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BOGOTA LASER REFRACTIVE INSTITUTEBOGOTA LASER REFRACTIVE INSTITUTEBOGOTA COLOMBIA BOGOTA COLOMBIA

SOUTHAMERICASOUTHAMERICA

GUSTAVO E. TAMAYO MD

BASIC PRINCIPLES OF PRESBYOPIA

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PRESBYOPIA DEFINITIONPRESBYOPIA DEFINITIONPRESBYOPIA DEFINITIONPRESBYOPIA DEFINITION

PRESBYOPIA IS LOSS OF ACCOMODATION INSIDE THE EYE

1. Loss of “auto-focus”2. Difficult vision at near3. Need to increase the distance between the

objects and the eye4. Distant vision remains unchanged.

PRESBYOPIA IS LOSS OF ACCOMODATION INSIDE THE EYE

1. Loss of “auto-focus”2. Difficult vision at near3. Need to increase the distance between the

objects and the eye4. Distant vision remains unchanged.

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PresbyopiaPresbyopia PresbyopiaPresbyopia

Progressive Age-related loss of accommodation

Begins early in life Early 40s: Functional vision affected Complete loss of accommodation by 5th to 6th

decade Most prevalent ocular affliction

– 100% of population

Progressive Age-related loss of accommodation

Begins early in life Early 40s: Functional vision affected Complete loss of accommodation by 5th to 6th

decade Most prevalent ocular affliction

– 100% of population

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Etiology of PresbyopiaEtiology of PresbyopiaEtiology of PresbyopiaEtiology of Presbyopia

Lenticular Changes– lenticular sclerosis– changes in capsular elasticity– change in zonular insertion angle

Extralenticular Changes– Neuromuscular changes– Ciliary muscle changes

Lenticular Changes– lenticular sclerosis– changes in capsular elasticity– change in zonular insertion angle

Extralenticular Changes– Neuromuscular changes– Ciliary muscle changes

Glasser, A et al RSIG 1997

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THE VISION WITH PRESBYOPIATHE VISION WITH PRESBYOPIATHE VISION WITH PRESBYOPIATHE VISION WITH PRESBYOPIA

Distance Intermediate Near

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Lens makes the auto focus Lens makes the auto focus

NORMAL YOUNG EYENORMAL YOUNG EYENORMAL YOUNG EYENORMAL YOUNG EYE

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HOW TO TREAT PRESBYOPIA?HOW TO TREAT PRESBYOPIA?HOW TO TREAT PRESBYOPIA?HOW TO TREAT PRESBYOPIA?

Glasses: a) two pairs: one for distance and one for near

b) bifocals or progressive multifocal

glasses Contact lenses: a) correction for distance and

addition of glasses for near

b) Multifocal contact lenses Surgery

Glasses: a) two pairs: one for distance and one for near

b) bifocals or progressive multifocal

glasses Contact lenses: a) correction for distance and

addition of glasses for near

b) Multifocal contact lenses Surgery

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SURGERY FOR PRESBYOPIASURGERY FOR PRESBYOPIASURGERY FOR PRESBYOPIASURGERY FOR PRESBYOPIA

CORNEA

SCLERA

ANTERIOR CHAMBER

LENS

CORNEA

SCLERA

ANTERIOR CHAMBER

LENS

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SURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEA CORNEAL INLAYS:

a) Acufocus: ACI 7000 (Irvine, Cal)

b) Presbylens (Revision Optics, Cal)

c) FlexiVue microlens (Presbia Corp. Amsterdam)

They are made of Biocompatible material inserted inside the cornea and alter the way light rays enter the eye (Like a Contact Lens)

CORNEAL INLAYS:

a) Acufocus: ACI 7000 (Irvine, Cal)

b) Presbylens (Revision Optics, Cal)

c) FlexiVue microlens (Presbia Corp. Amsterdam)

They are made of Biocompatible material inserted inside the cornea and alter the way light rays enter the eye (Like a Contact Lens)

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Corneal Inlays

Waring recently discussed results of the Kamra smallaperture corneal inlay to improve near vision in emmetropic presbyopes. The inlay is 5-μm thick and 3.8 mm in total diameter, with a 1.6-mm central aperture that increases depth of focus and improves near visual acuity by restricting bent light rays from entering the eye similar to the f-stop in a camera.

Corneal Inlays

Waring recently discussed results of the Kamra smallaperture corneal inlay to improve near vision in emmetropic presbyopes. The inlay is 5-μm thick and 3.8 mm in total diameter, with a 1.6-mm central aperture that increases depth of focus and improves near visual acuity by restricting bent light rays from entering the eye similar to the f-stop in a camera.

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SURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEA CORNEAL INLAYS:

Still not approved by FDA and therefore not

available in USA. All of them in Clinical FDA trials.

Several advantages:

a) Extraocular surgery

b) Reversible

c) Exchangeable

CORNEAL INLAYS:

Still not approved by FDA and therefore not

available in USA. All of them in Clinical FDA trials.

Several advantages:

a) Extraocular surgery

b) Reversible

c) Exchangeable

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Flexivue MicrolensFlexivue MicrolensFlexivue MicrolensFlexivue Microlens

The Flexivue Microlens, a corneal inlay treatment for presbyopia, is 3-mm in diameter and about 15 microns thick. The lens is placed about 280-300 microns deep in the cornea of the patient's non-dominant eye through a pocket created using a femtosecond laser.[1] The specific vision-correcting prescription for each patient is incorporated in the outer area of the lens.[2] The procedure lasts about 10 minutes, and after the lens insertion, the pocket self-seals and holds the lens in place.

The Flexivue Microlens, a corneal inlay treatment for presbyopia, is 3-mm in diameter and about 15 microns thick. The lens is placed about 280-300 microns deep in the cornea of the patient's non-dominant eye through a pocket created using a femtosecond laser.[1] The specific vision-correcting prescription for each patient is incorporated in the outer area of the lens.[2] The procedure lasts about 10 minutes, and after the lens insertion, the pocket self-seals and holds the lens in place.

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AcufocusAcufocusAcufocusAcufocus

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AcufocusAcufocusAcufocusAcufocus

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Flexivue MicrolensFlexivue MicrolensFlexivue MicrolensFlexivue Microlens

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SURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEA EXCIMER LASER SURGERY:

Monovision: one eye (dominant) for distance

and one eye (Non Dominant) for near

Only approved Corneal surgery in USA by the FDA.

Difficult to tolerate by most of the patients.

Loss of Contrast and depth perception by the patients (not suitable for high demanding visual needs)

Limited useful time.

EXCIMER LASER SURGERY:

Monovision: one eye (dominant) for distance

and one eye (Non Dominant) for near

Only approved Corneal surgery in USA by the FDA.

Difficult to tolerate by most of the patients.

Loss of Contrast and depth perception by the patients (not suitable for high demanding visual needs)

Limited useful time.

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SURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEA EXCIMER LASER SURGERY:

Multifocal Cornea: Excimer Laser reshapes the

cornea and alters the way light rays enter the eye. (Like Contact Lenses)

Has been named as PRESBYLASIK.

Both eyes see near and distance.

Several softwares in use by some of the Lasers Manufacturers.

Temporary solution for some years

Repeatable and/or reversible

EXCIMER LASER SURGERY:

Multifocal Cornea: Excimer Laser reshapes the

cornea and alters the way light rays enter the eye. (Like Contact Lenses)

Has been named as PRESBYLASIK.

Both eyes see near and distance.

Several softwares in use by some of the Lasers Manufacturers.

Temporary solution for some years

Repeatable and/or reversible

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Frequently Asked QuestionFrequently Asked QuestionFrequently Asked QuestionFrequently Asked Question How Does this treatment work if the pupil gets

smaller when reading?

How Does this treatment work if the pupil gets smaller when reading?

CREATION OF A PERIPHERAL KNEE

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Multifocal CorneaMultifocal CorneaMultifocal CorneaMultifocal Cornea

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HOW THE TREATMENT WORKS HOW THE TREATMENT WORKS WITH A SMALL PUPIL?WITH A SMALL PUPIL?

HOW THE TREATMENT WORKS HOW THE TREATMENT WORKS WITH A SMALL PUPIL?WITH A SMALL PUPIL?

PREOPERATIVE POSTOPERATIVE

The knee

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Intracore Femtosecond LaserIntracore Femtosecond LaserIntracore Femtosecond LaserIntracore Femtosecond Laser Femtosecond Lasers In a prospective, nonrandomized trial, Holzer et al presented early outcomes of Intracor femtosecond laser treatment for presbyopia. The investigators treated the nondominant eye of 25 patients using the Technolas Perfect Vision femtosecond laser (Technolas Perfect Vision GmbH). The procedure involves the creation of five consecutive intrastromal rings around the line of sight. Treatment times were approximately 20 seconds. The mean gain in UCVA was 4.42 lines, with a range of 0 to 9 lines of improvement. The mean loss of distance BCVA was -0.46 ±0.83.9 Similarly, Ruiz et al evaluated 83 eyes of 45 patients with 6- to 12-month follow-up. Of the 83 eyes, 89.2% achieved both J2 and 20/25 or better, and 69.9% achieved a near UCVA of J1.

Femtosecond Lasers In a prospective, nonrandomized trial, Holzer et al presented early outcomes of Intracor femtosecond laser treatment for presbyopia. The investigators treated the nondominant eye of 25 patients using the Technolas Perfect Vision femtosecond laser (Technolas Perfect Vision GmbH). The procedure involves the creation of five consecutive intrastromal rings around the line of sight. Treatment times were approximately 20 seconds. The mean gain in UCVA was 4.42 lines, with a range of 0 to 9 lines of improvement. The mean loss of distance BCVA was -0.46 ±0.83.9 Similarly, Ruiz et al evaluated 83 eyes of 45 patients with 6- to 12-month follow-up. Of the 83 eyes, 89.2% achieved both J2 and 20/25 or better, and 69.9% achieved a near UCVA of J1.

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Femtosecond LasersFemtosecond LasersFemtosecond LasersFemtosecond Lasers

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Excimer Lasers and MultifocalExcimer Lasers and MultifocalCorneal AblationsCorneal Ablations

Excimer Lasers and MultifocalExcimer Lasers and MultifocalCorneal AblationsCorneal Ablations

It should be noted that, although near vision is better, the quality of distance

vision provided by these models is worse than that of a

presbyopic emmetropic eye.6

It should be noted that, although near vision is better, the quality of distance

vision provided by these models is worse than that of a

presbyopic emmetropic eye.6

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SURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEASURGERY IN THE CORNEA CONDUCTIVE KERATOPLASTY:

A probe touches the cornea with High

Radiofrequency and by collagen shrinkage reshapes the cornea.

Produces controlled monovision inducing Myopia

Only suitable for Hyperopes FDA approved as Monovision Blended Vision Rapid loss of effect is the main problem Its use has decreased in the last years.

CONDUCTIVE KERATOPLASTY:

A probe touches the cornea with High

Radiofrequency and by collagen shrinkage reshapes the cornea.

Produces controlled monovision inducing Myopia

Only suitable for Hyperopes FDA approved as Monovision Blended Vision Rapid loss of effect is the main problem Its use has decreased in the last years.

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CONDUCTIVE KERATOPLASTYCONDUCTIVE KERATOPLASTYCONDUCTIVE KERATOPLASTYCONDUCTIVE KERATOPLASTY

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CONDUCTIVECONDUCTIVE KERATOPLASTY KERATOPLASTYCONDUCTIVECONDUCTIVE KERATOPLASTY KERATOPLASTY

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SURGERY IN THE SCLERASURGERY IN THE SCLERASURGERY IN THE SCLERASURGERY IN THE SCLERA SCLERAL EXPANSION PROCEDURE:

Small incisions in the sclera close to the

cornea and insertion of a band to create an space for the ciliary muscle to move.

Ciliary muscle is the “autofocus” muscle Defensors claim improve accomodation Not FDA approved. Not in use in USA. Its use has declined dramatically due to not

consistent results.

SCLERAL EXPANSION PROCEDURE:

Small incisions in the sclera close to the

cornea and insertion of a band to create an space for the ciliary muscle to move.

Ciliary muscle is the “autofocus” muscle Defensors claim improve accomodation Not FDA approved. Not in use in USA. Its use has declined dramatically due to not

consistent results.

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SCLERAL EXPANSION SCLERAL EXPANSION SURGERYSURGERY

SCLERAL EXPANSION SCLERAL EXPANSION SURGERYSURGERY

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Scleral Expansion SurgeryScleral Expansion SurgeryScleral Expansion SurgeryScleral Expansion Surgery

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SURGERY IN THE ANTERIOR CHAMBERSURGERY IN THE ANTERIOR CHAMBERSURGERY IN THE ANTERIOR CHAMBERSURGERY IN THE ANTERIOR CHAMBER

PHAKIC MULTIFOCAL INTRAOCULAR

LENSES:

Lenses inserted inside the eye over the iris

(Verizyse-Artisan) or under the iris (Visian ICL) The natural Lens is not removed FDA approved for correction of Myopia not for

Presbyopia Still prototypes. Main advantage is reversibility..

PHAKIC MULTIFOCAL INTRAOCULAR

LENSES:

Lenses inserted inside the eye over the iris

(Verizyse-Artisan) or under the iris (Visian ICL) The natural Lens is not removed FDA approved for correction of Myopia not for

Presbyopia Still prototypes. Main advantage is reversibility..

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PHAKIC LENS: VERISYSEPHAKIC LENS: VERISYSEPHAKIC LENS: VERISYSEPHAKIC LENS: VERISYSE

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SURGERY IN THE LENSSURGERY IN THE LENSSURGERY IN THE LENSSURGERY IN THE LENS

MULTIFOCAL INTRAOCULAR LENSES

ACCOMODATIVE INTRAOCULAR LENSES

The natural lens is removed through surgery and

replaced by one of those lenses. FDA approved to be used for cataract surgery Off Label used as clear lens exchange (PRELEX) Very popular method internationally Not very commonly used in USA Cristalens Accomodative is number one used in

USA

MULTIFOCAL INTRAOCULAR LENSES

ACCOMODATIVE INTRAOCULAR LENSES

The natural lens is removed through surgery and

replaced by one of those lenses. FDA approved to be used for cataract surgery Off Label used as clear lens exchange (PRELEX) Very popular method internationally Not very commonly used in USA Cristalens Accomodative is number one used in

USA

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Multifocal IOLMultifocal IOLMultifocal IOLMultifocal IOL

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Multifocal IOLMultifocal IOLMultifocal IOLMultifocal IOL

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ACCOMODATIVE CRISTALENSACCOMODATIVE CRISTALENSACCOMODATIVE CRISTALENSACCOMODATIVE CRISTALENS

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SURGERY IN THE LENSSURGERY IN THE LENSSURGERY IN THE LENSSURGERY IN THE LENS

MULTIFOCAL INTRAOCULAR LENSES

ACCOMODATIVE INTRAOCULAR LENSES

Both types still under development and research. Very strong visual symptoms have produced

decrease of its use in “young” presbyopes. Not reversible surgery Decreased contrast sensitivity They require a careful selection of candidates and

lots of counseling.

MULTIFOCAL INTRAOCULAR LENSES

ACCOMODATIVE INTRAOCULAR LENSES

Both types still under development and research. Very strong visual symptoms have produced

decrease of its use in “young” presbyopes. Not reversible surgery Decreased contrast sensitivity They require a careful selection of candidates and

lots of counseling.

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Capsular Bag RefillingCapsular Bag RefillingCapsular Bag RefillingCapsular Bag Refilling

Hao et al recently introduced data on injectable in situ curable accommodating IOLs. Using functionalized polysiloxane macromonomers, they were able to refill the empty lens capsular bag via an injection. To prevent leakage from the capsular bag, the investigators performed in situ cross-linking of polysiloxane gel using blue light (wavelength, 400-500 nm) at an intensity of 70 mW/cm2. A 3-month in vivo biocompatibility study was performed in rabbits. No iritis, uveitis, retinal detachment. or corneal decompensation was observed.

Hao et al recently introduced data on injectable in situ curable accommodating IOLs. Using functionalized polysiloxane macromonomers, they were able to refill the empty lens capsular bag via an injection. To prevent leakage from the capsular bag, the investigators performed in situ cross-linking of polysiloxane gel using blue light (wavelength, 400-500 nm) at an intensity of 70 mW/cm2. A 3-month in vivo biocompatibility study was performed in rabbits. No iritis, uveitis, retinal detachment. or corneal decompensation was observed.

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Capsular Bag RefillingCapsular Bag RefillingCapsular Bag RefillingCapsular Bag Refilling

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Capsular Bag RefillingCapsular Bag RefillingCapsular Bag RefillingCapsular Bag Refilling

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THANK YOUTHANK YOUTHANK YOUTHANK YOU