Pharmacological Correction of Presbyopia: A preliminary Study Claes Feinbaum M.Sc. PhD Professor & Clinical Director Vision4You Lund, Sweden Visiting Professor at Ben Gurion University of the Negev Israel & Medicinski Center Vid Dr. Franc Salamun Dr. Katja Matovic Eilat January 2014

Current Procedures for the Correction of Presbyopia Corneal Excimer Laser Surgery (PresbiLasik) Corneal Inlays IntraCor SupraCor Multifocal IOLs Others Some of these procedures are irreversible!!

Reversability While excimer laser ablations from various manufacturers (PresbyLASIK, Abbott Medical Optics; PresbyMax, Schwind eye-tech solutions; Supracor, Technolas Perfect Vision) and femtosecond laser intrastromal ablation (Intracor, Technolas Perfect Vision) are effective treatments in the majority of patients, visual side effects and reduced vision can occur and may be intolerable for some

Reversability?????!!!! Reversability of these procedures has not been shown to date. Therefore, surgeons must take utmost care in patient selection to make sure that the procedure does not cause permanent harm

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Pharmacological Correction of Presbyopia

Accommodation Ciliary muscle contraction (modifying the shape and the position of the crystalline lens) Miosis Convergence

Pharmacological Correction * Parasympathomimetics: Stimulation of parasympathetic innervation (accomodation) and * Non-steroidal anti-inflammatories (NSAID): Prolonging the effect of the parasympathomimetic action * Artificial tear substitute prolonging action and preventing dryness

Resulting in

Increased Depth of Focus

More on DoF Increasing the DOF is advantageous in some circumstances. The age-related reduction in amplitude of accommodation that causes presbyopia can be ameliorated by increasing DOF. Depth of focus is most strongly affected by the pupil size--- when the pupil is very constricted, the depth of focus is large, and when the pupil is dilated, it is narrow.

Decrease of Higher Order Aberrations

More on HOA Studies show that less higher-order aberrations in the eye result in better quality of vision. In the laboratory, Pablo Artal, Ph.D., showed eliminating all higher-order aberrations produces the best visual performance. In addition, studies from Steve Schallhorn, M.D., global medical director of Optical Express, with 140 pilots and 228 clinic patients showed that the best visual performance occurred with the lowest amount of higher- order aberrations.

HOA There are numerous higher-order aberrations, of which only spherical aberration, coma and trefoil are of clinical interest. Doubling pupil diameter increases spherical aberration 16 times. Thus, a small change in pupil size can cause a significant change in refraction.

Results n=81

Exclusion Criteria Myopia or Astigmatism > 1.0 diopters Hyperopia > 1,0 diopters Corneal, Lens and Vitreous opacities A question mark for lens opacities (cataracts) Retinal pathologies Chronic general pathologies

Age & Gender Number of eyes: 81 48 female eyes 33 male eyes Age ranging from 42 to 74 years of with a mean of 52 years.

Ophthalmological Status 2 eyes with toric iol 8 eyes with spherical iol 4 eyes with cataract 10 eyes post LASIK and PRK 57 presbyopic eyes

Refraction Spherical refraction ranging from +1,50D to - 0,75D Astigmatism ranging from Plano to -1,75 D.C.

All the eyes received 1-2 drops Patients with dark iris received as a rule 2 drops

Pupil Reaction

UCVA Distance 0.932

UCVA Near 0.649 0.356

Depth of Focus 2.596 1.656

Adverse Reactions 4 eyes with nausea just after instillation and very quickly relieved. 2 eyes with dryness that gradually disappeared 2 eyes with burning feeling that gradually disappeared 4 eyes with stinging feeling that gradually disappeared 4 eyes with headache that gradually disappeared 4 eyes with blurry dist. vision that gradually disappeared 0 reaction 61 eyes

Post LASIK Post Cataract N=24

IOL & R.S. improvement

Conclusions Topic treatment to correct presbyopia is a safe and easy way to eliminate the use of glasses in presbyopic patients. But a complete and careful examination of each patient is necessary and you have to know that it is not suitable for all presbyopic patients. On average, a 1mm reduction of pupil size was associated with a 0,9D increase in depth of focus. Complete reversability – no use of drops means no improvement of UCVA for distance or near