3. Why is it
important?
• 1.3 billion presbyopes world wide
• Like death and taxes it is relentless and
predictable
• Cost implications
• Productivity and functional implications
4. Why is it important?
• “Baby boomers”
– Generation with high expectations
– High levels of activity
– Do not want to accept limitations with vision
6. Accommodation according to Helmholtz
• Ciliary muscle contracts ant lens becomes
more convex due to slackening of zonules
7. Accommodation according to Schachar
• Directly contrasts Helmholtz
• Zonular tension is increased- rather than
decreased- with ciliary body contraction
9. Amplitude of accommodation
- From 1 mth old.
- More regular by 2-3 mths.
- Almost adult-like by 6 mths.
- Falls from maximum of 18D at 10yrs
- To zero by 70 yrs
16. Treatment options
• Glasses and contact lenses
– Still no.1
– Recent technological innovations vaulted
management of presbyopia into the surgical
arena
– Internet has educated patients
– Advise patients on options
– Can enhance your practice
17. Treatment options
• Surgery
– Corneal based surgery
• Laser correction (lasik)
• Conductive keratoplasty
• Corneal inlays
– Scleral expansion and anterior ciliary sclerotomy
– Lens based surgery
• Mulitfocal intraocular lenses
• Accommodating intraocular lenses
19. Monovision
• Mild myopia –0.5 to –1.5D in non-
dominant eye (avoid anisometropia no more
than 2D diff between the eyes)
• Need to be able to suppress blurred image
• Only a mild decrease in distance, good
stereo, very good intermediate
20. Monovision
• Not for patients with high visual
requirements for near or distance
• Glasses for driving or detailed near tasks
• Monovision with contact lenses success rate
of 80%
• Monovision excimer laser ablation with
lasik or PRK still the most commonly
performed surgical correction of presbyopia
22. Lasik
• Creating a multi-focal cornea
• Various possible ablation patterns
– Central near, midperiphery distance
– Inferior near, rest distance
– Central distance intermediate near
• Data limited but so far good
• Often compromises distance vision
• Induce abberations
25. Conductive
keratoplasty
• Probe delivers radiofrequency energy to the
cornea that heats up the collagen and causes it to
shrink
• Performed in the midperiphery with resultant
corneal flattening and central steepening
• Amt. of steepening depends on the no. of spots
and the no. of rings
• Non-dominant eye corrected for near(monovision)
27. Conductive keratoplasty
• Safe and easy to perform
• Can only be performed on emmetropes and
hypermetropes
• Less popular because prone to slow
regression towards hyperopia
• Corneal scaring
• Unpredictable
29. Corneal inlays
• Biocompatible device placed in a pocket
created with a microkeratome or intralase
flap
• Designed for use in emmetropic
or hypermetropic eyes
• Aperture 1.6mm, outer rim 3.8mm
• Pin hole effect increases depth of focus
• Micro pores for nutrients
32. Scleral surgery
• Objective of increasing zonular tension by
weakening or altering the sclera over the
CB in order to allow for passive expansion
• Based on Schachar
theory
35. Lens based surgery
• Multifocal intraocular lenses
• Accommodating intraocular lenses
36. Presbyopic correcting IOL’s
• Because of recent advances in lens
technology the future of presbyopia
correction is rapidly moving towards lens-
based surgical options
• Multiple designs by different companies
• Goal is to minimize the dependence on
spectacles or contact lenses after cataract or
clear lens surgery
37. Multifocal IOL design
• Multiple- zone IOLs ; 3 zones
• Central and outer for distance ( distance for large and small
pupils )
• Inner annulus for near ( near for moderately small pupils )
38. • Diffractive multifocal IOL :
• Uses geometric optics and diffraction optics
• Overall spherical shape of anterior surface produces image for
distance vision
• Posterior surface has stepped structure (like Fresnel prism)
• Diffraction from these multiple rings produces a second image
with an effective add
39. Presbyopic correcting IOL’s
• By design all of these lenses present more
than one image to the retina at the same
time
• This leads to reduction in contrast
• Abberrations such as glare and halos
• Pupil size may be an issue
40. Presbyopic correcting IOL’s
• Array(AMO)
– 50% glare and halos
• Rezoom(AMO)
– smoothing over zones
– light dependent
– poor intermediate
47. Accommodating IOL’s
• Ideal accommodating lens would mimic a
juvenile lens that changes in shape and
dioptic power when the ciliary muscle
contracts
48. Accommodating IOL’s
• Lens refilling
– Surgical technique
– Material (volume and shape)
– Optics
– PCO
• Lens softening
• IOL that moves in the bag
49. Accommodating IOL’s
• Potential to correct near,
intermediate and distance
without glasses
• Potentially less side
effects
• Designed to sit posteriorly
in the bag
• With contraction of the
ciliary muscle the lens
shifts anteriorly allowing
“accommodation”
50. Accommodating IOL’s
• Mechanism – has hinges at the lens-haptic
juncture
• There is only one focal length but it shifts
• 1D power generated for near
• Increased depth of focus due to it’s posterior
positioning
• There is a learning curve, the patient needs to
learn how to accommodate with this lens in place
56. Patient discussions
• Expectations
• Alternatives
• Financial implications
• Side effects
• Bilateral need for surgery
• Neuro adaptation – may take months
57. Patient selection
• Pre-operative exclusion criteria
– Hypercritical patients
– Patients with unrealistic expectations
– Occupational - night drivers, pilots
– Unmotivated patients
58. Patient selection
• Pre-operative exclusion criteria
– No eye pathology
– Excelent visual potential
– Astigmatism <1.5D (Toric IOL’s, LRI’s)
– Presbyopic hypermetropes do the best
60. Post operative considerations
• Astigmatism
• Post capsule opacities - yag
• Glare and halos - brimonidine
• Neural adaptation - 6months
• Enhancement
• Explantation
61. Discussion
• 10% of cataract surgery in the USA is now
done with multifocal lenses
• Large studies have shown that 45 % of
patients still use glasses (near, distance,
computer, driving)
• Light adjustable lenses
Became frustrated switching gls, combined distance and near in one pair of glasses
Though spec corrections have long dominated the options for presbyopia correction recent technological innovations have vaulted the management of presbyopia into the surgical arena Internet, advice, enhance practice N01 is still gls and cl
Though spec corrections have long dominated the options for presbyopia correction recent technological innovations have vaulted the management of presbyopia into the surgical arena Internet, advice, enhance practice N01 is still gls and cl
Topographical map showing before and after
Very
Need to be centered carefully Easily reversabile
After monovision lasik and iol replacement the next most common surgical option
Because of the
Problem with this type of lens is that its pupil size dependent