1. Multifocal Corneal Excimer Ablations for Presbyopia
Guy M. Kezirian, MD, FACS
Scottsdale, Arizona
Carlos Verges, MD, PhD
Barcelona, Spain
AAO 2006 Las Vegas, Nevada
November 14, 2006

2. Disclosures
Presenter is has financial relationships with WaveLight AG, AMO-Visx, eyeonics Inc.
Owner of SurgiVision® Consultants, Inc. and Refractive Consultant Group, Inc.
Some procedures mentioned in this presentation have NOT received FDA approval

3. Acknowledgments Theo Seiler, MD, PhD AMO-Visx / Bruce Jackson, MD
Many of the slides and concepts used in this presentation
AMO-Visx / Bruce Jackson, MD

4. Multifocal Excimer Ablations for Presbyopia
Presbyopia is the most prevalent refractive disorder without a successful treatment
Current treatments include
Spectacles
Monovision (contacts or surgery)
Multifocal excimer ablation procedures
Corneal Inlays
Conductive keratoplasty (CK)
Presbyopic IOL’s

5. Multifocal Excimer Ablations for Presbyopia
Attempted from early 1990’s (Ruiz)
Ablated around opaque disks placed manually on the cornea
Have been attempted with various ablation profiles since that time
These approaches differ from monovision because they attempt to divide monocular vision (W. Maloney)

6. Monocular Multifocal Vision
Monovision requires suppression of the image from one eye
Maintains full clarity, brightness of vision from remaining eye
Suppression is common in daily life
Cameras, rear-view mirrors, etc.
Multifocal vision requires partial suppression of image from one eye
Not a physiological condition

7. Monocular Multifocal Vision
All corneal-based multifocal treatments are pupil-size dependent
Effect varies depends on ambient light, physiologic pupil size
Attempt is to provide adequate near vision and retain as much distance vision as possible
Visual quality is compromised at all distances

8. Approaches to Multifocal Ablations
Central Steep Island
VISX, Schwind, B&L
Central Steep Annulus
Nidek
Decentered Steep Island
Historical
Asphericity, optimization
Zeiss, WaveLight

9. Ablation Techniques For Presbyopic Correction
Central Near with Peripheral for Far :
Near
Luis A Ruiz : Presby lasik
W Bruce Jackson, ( 2001)
Franco Bartoli ( 2002)
Far

10. Sector Near Zone Ablation Techniques For Presbyopic Correction Far
Anschütz, Dausch, Klein, Joly
(1991)
Near

11. Ablation Techniques For Presbyopic Correction
Peripheral Near Zone
with Central Distance
Far
Avalos , Rozakis, Agarwal
(PARM- Technique, 1998)
G.Tamayo (2000)
Near

12. Ablation Techniques For Presbyopic Correction
“Global Asphericity” Or
“Q-Optimized”
Near
Far
Seiler (2005)

13. Why Central Near? Miosis with accommodation amplifies effect
Permits a prolate corneal shape
Usually provides the best vision depending on overall optical system
Causes negative asphericity, which also occurs during accommodation
Measured as positive spherical aberration on wavefront

14. Wavefront Spherical Aberration in Unoperated Myopic Eyes (N = 374)
Negative: 6%
None:
51%
Positive:
43%
Data from the US FDA Study of the WaveLight Allegretto Laser

15. Presby-LASIK Profile Design
Superimposition of a standard correction profile
(in this example myopic) with a small diameter hyperopic profile in the center:

16. Custom Q : profile design:
Superimposition of a wavefront optimized correction profile with a highly negative target Q value ( )

17. Multifocal Corneas Advantages: Disadvantages:
Ability to read with less defocus at distance
Preservation of better distance Snellen acuity
Disadvantages:
“Light Starved”
Glare, haloes, loss of contrast
Loss of best-corrected acuity
Patient acceptance

18. Current Clinical Outcomes
Visx
WaveLight

19. Visx Multifocal Presbyopia Treatments
Bruce Jackson et al (Canada)
Central steep zone approach
Done in conjunction with hyperopia treatments
BILATERAL (not just for monovision)
75 eyes in 48 patients, preop spheroequivalent up to 3.5 D

20. Monocular Simultaneous Uncorrected Distance and Near Vision
J3 or better
20/25 or better
77% of eyes achieve both 20/25 distance and J3 near or better
Slide courtesy of Bruce Jackson, MD and AMO-Visx, Inc.

21. Questionnaire Results Spectacle Use
Percent of subjects
Slide courtesy of Bruce Jackson, MD and AMO-Visx, Inc.

22. Wavefront Aberrations
Post-op WaveScan™ HOA pattern shows central myopic area
Rx Correction Map (in diopters)
Case Example:
ID# OD
6M post-op
Dist UCVA: 20/25
Near UCVA: J1
ggg
Slide courtesy of Bruce Jackson, MD and AMO-Visx, Inc.

23. WaveLight Global Asphericity
Theo Seiler, MD, PhD and Tobias Koller, MD
Zurich, Switzerland

24. refractive difference / dpt
Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD
difference in size of the retinal image
fusion
100% 8% 6%
50% 4% 2% 0% 1 2 3 4 5 6 7
refractive difference / dpt

25. Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD

26. Asphericity Basics Prolate shape, Q < 0, slightly myopic
Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD
Asphericity Basics
Prolate shape, Q < 0, slightly myopic

27. Alternative approach: central steep island (CSI)
Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD
PresbyLASIK and Asphericity
Alternative approach: central steep island (CSI)

28. Central cornea has higher refractive power
Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD
Precondition for a corneal shape that supports near vision in a presbyopic eye
Central cornea has higher refractive power
compared to
peripheral cornea
(= prolate cornea)

29. PresbyLASIK and Asphericity
Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD
PresbyLASIK and Asphericity
Optimal corneal shape (R,Q)
with a 2.5mm-pupil for near objects (0.4m)
and a 5mm-pupil for far objects (5m)
GLOBAL OPTIMUM (R,Q)
myopia of -1.5 D regarding the central cornea
asphericity constant Q = -0.7 to -0.9 (hyperprolate)

30. PresbyLASIK and Asphericity
Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD
PresbyLASIK and Asphericity
photoreceptor layer
retina
6 mm
4 mm
2 mm
pupil size
-1 mm
-500μm
+500μm
-410μm
-280μm
+ 70μm

31. PresbyLASIK and Asphericity
Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD
Please note
The global optimum shape of the cornea is not a multifocal cornea but an aspheric hyperprolate cornea
It does not produce 2 foci and the brain selects the appropriate image like in bifocal IOL's
The driving force is the pupil diameter that shifts the focus of the optics
The procedure is recommended for ONE EYE (modified monovision concept)

32. PresbyLASIK clinical data
Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD
pilot study, n=15, non-dominant eyes preop sph -0.5 to +1.5D, cyl < 0.75D
distant VA near VA low contrast VA
(100cd) (100cd) (80cd)
mean (J3) (pre 0.62)
SD ± ± ± 0.12 (0.2)
range to J2 to J to 0.8

33. global optimum (R,Q) for near and distant vision
PresbyLASIK and Asphericity
Slide courtesy of Theo Seiler MD, PhD and Tobias Koller, MD
monovision -1.5D
global optimum (R,Q) for near and distant vision
CSI with optimal Q
distance 5m near 0.4m
pupil 5mm pupil 2.5mm

34. Conclusions Multifocal ablations are possible with today’s technology
Issues over ablation shape, contour and location are largely solved
Bilateral treatments seem less likely to succeed than modification of monovision with a multifocal approach
Neural adaptation may be delayed compared with monovision due to intra-ocular multifocal effect rather than total eye suppression

35. Conclusions
Procedures seem at odds with current efforts to optimize vision and improve overall wavefronts
Either procedure may be appropriate in some cases but patient selection will be a challenge –
Providing realistic preoperative simulations is difficult

36. Thank You