Surgical correction of presbyopia

Outcomes of Corneal Compound Myopic Astigmatism with Presbyopia by Zeiss PRESBYOND® Laser Blended Vision LASIK Using Default CRS-Master® Target Refractions for Reduced Anisometropia

Background/Objectives: Presbyopia, a common age-related refractive error, affects over a billion people globally and significantly impacts daily life. Methods: This retrospective study analyzed 288 eyes of 144 patients undergoing LBV PRESBYOND® treatment for myopic presbyopia with astigmatism, aiming to evaluate precision, efficacy, safety, and stability over six months. Results: Key findings include high efficacy, with 99% of distance-eyes achieving uncorrected distance visual acuity (UDVA) of 20/25 or better, and 85% of near-eyes achieving UDVA of 20/32 or better. The results show excellent refractive outcomes, with 99% of long-sighted eyes and 97% of near-sighted eyes having a postoperative spherical equivalent within ±1.00 D. Safety was demonstrated by no loss of two or more Snellen lines after treatment, with 94% of patients maintaining corrected distance visual acuity (CDVA) before and after surgery. Conclusions: Overall, LBV PRESBYOND® proved effective, safe, and well tolerated for myopic presbyopia correction, offering satisfactory visual outcomes and potential spectacle independence for various distances. This study underscores the importance of individualized treatment based on patient age, highlighting the positive impact of binocular summation on visual function. This study contributes to the growing body of evidence supporting LBV PRESBYOND® as a viable option for addressing presbyopic myopia, offering insights into its efficacy and safety profile. Further research could explore postoperative stereopsis and long-term outcomes to enhance understanding and refine treatment protocols.

BCLA CLEAR Presbyopia: Evaluation and diagnosis

It is important to be able to measure the range of clear focus in clinical practice to advise on presbyopia correction techniques and to optimise the correction power. Both subjective and objective techniques are necessary: subjective techniques (such as patient reported outcome questionnaires and defocus curves) assess the impact of presbyopia on a patient and how the combination of residual objective accommodation and their natural DoF work for them; objective techniques (such as autorefraction, corneal topography and lens imaging) allow the clinician to understand how well a technique is working optically and whether it is the right choice or how adjustments can be made to optimise performance. Techniques to assess visual performance and adverse effects must be carefully conducted to gain a reliable end-point, considering the target size, contrast and illumination. Objective techniques are generally more reliable, can help to explain unexpected subjective results and imaging can be a powerful communication tool with patients. A clear diagnosis, excluding factors such as binocular vision issues or digital eye strain that can also cause similar symptoms, is critical for the patient to understand and adapt to presbyopia. Some corrective options are more permanent, such as implanted inlays / intraocular lenses or laser refractive surgery, so the optics can be trialled with contact lenses in advance (including differences between the eyes) to better communicate with the patient how the optics will work for them so they can make an informed choice.

Rate of Complete Spectacle Independence with a Trifocal Intraocular Lens: A Systematic Literature Review and Meta-Analysis

INTRODUCTION

A systematic literature review and meta-analysis was conducted to identify and obtain a precise single summary estimate on complete spectacle independence after bilateral implantation of a trifocal intraocular lens (IOL) (AcrySof PanOptix, TFNTXX/TFATXX) for patients undergoing cataract surgery.

METHODS

A search was conducted in PubMed from January 2017 to September 2021. Relevant congress presentations were also searched to include data from completed studies not yet published. Search terms included the intervention (TFNTXX, TFATXX, PanOptix) and outcomes of interest (patient-reported spectacle independence rates). A Bayesian random-effects meta-analysis was conducted, providing a pooled estimate (median and its 95% credible interval) of complete spectacle independence rates among cataract surgery patients. Subgroup analyses evaluated spectacle independence after cataract surgery across different working distances (near, intermediate, far).

RESULTS

Nineteen unique clinical studies were identified. Based on a meta-analysis of 13 studies (N = 513 patients), the complete spectacle independence rate after cataract surgery with TFNTXX/TFATXX IOL was 91.6% (95% credible interval 86.8-95.9%). Additionally, the spectacle independence rates at each focal point (N = 13 studies, 603 patients) were 89.6% (near), 96.3% (intermediate), and 95.9% (far).

CONCLUSIONS

This meta-analysis demonstrated that at least nine out of ten patients receiving TFNTXX/TFATXX trifocal IOL during cataract surgery can expect to achieve complete spectacle independence. This study provides informative data for clinicians and patients to feel confident in the use of trifocal intraocular lenses as presbyopia-correcting IOLs that offer high rates of complete spectacle independence.

New insights in presbyopia: impact of correction strategies

Presbyopia occurs when the physiologically normal age-related reduction in the eyes focusing range reaches a point, when optimally corrected for distance vision, that the clarity of vision at near is insufficient to satisfy an individual’s requirements. Hence, it is more about the impact it has on an individual’s visual ability to function in their environment to maintain their lifestyle than a measured loss of focusing ability. Presbyopia has a significant impact on an individual’s quality of life and emotional state. While a range of amelioration strategies exist, they are often difficult to access in the developing world and prescribing is generally not optimal even in developed countries. This review identified the need for a standardised definition of presbyopia to be adopted. An appropriate battery of tests should be applied in evaluating presbyopic management options and the results of clinical trials should be published (even if unsuccessful) to accelerate the provision of better outcomes for presbyopes.

A Cost-Effectiveness Analysis of AcrySof IQ Vivity Intraocular Lens (IOL) from Private Health Fund Perspective in Australia

Purpose

AcrySof IQ Vivity is a unique non-diffractive extended depth of focus intraocular lens with wavefront-shaping X-WAVE technology. This study evaluated the cost-effectiveness of AcrySof IQ Vivity intraocular lens (DFT015) compared with standard aspheric monofocal intraocular lens (SN60WF), from a private health fund perspective in Australia.

Methods

A Markov model was developed using the following health states: well, need for spectacles (near/distance/bifocal/varifocal), very bothersome visual disturbances (glare/haloes/starbursts) – with/without spectacles, and death. Model inputs were sourced from a randomized clinical study (NCT03010254), published literature, prostheses list and clinical opinion. A lifetime horizon (up to 30 years) was considered, and cost and health outcomes were discounted at 5% per annum. Model outcomes included incremental cost–effectiveness ratio defined as incremental cost per quality adjusted life year gain. Sensitivity and scenario analyses were also conducted.

Results

Bilateral implantation of DFT015 intraocular lens provided quality adjusted life year gain of 0.16 at an incremental cost of AU$307 compared to bilateral SN60WF, leading to an incremental cost-effectiveness ratio of AU$1908/quality adjusted life year, well below the cost-effectiveness threshold (Range: AU$45,000-AU$75,000) typically used by Medical Services Advisory Committee in Australia. Results were most sensitive to intraocular lens costs, post-operative spectacle dependence, and disutility due to wearing glasses. Robustness of the results was further confirmed by probabilistic sensitivity analysis and scenario analyses.

Conclusion

AcrySof IQ Vivity intraocular lens is a highly cost-effective treatment strategy with improved vision-related quality of life outcomes for presbyopic cataract surgery patients.

Exploring the Experience of Living With and Managing Presbyopia

SIGNIFICANCE

Presbyopia typically occurs around 40 years of age and affects approximately one-quarter of the global population. Up to October 2021, there were no approved pharmacotherapies for presbyopia and common treatments, such as glasses, can have disadvantages for individuals' health-related quality of life.

PURPOSE

To document the experience of living with and managing presbyopia, identify perspectives on treatment options, and determine whether there is an unmet need in the treatment landscape.

METHODS

Coded transcripts of concept elicitation (CE; N = 20) and cognitive debriefing (CD; N = 20) interviews with presbyopic individuals, originally conducted for development of patient-reported outcome instruments, were reanalyzed to identify salient concepts describing participants' experiences with presbyopia treatments. Qualitative ranking exercises assessed participants' preferences for a potential pharmacotherapy versus existing treatments.

RESULTS

As most concepts were identified with the CE interviews, data reflect CE findings unless otherwise noted. Average age across CE/CD interviews was 49.4 years; a vast majority of participants used glasses for presbyopia treatment. Four themes related to treatment with glasses were identified with the interviews: inconvenience during daily activities, negative physical sensations around the eyes/head, limitations, and undesirable impacts on daily life (e.g., psychosocial). Most commonly, participants reported inconveniences related to forgetting glasses and psychosocial impacts (e.g., feeling/looking older). Strained/tired eyes and limited ability to see at varying distances were also reported. Among participants with near-vision glasses who provided data, two thirds expressed interest in alternative treatments. Additionally, almost three quarters of the participants ranked hypothetical eye drops as their first or second preferred option, versus reading glasses, contact lenses, magnifying glasses, and surgery.

CONCLUSIONS

This study explored the experience of living with and managing presbyopia, identified limitations and negative impacts of current treatments. Pharmacological development (e.g., eye drops) may fulfill an unmet need in the presbyopia treatment landscape.

The effects of premium intraocular lenses on presbyopia treatments

Background

Presbyopia has become a global disease affecting the world's aging population. Among various treatments, cataract extraction and intraocular lens (IOL) implantation have become the most popular and common methods of presbyopia correction. During the twentieth century, IOLs have underwent significant innovation and advancements to meet the patients' high demands for functional vision at all distances.

Main Text

To meet the increasing needs for excellent near and intermediate vision for daily activities, some premium IOLs with more than one focus have been developed, for example, the refractive MfIOLs, diffractive MfIOLs, extended depth of field (EDOF) IOLs, and accommodating IOLs (AIOLs) were introduced to meet this need. In addition, the add-on MfIOLs have been explored as promising supplementary IOLs for pseudophakic presbyopia. When selecting the MfIOLs, the IOLs' features, patients' characteristics, preoperative eye conditions, and treatment expectations should be considered.

Conclusions

In this review, we focus on the multifocal IOLs (MfIOLs) commonly used for presbyopia correction and systematically summarized their optical designs and clinical outcomes. More evidence-based studies are required to provide guidelines for MfIOL selection, provide maximum visual benefits, and develop personalized visual solutions in the future.

Effect of minimonovision in bilateral implantation of a novel non-diffractive extended depth-of-focus intraocular lens: Defocus curves, visual outcomes, and quality of life

PURPOSE

To evaluate overall patient satisfaction, spectacle independence, visual acuity, and prevalence of optical phenomena following bilateral implantation of a new non-diffractive extended depth-of-focus intraocular lens targeted for minimonovision.

METHODS

Multicenter prospective case series. Postoperative far and near visual acuity at 3 months and patient quality of life by NEI-VFQ-25 questionnaire were assessed. Postoperative evaluation included defocus curves analysis, spectacle independence assessment, and recording of photic phenomena.

RESULTS

The study enrolled 97 eyes of 59 patients that underwent femtosecond-assisted cataract surgery with AcrySof IQ Vivity intraocular lens implantation. Thirty subjects (60 eyes) were eligible for analysis. After 3 months, postoperative achieved binocular uncorrected visual acuity was -0.03  ±  0.06 logarithm of the minimum angle of resolution for distance, 0.06  ±  0.06 logarithm of the minimum angle of resolution for intermediate, and 0.19  ±  0.03 logarithm of the minimum angle of resolution for near. Defocus curve showed a smooth profile with no abrupt decrease of visual acuity. Minimonovision significantly improved visual acuity compared to when minimonovision was neutralized, for values of defocus curves from -1 to -3 D (p < 0.05). Twenty-six (87%) patients reported complete spectacle independence. High levels of satisfaction for distance and near vision resulted at VFQ-25 questionnaire. Only two patients complained of halos (6.7%) and one of them also of glare (3.3%).

CONCLUSIONS

Implantation of this new non-diffractive extended depth-of-focus intraocular lens with minimonovision resulted in satisfying far, intermediate, and near visual acuity with a consistent reduction of spectacle dependence and improvement in patient's quality of life.

Clinical Outcome of Lentis Comfort Intraocular Lens Implantation

PURPOSE

To evaluate visual outcome and patient satisfaction following Lentis Comfort intraocular lens (IOL) implantation.

METHOD

This retrospective case series examined 68 eyes of 41 patients (mean age 72.0 ± 8.1 years) who underwent Lentis Comfort (LS-313 MF15, Oculentis GmbH, Berlin, Germany; Santen, Osaka, Japan) implantations. Patients were evaluated for visual acuity (VA) at several distances (0.3, 0.5 and 5 meters), refractive error, defocus curve and contrast sensitivity, in addition to answering a questionnaire on photic phenomena, visual discomfort and patient satisfaction.

RESULTS

Uncorrected visual acuity was 0.05 ± 0.13 (logMAR) for distance, 0.23 ± 0.17 (logMAR) for intermediate, and 0.52 ± 0.20 (logMAR) for near. Defocus curve showed the binocular visual acuity attained was almost 20/20 within the range of +0.5 D to -1.5 D. Contrast sensitivity was within the normal range. The Lentis Comfort IOL tolerated astigmatism to some extent. Patient age could potentially be related to uncorrected visual acuity. Questionnaire results showed almost all patients were satisfied with Lentis Comfort IOL implantation.

CONCLUSION

Lentis Comfort IOLs provided better visual function at far and intermediate distances.

Clinical Outcomes After Phacoemulsification With Implantation of Trifocal and Toric Trifocal Intraocular Lenses

PURPOSE

To evaluate the visual and refractive outcomes, visual quality, patient satisfaction, and spectacle independence after phacoemulsification with bilateral implantation of a diffractive trifocal intraocular lens (IOL).

METHODS

The study sample comprised 36 consecutive patients (72 eyes). Twenty-three (64%) patients underwent refractive lens exchange and 13 (36%) underwent cataract surgery. Exclusion criteria included previous ocular surgery, corneal higher order aberrations of greater than 0.4 µm, angle kappa of greater than 0.6 mm, and corneal astigmatism of greater than 5.00 diopters (D). All eyes were targeted for emmetropia. A toric IOL was used in 35 (48.6%%) eyes with corneal astigmatism of greater than 1.00 D. Uncorrected distance visual acuity (UDVA) and distance-corrected visual acuity were measured at 4 m and 80 and 40 cm. Patients underwent routine ophthalmic examination for 6 months postoperatively. Patient satisfaction was assessed with a subjective questionnaire at 6 months postoperatively. A P value of less than .05 was statistically significant.

RESULTS

At 6 months postoperatively, the mean manifest refractive spherical equivalent was -0.01 ± 0.51 D. Binocular UDVA at 4 m and 80 and 40 cm was -0.02 ± 0.10, -0.07 ± 0.11, and 0.08 ± 0.10 logMAR, respectively. Binocular defocus curves presented two peaks of -0.07 and -0.02 logMAR for 0.00 and -2.00 D defocus, respectively. The Objective Scatter Index score decreased significantly in the cataract group and increased significantly in the refractive lens exchange group (P < .05, both cases). All patients were satisfied or very satisfied with the postoperative outcome.

CONCLUSIONS

Bilateral implantation of a diffractive trifocal IOL resulted in good visual performance at all distances with high patient satisfaction and spectacle independence at 6 months postoperatively. [J Refract Surg. 2021;37(6):372-379.].

Presbyopia - A Review of Current Treatment Options and Emerging Therapies

Presbyopia is a common age-related vision disorder characterized by a progressive inability to focus on near objects. If uncorrected or under-corrected, presbyopia can significantly impact patients' quality of life. Presbyopia represents an area of considerable unmet need due to its rising prevalence worldwide as the population ages, the high proportion of under-treated individuals in some parts of the world, and the limitations of currently available corrective methods. Progressive or bifocal spectacles are associated with peripheral blur, a restricted visual field and impaired depth perception, which have been linked to an increased risk of falls in the elderly. Contact lens options can be difficult to maintain due to the development of age-related dry eye symptoms and reduced manual dexterity. Other corrective methods involve surgical interventions that modify the optics of the cornea, replace the crystalline lens, or attempt to restore active accommodation. While patients undergoing surgery report satisfactory outcomes post-operatively, many of them eventually require reading glasses. Non-invasive therapies with novel mechanisms of action are currently being investigated; these include miotic agents and UNR844, a lipoic acid choline ester. In this narrative review, available evidence on presbyopia prevalence, quality of life impact and risk factors are described, with a focus on observational studies in non-clinical settings. The diagnosis pathway and patient journey in presbyopia are outlined, and various treatment options are analyzed. The data reviewed herein reveals significant gaps in the provision of vision correction for this common condition, with a paucity of effective, non-invasive treatment options broadly accessible to presbyopic individuals.

Unilateral Versus Bilateral Refractive Lens Exchange With a Trifocal Intraocular Lens in Emmetropic Presbyopic Patients

PURPOSE

To compare visual outcomes and patient satisfaction between unilateral and bilateral trifocal diffractive intraocular lens (IOL) implantation in emmetropic patients with presbyopia.

DESIGN

Retrospective observational case series.

METHODS

This is a multicenter, multisurgeon study of emmetropic presbyopes who underwent refractive lens exchange (RLE) followed by an implantation of FineVision IOL (PhysIOL). Inclusion criteria were emmetropic eyes, with a sphere between -0.25 and +0.50 diopters (D), cylinder of less than 0.75 D and spherical equivalent (SE) between -0.25 and +0.25 D. In addition, uncorrected distance visual acuity (UDVA) had to be Snellen >0.9 in each eye. A total of 171 eyes of 122 patients were evaluated. This sample was divided into 2 groups depending on whether they have been operated monocularly or binocularly. Visual and refractive performance, patient satisfaction, and spectacle independence were evaluated.

RESULTS

UDVA and corrected distance visual acuity (CDVA) remained almost unchanged after monocular and binocular surgery. Binocular uncorrected intermediate (UIVA) and near visual acuity (UNVA) were better in those operated binocularly (0.3±0.12 vs 0.22±0.06, P < .063, and 0.09±0.08 vs 0.04±0.05, P < .027, respectively). Predictability and efficacy were higher in the binocular group, whereas safety was better in the monocular group. Visual dysphotopsia was worse and spectacle independence for all distances was higher in binocular group.

CONCLUSIONS

Our research shows that RLE with binocular implantation of a trifocal diffractive IOL in presbyopic emmetropic patients is more successful in UNVA than monocular implantation. However, no significant differences were observed in UDVA, UIVA, and patient satisfaction.

Evaluation of the Cataract Surgery 2018 Survey in Terms of Achieving Refractive Cataract Surgery Targets

Objectives

The aim of this study was to show at what rate the technological equipment used in cataract surgery by Turkish ophthalmologists and their knowledge are reflected in practice and how up to date they are.

Materials and Methods

A questionnaire conducted using SurveyMonkey was used to evaluate the answers to 17 questions from 823 members of the Turkish Ophthalmological Association. Results were evaluated in subgroups according to the participants' age, occupational status, institutions, and whether they conducted relevant academic activities, and the data were compared as inadequate, standard, and contemporary approaches according to the determined criteria.

Results

Optical biometry devices were used at rates of 77.7% and 67.3% for intraocular lens (IOL) power calculations and keratometric measurements in preparation for cataract surgery, respectively. For IOL power calculation, third-generation formulas, especially the SRK-T, were used most commonly (46.2%), followed by second-generation formulas (21.9%), and fourth/fifth-generation formulas and multiple evaluations for different axial lengths (31.9%). The most common incision size was 2.8 mm (51.6%), while the percentage of 2.2 mm and shorter incisions considered to be neutral in terms of surgically induced astigmatism was 18.8%. When selecting incision location, approaches to reduce corneal astigmatism were reported by 28.9%, neutral approaches by 26.2%, and insensitive approaches by 44.9%. Additionally, 55.6% of participants never implanted toric IOLs and 50.7% did not use presbyopia-correcting IOLs. The proportion of surgeons who have experience with femtosecond laser-assisted cataract surgery was 10.3% and the rate of intracameral antibiotic injection at the end of the operation was 89.4%.

Conclusion

It was seen that Turkish cataract surgeons were able to use high technology for surgical preparation and surgery at high rates, but this was not reflected in practice at same rate in terms of achieving contemporary standards of refractive cataract surgery.

Visual performance after bilateral toric extended depth-of-focus IOL exchange targeted for micromonovision

PURPOSE

To evaluate overall patient satisfaction, spectacle independence, binocular visual acuity, rotational stability, prevalence of optical phenomena, and decentration and tilt after bilateral toric extended depth-of-focus intraocular lens (EDOF IOL) implantation targeted for micromonovision.

SETTING

Department of Ophthalmology, Hanusch Hospital, Vienna, Austria.

DESIGN

Prospective case series.

METHODS

The study included 52 eyes of 26 patients with regular corneal astigmatism from 0.75 to 2.60 diopters (D) that were implanted bilaterally with a toric EDOF IOL targeted for micromonovision. Postoperative visual acuity, astigmatism reduction, rotation, tilt, decentration, spectacle independence, patient satisfaction, and photic phenomena were assessed.

RESULTS

For the 52 eyes studied, binocular means expressed in logarithm of the minimum angle resolution for postoperative corrected distance, uncorrected distance, uncorrected intermediate, and uncorrected near visual acuities were -0.10 (±0.12), -0.01 (±0.13), 0.01 (±0.14), and 0.13 (±0.14), respectively. Mean refractive astigmatism reduction was 1.31 ± 0.67 D resulting in a mean refractive cylinder of 0.47 ± 0.46 D at the 3-month visit. Mean postoperative rotation was 3.5 ± 3.5 degrees, at the 3-month time point. Most prevalent dysphotopsia were halos, starburst, and glare affecting 6 (23%), 6 (23%), and 5 (19%) of 26 patients, respectively; 20 (77%) of 26 patients reported spectacle independence, with 19 (95%), 19 (95%), and 14 (70%) of 20 patients questioned being satisfied with distance, intermediate, and near vision, respectively.

CONCLUSIONS

Toric EDOF IOL implantation targeted for micromonovision resulted in reliable reduction of preoperative astigmatism with a high degree of postoperative rotational predictability and centration, enabling functional distance, intermediate, and near vision, which manifested itself in high patient satisfaction.

Contact lenses, the reverse Pulfrich effect, and anti-Pulfrich monovision corrections

Interocular differences in image blur can cause processing speed differences that lead to dramatic misperceptions of the distance and three-dimensional direction of moving objects. This recently discovered illusion-the reverse Pulfrich effect-is caused by optical conditions induced by monovision, a common correction for presbyopia. Fortunately, anti-Pulfrich monovision corrections, which darken the blurring lens, can eliminate the illusion for many viewing conditions. However, the reverse Pulfrich effect and the efficacy of anti-Pulfrich corrections have been demonstrated only with trial lenses. This situation should be addressed, for clinical and scientific reasons. First, it is important to replicate these effects with contact lenses, the most common method for delivering monovision. Second, trial lenses of different powers, unlike contacts, can cause large magnification differences between the eyes. To confidently attribute the reverse Pulfrich effect to interocular optical blur differences, and to ensure that previously reported effect sizes are reliable, one must control for magnification. Here, in a within-observer study with five separate experiments, we demonstrate that (1) contact lenses and trial lenses induce indistinguishable reverse Pulfrich effects, (2) anti-Pulfrich corrections are equally effective when induced by contact and trial lenses, and (3) magnification differences do not cause or impact the Pulfrich effect.

A Novel Concept of Correcting Presbyopia: First Clinical Results with a Phakic Diffractive Intraocular Lens

Purpose

To evaluate the effect of a novel technique to correct presbyopia. A phakic IOL (presbyopic IPCL; implantable phakic contact lens) with a diffractive optic is implanted and its impact on visual acuity, refraction, patient satisfaction in patients striving for spectacle-independence is evaluated.

Design

Retrospective noncomparative open-label clinical trial.

Methods

Sixteen eyes of 8 patients (average age 47 years) had a presbyopic IPCL implanted in the posterior chamber. The visual acuity on different distances, refractive status, corneal topography, endothelial cell density, anterior chamber depth, white-to-white, mesopic pupil size and intraocular pressure (IOP) were measured before implantation of this novel phakic IOL with diffractive optic and four weeks after surgery.

Results

At follow-up four weeks after surgery, 9 of the 16 eyes were emmetropic and uncorrected distance visual acuity was at least 0.8. Near vision was excellent in all patients without the need to wear reading glasses. There was neither a significant change in IOP nor a significant surgical impact on endothelial cells. Patient satisfaction was high. There was no major complaint of halos or glare.

Conclusion

The presbyopic IPCL can provide the presbyopic patient with good visual acuity and spectacle-independence for far and near distance. We found this novel technique to have a good safety profile during the surgical procedure and our short follow-up period. Further long-term follow-up is mandatory.

One year results of presbyLASIK using hybrid bi-aspheric micro-monovision ablation profile in correction of presbyopia and myopic astigmatism

AIM

To analyze one year clinical outcomes and subjective rating of hybrid bi-aspheric multifocal central presbyLASIK with micro-monovision for correction of presbyopia and myopic astigmatism.

METHODS

Seventy-four eyes of 37 patients consecutively treated with presbyLASIK were assessed. The mean age of the patients was 43.8±3.0y with a mean spherical equivalent refraction of -5.21±1.87 diopters (D) and mean astigmatism of -0.82±0.64 D. Visual acuity, manifest refraction, contrast sensitivity, aberrometry and patients' subjective rating were evaluated pre- and postoperatively.

RESULTS

At 1y postoperatively (68 eyes of 34 patients), the mean spherical equivalent (SE) refraction in distance eyes was 0.06±0.05 D, whereas the achieved SE in near eyes was -0.83±0.05 D. Ninety-nine percent of eyes were within ±0.50 D of target correction of SE. The binocular mean uncorrected distance visual acuity (UDVA) was 0.00±0.18 logMAR (20/20). Sixty-four percent of patients achieved 0.0 logMAR (20/20) or better of UDVA and 0.1 logRAD or better of UNVA as well. There was a binocularly loss of one line CDVA after surgery for only one patient (3%, 1/34) and no patient lost 2 lines. The changes in binocular contrast sensitivity (CS) in all test conditions were not significant at any frequency after surgery. The changes of entire eye total higher order aberrations (tHOA) and spherical aberrations (SA) significantly higher in near eyes than in distance eyes. The overall satisfaction score for surgery was 93±8.

CONCLUSION

The hybrid bi-aspheric multifocal central presbyLASIK with micro-monovision appears to be an efficacious option for myopic presbyopes. One year postoperative outcomes in a relatively young presbyopia population indicate improvements in both far and near vision with high satisfaction.

Clinical outcomes of a novel presbyopia-correcting soft contact lens with a small aperture

PURPOSE

To investigate the efficacy and safety of a newly developed pinhole soft contact lens (Eyelike Pinhole II; Koryo Eyetech Co. Ltd.) for presbyopia correction.

METHODS

This prospective clinical study enrolled 29 patients with presbyopia between October 2018 and December 2018. All participants wore the Eyelike Pinhole II in the non-dominant eye for >3 h/day for a period of 1 week. Binocular and monocular uncorrected near visual acuities, distance-corrected near visual acuity (DCNVA), uncorrected distance visual acuity, and corrected distance visual acuity (CDVA) were measured before and after the intervention. All visual acuities were measured in logarithm of the minimal angle of resolution (logMAR) units. In addition, binocular defocus curves were generated, and contrast sensitivity values were obtained under photopic and mesopic conditions before and after lens wear.

RESULTS

The mean DCNVA of the treated eye and the mean binocular DCNVA improved from 0.34 ± 0.12 to 0.15 ± 0.14 (P < 0.001) and 0.31 ± 0.13 to 0.11 ± 0.10 (P < 0.001) logMAR, respectively, after pinhole contact lens wear. Although the mean CDVA of the treated eye deteriorated from -0.04 ± 0.05 to 0.02 ± 0.11 logMAR (P = 0.015), there was no significant change in the mean binocular CDVA (P = 0.79). The binocular defocus curve showed a significant improvement from -5.0 dioptres (D) to -1.0 D after pinhole contact lens wear.

CONCLUSIONS

The newly developed Eyelike Pinhole II soft contact lens showed safe and effective outcomes; thus, it could be a promising option for the treatment of presbyopia.

Bifocal nondiffractive intraocular lens for enhanced depth of focus in correcting presbyopia: Clinical evaluation

PURPOSE

To assess the clinical outcomes and patient satisfaction after bilateral cataract surgery with implantation of a bifocal refractive enhanced depth of focus intraocular lens (IOL) with a low near addition (add).

SETTING

Department of Ophthalmology, Ludwig-Maximilians-University Munich, Munich, Germany.

DESIGN

Prospective longitudinal case series.

METHODS

Eyes with bilateral age-related cataract and corneal astigmatism of less than 1.0 diopter (D) had standard microincision cataract surgery with implantation of a bifocal nondiffractive shape-segmented enhanced depth of focus IOL (Lentis Comfort, LS-313 MF15). The corrected and uncorrected (UDVA) distance visual acuities, uncorrected intermediate (UIVA) and near (UNVA) visual acuities, defocus, corneal astigmatism, spectacle independence, contrast sensitivity, rotational stability, photic phenomena, and patient satisfaction were evaluated over a 3-month follow-up.

RESULTS

The study comprised 22 patients (44 eyes). The mean postoperative manifest spherical equivalent was -0.10 D ± 0.58 (SD), resulting in a mean UDVA of 0.07 ± 0.10 logMAR, mean UIVA of 0.21 ± 0.15 logarithm of minimum angle of resolution (logMAR), and mean UNVA of 0.53 ± 0.15 logMAR. Binocular UDVA was 0.01 ± 0.08 logMAR. The best reading distance was 0.46 ± 0.09 m. More than 95% of patients were satisfied with their visual acuity, and less than 10% reported photic phenomena. The IOL showed an excellent rotational stability.

CONCLUSIONS

The enhanced depth of focus IOL with 1.5 D of near add showed excellent intermediate and far visual performance and acceptable near visual restoration. Patient satisfaction was very high, and few patients reported disturbing photic phenomena.

Retrospective comparative analysis of intraocular lens calculation formulas after hyperopic refractive surgery

Purpose

To compare the intraocular lens calculation formulas and evaluate postoperative refractive results of patients with previous hyperopic corneal refractive surgery.

Design

Retrospective, comparative, observational study.

Setting

Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

Methods

Clinical charts and optical biometric data of 39 eyes from 24 consecutive patients diagnosed with previous hyperopic laser vision correction and cataract surgery were reviewed and analyzed. The Intraocular lens (IOL) power calculation using the Holladay 2 formula (Lenstar) and the American Society of Cataract and Refractive Surgery (ASCRS) Post-Refractive IOL Calculator (version 4.9, 2017) were compared to the actual manifest refractive spherical equivalent (MRSE) following cataract surgery. No pre-Lasik / PRK or post-Lasik / PRK information was used in any of the calculations. The IOL prediction error, the mean IOL prediction error, the median absolute refractive prediction error, and the percentages of eyes within ±0.50 diopter (D) and ±1.00 D of the predicted refraction were calculated.

Results

The Holladay 2 formula produced a mean arithmetic IOL prediction error significantly different from zero (P = 0.003). Surprisingly, the mean arithmetic IOL prediction errors generated by Shammas, Haigis-L and Barret True K No History formulas were not significantly different from zero (P = 0.14, P = 0.49, P = 0.81, respectively).There were no significant differences in the median absolute refractive prediction error or percentage of eyes within ± 0.50 D or ± 1.00 D of the predicted refraction between formulas or methods.

Conclusion

In eyes with previous hyperopic LASIK/PRK and no prior data, there were no significant differences in the accuracy of IOL power calculation between the Holladay 2 formula and the ASCRS Post-refractive IOL calculator.

Scleral structure and biomechanics

As the eye's main load-bearing connective tissue, the sclera is centrally important to vision. In addition to cooperatively maintaining refractive status with the cornea, the sclera must also provide stable mechanical support to vulnerable internal ocular structures such as the retina and optic nerve head. Moreover, it must achieve this under complex, dynamic loading conditions imposed by eye movements and fluid pressures. Recent years have seen significant advances in our knowledge of scleral biomechanics, its modulation with ageing and disease, and their relationship to the hierarchical structure of the collagen-rich scleral extracellular matrix (ECM) and its resident cells. This review focuses on notable recent structural and biomechanical studies, setting their findings in the context of the wider scleral literature. It reviews recent progress in the development of scattering and bioimaging methods to resolve scleral ECM structure at multiple scales. In vivo and ex vivo experimental methods to characterise scleral biomechanics are explored, along with computational techniques that combine structural and biomechanical data to simulate ocular behaviour and extract tissue material properties. Studies into alterations of scleral structure and biomechanics in myopia and glaucoma are presented, and their results reconciled with associated findings on changes in the ageing eye. Finally, new developments in scleral surgery and emerging minimally invasive therapies are highlighted that could offer new hope in the fight against escalating scleral-related vision disorder worldwide.

Near Vision Improvement with the Use of a New Topical Compound for Presbyopia Correction: A Prospective, Consecutive Interventional Non-Comparative Clinical Study

Introduction

To report the outcomes in near vision, optical quality and pupil diameter of a new pharmacological therapy (FOV tears) for presbyopia.

Methods

This was a prospective, consecutive, interventional, non-comparative clinical study in which 117 presbyopic patients were given one drop of the novel therapy (FOV tears) in each eye, followed 2 h after the instillation of the eye drop by an evaluation of the binocular uncorrected near visual acuity (UNVA) and uncorrected distance visual acuity. The objective scatter index and pupil diameter under photopic and scotopic conditions before and after instillation were also assessed. The patients were divided into two groups according to their age, with group 1 patients being 41 and 50 years old and group 2 patients, between 51 and 65 years old.

Results

The mean age of the patients was 50.2 years. The mean UNVA before the use of the eye drop was 0.35 LogMAR, which improved to 0.16 LogMAR at 2 h after the use of the eye drop (p = 0.000). Nine patients did not show an improvement in UNVA, but no patient showed a loss of lines. Fourteen patients (11.9%) reported headaches as a side effect of the therapy.

Conclusion

This pharmacological therapy improved near vision by one or more lines (mean improvement 0.18 lines) in 92.3% of the patients at 2 h following the instillation of the eye drops. The group with the youngest patients gained more lines than the group with the oldest patients.

Scleral surgery for the treatment of presbyopia: where are we today?

Presbyopia corrections traditionally have been approached with attempts to exchange power, either at the cornea or the lens planes, inducing multifocality, or altering asphericity to impact the optical system. Treatments that affect the visual axis, such as spectacle and contact lens correction, refractive surgeries, corneal onlays and inlays, and intraocular lenses are typically unable to restore true accommodation to the presbyopic eye. Their aim is instead to enhance 'pseudoaccommodation' by facilitating an extended depth-of-focus for which vision is sufficient. There is a true lack of technology that approaches presbyopia from a treatment based or therapy based solution, rather than a 'vision correction' solution that compromises other components of the optical system. Scleral surgical procedures seek to restore true accommodation combined with pseudoaccommodation and have several advantages over other more invasive options to treat presbyopia. While the theoretical justification of scleral surgical procedures remains controversial, there has nevertheless been increasing interest and evidence to support scleral surgical and therapeutic approaches to treat presbyopia. Enormous progress in scleral surgery techniques and understanding of the mechanisms of action have been achieved since the 1970s, and this remains an active area of research. In this article, we discuss the historic scleral surgical procedures, the two scleral procedures currently available, as well as an outlook of the future for the scleral surgical space for treating presbyopia.

Prevalence and incidence of presbyopia in urban Southern China

AIMS

To investigate the prevalence and incidence of presbyopia in an urban Chinese population.

METHODS

1817 subjects aged ≥35 years were identified by random cluster sampling in Yuexiu District, Guangzhou, China, at baseline in 2008, and all were invited for the follow-up examination in 2014. Distance and near visual acuity (VA) tests, as well as non-cycloplegic automated refraction were performed at each examination as per standardised protocol. Participants with presenting near VA ≤20/40 were further tested with add power at a standard distance of 40 cm to obtain their best-corrected near VA. Functional presbyopia was defined as near VA under presenting distance refraction correction of <20/50 and could be improved by at least one line with add power.

RESULTS

A total of 1191 (83.5% of the 2014 follow-up) participants were included in the current analysis with a mean (SD) age of 50.4 (9.7) years, and 52.9% were female. Prevalence of functional presbyopia at baseline was 25.2% (95% CI 21.5 to 28.9) and the 6-year incidence was 42.8% (95% CI 39.4 to 50.1). Older and more hyperopic subjects had both higher prevalence and incidence of presbyopia (P<0.001). Average presbyopic correction coverage (PCC) was 87.7% at baseline and was significantly lower in myopic participants (P=0.006).

CONCLUSIONS

Prevalence of functional presbyopia in urban China is relatively lower along with a higher PCC compared with previous population-based rural cohorts. We identified a high presbyopia incidence, and further studies are needed to understand longitudinal presbyopia progression as well as the urban-rural gap in presbyopia to throw light on future strategic planning.

Correction of presbyopia: An integrated update for the practical surgeon

Presbyopia results from loss or insufficiency of the eye's accommodative ability, and clinically manifests as the inability to focus near objects on the retina. It is one of the most common causes of visual impairment worldwide especially in adults of productive or working age. Various means of compensating for the loss of accommodative ability have been devised from optical tools such as spectacles and contact lenses, to topical medications and to surgical procedures. A comprehensive search on journal articles about topical and surgical correction of presbyopia was undertaken. The various techniques for presbyopia correction, as enumerated in these articles, are discussed in this paper with the addition of our personal experience and perspective on the future of these techniques.

Comparison between bilateral implantation of a trifocal intraocular lens and blended implantation of two bifocal intraocular lenses

Purpose

To compare visual outcomes and performance between bilateral implantation of a diffractive trifocal intraocular lens (IOL) Acrysof^®PanOptix^® TFNT00 and blended implantation of two different near add power bifocal IOLs: Acrysof^® Restor^® SV25T0 in dominant eye and Acrysof^® Restor^® SN6AD1 in the nondominant eye.

Methods

This prospective, nonrandomized, consecutive and comparative study assessed 20 patients (40 eyes) who had bilateral cataract surgery performed using the IOLs described. Patients were divided into groups, bilateral trifocal implant and blended implant. Evaluation included measurement of binocular uncorrected and corrected distance visual acuity at 4 m (UDVA, CDVA) and uncorrected intermediate (60 cm) and near (at 40 cm) visual acuity; contrast sensitivity (CS) and visual defocus curve.

Results

Postoperative CDVA comparison showed no statistical significance between groups. UDVA was significantly better in the trifocal groups. Under photopic conditions, the trifocal group had better CS in higher frequencies with and without glare. The binocular defocus curve demonstrated a trifocal behavior in both groups, with the bilateral trifocal group exhibiting better performance for intermediate vision.

Conclusion

Both lens combinations were able to provide good near, intermediate and distance vision, with the trifocal group showing significantly better performance at intermediate distances and better CS under photopic conditions.

Monovision Versus Multifocality for Presbyopia: Systematic Review and Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Refractive surgery in presbyopia tends to achieve spectacle independence with minimal optical disturbances. We compared monovision to multifocality procedures regarding these outcomes.

METHODS

We conducted a systematic review of published (till November 21, 2016) randomized controlled trials (RCTs) comparing any monovision to any multifocality method or comparing different monovision/multifocality methods to each other that enabled direct or indirect comparisons between particular monovision and particular multifocality procedures in presbyopic patients undergoing cataract-related or unrelated surgery in respect to spectacle independence, unaided binocular visual acuity (VA), contrast sensitivity (CS), and adverse events.

RESULTS

Three trials comparing monovision (monofocal lenses, LASIK) to multifocal intraocular lenses (MFIOLs; Isert refractive or Tecnis diffractive) and 6 comparing other MFIOLs to Tecnis were included (1-12 months duration). Spectacle independence. All reporting trials were of sufficient quality. Directly, pseudophakic monovision was inferior to Isert (1 trial, N = 75, RR = 0.49, 95% CI 0.28-0.80) and Tecnis (1 trial, N = 211, RR = 0.36, 95% CI 0.25-0.52) in cataract patients, and LASIK was comparable to Tecnis (1 trial, N = 100, RR = 0.93, 0.78-1.10) in refractive surgery. In network meta-regression (6 trials, 14 arms) pseudophakic monovision in cataract patients was inferior to Tecnis. Indirect data suggest also that it is inferior (ReZoom refractive, TwinSet diffractive) or tends to be inferior (Array refractive) to other MFIOLs. LASIK was comparable to Tecnis in refractive surgery. Indirect data suggest also that it tends to superiority vs. ReZoom or Array refractive MFIOLs. Adverse events. No pooling was possible (heterogeneity of assessment and reporting). One quality direct RCT indicated less glare/dazzle with pseudophakic monovision vs. Tecnis in cataract patients. Unaided VA and CS data were burdened with heterogeneity (assessment, reporting) and insufficient quality.

CONCLUSIONS

Randomized comparisons of monovision to multifocality are scarce. Existing estimates regarding spectacle independence (imprecision, indirectness) and particularly regarding unaided VA and CS (assessment/reporting heterogeneity, bias, imprecision, indirectness) are burdened with uncertainty. Dysphotopsia is less common with monovision, but estimate uncertainty is high (bias, imprecision).

Non-lens-based surgical techniques for presbyopia correction

INTRODUCTION

Presbyopia is the most prevalent refractive error. With a progressive aging population, its surgical correction is an important challenge for the ophthalmology community, as well as the millions of patients who suffer from it, and who are increasingly demanding alternatives to its correction with glasses or contact lenses.

MATERIAL AND METHODS

A review is presented with a synthesised discussion on the pathophysiological theories of presbyopia and an updated and analytical description of the non-lens involvement surgical techniques used to treat presbyopia.

RESULTS

Corneal procedures include various types of corneal implants and photo-ablative techniques that generate a multifocal cornea, or monovision. Scleral procedures exert a traction on supralenticular sclera that supposedly would improve the amplitude of accommodation.

CONCLUSIONS

None of the techniques are able to completely eliminate the need for near -vision glasses, but many of them manage to improve the refractive status of the patients. More studies with rigorous and standardised methods and longer follow-up are needed to evaluate the changes in the near vision of the patients, in order to corroborate the real and practical usefulness of many of these techniques.