The presbyopic patient options with corneal refractive surgery - PowerPoint PPT Presentation

The presbyopic patient – options with corneal refractive surgery Jakob Siedlecki University Eye Hospital LMU Munich, Germany Private Practice Dirisamer/Priglinger & SMILE Eyes Clinic Linz, Austria Financial Disclosure: Jakob Siedlecki has obtained speaker fees from Carl Zeiss Meditec AG, Novartis AG, Oculentis OSD Medical GmbH

Which corneal refractive options do we have for presbyopia? • Corneal inlays Loss of UDVA Yilmaz OF, JCRS 2008 Patient must tolerate monovision • Conductive keratoplasty Medium predictability Stahl JE et al., JRS 2007 Patient must tolerate monovision • Multifocal ablation profiles Good predictability • Loss of CDVA Vargas-Fragoso and Alio ́ , Eye and Vision 2017 Intraocular rivalry • Laser Monovision Excellent predictability Patient must tolerate monovision Wright KW et al., JCRS 1999 Luft N et al., EurJOph 2017 • PRESBYOND Excellent predictability Reinstein DZ et al., JRS 2009 & 2011 Better tolerance than monovision

Is SMILE compatible with monovision? SMILE might induce less higher order aberrations (HOA) and thus be less suitable in cases of presbyopia

Which experiences support SMILE monovision?

SMILE monovision: Study design • Interventional case series (SMILE EYES Linz Database) • 49 patients (= 98 eyes) with bilateral SMILE planned as monovision • Mean age: 49.1 ± 3.0 years • MRSE: Distance eyes: -5.10 ± 1.93 D Near eyes: -5.20 ± 1.92 D • Mean add: +1.15 ± 0.43 D • Assessment: UDVA/CDVA (Snellen chart 4 m) UNVA/DCNVA/CNVA (Jaeger chart 40 cm) • Target: Distance eyes: plano Near eyes: -0.5 to -1.25 D

SMILE monovision: Results • Results • MRSE: Distance eyes: -0.27 ± 0.40 D △ 0.66 ± 0.50 D Near eyes: -0.93 ± 0.38 D • UDVA: 90 % 20/20 100 % 20/25 Efficacy index 1.02 ± 0.23 • DCNVA preop: J3 = 20/40 J1 quadrupled from 20 to 82 % (p<0.001) • UNVA postop: J1 = 20/25 Efficacy index 0.87 ± 0.19

SMILE monovision: Results • Results • Safety: no loss of 2 or more lines Excellent safety!

SMILE monovision: Is the patient happy? • Results • Cumulative: 82 % UDVA 20/25 and J1 71 % UDVA 20/20 and J1 • Spectacle independence: - 92 % for near vision (4 patients requiring reading glasses for small print)  3 of these 4 overcorrected in the near eye (mean +0.50 ± 0.25 D) - 92 % for distance vision (4 patients requiring glasses for driving at night)  3 of these 4 undercorrected in the distance eye (mean -0.88 ± 0.50 D) SMILE monovision is an elegant option for patients seeking spectacle independence

Monovision: Is the surgeon ’ s quest for perfection satisfied? • gap Gap between what’s possible and what’s achieved: J1 UNVA vs. J1+ CNVA • What about the 8 to 28 % of patients who do NOT tolerate monovision? • . Patients will continue to age Partial accommodation is lost Stronger monovision is required Subjective symptoms will increase Acceptance will suffer

Why do some patients not tolerate monovision? 1. Interocular rivalry  summation loss  loss of stereoacuity 2. Asthenopia 3. Near eye: Distance vision loss 4. Blurred intermediate vision

Which corneal refractive options do we have for presbyopia? • Corneal inlays Loss of UDVA Yilmaz OF, JCRS 2008 Patient must tolerate monovision • Conductive keratoplasty Medium predictability Stahl JE et al., JRS 2007 Patient must tolerate monovision • Multifocal ablation profiles Good predictability • Loss of CDVA Vargas-Fragoso and Alio ́ , Eye and Vision 2017 Intraocular rivalry • Laser Monovision Excellent predictability Patient must tolerate monovision Wright KW et al., JCRS 1999 Luft N et al., EurJOph 2017 • PRESBYOND Excellent predictability Reinstein DZ et al., JRS 2009 & 2011 Better tolerance than monovision

PRESBYOND: Principle Ideal focus Natural optical systems: (small pupil) natural spherical aberration Increased DOF

DOF induced by spherical aberrations • DOF increases with both positive and negative SA

DOF induced by spherical aberrations: plateau • DOF plateaus around 0.6 – 0.9 µm of SA

DOF induced by spherical aberrations: toxicity • SA and HOA in general at some point become toxic (loss of contrast sensitivity)

PRESBYOND: Controlled induction of SA = DOF • Controlled induction of SA by a non-linear aspheric protocol  DOF: 1.5 D • Additional individual mini-monovision up to 1.5 D  DOF: 1.5 + 1.5 D = 3.0 D • Optical zone diameter depending on pupil size

PRESBYOND: Controlled induction of DOF Monovision PRESBYOND

PRESBYOND: Controlled induction of DOF PRESBYOND • Controlled induction of SA  consider baseline SA  consider amount of ablation

PRESBYOND results (Reinstein DZ et al 2009-2012) • Percentage of patients achieving 20/20 and J2 • Myopia (mean -3.60 ± 1.80 D) 95 % • Emmetropia (mean +0.25 ± 0.40 D) 95 % • Hyperopia (mean +2.60 ± 1.20 D) 77 % • Safety (loss of 1 line, since no loss of 2+ lines!) • Myopia 8 % • Hyperopia 17 % • Emmetropia 13 % Reinstein DZ JRS 2009, 2011 and 2012

PRESBYOND: advantages over multifocality and monovision • Tolerance: Monovision PRESBYOND 3% 8% 28% 72% 92% 97% • PRESBYOND: easy to enhance (re-LASIK) • Multifocal cornea: difficult to enhance • PRESBYOND: neuroadaptation up to 3 months (physiological interocular rivalry) • Multifocal IOL/cornea: neuroadaptation (traceable in fMRI) for up to 9 months (intraocular rivalry)

Monovision and PRESBYOND: What ’ s the potential? • Age: 45 – 50 % of patients asking about refractive options are > 45 years • Lens? About 70-80 % show normal aging of the crystalline lens without cataract • Every patient > 40 years is being informed about monovision/PRESBYOND in our practice. • About 80 % of these fancy additional presbyopia treatment • PRESBYOND vs. SMILE Monovision?  Main decision based on retreatments

PRESYBOND AND SMILE: ENHANCEMENT? PRESBYOND SMILE 2% 98% Liu YC et al Ophthalmology 2017 Reinstein DZ et al JRS 2009, 2011 and 2012 Siedlecki J et al. JRS 2017

SMILE (monovision): Is Enhancement frequent? Complicated? • Enhancement rate: 0 % after 7.4 ± 4.5 months last treatment December 2016 – still no enhancement … (up to 7 % in LASIK monovision near / 27.9 % in distance eyes) • PRK vs. CIRCLE: • Regression: The distance eye ’ s foe, the near eye ’ s friend …

TAKE HOME MESSAGE • In patients > 45 years, presbyopia correction on the cornea is very effective with unrivaled safety. • SMILE monovision is an elegant method of emmetropization with additional presbyopia correction. Anisometropia should be < 1.5 D. • PRESBYOND offers an optimization of binocular function (summation, acceptance…) and intermediate vision. • In the age of ray tracing and further advances in biometry, later cataract surgery should not pose a problem.

Thank you! Jakob Siedlecki University Eye Hospital LMU Munich, Germany Private Practice Dirisamer/Priglinger & SMILE Eyes Clinic Linz, Austria jakob.siedlecki@med.uni-muenchen.de