1. GT BOGOTA LASER REFRACTIVE INSTITUTE BOGOTA COLOMBIA SOUTHAMERICA GUSTAVO E. TAMAYO MD BASIC PRINCIPLES OF PRESBYOPIA

2. GT PRESBYOPIA DEFINITION  PRESBYOPIA IS LOSS OF ACCOMODATION INSIDE THE EYE 1. Loss of “auto-focus” 2. Difficult vision at near 3. Need to increase the distance between the objects and the eye 4. Distant vision remains unchanged.  PRESBYOPIA IS LOSS OF ACCOMODATION INSIDE THE EYE 1. Loss of “auto-focus” 2. Difficult vision at near 3. Need to increase the distance between the objects and the eye 4. Distant vision remains unchanged.

3. GT Presbyopia Presbyopia  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

4. GT Etiology 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

5. GT THE VISION WITH PRESBYOPIA DistanceIntermediate Near

6. GT  Lens makes the auto focus NORMAL YOUNG EYE

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9. 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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11. SURGERY FOR PRESBYOPIA  CORNEA  SCLERA  ANTERIOR CHAMBER  LENS  CORNEA  SCLERA  ANTERIOR CHAMBER  LENS

12. GT SURGERY 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)

13. GT 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.

14. GT SURGERY 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

15. GT Flexivue 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.

16. GT AcufocusAcufocus

17. AcufocusAcufocus

19. Flexivue Microlens

20. GT

21. SURGERY 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.

22. GT SURGERY 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

23. GT Frequently Asked Question  How Does this treatment work if the pupil gets smaller when reading? CREATION OF A PERIPHERAL KNEE

24. GT Multifocal Cornea

25. GT HOW THE TREATMENT WORKS WITH A SMALL PUPIL? PREOPERATIVE POSTOPERATIVE The knee

26. GT Intracore 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.

27. GT Femtosecond Lasers

28. GT Excimer Lasers and Multifocal Corneal 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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30. SURGERY 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.

31. GT CONDUCTIVE KERATOPLASTY

32. GT CONDUCTIVE KERATOPLASTY

33. GT SURGERY 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.

34. GT SCLERAL EXPANSION SURGERY

35. GT Scleral Expansion Surgery

36. GT SURGERY 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..

37. GT PHAKIC LENS: VERISYSE

38. GT SURGERY 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

39. GT Multifocal IOL

40. GT Multifocal IOL

41. GT ACCOMODATIVE CRISTALENS

42. GT SURGERY 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.

43. GT Capsular 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.

44. GT Capsular Bag Refilling

45. GT Capsular Bag Refilling

46. GT THANK YOU