The presbyopic patient options with corneal refractive surgery - - PowerPoint PPT Presentation

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The presbyopic patient options with corneal refractive surgery - - PowerPoint PPT Presentation

Mar 28, 2024 131 likes •391 views

The presbyopic patient options with corneal refractive surgery Jakob Siedlecki University Eye Hospital LMU Munich, Germany Private Practice Dirisamer/Priglinger & SMILE Eyes Clinic Linz, Austria Financial Disclosure: Jakob Siedlecki has

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SLIDE 1

The presbyopic patient –

  • ptions with corneal refractive surgery

Jakob Siedlecki University Eye Hospital LMU Munich, Germany Private Practice Dirisamer/Priglinger & SMILE Eyes Clinic Linz, Austria

Financial Disclosure: Jakob Siedlecki has obtained speaker fees from Carl Zeiss Meditec AG, Novartis AG, Oculentis OSD Medical GmbH

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SLIDE 2

Which corneal refractive options do we have for presbyopia?

  • Corneal inlays

Loss of UDVA Patient must tolerate monovision

  • Conductive keratoplasty

Medium predictability Patient must tolerate monovision

  • Multifocal ablation profiles

Good predictability

  • Loss of CDVA

Intraocular rivalry

  • Laser Monovision

Excellent predictability Patient must tolerate monovision

  • PRESBYOND

Excellent predictability Better tolerance than monovision

Vargas-Fragoso and Alió, Eye and Vision 2017 Wright KW et al., JCRS 1999 Luft N et al., EurJOph 2017 Stahl JE et al., JRS 2007 Yilmaz OF, JCRS 2008 Reinstein DZ et al., JRS 2009 & 2011

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SLIDE 3

Is SMILE compatible with monovision?

SMILE might induce less higher order aberrations (HOA) and thus be less suitable in cases of presbyopia

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SLIDE 4

Which experiences support SMILE monovision?

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SLIDE 5

SMILE monovision: Study design

  • Interventional case series (SMILE EYES Linz Database)
  • 49 patients (= 98 eyes) with bilateral SMILE planned as monovision
  • Mean age:

49.1 ± 3.0 years

  • MRSE:

Distance eyes:

  • 5.10 ± 1.93 D

Near eyes:

  • 5.20 ± 1.92 D
  • Mean add:

+1.15 ± 0.43 D

  • Assessment:

UDVA/CDVA (Snellen chart 4 m) UNVA/DCNVA/CNVA (Jaeger chart 40 cm)

  • Target:

Distance eyes: plano Near eyes:

  • 0.5 to -1.25 D
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SLIDE 6

SMILE monovision: Results

  • Results
  • MRSE:

Distance eyes:

  • 0.27 ± 0.40 D

Near eyes:

  • 0.93 ± 0.38 D
  • UDVA:

90 % 20/20 100 % 20/25 Efficacy index 1.02 ± 0.23

  • DCNVA preop:

J3 = 20/40

  • UNVA postop: J1 = 20/25

Efficacy index 0.87 ± 0.19

△ 0.66 ± 0.50 D J1 quadrupled from 20 to 82 % (p<0.001)

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SLIDE 7

SMILE monovision: Results

  • Results
  • Safety:

no loss of 2 or more lines

Excellent safety!

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SLIDE 8

SMILE monovision: Is the patient happy?

  • Results
  • Cumulative: 82 % UDVA 20/25 and J1

71 % UDVA 20/20 and J1

  • Spectacle independence:
  • 92 % for near vision (4 patients requiring reading glasses for small print)

 3 of these 4 overcorrected in the near eye (mean +0.50 ± 0.25 D)

  • 92 % for distance vision (4 patients requiring glasses for driving at night)

 3 of these 4 undercorrected in the distance eye (mean -0.88 ± 0.50 D)

SMILE monovision is an elegant option for patients seeking spectacle independence

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SLIDE 9

Monovision: Is the surgeon’s quest for perfection satisfied?

  • Gap between what’s possible and what’s achieved:

J1 UNVA vs. J1+ CNVA

  • What about the 8 to 28 % of patients who do NOT tolerate monovision?

gap

  • . Patients will continue to age

Partial accommodation is lost Stronger monovision is required Subjective symptoms will increase Acceptance will suffer

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SLIDE 10

Why do some patients not tolerate monovision?

  • 1. Interocular rivalry

 summation loss  loss of stereoacuity

  • 2. Asthenopia
  • 3. Near eye: Distance vision loss
  • 4. Blurred intermediate vision
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SLIDE 11
  • PRESBYOND

Excellent predictability Better tolerance than monovision

Which corneal refractive options do we have for presbyopia?

  • Corneal inlays

Loss of UDVA Patient must tolerate monovision

  • Conductive keratoplasty

Medium predictability Patient must tolerate monovision

  • Multifocal ablation profiles

Good predictability

  • Loss of CDVA

Intraocular rivalry

  • Laser Monovision

Excellent predictability Patient must tolerate monovision

Vargas-Fragoso and Alió, Eye and Vision 2017 Wright KW et al., JCRS 1999 Luft N et al., EurJOph 2017 Stahl JE et al., JRS 2007 Yilmaz OF, JCRS 2008 Reinstein DZ et al., JRS 2009 & 2011

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PRESBYOND: Principle

Natural optical systems: natural spherical aberration Ideal focus (small pupil)

Increased DOF

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DOF induced by spherical aberrations

  • DOF increases with both positive and negative SA
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SLIDE 14

DOF induced by spherical aberrations: plateau

  • DOF plateaus around 0.6 – 0.9 µm of SA
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SLIDE 15

DOF induced by spherical aberrations: toxicity

  • SA and HOA in general at some point become toxic

(loss of contrast sensitivity)

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SLIDE 16

PRESBYOND: Controlled induction of SA = DOF

  • Controlled induction of SA by a non-linear aspheric protocol

 DOF: 1.5 D

  • Additional individual mini-monovision up to 1.5 D

 DOF: 1.5 + 1.5 D = 3.0 D

  • Optical zone diameter depending on pupil size
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SLIDE 17

PRESBYOND: Controlled induction of DOF

Monovision PRESBYOND

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SLIDE 18

PRESBYOND: Controlled induction of DOF

PRESBYOND

  • Controlled induction of SA

 consider baseline SA  consider amount of ablation

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SLIDE 19
  • Percentage of patients achieving 20/20 and J2
  • Myopia

(mean -3.60 ± 1.80 D) 95 %

  • Emmetropia (mean +0.25 ± 0.40 D)

95 %

  • Hyperopia

(mean +2.60 ± 1.20 D) 77 %

  • Safety (loss of 1 line, since no loss of 2+ lines!)
  • Myopia

8 %

  • Hyperopia

17 %

  • Emmetropia

13 %

Reinstein DZ JRS 2009, 2011 and 2012

PRESBYOND results (Reinstein DZ et al 2009-2012)

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SLIDE 20

PRESBYOND: advantages over multifocality and monovision

  • Tolerance:
  • PRESBYOND:

easy to enhance (re-LASIK)

  • Multifocal cornea:

difficult to enhance

  • PRESBYOND:

neuroadaptation up to 3 months (physiological interocular rivalry)

  • Multifocal IOL/cornea: neuroadaptation (traceable in fMRI) for up to 9 months (intraocular rivalry)

72% 28% 92% 8% 97% 3%

Monovision PRESBYOND

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SLIDE 21

Monovision and PRESBYOND: What’s the potential?

  • Age:

45 – 50 % of patients asking about refractive options are > 45 years

  • Lens? About 70-80 % show normal aging of the crystalline lens without cataract
  • Every patient > 40 years is being informed about monovision/PRESBYOND in our practice.
  • About 80 % of these fancy additional presbyopia treatment
  • PRESBYOND vs. SMILE Monovision?

 Main decision based on retreatments

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SLIDE 22

PRESYBOND AND SMILE: ENHANCEMENT?

98% 2%

SMILE PRESBYOND

Reinstein DZ et al JRS 2009, 2011 and 2012 Liu YC et al Ophthalmology 2017 Siedlecki J et al. JRS 2017

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SLIDE 23

SMILE (monovision): Is Enhancement frequent? Complicated?

  • Enhancement rate:

0 % after 7.4 ± 4.5 months last treatment December 2016 – still no enhancement… (up to 7 % in LASIK monovision near / 27.9 % in distance eyes)

  • PRK vs. CIRCLE:
  • Regression:

The distance eye’s foe, the near eye’s friend…

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SLIDE 24

TAKE HOME MESSAGE

  • In patients > 45 years, presbyopia correction on the cornea is very effective with

unrivaled safety.

  • SMILE monovision is an elegant method of emmetropization with additional

presbyopia correction. Anisometropia should be < 1.5 D.

  • PRESBYOND offers an optimization of binocular function (summation, acceptance…)

and intermediate vision.

  • In the age of ray tracing and further advances in biometry, later cataract surgery should

not pose a problem.

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SLIDE 25

Thank you!

jakob.siedlecki@med.uni-muenchen.de

Jakob Siedlecki University Eye Hospital LMU Munich, Germany Private Practice Dirisamer/Priglinger & SMILE Eyes Clinic Linz, Austria