmetrope 45yo
Emmetrope 55yo
Introduction and Basics:Visual Acuity and Object Distance related to Age
The average distance (more than 1 m) visual acuity in emmetropes until 45 years of age is high, the senior population shows diminished performance.
The average near (less than 1 m) visual acuity in emmetropes until 40 years of age is ok, the senior population shows diminished performance.
Advantage/Comfort Disadvantage/Discomfort
Introduction and Basics:Monovision
Clear focus, i.e. sharp retinal image Anisometropia (more than 1 D)
Highly accept in patients and physicians Loss in stereopsis
Independent from pupil size
near
intermediate
farDE
NDE
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Advantage/Comfort Disadvantage/Discomfort
Introduction and Basics:Bi-Focality
Clear foci; i.e. two sharp images on the retinaDisturbing vision because of „steps“ between zones
Does typically not cover the whole distance range, especially not the intermediate part
Pupil size critically dependent
near
intermediate
far
OR
DE
NDE
Advantage/Comfort Disadvantage/Discomfort
Introduction and Basics:Q-value adjusted
Extended depth-of-focusThe Q-value is no predictor for visual performance
The Q-value describes the shape between the cornea centre and periphery
Influenced by the change in radius of curvature (dioptric power); i.e. kind of unpredicted
Unilateral (non-dominant eye)
near
intermediate
far
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Advantage/Comfort Disadvantage/Discomfort
Introduction and Basics:Multifocality
Covers the whole distance range due to different foci for distance, intermediate, near
Pupil size dependent
Typically bilateral which keeps stereopsis Time of (neural) adaptation
Possibly reduced contrast sensitivity
near
intermediate
far
OR
DE
NDE
micro-monovision (ZEiSS) Aspheric (Nidek) PresbyM AX PresbyMAX µ-monovision
DominantEye
Non-dominantEye
near
far
near
far
near
far
near
far
SCHWIND PresbyMAX®
vs. Competing Multifocal Technologies
near
intermediate
far
near
far
near
far
far
near
far
near
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Near(40cm)
Intermediate(70cm)Far (>5m)
MonovisionDENDE
AMO VISXCustomVue Presbyopia
DENDE
Technolas PVSupracor
DENDE
NidekPAC Aspheric
DENDE
ZEiSSLaser Blended Vision
DENDE
Alcon WavelightQ-value adjusted
DENDE
SCHWIND PresbyMAX
DENDE
SCHWIND PresbyMAX µ-
monovision
DENDE
SCHWIND PresbyMAX®
vs. Competing Technologies
Alternative Presbyopic Solutions:IntraCOR
Advantage/Comfort Disadvantage/Discomfort
No refractive correction procedure, i.e. for „emmetropes“ only Fast visual recovery
No reverse application or re-treatmentMinimally invasive
Difficulties in post-LASIK patients exist
Intrastromal presbyopia treatment using photodisruption with the Technolas femtosecond
• Five rings (1.8, 2.2, 2.6, 3.0 and 3.4 mm in diameter) are created
• Cutting design and stromal depth based on refractive error
• A shift towards myopia exists due to central corneal steepening (hyper-prolate shape)
Difficulties for LASIK post-IntraCOR
No tissue removal
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Alternative Presbyopic Solutions:Corneal Inlay
Advantage/Comfort Disadvantage/Discomfort
Easily removed or replacedNo refractive correction procedure, i.e. for „emmetropes“ only
Increased depth-of-focus without tissue removal
Really fast recovery
Intracorneal inlays have been designed to create a small aperture effect or central steepening.The implant is intended to be placed intra-stromally either under a corneal flap or into a cornealpocket. Placement of the CI will be centered over the pupil, typically in the non-dominant eye.
I. The AcuFocus Kamra corneal inlay (US): Ø 3.8 mm, 10 µm thick, central opening of Ø 1.6 mm, thousands of small laser openings for good corneal nutrition transport
II. Flexivue Micro-Lens (NL): clear circular implant of Ø 1.5 mm, 10 µm thick in the periphery, increase of 24 to 40 µm to the centre, out of hydrogel (hydrophilic polymer)
III. PresbyLens (US): clear circular implant of Ø 2 mm – like a tiny contact lens – out of hydrogel
Before PresbyMAX ® With PresbyMAX ®
Presbyopia software that offersa broad treatment spectrum for different indications:
Treatment of emmetropic, myopic,hyperopic, and astigmatic eyes
Correction of these visual defects can beperformed as “Aberration-Free” or“Customized” treatments
Any treatment method possible:PRK, TransPRK, LASEK, LASIK and FemtoLASIK
Limited treatment range
e.g. only hyperopic patients
e.g. only patients with minor astigmatism
e.g. no presbyopia treatment ofemmetropic or myopic patients
e.g. only in combination with standardtreatments
e.g. only in combination with wavefrontguided treatments
PresbyMAX® - Unique Treatment Range
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extendeddepth-of-focus
PresbyMAX®
pseudo-far-point
PresbyMAX®
pseudo-near-point
foveola
PresbyMAX®
multiaspheric cornea
PresbyMAX® - The Principle
Introduction and Basics:Visual Acuity Scales
Near Visual Acuity Scales
logRAD(40 cm)
Revised Jaeger(35 cm)
Nieden(40 cm)
-0.2 - -
-0.1 - N1
0.0 J1: = 1.00 N2
0.1 J2: = 0.80 N3
0.2 J4: = 0.63 N4
0.3 J5: = 0.50 N5
0.4 J6: = 0.40 N6
0.5 J8: = 0.32 N7
0.6 J9: = 0.25 N8
0.7 J10: = 0.20 N9
0.8 J12: = 0.16 N10
0.9 J13: = 0.13 N11
1.0 J14: = 0.10 N12
Distance Visual Acuity Scales
logMAR feet20/
decimal
-0.2 10 1.60
-0.1 12.5 1.25
0.0 20 1.00
0.1 25 0.80
0.2 32 0.63
0.3 40 0.50
0.4 50 0.40
0.5 63 0.32
0.6 80 0.25
0.7 100 0.20
0.8 125 0.16
0.9 160 0.13
1.0 200 0.10
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PresbyMAX® - ExpectationsReading Acuity vs. Print Size
» 0.4 logRAD (J6; 20/50) ≡ 10 Pt @ 40 cm
» 0.5 logRAD (J8; 20/63) ≡ 12 Pt @ 40 cm
» 0.7 logRAD (J10; 20/100) ≡ 18 Pt @ 40 cm
» 0.8 logRAD (J12; 20/125) ≡ 20 Pt @ 40 cm
» 0.2 logRAD (J4; 20/30) ≡ 6 Pt @ 40 cm
normally suffices to clearly recognize newspaper print in well lit conditions
Pupil ∅ 3.0 mm 3.8 mm 4.5 mm 5.5 mm
Far
(6 m)
Far Intermediate
(1.5 m)
Intermediate
(70 cm)
Near
(40 cm)
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Visual Acuity as a function of the object distance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4 5 6 7 8
Object distance (m)
Vis
ual A
cuity
(%
)
PresbyMAX V2 +3D (6 mm)
PresbyMAX V2 +3D (3,8 mm)
PresbyMAX V2 +3D (2 mm)
Visual Acuity as a function of the object distance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00
Object distance (m)
Vis
ual A
cuity
(%
)
PresbyMAX V2 +3D (6 mm)
PresbyMAX V2 +3D (3,8 mm)
PresbyMAX V2 +3D (2 mm)
Visual Acuity after PresbyMAX®
related to different Pupil Sizes
Visual Acuity as a function of the object distance
0%
20%
40%
60%
80%
100%
120%
0 1 2 3 4 5 6 7 8
Object distance (m)
Vis
ual A
cuity
(%
)
Emmetrope (55 yo)
PresbyMAX V2 +2D (50 yo)
PresbyMAX V2 +3D (60 yo)
Visual Acuity as a function of the object distance
0%
20%
40%
60%
80%
100%
120%
0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00
Object distance (m)
Vis
ual A
cuity
(%
)
Emmetrope (55 yo)
PresbyMAX V2 +2D (50 yo)
PresbyMAX V2 +3D (60 yo)
As a compromise between multifocality, distance and near UCVAs, consider planning additions between 1.25 D to 2.50 D
Visual Acuity after PresbyMAX®
related to different Additions
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PresbyMAX® - ExpectationsUncorrected Visual Acuity over time
10
15
20
25
30
35
400 1 2 3 4 5 6 7 8 9 10 11 12
Follow-up time (months)
DU
CV
A (20
/n)
1
2
3
NU
CV
A (Jm
)
DUCVA (20/n)NUCVA (Jm)
The postoperative progress behaves in all refraction types similar but the acceptance patient by patient may differ.
PresbyMAX® - Key Factors for Success
Patients with positive thinking preoperatively knowing that reduced distance vision postoperatively (DBCVA pre-op vs. UCVA post-op) may occur.
Trial with multifocal contact lenses (centre for near, periphery for distance) could be done prior to surgery or easier, even if no influence/effect in multifocality (SphAb) can be demonstrated, simulate a vision of 1 to 2 lines less than BSCVA and ask for the postoperative acceptance (e.g. simulate distance refraction 0.25 to 0.50 D less than BCVA to the patient; simulate near refraction with addition +0.25 to +0.50 less than BCVA to the patient).
Most satisfied patients are hyperopes, then high as tigmatics, then high myopes, then emmetropes, then low myopes .
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PresbyMAX® - a possible Trial Contact LensCibaVision AirOptix Aqua Multifocal
aus AirOptix® Kontaktlinsen Broschüre
PresbyMAX® - Key Factors for Success
Exports are done for selected OZ
» between 5.8 and 6.3 mm (~6.0 mm) in presbyopic myopia,
» between 6.2 and 6.7 mm (~6.5 mm) in presbyopic hyperopia,
» between 6.5 and 7.0 mm (~6.8 mm) in presbyopic astigmatism dominance
Make sure the ablation map is large enough for the scotopic pupil size.
Do both eyes simultaneously since otherwise the binocular vision will suffer from the multifocality on only 1 eye (anisometropia and aniseikonia).
Perform treatments on the corneal vertex to reduce induction of coma aberrations disturbing vision at all distances.
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PresbyMAX® - The PrinciplesTargets for the Central and Mid-Peripheral Areas
∆ 0.0D
Dominant Eye Non-dominant Eye
-0.5D
∆ 0.75D-0.125D
-1.75D -1.75D
-0.875D
-0.5D
-1.0D -1.75D
with µ-monovision
PresbyMAX
PresbyMAX®
The Software Solution V4.4: Hyp.Astigmatism
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PresbyMAX®
The Software Solution V4.4: Myo.Astigmatism
PresbyMAX® with µ-monovisionThe Software Solution V4.4: Hyp.Astigmatism
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Addition as a function of age
0,00
0,50
1,00
1,50
2,00
2,50
3,00
3,50
4,00
25 30 35 40 45 50 55 60 65 70 75
Age (years old)
Add
ition
(D
)
Addition
Model
PresbyMAX
PresbyMAX® - The Presbyopic Compensation
SCHWIND PresbyMAX® proposes a presbyopiccompensation based on the age of the patient.
PresbyMAX® - GuideSCHWIND Recommendation Document
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Re-treatment Options
PresbyMAX® can be repeated if reading-spectacles demands renew.
PresbyMAX® can be repeated if reading quality (multifocality) is not sufficient but distance vision is satisfying.
Aberration-Free treatment (with equal optical zone size to previous PresbyMAX® procedure) can be performed on top for improved distance correction if reading quality (multifocality) is satisfying.
PresbyMAX® Reversal option with distance best corrected refraction included can be performed if the patient does not accept the PresbyMAX® concept at all (too much compromise for the individual).
Due to healing process and neuronal adaptation, a r e-treatment procedure shall not be performed prior 6 months aft er surgery.
PresbyMAX® – The Reversal Concept
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PresbyMAX® after Previous Refractive Surgery
Previous Corneal Refractive Surgery (with the aim of emmetropic distance vision)
Decision shall be equal to patients with virgin corneae.Futhermore, the SCHWIND decision tree for Aberration-Free, Corneal and Ocular Wavefront treatments might be considered
Previous cataract surgery (natural lens exchange)
Multifocal enhancement can be performed on the patient’s cornea.
Intraocular Surgery after PresbyMAX®
Aspheric IntraOcular Lenses:
Properly calculated aspheric lenses (in the sense of aberration-neutral) after PresbyMAX provide the best quality of vision without compromising the already achieved pseudoaccommodation. (No decentration and tilting of the IOL and correct IOL power assumed)
Spheric IntraOcular Lenses:
Spheric Ienses induce positive spherical aberration and thus would remove in part or in total the already achieved pseudo-accommodation.
Multifocal IntraOcular Lenses:
Multifocal (refractive, diffractive, or accommodative) lenses induce negative spherical aberration and multiple foci and thus would enhance the already achieved pseudoaccommodation. But centration issues of the lenses become critical and may induce large amounts of coma from the misalignment between the PresbyMAX® multifocal cornea and the multifocal IOL.
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SCHWIND eye-tech-solutionsfon: +49(0)6027 / 5 08-0fax: +49(0)6027 / 5 08-208email: [email protected]: www.eye-tech-solutions.com
SCHWIND eye-tech-solutions GmbH & Co. KG · Mainparkstrasse 6-10 · 63801 Kleinostheim · Germany
Thank you very much for your kind attention!Vielen Dank für Ihre Aufmerksamkeit!¡Muchas gracias por su amable atención!