Corneal Compensation of PresbyopiaINSTRUCTIONAL COURSE
COURSE DIRECTOR:Jorge L. Alió, Spain
COURSE PARTICIPANTS:Dan Reinstein, UK
Ioannis Pallikaris, GreeceGünther Grabner, Austria
Julian Stevens, UKMike Holzer, Germany
ESCRS, VIENNA, 2011
Course scheduleIntroduction: Is corneal accommodation possible?:
Jorge Alio
Femtosecond presbyopic correction: Mike Holzer
Refractive inlays: Flexivue Presbylens: Ioannis Pallikaris The Presbylens (Revision Optics): Julian Stevens
Pinhole inlays: Fundamentals of pinhole inlays. The Kamra Acufocus: Gunther Grabner
Excimer laser Presbylasik techniques: Peripheral presbylasik techniques: Daniel ReinsteinCentral Presbylasik techniques: Jorge Alio
Panel discussion:
FF F’N N’PP’
The optical system of the human eye CORNEAL ACCOMODATIONHow does the cornea focus at
different distances
1. MULTIFOCALITY
2. DEPTH OF FIELD
NORMAL CORNEA DEPTH OF FOCUS
DOF=0,75 D
FACTORS THAT INFLUENCE NORMAL CORNEAL ACCOMMODATION
• Myopic Astigmatism
• Irregular Cornea: Keratoconus
• Manipulated corneas: Spherical & Coma aberration
Grado I: Grado II:
-2 X 90º
CORNEAL ACCOMODATIONHow does the cornea focus at
different distances?
1. MULTIFOCALITY
2. DEPTH OF FIELD
METHODS TO INDUCE CORNEAL ACCOMMODATION
• CORNEAL LASER SURGERY: Excimer Laser Multifocal Cornea (PresbyLasik techniques):Intrastromal Femtosecond mutifocality
• CORNEAL INLAYS:Refractive InlaysPinhole Inlays
EXCIMER LASER SURGERY:MODERN PRESBYLASIK
1. CENTER FOR NEAR : Central hyperpositive multifocal area(Central Presbylasik).
2. CENTER FOR FAR: Peripheral multifocal area (Peripheral Presbylasik).
MODERN REQUIREMENTS FOR PRESBYLASIK TECHNIQUES
• Bilateral• Should not decrease vision for far• Should improve functional vision to adequate
levels• Should not induce collateral negative
symptoms• Should be stable• Minimally invassive
FAR VISION
CENTRAL PRESBYLASIKCENTER FOR NEAR MIGHT BE
BETTER…• Synergistic with convergence myosis• Synergistic with the line of sight• Minimal tissue ablation added to the
correction of the main defect• Minimal neuroadaptation , immediate
outcome• Focus dominance FAR/NEAR depending on
pupil size• Minimal induction of HOA / minimal or no
degradation of the quality of the retinal image
0
1
2
3
4
5
0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5
IOL Rea Power Facto %r
0 0 58,0938
0,5 0,43 87% 58,527
1 0,86 86% 58,9541
1,5 1,28 85% 59,3747
2 1,70 85% 59,7888
2,5 2,10 84% 60,1962
3 2,50 83% 60,5968
3,5 2,90 83% 60,9905
4 3,28 82% 61,3772
4,5 3,66 81% 61,7568
5 4,04 81% 62,1292
EQUIVALENCE BETWEEN CORNEA AND IOL OPTICAL POWER FOR A…
REFRACTIVE INDEX
PERIPHERAL PRESBYLASIK
• Based on the induction of high levels of negative asphericity at the mid –peripheral cornea
• The inducton of high levels of negative spherical aberration increases dept of field
• Requires a period of neuroadaptation
FAR VISION
PERIPHERAL PRESBYLASIK
Visx Aspheric Presby Ablation
CENTRAL Vs PERIPHERAL PRESBYLASIK
Differences in tissue removal :
4 micron more
CENTRAL PERIPHERALHYPEROP +3(+2 near ADD)
150 micron for -0.5 asphericity
MYOP -3(+2 near ADD)
4 micron200 micron for
-0.25 asphericity > 270 micron for -0.5 asphericity
CENTRAL PresbyLasikPresbyMax ®
Aspheric Visx TreatmentAspheric Visx TreatmentCustomVueCustomVue
Presbyopia AblationPresbyopia Ablation
CustomVue + PresbyCustomVue + Presby
+2.00+0.50x125+2.00+0.50x125
PERIPHERAL PRESBYLASIK PresbyLasik Meta-analysis(only bilateral procedures)
Number of studies:Peripheral: 9Central: 4
Years:2004 to 2009
Number of eyes included: Peripheral: 1072Central: 140
Level of evidence:Peripheral: 1.66Central: 2
PresbyLASIK PresbyLASIK –– Main ReportsMain ReportsInvestigatorInvestigator AliAlióó ** JacksonJackson Jung **Jung ** WilliamsWilliamsLaserLaser H. Eye TechH. Eye Tech AMO/VISX AMO/VISX (software)(software) AMO/VISX AMO/VISX (software)(software) AMO/VISX AMO/VISX (software)(software)
N=eyes/patientsN=eyes/patients 50/25 LASIK50/25 LASIK 56/28 LASIK56/28 LASIK 54/27 LASIK (25) PRK (29)54/27 LASIK (25) PRK (29) 60/30 PRK60/30 PRK
AgeAge 58 (5158 (51--68)68) 56 (4556 (45--65)65) 53 (4553 (45--63)63) 52 (4652 (46--61)61)
Mean SEMean SE +1.69 +1.69 ±± 0.63 D0.63 D(+0.50 to +3.00 D)(+0.50 to +3.00 D)
+1.92 +1.92 ±± 0.56 D0.56 D +1.16 +1.16 ±± 0.82 D0.82 D +1.46 +1.46 ±± 0.55 D0.55 D
FollowFollow--up (mths)up (mths) 66 1212 66 66
Binocular UCDVA Binocular UCDVA 20/25 or better20/25 or better
88%88% 100%100% 93% (monocular)93% (monocular) 86%86%
Binocular UCNVA J3 Binocular UCNVA J3 or betteror better
91%91% 100%100% 64%64% 97%97%
Mean PostMean Post--op SEop SE --0.34 0.34 ±± 0.55 D0.55 D +0.07 +0.07 ±± 0.48 D0.48 D +0.33 +0.33 ±± 0.45 D0.45 D +0.16 +0.16 ±± 0.60 D0.60 D
Simultaneous 20/25 & J3Simultaneous 20/25 & J3 -- 100%100% 64%64% --
Lines Lost Dist & NearLines Lost Dist & Near 14% 2 lines dist 14% 2 lines dist 16% for near16% for near
14% 2 lines dist14% 2 lines dist8.3% near8.3% near
4% 2 lines dist4% 2 lines dist0% near0% near
0% 2 lines dist0% 2 lines dist0% near0% near
Contrast AcuityContrast Acuity DecreasedDecreased Decrease Decrease –– Not SignificantNot Significant Decrease Decrease –– Not SignificantNot Significant --
HOAHOA SA SA ↓↓ Coma Coma ↑↑ SA SA ↓↓ Coma Coma ↑↑ SA SA ↓↓ Coma Coma ↑↑ --
Satisfaction Dist & Satisfaction Dist & NearNear
High, 72% no High, 72% no glassesglasses
High, 49% no glassesHigh, 49% no glasses -- High, 79% satisfiedHigh, 79% satisfied
RetreatmentsRetreatments 12%12% 00 00 00
** AliAlióó et al. Correction of presbyopia by technovision central multifoet al. Correction of presbyopia by technovision central multifocal LASIK (PresbyLASIK). J Refract Surg. 2006;22:453cal LASIK (PresbyLASIK). J Refract Surg. 2006;22:453--460.460.
**** Jung et al. Multifocal Corneal Ablation for Hyperopic PresbyopeJung et al. Multifocal Corneal Ablation for Hyperopic Presbyopes. J Refract Surg. 2008;24:903s. J Refract Surg. 2008;24:903--910. 910.
MONOCULAR BINOCULAR
Type of presbylasik CENTRAL
No. EyesPERIPHERAL
No. EyesCENTRAL
No. PatientsPERIPHERALNo. Patients
UCVADISTANCE≥ 0.8 (20/25)
89 (94.4%) 786 (86.1%) 68 (97.1%) 264 (100%)
UCVANEAR ≥ J3
90 (100%) 975 (90.9%) 70 (100%) 277 (100%)
Last 5 years reports (only binocular procedures)Definition of success:•Far: ≥ 0.8 (20/25)•Near: ≥ J3
* COMMENT: Peripheral presbylasik requires a longer follow-up to achieve success
FEMTOSECONDS MULTIFOCAL CORNEA SURGERY
(Intracore )®
IOP
INTRACOR presbyopia mechanism®
• J1 post op
• 5min post op
CENTER FOR NEAR CORNEAL LASER PROCEDURES
• Both PresbyMax and Intracore works improving near vision related to pupil size
• Both, confirmed by optical analysis by simulated RayTrace on real case data
• To add central corneal power should have equivalent effects to multifocal pupil dependent IOLs
• Still these techniques require to pass the test of time to confirm stability of the outcomes
CORNEAL INLAYS
• REFRACTIVE :
• PINHOLE :
CrystallineLens
Retina
Pupil
Cornea
• Inlay steepens central cornea– Dilated pupil allows for distance image focus– Pupil constriction during accomodative response
increases near power to create pseudo-accommodation
FLEXIVUE® Optical Design
Model Eye
FLEXIVUE SLIT LAMP APPEARANCE
Random hole pattern
Solid ID andOD edge
Pores are 5 to 11 microns diameter
CORNEA INLAYS
• PINHOLE EFFECT
Near Object Less Blurred
Image
Lens Cannot Accommodate
Presbyopic Near Vision with a Pinhole Inlay
Focus Behind Retina
Smaller Blur Circle
ACI
Depth of Field with Kamra
Near Vision is Clear
Intermediate Vision is Clear
Distance Vision is Clear
Kamra Slit Lamp appearance
CONCLUSIONS• Corneal compensation of presbyopia can be
accomplished through different mechanisms and surgical techniques
• Such methods are feasible and successful• They will have probably different indications
depending on patient´s profile and corneal anatomy
• They may offer a more attractive option than CLT (Cristaline Lens Mutilation and substitution by an IOL) as they are less invasive and, in some cases, reversible
Pinhole InlaysFundamentals, Results ,Complications and Outlook of the
AcuFocus™ Kamra Inlay
Pinhole InlaysFundamentals, Results ,Complications and Outlook of the
AcuFocus™ Kamra Inlay
G.Grabner
and co-workersO.Seyeddain, M.Hohensinn, W.Riha, G.Nix, T. Rückl, M.Rasp, A.K.Dexl
G.Grabner
and co-workersO.Seyeddain, M.Hohensinn, W.Riha, G.Nix, T. Rückl, M.Rasp, A.K.Dexl
ESCRS Paris, 2010, Instructional Course ESCRS Paris, 2010, Instructional Course ““Corneal Compensation of Corneal Compensation of PresbyopiaPresbyopia””
Universitätsaugenklinik Salzburg
AcuFocus™ ACI-7000 Corneal InlayAcuFocusAcuFocus™™ ACIACI--7000 Corneal Inlay7000 Corneal Inlay
•• Designed to improve near and intermediate Designed to improve near and intermediate vision invision in presbyopiapresbyopia
•• PolyvinylidenePolyvinylidene fluoridefluoride•• 1600 random nutritional holes 1600 random nutritional holes (25(25µµm m ØØ))
Central aperture:Central aperture: 1.6 mm1.6 mmOverall diameter: 3.8 mmOverall diameter: 3.8 mm
10 microns thin10 microns thin
Blocks Blocks unfocused lightunfocused light
Allows focused Allows focused light into the eyelight into the eye
Universitätsaugenklinik Salzburg
Near Vision Same principle used in camera lenses to increase range of vision
Normal
Presbyopia
With ACI
Increasing DepthIncreasing Depth ofof FieldField !!
Universitätsaugenklinik Salzburg
Surgical ProcedureSurgical ProcedureSurgical Procedure
Non dominant EyeTopical anesthesiaFlap created (Intralase, 170 µm depth)ACI-7000 insertion and centrationClosing of flap< 30 minutes - start to finish
Non dominant EyeNon dominant EyeTopical anesthesiaTopical anesthesiaFlap created (Flap created (IntralaseIntralase, 170 , 170 µµm depth)m depth)ACIACI--7000 insertion and7000 insertion and centrationcentrationClosing of flapClosing of flap< 30< 30 minutes minutes -- start to finishstart to finish
Universitätsaugenklinik Salzburg
Inclusion criteriaInclusion criteria•• naturalnatural presbyopic emmetropespresbyopic emmetropes•• age between 45 age between 45 -- 55 years55 years•• spherical Equivalent of spherical Equivalent of ±± 0.50.5 sphsph•• reading add between +1.0reading add between +1.0 sphsph to +2.5to +2.5 sphsph•• KK--value value ≥≥ 41.00D and 41.00D and ≤≤ 47.00D 47.00D •• UNVA UNVA ≥≥ 20/100 and 20/100 and ≤≤ 20/4020/40•• BCDVA BCDVA ≥≥ 20/20 in both eyes20/20 in both eyes
Exclusion criteriaExclusion criteria•• prior eye surgeryprior eye surgery•• any other eye diseaseany other eye disease•• cycloplegiccycloplegic Refraction > Refraction > ±± 0.50.5 sphsph
StudyStudy Design / Salzburg GroupDesign / Salzburg GroupAs part of a prospective nonrandomizedAs part of a prospective nonrandomizedMulticenterMulticenter FDA Study FDA Study (U.S. & European Sites)(U.S. & European Sites)
Universitätsaugenklinik Salzburg
RE49 year old presbyopeNON-implanted eye
Universitätsaugenklinik Salzburg
LE49 year old presbyopeIMPLANTED eye
Universitätsaugenklinik Salzburg
Uncorrected Visual Acuity Results (mean)Uncorrected Visual Acuity Results (mean)
SalzburgResults
PreOP
n=321Mon=32
3Mon=32
6Mon=32
9 Mon=32
12Mon=32
24Mon=32
30Mon=31
36Mon=32
NEAR (IE)line change vs base
J-7/J-8
J2+3.6
J2+4.4
J2+4.3
J1+4.7
J2+4.4
J2+4.4
J2+4.4
J1+4.6
Intermediate (IE)* line change vs base
20/40 20/25+1.4
20/25+1.8
20/25+1.7
20/25+1.7
20/25+1.7
20/25+1.6
20/25+1.8
20/25+2.3
Distance (IE)line change vs base
20/16 20/25-0.9
20/20-0.7
20/20-0.8
20/20-1.0
20/20-0.8
20/20-0.7
20/20-0.8
20/20-0.8
Distance (OU)line change vs base
20/16 20/160
20/160
20/16-0.1
20/16-0.1
20/160
20/160
20/16-0.1
20/160
* Letter size seen at 80 cm testing distance
Universitätsaugenklinik Salzburg
Uncorrected Near VA (Implanted Eye)Uncorrected Near VA (Implanted Eye)
FDA: 75% ≥ J5
Optec 6500P Vision tester
Universitätsaugenklinik Salzburg
Uncorrected Intermediate VA (IE)Uncorrected Intermediate VA (IE)
Optec 6500P Vision tester
Universitätsaugenklinik Salzburg
Uncorrected Distance VA (IE)Uncorrected Distance VA (IE)
Optec 6500P Vision tester
Universitätsaugenklinik Salzburg
Uncorrected Distance & Near VAUncorrected Distance & Near VA
20/2020/20
Optec 6500P Vision tester
Universitätsaugenklinik Salzburg
Complications
0.5 mm recentration after 7 months0.5 mm0.5 mm recentration afterrecentration after 77 monthsmonths
11 case with epithelial ingrowthcase with epithelial ingrowth andand repeated flaprepeated flap lift lift
22 cases with decentered inlayscases with decentered inlaysLow decreaseLow decrease UDVA,UDVA, low increaselow increase in UNVA & UIVA 6in UNVA & UIVA 6 months after implantation months after implantation
Universitätsaugenklinik Salzburg
Visual Acuity after Recentration
4545
4550
44
40
23
41
34
43
30
5147
45
0
10
20
30
40
50
60
preOp 1 Month 3 Month 9 Month 15 Month 21 Month 30 Month
Time
UCN
VA E
DTRS
Patient 1 Patient 2
Visual Acuity after Recentration
39
32
5049
5047
48
5554
5045
49
43
50
0
10
20
30
40
50
60
preOp 1 Month 3 Month 9 Month 15 Month 21 Month 30 Month
Time
UCDV
A E
DTRS
Patient 1 Patient 2
22 cases with decentered inlayscases with decentered inlays
UncorrectedUncorrected distance anddistance and nearnear VA 30VA 30 months after recentrationmonths after recentration
UCNVA UCDVA
20/20
Complications
Universitätsaugenklinik Salzburg
Solution for optimising centration
LineLine--ofof--sightsight (LOS) (LOS) -- DeviceDevice
TheThe KAMRA KAMRA AcuTargetAcuTargetTMTM
Universitätsaugenklinik Salzburg
For the AcuFocus Corneal Inlay (ACI)
Universitätsaugenklinik Salzburg
Future ?
1600 holes1600 holesconstant sizeconstant sizethickness 10 thickness 10 µµ
8400 holes8400 holesvariable sizevariable sizethicknessthickness 5 5 µµ
new Pocket – technique (target depth 200 - 220 µ)
LDVLDV IntraLaseIntraLase
n = 10n = 101 1 yearyear ff--uu
- is here !
newnew implantimplant
Universitätsaugenklinik Salzburg
Effective
Extraocular and minimally invasive
Stable and well toleratedpotentially reversible
Allows for complete ocular exam / Tx postop.Great potential
post-LASIK presbyopiapseudophakia
AcuFocus™ ACI 7000 - ConclusionsAcuFocus™ ACI 7000 - Conclusions
Universitätsaugenklinik Salzburg
4 years postfs-LASIK
iFS > 220 µ
140 µ
Universitätsaugenklinik Salzburg
Excellent option forExcellent option for presbyopiapresbyopia ! !
Laser Blended Vision with MEL80
Dan Z Reinstein MD MA(Cantab) FRCSC FRCOphth1,2,3,4
1. London Vision Clinic, London, UK2. St. Thomas’ Hospital - Kings College, London, UK 3. Weill Medical College of Cornell University, New York, USA4. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France
This indication for use is not cleared by the FDA for distribution in the United States
©DZ Reinstein [email protected]
Financial Disclosure
The author (DZ Reinstein) acknowledges a financial interest in Artemis™ VHF digital ultrasound (ArcScan Inc, Morrison, CO)
The author (DZ Reinstein) is a consultant for Carl Zeiss Meditec AG (Jena, Germany)
©DZ Reinstein [email protected]
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image processing
[edge detection]6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
©DZ Reinstein [email protected]
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image processing
[edge detection]6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
©DZ Reinstein [email protected]
Presbyopia: Ideal Solution
Near
Intermediate
Distance
Far Distance
Right Eye Left Eye
3.00 D 3.00 D
©DZ Reinstein [email protected]
Influence of Spherical Aberration on Depth of Field
without spherical aberration
with spherical aberration
Slides courtesy Hartmut Vogelsang, PhD
©DZ Reinstein [email protected]
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image processing
[edge detection]6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
©DZ Reinstein [email protected]
Control Pre Control Post Pre CRS-M Repair
Post CRSM-Repair
Sph Ab Area 122 276 563 410
0100200300400500600700800900
µm
2
p
3 cpd 6 cpd 12 cpd 18 cpdControl Pre 1.02 1.02 1.03 1.04Control Post 1.04 1.01 1.03 1.01Pre CRSM-Repair 0.85 0.84 0.77 0.75Post CRSM-Repair 1.04 1.02 1.02 1.00
0.5
0.6
0.7
0.8
0.9
1.0
1.1
1.2
Normalized Contrast
Sensitivity Ratio
How much spherical aberration?Spherical Aberration Normalized Contrast
Sensitivity Ratio
27%
• Tolerable level ~0.56 µm @ 6mm
Control WFG Repair
©DZ Reinstein [email protected]
Depth of Field by SA: Myopia
Sphe
rical
Abe
rrat
ion
+ve
-ve
0
Low High High Pre SA
Threshold
©DZ Reinstein [email protected]
Depth of Field by SA: Hyperopia
Sphe
rical
Abe
rrat
ion
+ve
-ve
0
Low High Dist/Near Eye
Threshold
Threshold
©DZ Reinstein [email protected]
Depth of Field by SA: Emmetropia
Sphe
rical
Abe
rrat
ion
+ve
-ve
0
Dist Eye Near Eye
Threshold
Threshold©DZ Reinstein 2010
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image
processing [edge detection]
6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
If we can increase depth of field fully by
spherical aberration, brain can create sharp
perception at all distances
©DZ Reinstein [email protected]
Simulation for -1.50 D defocus-1.50 D @ 7 mm
Add spherical aberrationReduce pupil size to 4 mm
With spherical aberration and @ 4 mm
Central neural processing©DZ Reinstein 2010
Presbyopia: Ideal Solution
Near
Intermediate
Distance
Far Distance
Right Eye Left Eye
3.00 D 3.00 D
©DZ Reinstein [email protected]
Current Possible Depth of Field Increase
Near
Intermediate
Distance
Far Distance
Right Eye Left Eye
1.50 D 1.50 D
Loss of contrast
©DZ Reinstein [email protected]
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image processing
[edge detection]6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
©DZ Reinstein [email protected]
Laser Blended Vision – Micro-Monovision
Near
Intermediate
Distance
Far Distance
Dominant Eye Non-Dominant Eye
“Blend Zone”
1.50 D 1.50 D
©DZ Reinstein [email protected]
Contact Lens Monovision
Near
Intermediate
Distance
Far Distance
Dominant Eye Non-Dominant Eye
“Blend Zone”“Blur Zone”
1.50 D
1.50 D
©DZ Reinstein [email protected]
Correcting Presbyopia: Contact Lens Monovision
Dominant eye:mainly corrected for distance
Non-dominant eye:mainly corrected for near
Brain merges two images to see near and
far without glasses
59-67%Patients Tolerate
Evans BJ. Monovision: a review. Ophthalmic Physiol Opt.2007;27:417-439.
©DZ Reinstein [email protected]
Correcting Presbyopia: Laser Blended Vision
Brain merges two images to see near and
far without glasses
Dominant eye:mainly corrected for distance
Non-dominant eye:mainly corrected for near
~97%Patients Tolerate
Reinstein DZ et al. LASIK for Hyperopic Astigmatism and Presbyopia Using Micro-monovision With the Carl Zeiss Meditec MEL80. JRS. 2009;25(1):87-93
©DZ Reinstein [email protected]
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image processing
[edge detection]6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
Online Feb 2010
Laser Blended Vision:Binocular UDVA > Monocular UDVA (distance eye)
Evans BJ. Monovision: a review. Ophthalmic Physiol Opt. 2007;27:417-439.
Traditional Monovision:Binocular UDVA < Monocular UDVA (distance eye)
©DZ Reinstein [email protected]
Binocular Vision: Neural Summation
0%10%
20%30%40%50%60%70%80%
90%100%
Distance UCVA After All Treatments
Cum
ulat
ive
Perc
enta
ge E
yes
Near Eyes 1% 3% 15% 24% 36% 45% 80%
Distance Eyes 9% 45% 92% 98% 99% 100% 100%
Binocular 13% 53% 96% 98% 100% 100% 100%
20/12.5 or better
20/16 or better
20/20 or better
20/25 or better
20/32 or better
20/40 or better
20/63 or better
Distance UCVA After All Treatments
Near Eyes 1% 3% 15% 24% 36% 45% 80%
Distance Eyes 9% 45% 92% 98% 99% 100% 100%
Binocular 13% 53% 96% 98% 100% 100% 100%
©DZ Reinstein [email protected]
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image processing
[edge detection]6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
©DZ Reinstein [email protected]
Blur Adaptation
Wore glasses except for VA measurement
No glasses throughout
Wore glasses throughout
No change in Rx
©DZ Reinstein [email protected]
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image processing
[edge detection]6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
©DZ Reinstein [email protected]
Ocular Rivalry and Blur Suppression vs Multifocal
• Neuronal gates instantaneously select the better image, or elements of each, to obtain the best image for the task at hand
Awareness OD
Suppression OS
Source: Monovision in name only. William F Maloney. Ocular Surgery News US Edition October 1, 2006
Binocular Mediating Neuron
OD
OS
©DZ Reinstein [email protected]
Brain adaptation
Multi-focality Binocular Fusion
©DZ Reinstein [email protected]
Problem With Multi-focality
ReSTOR ReZoom
Near
Far
Near
Far
Anschütz,Dausch,Klein,Joly
(Meditec group, 1991)
Avalos, Rozakis, Agarwal (PARM-technique, 1998)
G.Tamayo (2000)
Concentric distance near zonesDiffraction design
PROBLEM:Two Images
Multi-focal Ablation Profiles
Multi-focal IOLs
©DZ Reinstein [email protected]
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image processing
[edge detection]6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
©DZ Reinstein [email protected]
Centration: Visual Axis vs Entrance Pupil
Phoroptor Lens
No Angle Kappa
Phoroptor Manifest Refraction Excimer Laser Ablation
Large Angle Kappa
Ablation Profile
Phoroptor Lens
©DZ Reinstein [email protected]
Centration: Visual axis vs Pupil centre
Higher order
wavefront map
Objective
Point Spread Function
Subjective
Point Spread Function
Vertex centration Pupil centration
Subjective PSF correlates with vertex PSF, NOT pupil PSF
©DZ Reinstein [email protected]
Laser Blended Vision: 8-in-1 Mechanism5. Retinal image processing
[edge detection]6. Neural summation7. Blur adaptation8. Neural suppression
1. Monovision principle2. Depth of field to reduce anisometropia3. Spherical aberration control
[DOF without decrease quality of vision]
4. Vertex centration of spherical aberration[OSA coma, on-axis symmetry of image blur]
Outcomes
Measurement of Effective Depth of Field
Example: Emmetropic Patient
©DZ Reinstein [email protected]
Laser BV Emmetropic LASIK – 56 yo Female
56 yo OD OS Binocular
Pre
Manifest +0.75 -0.75 x 158 +0.50 -0.75 x 170
BSCVA 20/16 20/16
1 Yr Post Op
UCVA 20/16 20/32 20/16 & J2
Manifest +0.25 sph -1.00 -0.50 x 20
BSCVA 20/16 20/16
©DZ Reinstein [email protected]
• Near eye Rx: -1.00 -0.50 x 20– SEQ -1.25 D UCVA 20/63
20253240506380
100125160
-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00
Spherical Equivalent (D)
Dis
tanc
e U
CVA
(log
Mar
)
Expected Distance UCVA
20/20 0.00
20/25 -0.25
20/32 -0.50
20/40 -0.75
20/50 -1.00
20/63 -1.25
20/80 -1.50
©DZ Reinstein [email protected]
20253240506380
100125160
-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00
Spherical Equivalent (D)
Dis
tanc
e U
CVA
(log
Mar
)
Expected Distance UCVA
• Near eye Rx: -1.00 -0.50 x 20– SEQ -1.25 D UCVA 20/63– Actual UCVA 20/32 -0.50 D
20/20 0.00
20/25 -0.25
20/32 -0.50
20/40 -0.75
20/50 -1.00
20/63 -1.25
20/80 -1.50
©DZ Reinstein [email protected]
20253240506380
100125160
-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00
Spherical Equivalent (D)
Dis
tanc
e U
CVA
(log
Mar
)
Expected Near Addition – 56 yo Female
• Near eye Rx: -1.00 -0.50 x 20– SEQ -1.25 D UCVA 20/63– Actual UCVA 20/32 -0.50 D
Age Add50-52 +1.50 D
52-54 +1.75 D
54-56 +2.00 D
56-58 +2.25 D
Over 58 +2.50 D
Near UCVA: J2
©DZ Reinstein [email protected]
20253240506380
100125160
-2.50-2.25-2.00-1.75-1.50-1.25-1.00-0.75-0.50-0.250.00
Spherical Equivalent (D)
Dis
tanc
e U
CVA
(log
Mar
)
Depth of Field – 56 yo Female
• Near eye Rx: -1.00 -0.50 x 20– SEQ -1.25 D UCVA 20/63– Actual UCVA 20/32 -0.50 D
Age Add50-52 +1.50 D
52-54 +1.75 D
54-56 +2.00 D
56-58 +2.25 D
Over 58 +2.50 D
Near UCVA: J2
Depth of field: 1.50 D
Outcomes of Non-linear Aspheric Presbyopic Micro-monovision LASIK for Myopia, Hyperopia, and Emmetropia
Online Feb 2010
©DZ Reinstein [email protected]
Blended Vision: Methods
Myopia Hyperopia Emmetropia
# Patients 136 111 119
SEQ-3.58 ± 1.80 Dup to -8.50 D
+2.58 ± 1.17 Dup to +5.75 D
+0.35 ± 0.35 D-0.50 to +0.75 D
Cylinder -0.83 ± 0.64 D up to -2.50 D
-0.49 ± 0.50 D up to -3.25 D
-0.39 ± 0.30 D up to -1.00 D
Agemedian 49 yrs
43 to 63median 56 yrs
44 to 66median 54 yrs
43 to 71
©DZ Reinstein [email protected]
Routine LASIK Procedure
• Hansatome 160• CRS-Master custom programming
– Non-linear aspheric ablation profile DOF• MEL80 excimer laser• Micro-monovision:
– Dominant: “plano” [plano to -0.75] – Non-dominant: “-1.50 D” [-0.75 to -2.25]
• >90% follow up at 1 year• Results presented including enhancements
©DZ Reinstein [email protected]
Laser Blended Vision: Results
Emmetropic Population
(In Press)Online Feb 2010
Myopia20/20 & J5
98.5%
Hyperopia20/20 & J5
94.5%
Emmetropia20/20 & J5
97.7%
20/20J5
upto -8.50 D upto +5.75 D
©DZ Reinstein [email protected]
Blended Vision: Safety
0%
10%
20%
30%
40%
50%
60%
70%
Lines Change in BSCVA
Perc
enta
ge E
yes
Myopia 0.0% 8% 55% 36% 1%
Hyperopia 0.0% 17% 62% 19% 2%
Emmetropia 0.0% 13% 64% 22% 1%
Loss 2 or More Loss 1 No Change Gain 1 Gain 2 or More
Range: -8.50 D – plano – +5.75 D
©DZ Reinstein [email protected]
Laser Blended Vision: Contrast Sensitivity
*
Statistically significant improvement (p<0.05)
* * ** *
MyopiaUpto -8.50D, n=272
HyperopiaUpto -8.50D, n=222
Emmetropian=142
Stereo Acuity
©DZ Reinstein [email protected]
Stereo Acuity: Patients & Methods• 22 myopes, 38 hyperopes, 16 emmetropes
• Stereo acuity measurements (4-dot test)– Pre-op: near-corrected– Post-op: near-corrected– Post-op: uncorrected
• Analysis– Safety: post-op near corrected – pre-op near
corrected– Efficacy: post-op uncorrected – pre-op near
corrected
# Patients 76
SEQ-0.40 ± 2.69 D
-7.13 to +3.75 D
Cylinder-0.73 ± 0.54 Dup to -2.25 D
Agemedian 57 yrs
45 to 69
©DZ Reinstein [email protected]
• All eyes retained BCSA of 100 arcsec or better post-operatively• No statistically significant difference between pre-op best-corrected
stereaoacuity and post-op best-corrected stereoacuity (p>0.185)
Stereo Acuity: Safety(near-corrected pre vs near-corrected post)
Fawcett et al demonstrated a loss of best-corrected stereo after monovision LASIK/PRK (J.AAPOS. 2001;5(6):342-7)
Control Monovision <1.50D Monovision ≥1.50D
Stereo (median) 40 sec 100 sec 150 sec
Time in monovision14.5 months (6-47m)
©DZ Reinstein [email protected]
Stereo Acuity: Efficacy(near-corrected pre vs near-uncorrected post)
• All eyes retained UCSA of 400 arcsec or better post-operatively
Non-linear Aspheric Micro-Monovision:Summary
©DZ Reinstein [email protected]
Summary
• Non-linear aspheric micro-monovision– Correction of pure presbyopia (distance normal)– Wide range of refractive error: +5.00 to -9.00– Simultaneous accurate correction of cylinder– Easily enhanced in future if required– Centration on visual axis– Minimal compromise to contrast sensitivity and night
vision disturbances– Tolerated by >95% of patients– Functional stereo acuity maintained– Performed as bilateral simultaneous 10 minute
procedure with fast recovery
Laser Blended Vision with MEL80
Dan Z Reinstein MD MA(Cantab) FRCSC1,2,3,4
1. London Vision Clinic, London, UK2. St. Thomas’ Hospital - Kings College, London, UK 3. Weill Medical College of Cornell University, New York, USA4. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France
Thank YouThis indication for use is not cleared by the FDA for distribution in the United States
1
• The Lens is implanted into the corneal stroma of the non-dominant eye, inside a pocket created using femtosecondlaser
Intracorneal Inlays for Presbyopia
Figure 1: The Flexivue Microlens™ is a transparent, hydrophilic disc with 3 mm diameter and approximately 15 μm edge thickness. The central 1,8 mm diameter of the disc is plano and the peripheral zone has an add power. The base power available range from +1,25 D to +3,50 D in 0,25 D increments. At the center of the disc there is a hole of 0,5mm diameter that permits the transfer of oxygen and nutrients of the cornea through the lens.
15 µm 3 mm
Refractive Power:
+1,25D to +3,50D
No Refractive
Power
1,8 mm
Flexivue Micro-Lens (Presbia)
Intracorneal Inlays - During Far Vision
Figure 2: During far vision the rays pass through the central zone of the implant (blue line) and through the free peripheral corneal tissue (interrupted blue line) without the Lens add refractive effect and will be sharply focused on the retina, whereas the rays which pass through the refractive peripheral zone (red line) will be focused in front of the retina.
Flexivue Micro-Lens (Presbia)
Figure 3: During near vision the rays pass through the central zone of theLens (blue line) will be out of focus behind the retina and the rays passing through the peripheral clear cornea will be blocked by the pupil (interrupted blue lines). The rays passing through the peripheral refractive zone (red lines) will be focus on the retina.
Intracorneal Inlays - During Near Vision
Flexivue Micro-Lens (Presbia)
Femtosecond-assisted Corneal Pocket
Femto parameters:•iPockets software
–Depth: 280-300–Diameter: 4 mm–Bed energy:0.60-0,70–Spot-Line Sep: 2-2 (or 3-3)–Side cut energy: 1.6-1.7–Side cut angle: 160
•Deactivate pocket•Suction-applanation
Flexivue Micro-Lens (Presbia)
The Four Principal Phases
Create the corneal
Implant the Lens Check the position of
the Lens
Mark the center of the
visual axes
1 2
3 4
Flexivue Micro-Lens (Presbia) Flexivue Micro-Lens (Presbia)