Mechanism and outcomes of PRESBYOND€¦ · Correcting Presbyopia: Laser Blended Vision Brain...

Mechanism and outcomes

of PRESBYOND

Glenn I Carp MBBCh, FC Ophth (SA)1 Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth FEBO1,2,3,4

Timothy J Archer, MA(Oxon), DipCompSci(Cantab)1

1. London Vision Clinic, London, UK

2. Columbia University Medical Center, New York, USA

3. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France

4. Biomedical Science Research Institute, Ulster University, Coleraine, Northern Ireland

©DZ Reinstein 2016

dzr@londonvisionclinic.com

Financial Disclosure

The author (GI Carp) receives travel expenses

from Carl Zeiss Meditec AG (Jena, Germany)

The author (DZ Reinstein) is a consultant for

Carl Zeiss Meditec AG (Jena, Germany)

The author (DZ Reinstein) acknowledges a

financial interest in Artemis™ VHF digital

ultrasound (ArcScan Inc., Golden, CO)

©DZ Reinstein 2016

Objective

PRESBYOND is….

not monovision!

not micro/modest monovision!

not a multifocal treatment!

It’s PRESBYOND!!!!!

©DZ Reinstein 2016

Monovision Disadvantages: Low Tolerance

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 2016

Monovision: Challenges

3. Distance vision loss 1. Intermediate vision loss 2. Tolerance

4. Summation loss 5. Stereo acuity loss

(unrecoverable)

©DZ Reinstein 2016

Modest Monovision

** Pardhan et al., The Effect of Monocular Defocus on Binocular Contrast

Sensitivity, Ophthal. Physiol. Opt., 1990, Vol. 10, January

Literature suggests a defocus value of -1.3D delivers the best balance of

summation and near acuity

Summation

Subtraction Suppression

©DZ Reinstein 2016

3. Poor distance vision in

the near eye

1. Blur zone at intermediate

distances

2. Anisometropia not

tolerated by many

4. Loss of binocular distance

vision (rivalry/suppression)

5. Loss of stereo acuity

(unrecoverable)

Improves on

these challenges

Modest

Monovision

Graham Barrett

©DZ Reinstein 2016

Stereoacuity and anisometropia

Up to -1.25 D

-1.50 D or more

Minimal stereopsis impairment for

anisometropia <1.5D

©DZ Reinstein 2016

Stereoacuity and anisometropia

Up to -1.25 D

-1.50 D or more

Minimal stereopsis impairment for

anisometropia <1.5D

However, near visual acuity is

compromised as max -1.25 add!

©DZ Reinstein 2016

(unrecoverable)

Improves on all

of these Presbyond

Increased Depth of Field by

controlling

Spherical Aberration

• Naturally occurring aberration

• Increases with age

• Increases during accommodation

©DZ Reinstein 2016

Influence of Spherical Aberration on Depth of Field

without spherical aberration

with spherical aberration

courtesy Hartmut Vogelsang, PhD

©DZ Reinstein 2016

Influence of Spherical Aberration on Depth of Field

0.00 D -0.50 D -1.00 D -1.50 D -2.00 D

without

spherical

aberration

@ 7 mm

spherical

aberration

@ 7 mm

Slides courtesy Hartmut Vogelsang, PhD

©DZ Reinstein 2016

Simulation for -1.50 D defocus

-1.50 D @ 7 mm

Add spherical aberration Reduce pupil size to 4 mm

With spherical

aberration and @ 4 mm

Central neural processing

Spherical Aberration Increases Depth of

Field: Confirmed by Adaptive Optics

©DZ Reinstein 2016

Spherical Aberration Increases Depth of Field

Depth of field increases with both negative and positive

spherical aberration

PRESBYOND Laser Blended Vision for

Myopia, Hyperopia, and Emmetropia (Non-linear Aspheric Presbyopic Micro-monovision LASIK)

©DZ Reinstein 2016

Current Possible Depth of Field Increase

Intermediate

Distance

Far Distance

Right Eye Left Eye

1.50 D 1.50 D

Loss of contrast

©DZ Reinstein 2016

Depth of Field by SA: Myopia S

Low High High Pre SA

Threshold

©DZ Reinstein 2016

Depth of Field by SA: Hyperopia S

Low High

Threshold

©DZ Reinstein 2016

Depth of Field by SA: Emmetropia S

Dist Eye Near Eye

Threshold

©DZ Reinstein 2016

Laser Blended Vision – Micro-Monovision

Intermediate

Distance

Far Distance

Dominant Eye Non-Dominant Eye

“Blend Zone”

©DZ Reinstein 2016

Laser Blended Vision – Micro-Monovision

Intermediate

Distance

Far Distance

Dominant Eye Non-Dominant Eye

Nominal Rx: plano

Nominal Rx: -1.50 D

-2.25 D

“Blend Zone”

-0.75 D

PRESBYOND Laser Blended Vision for

Myopia, Hyperopia, and Emmetropia (Non-linear Aspheric Presbyopic Micro-monovision LASIK)

©DZ Reinstein 2016

Blended Vision: Methods

Myopia Hyperopia Emmetropia

# Patients 136 111 148

SEQ -3.58 ± 1.80 D

up to -8.50 D

+2.58 ± 1.17 D

up to +5.75 D

+0.25 ± 0.43 D

-0.88 to +1.00 D

Cylinder -0.83 ± 0.64 D

up to -2.50 D

-0.49 ± 0.50 D

up to -3.25 D

-0.44 ± 0.31 D

up to -1.25 D

Age median 49 yrs

43 to 63

median 56 yrs

44 to 66

median 55 yrs

44 to 65

• >90% follow up at 1 year

• Results presented including enhancements

©DZ Reinstein 2016

Blended Vision: Enhancement Rate

Myopia

Hyperopia

+5.75 Emmetropia

All 19% 22% 12%

Distance eyes

(20/25 or worse) 9% 9% 6%

Near eyes

(J3 or worse) 8% 9% 7%

©DZ Reinstein 2016

Laser Blended Vision: Results

Myopia to -8.50D

20/20 & J2

Hyperopia to +5.75 D

20/20 & J2

Emmetropia

20/20 & J2

upto -8.50 D upto +5.75 D

-0.88 to +0.88 D

©DZ Reinstein 2016

Safety: Laser Blended Vision

All 395 Patients: Range: -8.50 D – plano – +5.75 D

©DZ Reinstein 2016

Laser Blended Vision: Contrast Sensitivity

Statistically significant improvement (p<0.05)

Myopia Upto -8.50D, n=272

Hyperopia Upto -8.50D, n=222

Emmetropia n=292

©DZ Reinstein 2016

(unrecoverable)

©DZ Reinstein 2013

Intermediate Vision: Myopic Patients

• 238 Patients

• SEQ: up to -12.00 D

• Age: 40 to 70 years

• Follow-up: 3 mo to 5 yrs

Computer

font size 12

©DZ Reinstein 2013

Intermediate Vision: Hyperopic Patients

• 334 Patients

• SEQ: up to +6.00 D

• Age: 40 to 70 years

• Follow-up: 3 mo to 5 yrs

Computer

font size 12

©DZ Reinstein 2013

3. Poor distance vision in

the near eye

1. Blur zone at intermediate

distances

2. Anisometropia not

tolerated by many

(unrecoverable)

©DZ Reinstein 2013

Monovision Disadvantages: Low Tolerance

Dominant eye:

mainly corrected

for distance

Non-dominant eye:

mainly corrected

for near Brain merges two

far without glasses

59-67%

Patients Tolerate

Evans BJ. Monovision: a review.

Ophthalmic Physiol Opt.

2007;27:417-439.

©DZ Reinstein 2013

Correcting Presbyopia: Laser Blended Vision

Brain merges two

far without glasses

Dominant eye:

mainly corrected

for distance

Non-dominant eye:

mainly corrected

for near

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

(unrecoverable)

Binocular Vision: Neural Summation

20/12.5or better

20/16 orbetter

20/20 orbetter

20/25 orbetter

20/32 orbetter

20/40 orbetter

20/63 orbetter

Near Eyes 0.0055096 0.0330579 0.1460055 0.2369146 0.3636364 0.446281 0.8044077

Distance Eyes 0.0931507 0.4465753 0.9232877 0.9780822 0.9945205 0.9972603 1

Binocular 0.1315068 0.5342466 0.9616438 0.9808219 1 1 1

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%

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

-1.50 D refraction expect 20/80

(unrecoverable)

94%100%

100% 100%

97% 100%

≤100 sec ≤200 sec ≤400 sec

Emmetropes

Myopes

Hyperopes

Stereo Acuity: Efficacy (near-corrected pre vs near-uncorrected post)

• All eyes retained uncorrected stereo acuity of

400 arcsec or better post-operatively

(unrecoverable)

Summary

• PRESBYOND Laser Blended Vision

– Correction of pure presbyopia (distance normal)

– Wide range of refractive error: +5.00 to -9.00

– Based on induction of ‘natural aberrations’

– 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

Mechanism and outcomes

of PRESBYOND

Glenn I Carp MBBCh, FC Ophth (SA)1

Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth FEBO1,2,3,4

Timothy J Archer, MA(Oxon), DipCompSci(Cantab)1

1. London Vision Clinic, London, UK

2. Columbia University Medical Center, New York, USA

3. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France

4. Biomedical Science Research Institute, Ulster University, Coleraine, Northern Ireland

Thank You

So how much compromise in near vision?

≤J4 92%

Modest Monovision vs Multifocals

Near eye target: -1.00 to -1.50 D

Achieved: -0.92 ±0.65

Eccentric Visual Function

• Adler’s Physiology of the Eye

Wertheim T. Uber die indirekte Sehschärfe,

Z. Pyschol 7:172, 1894

Visual Function

20/200

30 10 5 0 5 10 30

Normal

Traditional Monovision

Blended Vision

Eccentricity (degrees)

Visual Function

20/200

30 10 5 0 5 10 30

Normal

Traditional Monovision

Blended Vision

Eccentricity (degrees)

Summation

Suppression

Slit Lamp Examination in OR

• Take patient to the slit-lamp in the operating room to redistribute any redundant cap to the periphery

• Use Fluorescein stain to review the cap tension

• Minor cap adjustment can be carried out at the slit-lamp using a sterile spear-tip sponge if necessary

Slit-lamp Smoothing in OR

Mechanism and outcomes of PRESBYOND€¦ · Correcting Presbyopia: Laser Blended Vision Brain...

Documents

Transcript of Mechanism and outcomes of PRESBYOND€¦ · Correcting Presbyopia: Laser Blended Vision Brain...

REFRACTIVE AND DIFFRACTIVE PRINCIPLES IN PRESBYOPIA ...

Email Merges

Rapid Assessment of Refractive Error, Presbyopia, and ...

New developments in refractive cataract surgery · AMO Technis Symfony lens • Merges 2 complimentary technologies to deliver the first presbyopia-correcting extended range of vision

Merges & Acquisition

Advances in presbyopia treatment

Correcting presbyopia - Modern Options

Presbyopia Guide

Correction of Presbyopia

The Etiology of Presbyopia, Contributing Factors, and ... · Presbyopia has been a complicated problem for clinicians and researchers for centuries. Defining what constitutes presbyopia

Patent Law Prof. Merges

Physiology of Accommodation and Presbyopia · Physiology of Accommodation and Presbyopia Presbyopia is one of the earliest universal signs of aging and the basic pathophysiology involved

PRESBYOPIA CORRECTION TOLERATE THE KAPPA ANGLE …

presbyopia - Retina Consultants of WNY · presbyopia With presbyopia, reading glasses can help refract (bend) light rays before they enter the eye to compensate for loss of near vision.

What is presbyopia? Signs and symptoms · Presbyopia What is presbyopia? Presbyopia is a common, age-related vision condition in which people have difficulty focusing on things up

Guide to Presbyopia / Reading Vision Correction

CustomVis Multizone Presbyopia Treatment Progressive ...

Small Aperture Solution for Presbyopia - Medicals Intl...Setting the Standard in Presbyopia Correction As the only presbyopia procedure utilizing small aperture optics, the KAMRA inlay

Accommodation & presbyopia expected amplitude of accommodation

Presbyopia: Effectiveness of correction strategies · Presbyopia is a global problem affecting over a billion people worldwide. The prevalence of unmanaged presbyopia is as high as