1. New Treatments for Presbyopia
Erin D. Dunphy, O.D.

2. Presbyopia As we age, the lens stiffens
making it harder and harder to focus on near objects
symptoms typically begin between the ages of 40 and 45

3. The Numbers 1.7 Billion people in world have presbyopia
In the United States- 152 million -99 million wear some type of vision correction
as the population ages these numbers are increasing
Many want better choices than glasses or contacts

4. Other options
options

5. Let them have drops!
there are many ongoing studies investigating eye drops to aid in accommodation

6. EVO6 by Novartis designed to restore the lenses flexibility
It is a prodrug- a medication that after administration is metabolized into a pharmacologically active drug

7. EVO6
lipoic acid choline ester 1.5% penetrates the cornea and breaks down into lipoic acid and choline
The lipoic acid converts to dihydolipoic acid which breaks down the disulphide bonds in the lens which INCREASES LENS FLEXIBILITY

8. Cool Chemistry
EVO6

9. Placebo Controlled Study
50 patients treated daily with EVO6 for 90 days
25 patients were given a placebo
EVO6 showed a statistical difference from the placebo
By day 90, 82 % of the participants treated with EV06 had 20/40 near vision versus only 48 % in the placebo group

10. EVO6 Study
The comfort of the drop was well tolerated and there was no loss of distance acuity
Other tools require us to adapt to imbalance or simultaneous multiple points of focus
there was no change in pupil size or IOP
More studies of larger groups and over a longer time period need to done but the results are promising

11. EVO6 Fountain of Youth
this drop could potentially halt or reverse lens hardening which would allow the lens to maintain or regain its ability to accommodate

12. A place for us
presbyopia correcting drops may be used in conjunction with other available options, such as low powered readers or low powered multifocal contacts
if used with low powered multifocal contacts the idea is there will be less blur in the distance

13. Liquid Vision Drop made by Presbyopia Therapies
Combines aceclidine- a miotic and Tropicamide a cycloplegic to create a super pinhole effect and moderate accommodation
The miotic causes the pinhole effect and creates strong accommodation and distance blur but in combination with tropicamide moderates the accommodation at the same time
the combination is uses to improve near and far vision

14. Liquid Vision Drop fast acting , 30 minutes!
meant to be used daily and as a complement to current options
put drops in, drive to work and be able to see the computer in to early afternoon, then put in another drop
Still in FDA trials expected on the market in 2021

15. Liquid Vision
liquid vision

16. FOV Tears
a presbyopia correcting drop approved in Columbia and is going through approval in Argentina, Peru and Spain
It is a combination of parasympathetic, alpha agonist 1 and 2, an anti-cholinesterase and and NSAID
it affects the ciliary muscle- causes a physiological accommodation and a dynamic pseudo- accommodation- dynamic miosis that changes with light intensity

17. FOV tears
FOV

18. Study results
A small study found the drops lasted 4-5 hours at first but this increased to 8 hours with use of the drop over a long period of time
the onset of the drop’s effects accelerated with longer use of the drop, by the 3rd month 70 percent stated it took only 5-10 minutes to take effect
improved near acuity by 2-3 lines at first
after 3 months study subjects improved 1-2 more lines of acuity and improved a line in the distance as well

19. Study results
after 3 months the patient’s near vision improved one to two additional lines
distance improved by one line and intermediate vision was 20/25
by the third month of use, 100 percent of the participants were totally independent of their near vision correction for normal activities

20. Monocular Drop
small pilot study of presbyopes with 20/20 uncorrected distance vision were give 3% carbachol and .2% brimonidine separately and in combination to their non-dominant eye
The drop constricts the pupil increases depth of focus with the pinhole effect
disadvantage is that it is monocular and their is some dimming of vision due to the small aperture optics

21. Market for drops Results from the recent studies seem promising
May be especially useful in the early stages of presbyopia for patients that want to delay their dependency on readers or glasses
could introduce new patients into a practice- patients that self treated with readers will need to see an eye doctor for annual exams for these Rx drops

22. You Can’t Read This

23. Presby LASIK
Creating a corneal flap and applying a variable ablative treatment pattern to the stoma creating a multifocal cornea
Peripheral presby LASIK- the central corneal is treated for distance acuity and peripheral corneal tissue is removed to create a negative asphericity to increase depth of field

24. Peripheral PresbyLASIK
may be limited to hyperopes, low myopes and emmetropes due to the amount of peripheral tissue that needs to be ablated in higher myopes

25. Central PresbyLASIK
Creates a hyperpositive area in the central cornea for near acuity while reserving the peripheral cornea for distance
Pupil dependent and targets a similar purpose to diffractive multifocal lenses- leaving the central cornea of near vision
the only LASIK approved in the United States at this time is monovision LASIK, more studies need to be done on these alternative options

26. Disadvantages
Unwanted diffractive effects, improper centration progression of loss of effect from the biomechanical properties of the cornea
one study reported reduced contrast sensitivity in these patients

27. Intracor
a femtosecond laser ablates only the intrastromal corneal tissue
it is delivered in a series of concentric disruptive cylindrical rings within the posterior stroma that extend out to mid stroma
intraocular pressure then induces corneal steepening on the anterior corneal surface

28. Intracor
Pattern depends on patient's refractive error, improves distance and near acuity without disrupting the epithelium
Short recovery time and anterior stromal fibers are preserved
more investigation needs to be done

29. Intracor
Intracor

30. Intracor
Intracor

31. Corneal Inlays
they improve near vision without hindering distance vision in emmetropic presbyopes
April FDA approved Kamra inlay Acufocus
thin , small disc as a 1.6 mm central opening that acts as a pinhole to increase the patient’s depth of field and improve near vision with little effect on distance vision

32. Kamra
has thousands of microperforations in the donut- shaped inlay to allow nutrients to pass through the implant within the cornea
this pseudo-random distribution of perforations ensures the delivery of more focusable light rays to the retinal plane
better optical regulations and improves vision in dimmer environments

33. Kamra Inlay it can be removed
in clinical trials the near acuity pre-op to post-op improved form J 8 to J 2
Distance vision was maintained at 20/20 to 20/25

34. Inlay Issues some reports of glare at night
challenges with viewing the retina during retinal surgery

35. Inlay surgery

36. Raindrop
hydrogel plastic inlay placed in the cornea of the non dominant eye under a LASIK style flap using a femtosecond laser
It changes the curvature of the front of the cornea so the front of the eye acts like a multifocal lens
It was approved in 2016 by the FDA

37. Flexivue Inlay
another hydrophilic inlay that is placed in the non dominant eye and is offered in powers from to
works well for emmetropic presbyopes

38. Disadvantages sacrifices some distance vision
people must have good distance vision to be a candidate
corrects for 1.5 to 2.5 diopters of reading

39. New Contacts for Presbyopia
E Vision smart optics electronic contact lens
have a prototype that adds a liquid crystal material to a conventional lens that can be tuned to different focal lengths over 3 diopters through embedded electrodes
the electronic portion of the lens is less than 5 mm

40. AMAZING
WHAT that’s like a bionic eye!!!

41. E Vision
the patients can adjust it 3 diopters in either direction giving them a 6 diopter range, pre set distances can be programmed for far, near an intermediate
changes within 200 milliseconds

42. E vision they automatically tint in sunlight WOW!
They should hold a charge during the days wear
charging kit comes with the cleaner

43. Extended Depth of Focus CL
approved by the FDA in 2017
the design uses higher order aberrations to improve image quality over a range of distances while minimizing ghosting and haloes
It is supposed to perform independently of a patient’s natural aberrations and changes in pupil size

44. EDOF

45. Google and Alcon’s Smart Lens
the two companies are partnering to develop a lens with embedded sensors, microchips and other miniaturized electronics
Alcon expects the lens to help restore the eyes natural autofocus for near objects in the form of an accommodative contact lena or an IOL implanted during cataract surgery

46. New Progressive Digital Design
with advanced computer algorithms
the corridor length can be designed to custom fit the patients frame of choice with the appropriate width of distance and near portion
this can reduce unwanted distortions and improve adaption leading to high patient satisfaction

47. Essilor’s Varilux Portfolio
includes technology to provide sharper vision in all lighting conditions and easier transition between distance and near zones and a reduction in swim

48. Future is Clear!
With the increasing numbers of presbyopes due to the aging of the population, many patients will be seeking better options than those that are currently available.

49. Future options Continued advancement in multifocal IOL’s,
eye drops to increase accommodation
corneal inlays
PresbyLASIK
electronic contacts
advancements in glasses options

50. Thank you!
Thanks for attending. GO CUBS!