Aging of the human crystalline lens and presbyopia

BCLA CLEAR presbyopia: Mechanism and optics

With over a billion adults worldwide currently affected, presbyopia remains a ubiquitous, global problem. Despite over a century of study, the precise mechanism of ocular accommodation and presbyopia progression remains a topic of debate. Accordingly, this narrative review outlines the lenticular and extralenticular components of accommodation together with the impact of age on the accommodative apparatus, neural control of accommodation, models of accommodation, the impact of presbyopia on retinal image quality, and both historic and contemporary theories of presbyopia.

Pharmacological treatments for the correction of presbyopia

Presbyopia affects between 1.7 and 2 billion people worldwide. Presbyopia significantly impacts productivity and quality of life in both developed and developing countries. During accommodation, the human eye changes its dioptric power by altering the shape of the lens, but the exact nature of this change has not been fully explained. Recently, topical treatments have been marketed for the treatment of presbyopia and others are under investigation. In order to prepare a review of these novel therapies, we searched the major biomedical search engines. We found 15 randomized clinical trials and 12 reviews that met our review criteria. There are two different strategies for this purpose, the pinhole effect that increases depth of focus and "crystalline lens relaxation" for which parasympathetic mimetics and lens oxidation intermediates have been used. The results are generally favorable in terms of improvement of near visual acuity, although the follow-up period of the studies is short. These are novel strategies in the early stages of research that could be useful in the treatment of presbyopia.

The human lens is capable of trilineage differentiation towards osteo-, chondro-, and adipogenesis-a model for studying cataract pathogenesis

The potential for trilineage differentiation of cells in tissues represents a model for studying disease pathogenesis and regeneration pathways. Human lens trilineage differentiation has not yet been demonstrated, and so has calcification and osteogenic differentiation of human lens epithelial cells in the whole human lens. Such changes can pose a risk for complications during cataract surgery. Human lens capsules (n = 9) from cataract patients undergoing uneventful surgery were trilineage-differentiated toward osteogenesis, chondrogenesis, and adipogenesis. Furthermore, whole human healthy lenses (n = 3) collected from cadaveric eyes were differentiated into bone and characterized by immunohistochemistry. The cells in the human lens capsules were capable of undergoing trilineage differentiation, while the whole human healthy lenses could undergo osteogenesis differentiation, expressing osteocalcin, collagen I, and pigment epithelium-derived factor. We, hereby, show an ex vivo model for cataract formation through different stages of opacification, as well as provide in vivo evidence from patients undergoing calcified lens extraction with bone-like consistency.

Adaptive optical two-photon fluorescence microscopy probes cellular organization of ocular lenses in vivo

The mammalian ocular lens is an avascular multicellular organ that grows continuously throughout life. Traditionally, its cellular organization is investigated using dissected lenses, which eliminates in vivo environmental and structural support. Here, we demonstrated that two-photon fluorescence microscopy (2PFM) can visualize lens cells in vivo. To maintain subcellular resolution at depth, we employed adaptive optics (AO) to correct aberrations due to ocular and lens tissues, which led to substantial signal and resolution improvements. Imaging lens cells up to 980 μm deep, we observed novel cellular organizations including suture-associated voids, enlarged vacuoles, and large cavities, contrary to the conventional view of a highly ordered organization. We tracked these features longitudinally over weeks and observed the incorporation of new cells during growth. Taken together, non-invasive longitudinal in vivo imaging of lens morphology using AO 2PFM will allow us to directly observe the development or alterations of lens cellular organization in living animals.

Accommodative movements of the choroid in the optic nerve head region of human eyes, and their relationship to the lens

The ciliary muscle (CM) powers the accommodative response, and during accommodation the CM pulls the choroid forward in the region of the ora serrata. Our goal was to elucidate the accommodative movements of the choroid in the optic nerve region in humans and to determine whether these movements are related to changes in the lens dimensions that occur with aging, in the unaccommodated and accommodated state. Both eyes of 12 human subjects (aged 18-51 yrs) were studied. Homatropine (1 drop/5%) was used to relax the ciliary muscle (unaccommodated or "resting" eye) and pilocarpine was used to induce the maximum accommodative response (2 drops/4%) (accommodated eye). Images of the fundus and choroid were collected in the region of the optic nerve (ON) via Spectralis OCT (infrared and EDI mode), and choroidal thickness was determined. Ultrasound biomicroscopy (UBM; 50 MHz, 35 MHz) images were collected in the region of the lens/capsule and ciliary body. OCT and UBM images were collected in the resting and accommodated state. The unaccommodated choroidal thickness declined significantly with age (p = 0.0073, r = 0.73) over the entire age range of the subjects studied (18-51 years old). The choroidal thickness was significantly negatively correlated with lens thickness in the accommodated (p = 0.01) and the unaccommodated states (p = 0.005); the thicker the lens the thinner the choroid. Choroid movements around the optic nerve during accommodation were statistically significant; during accommodation the choroid both thinned and moved centrifugally (outward/away from the optic nerve head). The accommodative choroid movements did not decline significantly with age and were not correlated with accommodative amplitude. Measurement of the choroidal thickness is possible with the Spectralis OCT instrument using EDI mode and can be used to determine the accommodative changes in choroidal thickness. The choroidal thickness decreased with age and during accommodation. It may be that age-related choroidal thinning is due to changes in the geometry of the accommodative apparatus to which it is attached (i.e., ciliary muscle/lens complex) such that when the lens is thicker, the choroid is thinner. Accommodative decrease in choroidal thickness and stretch of the retina/choroid may indicate stress/strain forces in the region of the optic nerve during accommodation and may have implications for glaucoma.

In vivo SS-OCT imaging of crystalline lens sutures

We demonstrate in vivo three-dimensional (3-D) visualization of crystalline lens sutures in healthy eyes using swept source optical coherence tomography (SS-OCT). Volumetric data sets of the crystalline lenses were acquired and processed to obtain enhanced contrast projection images and to extract suture patterns in both anterior and posterior lens. The results presented different types of the sutures including Y-sutures, simple and complex star sutures. Age-related changes in suture arrangement were characterized quantitatively. Crystalline lens suture imaging with SS-OCT might be a useful tool in fundamental studies on development and ageing of human lens.

Simultaneously imaging and quantifying in vivo mechanical properties of crystalline lens and cornea using optical coherence elastography with acoustic radiation force excitation

The crystalline lens and cornea comprise the eye's optical system for focusing light in human vision. The changes in biomechanical properties of the lens and cornea are closely associated with common diseases, including presbyopia and cataract. Currently, most in vivo elasticity studies of the anterior eye focus on the measurement of the cornea, while lens measurement remains challenging. To better understand the anterior segment of the eye, we developed an optical coherence elastography system utilizing acoustic radiation force excitation to simultaneously assess the elasticities of the crystalline lens and the cornea in vivo. A swept light source was integrated into the system to provide an enhanced imaging range that covers both the lens and the cornea. Additionally, the oblique imaging approach combined with orthogonal excitation also improved the image quality. The system was tested through first ex vivo and then in vivo experiments using a rabbit model. The elasticities of corneal and lens tissue in an excised normal whole-globe and a cold cataract model were measured to reveal that cataractous lenses have a higher Young's modulus. Simultaneous in vivo elasticity measurements of the lens and cornea were performed in a rabbit model to demonstrate the correlations between elasticity and intraocular pressure and between elasticity and age. To the best of our knowledge, we demonstrated the first in vivo elasticity of imaging of both the lens and cornea using acoustic radiation force-optical coherence elastography, thereby providing a potential powerful clinical tool to advance ophthalmic research in disorders affecting the lens and the cornea.

Assessing the biomechanical properties of the porcine crystalline lens as a function of intraocular pressure with optical coherence elastography

In this study, we investigated the relationship between the biomechanical properties of the crystalline lens and intraocular pressure (IOP) using a confocal acoustic radiation force (ARF) and phase-sensitive optical coherence elastography (OCE) system. ARF induced a small displacement at the apex of porcine lenses in situ at various artificially controlled IOPs. Maximum displacement, relaxation rate, and Young's modulus were utilized to assess the stiffness of the crystalline lens. The results showed that the stiffness of the crystalline increased as IOP increased, but the lens stiffening was not as significant as the stiffening of other ocular tissues such as the cornea and the sclera. A mechanical hysteresis in the lens was also observed while cycling IOP, indicating that the viscoelastic response of the lens is crucial to fully understanding its biomechanical properties.

Impact of Presbyopia and Its Correction in Low- and Middle-Income Countries

Presbyopia affects more than 1 billion people worldwide, and the number is growing rapidly due to the aging global population. Uncorrected presbyopia is the world's leading cause of vision impairment, and as with other causes. The burden falls unfairly on low- and middle-income countries (LMICs), in which rates of presbyopic correction are as low as 10%. The importance of presbyopia as a cause of vision impairment is further underscored by the fact that it strikes at the heart of the productive working years, although it can be safely and effectively treated with a pair of inexpensive glasses. To galvanize action for programs to address uncorrected presbyopia in the workplace and beyond LMICs, it is crucial to build a solid evidence base detailing the impact of presbyopia and its correction in important areas such as work productivity, activities of daily living, visual function, and quality of life. The aim of this review was to provide an up-to-date reference for program planners and policymakers seeking to build support for programs of presbyopia correction, particularly in low-resource settings.

The Proteome of Cataract Markers: Focus on Crystallins

Cataract is a major cause of blindness worldwide. It is characterized by lens opacification and is accompanied by extensive posttranslational modifications (PTMs) in various proteins. PTMs play an essential role in lens opacification. Several PTMs have been described in proteins isolated from relatively old human lenses, including phosphorylation, deamidation, racemization, truncation, acetylation, and methylation. An overwhelming majority of previous cataract proteomic studies have exclusively focused on crystallin proteins, which are the most abundant proteome components of the lens. To investigate the proteome of cataract markers, this chapter focuses on the proteomic research on the functional relevance of the major PTMs in crystallins of human cataractous lenses. Elucidating the role of these modifications in cataract formation has been a challenging task because they are among the most difficult PTMs to study analytically. The proteomic status of some amides presents similar properties in normal aged and cataractous lenses, whereas some may undergo greater PTMs in cataract. Therefore, it is of great importance to review the current proteomic research on crystallins, the major protein markers in different types of cataract, to elucidate the pathogenesis of this major human-blinding condition.

Noninvasive assessment of age-related stiffness of crystalline lenses in a rabbit model using ultrasound elastography

Background

The pathological or physiological changes of a crystalline lens directly affect the eye accommodation and transmittance, and then they increase the risk of presbyopia and cataracts for people in the middle and old age groups. There is no universally accepted quantitative method to measure the lens' mechanical properties in vivo so far. This study aims to investigate the possibility of assessing the age-related stiffness change of crystalline lens by acoustic-radiation-force-based ultrasound elastography (ARF-USE) in a rabbit model in vivo.

Methods

There were 13 New Zealand white rabbits that were divided into four groups and fed normally until they were 60 (n = 4), 90 (n = 2), 120 (n = 4), and 150 (n = 3) days old, respectively. An ARF-USE platform was built based on the Verasonics™ Vantage 256 system. The shear waves were excited and traced in the lens by a linear ultrasound probe after a rabbit was anaesthetized.

Results

The average group velocities were 1.38 ± 0.2 m/s, 2.06 ± 0.3 m/s, 2.07 ± 0.29 m/s, and 2.30 ± 0.28 m/s, respectively, for the four groups of rabbits. The results shows that the group velocity has a strong correlation with the day age (r = 0.84, p < 1 × 10⁻⁷) and the weight (r = 0.83, p < 1×10⁻⁷) of the rabbits while the maximum displacement has no correlations with the day age (r = 0.27, p > 0.1) and the weight (r = 0.32, p > 0.1).

Conclusion

This study demonstrated that the group velocity measured by ARF-USE had a strong correlation with age-related stiffness in a rabbit model, suggesting that group velocity is a good biomarker to characterize the stiffness of a crystalline lens. This study also demonstrated the feasibility of using this USE technique to assess the mechanical properties of the lens in vivo for clinical or research purposes.

The klotho-related protein KLPH (lctl) has preferred expression in lens and is essential for expression of clic5 and normal lens suture formation

KLPH/lctl belongs to the Klotho family of proteins. Expressed sequence tag analyses unexpectedly revealed that KLPH is highly expressed in the eye lens while northern blots showed that expression is much higher in the eye than in other tissues. In situ hybridization in mouse localized mRNA to the lens, particularly in the equatorial epithelium. Immunofluorescence detected KLPH in lens epithelial cells with highest levels in the germinative/differentiation zone. The gene for KLPH in mouse was deleted by homologous recombination. Littermate knockout (KO) and wild type (WT) mice were compared in a wide panel of pathology examinations and were all grossly normal, showing no systemic effects of the deletion. However, the lens, while superficially normal at young ages, had focusing defects and exhibited age-related cortical cataract by slit lamp examination. Whole-lens imaging showed that KO mice had disorganized lens sutures, forming a loose double-y or x instead of the tight y formation of WT. RNA-seq profiles for KO and WT littermates confirmed the absence of KLPH mRNA in KO lens and also showed complete absence of transcripts for Clic5, a protein associated with cilium/basal body related auditory defects in a mouse model. Immunofluorescence of lens epithelial flat mounts showed that Clic5 localized to cilia/centrosomes. Mice mutant for Clic5 (jitterbug) also had defective sutures. These results suggest that KLPH is required for lens-specific expression of Clic5 and that Clic5 has an important role in the machinery that controls lens fiber cell extension and organization.

The impact of intraocular pressure on elastic wave velocity estimates in the crystalline lens

Intraocular pressure (IOP) is believed to influence the mechanical properties of ocular tissues including cornea and sclera. The elastic properties of the crystalline lens have been mainly investigated with regard to presbyopia, the age-related loss of accommodation power of the eye. However, the relationship between the elastic properties of the lens and IOP remains to be established. The objective of this study is to measure the elastic wave velocity, which represents the mechanical properties of tissue, in the crystalline lens ex vivo in response to changes in IOP. The elastic wave velocities in the cornea and lens from seven enucleated bovine globe samples were estimated using ultrasound shear wave elasticity imaging. To generate and then image the elastic wave propagation, an ultrasound imaging system was used to transmit a 600 µs pushing pulse at 4.5 MHz center frequency and to acquire ultrasound tracking frames at 6 kHz frame rate. The pushing beams were separately applied to the cornea and lens. IOP in the eyeballs was varied from 5 to 50 mmHg. The results indicate that while the elastic wave velocity in the cornea increased from 0.96  ±  0.30 m s^-1 to 6.27  ±  0.75 m s^-1 as IOP was elevated from 5 to 50 mmHg, there were insignificant changes in the elastic wave velocity in the crystalline lens with the minimum and the maximum speeds of 1.44  ±  0.27 m s^-1 and 2.03  ±  0.46 m s^-1, respectively. This study shows that ultrasound shear wave elasticity imaging can be used to assess the biomechanical properties of the crystalline lens noninvasively. Also, it was observed that the dependency of the crystalline lens stiffness on the IOP was significantly lower in comparison with that of cornea.

A decrease in the permeability of aquaporin zero as a possible cause for presbyopia

The crystalline lens appears to be a simple organ with the sole role of focusing light upon the retina. However, numerous studies have underscored its dynamic nature with a host of compartmentalized physiological processes. As the individual ages, the normal lens develops two inescapable processes, presbyopia and cataracts. Yet, to date, there is no uniform explanation for presbyopia and many factors have been proposed as contributors including continuous enlargement of the lens, loss of power of the ciliary muscle and hardening of the lens fibers. Proposed explanations are incomplete and need experimental confirmation. This paper analyzes the possible causes for presbyopia and proposes a new one for it: a decrease in the permeability of aquaporin zero (AQP-0) also known as major intrinsic protein (MIP). Based on original findings of our laboratory, this paper proposes that a fluid flow exists inside the avascular lens. This fluid enters and leaves the lens during the accommodation process. We believe that for this to occur the lens utilizes the permeability of aquaporin zero which is abundant in the membrane of the fiber cells. Volume change due to fluid traversing the surface of the lens occurs during accommodation. We present the hypothesis that increasing the permeability of AQP-0 would facilitate accommodation. Therefore, defects in AQP-0 permeability may be a cause for presbyopia. We would also like to propose that it is possible to visualize and measure the fluid volume lost during un-accommodation and determine if the fluid is lost across the anterior, posterior or both surfaces. An age-related loss in lens water permeability could reduce fluid fluxes during the shape changes of accommodation potentially contributing to presbyopia.

Assessing age-related changes in the biomechanical properties of rabbit lens using a coaligned ultrasound and optical coherence elastography system

PURPOSE

To evaluate the capability of a novel, coaligned focused ultrasound and phase-sensitive optical coherence elastography (US-OCE) system to assess age-related changes in biomechanical properties of the crystalline lens in situ.

METHODS

Low-amplitude elastic deformations in young and mature rabbit lenses were measured by an US-OCE system consisting of a spectral-domain optical coherence tomography (OCT) system coaligned with a focused ultrasound system used to produce a transient force on the lens surface. Uniaxial compressional tests were used to validate the OCE data.

RESULTS

The OCE measurements showed that the maximum displacements of the young rabbit lenses were significantly larger than those of the mature lenses, indicating a gradual increase of the lens stiffness with age. Temporal analyses of the displacements also demonstrate a similar trend of elastic properties in these lenses. The stress-strain measurements using uniaxial mechanical tests confirmed the results obtained by the US-OCE system.

CONCLUSIONS

The results demonstrate that the US-OCE system can be used for noninvasive analysis and quantification of lens biomechanical properties in situ and possibly in vivo.

Review of the impact of presbyopia on quality of life in the developing and developed world

PURPOSE

To examine the public health impact of presbyopia regarding its effect on quality of life (QoL) and society in both the developed and developing worlds.

METHODS

A database was created from articles found on PubMed, the Cochrane Library and Science Direct using the following search terms: presbyopia, QoL, accommodation, impact, cost, prevention, treatment and public health. Articles were accepted into the database if they addressed presbyopia and public health.

RESULTS

This study showed in the developed world presbyopic subjects treated with reading glasses suffered a reduction in QoL parameters compared with those who were younger and emmetropic. A small minority of subjects were assessed to be a candidate for additional non-spectacle treatment measures. In undeveloped areas, the manifestations of presbyopia were similar to the developed world in symptoms, age and reduced QoL. However, there was inadequate treatment of this condition, even with reading glasses. The availability of reading glasses ranged from 6 to 45%. Activities of daily living could not be accomplished as easily without near correction of reading. Reasons described for the lack of correction included: lack of access to medical care, poor awareness of decreased near vision, lack of motivation and cost. Overall scant data exist regarding presbyopia and its impact and how treatment affects QoL.

CONCLUSIONS

This review suggests that the effect of presbyopia and its treatments on QoL remain poorly described and incompletely treated, especially in developing areas of the world.

Multiple zone multifocal phase designs

New multifocal phase designs aiming at expanding depth of focus in the presbyopic eye are presented. The designs consist of multiple radial or angular zones of different powers or of combined low- and high-order aberrations. Multifocal performance was evaluated in terms of the dioptric range for which the optical quality is above an appropriate threshold, as well as in terms of the area under the through-focus optical quality curves. For varying optical power designs optimal through-focus performance was found for a maximum of three to four zones. Furthermore adding more zones decreased the optical performance of the solution. Angular zone designs provided better multifocal performance (1.95 times on average) than radial zone designs with identical number of zones and the same power range. The optimal design (angular design with three zones) surpassed by 33% the multifocal performance of a bifocal angular zone design and by 32% a standard multifocal phase plate with induced spherical aberration only. By using combinations of low- and high-order aberrations the through-focus range can be extended further by another 0.5 D beyond that of the best design of varying optical power. These designs can be implemented in adaptive optics systems for testing their visual performance in subjects and converted into multifocal contact lenses, intraocular lenses, or presbyopic corneal laser ablation profiles.

Instability of the cellular lipidome with age

The human lens nucleus is formed in utero, and from birth onwards, there appears to be no significant turnover of intracellular proteins or membrane components. Since, in adults, this region also lacks active enzymes, it offers the opportunity to examine the intrinsic stability of macromolecules under physiological conditions. Fifty seven human lenses, ranging in age from 12 to 82 years, were dissected into nucleus and cortex, and the nuclear lipids analyzed by electrospray ionization tandem mass spectrometry. In the first four decades of life, glycerophospholipids (with the exception of lysophosphatidylethanolamines) declined rapidly, such that by age 40, their content became negligible. In contrast the level of ceramides and dihydroceramides, which were undetectable prior to age 30, increased approximately 100-fold. The concentration of sphingomyelins and dihydrosphingomyelins remained unchanged over the whole life span. As a consequence of this marked alteration in composition, the properties of fiber cell membranes in the centre of young lenses are likely to be very different from those in older lenses. Interestingly, the identification of age 40 years as a time of transition in the lipid composition of the nucleus coincides with previously reported macroscopic changes in lens properties (e.g., a massive age-related increase in lens stiffness) and related pathologies such as presbyopia. The underlying reasons for the dramatic change in the lipid profile of the human lens with age are not known, but are most likely linked to the stability of some membrane lipids in a physiological environment.

A high pulse repetition frequency ultrasound system for the ex vivo measurement of mechanical properties of crystalline lenses with laser-induced microbubbles interrogated by acoustic radiation force

A high pulse repetition frequency ultrasound system for an ex vivo measurement of mechanical properties of an animal crystalline lens was developed and validated. We measured the bulk displacement of laser-induced microbubbles created at different positions within the lens using nanosecond laser pulses. An impulsive acoustic radiation force was applied to the microbubble, and spatio-temporal measurements of the microbubble displacement were assessed using a custom-made high pulse repetition frequency ultrasound system consisting of two 25 MHz focused ultrasound transducers. One of these transducers was used to emit a train of ultrasound pulses and another transducer was used to receive the ultrasound echoes reflected from the microbubble. The developed system was operating at 1 MHz pulse repetition frequency. Based on the measured motion of the microbubble, Young's moduli of surrounding tissue were reconstructed and the values were compared with those measured using the indentation test. Measured values of Young's moduli of four bovine lenses ranged from 2.6 ± 0.1 to 26 ± 1.4 kPa, and there was good agreement between the two methods. Therefore, our studies, utilizing the high pulse repetition frequency ultrasound system, suggest that the developed approach can be used to assess the mechanical properties of ex vivo crystalline lenses. Furthermore, the potential of the presented approach for in vivo measurements is discussed.

Imaging properties of the light sword optical element used as a contact lens in a presbyopic eye model

The paper analyzes the imaging properties of the light sword optical element (LSOE) applied as a contact lens to the presbyopic human eye. We performed our studies with a human eye model based on the Gullstrand parameterization. In order to quantify the discussion concerning imaging with extended depth of focus, we introduced quantitative parameters characterizing output images of optotypes obtained in numerical simulations. The quality of the images formed by the LSOE were compared with those created by a presbyopic human eye, reading glasses and a quartic inverse axicon. Then we complemented the numerical results by an experiment where a 3D scene was imaged by means of the refractive LSOE correcting an artificial eye based on the Gullstrand model. According to performed simulations and experiments the LSOE exhibits abilities for presbyopia correction in a wide range of functional vision distances.

A comparative study on the viscoelastic properties of human and animal lenses

A new method of compression between two parallel plates is used to measure the viscoelastic properties of whole and decapsulated human lenses and compare them with other animal species. Compressive load relaxation was performed by deforming the lens by 10% and measuring the force relaxation response for 100 s to obtain thickness, stiffness and relaxation of the induced loading force and Maxwell parameters for human, monkey, porcine and leporine whole and decapsulated lenses. Thickness and percentage loading force relaxation increased linearly with lens age, whereas stiffness and induced loading force increased exponentially. Human and monkey lenses aged at different rates. Loading force relaxation in a generalized Maxwell model was described by three time constants ranging from 1 to 1000 s. Compressive load relaxation is a very versatile method to study the viscoelastic properties of whole and decapsulated lenses and potentially also artificial accommodating lenses. The data presented in the study will help researchers choose the most suitable animal lenses based on the desired properties and age to be mimicked from the human lenses.

Strehl ratios characterizing optical elements designed for presbyopia compensation

We present results of numerical analysis of the Strehl ratio characteristics for the light sword optical element (LSOE). For comparison there were analyzed other optical imaging elements proposed for compensation of presbyopia such as the bifocal lens, the trifocal lens, the stenopeic contact lens, and elements with extended depth of focus (EDOF), such as the logarithmic and quartic axicons. The simulations were based on a human eye's model being a simplified version of the Gullstrand model. The results obtained allow to state that the LSOE exhibits much more uniform characteristics of the Strehl ratio comparing with other known hitherto elements and therefore it could be a promising aid to compensate for the insufficient accommodation range of the human eye.

A simple description of age-related changes in crystalline lens thickness

PURPOSE

An increase in lens thickness is often described as a linear function of age. However, contradictory opinions exist about whether the lens thickness continues to increase after 50 years of age. Differences in slope exist between this increase in younger and older people, but these findings are inconsistent with the linear behavior of an increase in the lens thickness throughout life. We investigated among different functions, including slope variation, which would be the best to show the relation between lens thickness and age. An available model portraying lens growth could be advantageous in many practical applications. The possibility of differences between sexes in lens thickness growth is also analyzed.

METHODS

We evaluated 102 eyes of patients aged between 15 and 84 years: 41 men, 61 women. The biometric measurements were performed with the aid of the OcuScan® (Alcon, USA).

RESULTS

Both logarithmic and potential functions provide a good fit for the data (R2 = 0.905 and 0.906, respectively). The results do not show significant differences between men and women in any age range, nor when the data of the whole sample are considered (p = 0.29).

CONCLUSIONS

The best fits for the data are both logarithmic and double logarithmic functions. According to this model, lens growth continues throughout life, but after 50 years, age-related thickness variations are lower than statistical variability. No differences were found between the sexes.

Nested shell optical model of the lens of the human eye

A nested shell model of the human lens is developed based on the known anatomical construction of the lens, on the known way in which the lens grows throughout its life, on the measured characteristics of the lens surfaces as a function of the age of the lens, on the measured changes in the shape of the lens during accommodation, and on measured material characteristics of the lens materials, such as density and index of refraction throughout. The observed changes in central surface curvature and thickness force the shell thicknesses to vary in a predictable way and in turn force the shell surface asphericity to take certain values. Thus, in addition to giving the shape of each shell, the model predicts the change expected in the asphericity of the lens surfaces as the lens ages and adds cortical cell layers. Two examples are given, one for a 25-year-old lens and one for a 40-year-old lens, to show how the cortical layers change their shapes throughout the cortex and over time as the lens ages. The performance of the model of this paper is compared to that of two other nested shell models, one where the layers have constant thickness and one where the lens posterior is fixed within the eye over time, to show the superior performance of this model with respect to maintaining a constant refractive error for the eye as the lens ages and grows.

Surface change of the mammalian lens during accommodation

Classical theories suggest that the surface area of the crystalline lens changes during accommodation while the lens volume remains constant. Our recent work challenged this view by showing that the lens volume decreases as the lens flattens during unaccommodation. In this paper we investigate 1) the magnitude of changes in the surface of the in vitro isolated cow lens during simulated accommodation, as well as that of human lens models, determined from lateral photographs and the application of the first theorem of Pappus; and 2) the velocity of the equatorial diameter recovery of prestretched cow and rabbit lenses by using a custom-built software-controlled stretching apparatus synchronized to a digital camera. Our results showed that the in vitro cow lens surface changed in an unexpected manner during accommodation depending on how much tension was applied to flatten the lens. In this case, the anterior surface initially collapsed with a reduction in surface followed by an increase in surface, when the stretching was applied. In the human lens model, the surface increased when the lens unaccommodated. The lens volume always decreases as the lens flattens. An explanation for the unexpected surface change is presented and discussed. Furthermore, we determined that the changes in lens volume, as reflected by the speed of the equatorial diameter recovery in in vitro cow and rabbit lenses during simulated accommodation, occurred within a physiologically relevant time frame (200 ms), implying a rapid movement of fluid to and from the lens during accommodation.

The quality of life associated with presbyopia

PURPOSE

To determine the health-related quality of life associated with the presbyopia.

DESIGN

Cross-sectional, patient preference-based, time trade-off utility analysis.

METHODS

One hundred and ten patients with spectacle-corrected presbyopia and a best-corrected visual acuity of 20/40 or better were interviewed in a cross-sectional fashion using a standardized, validated, time trade-off utility analysis questionnaire.

RESULTS

The mean utility associated with the health state of presbyopia in our sample was 0.980 (standard deviation, 0.086; 95% confidence interval, 0.964 to 0.996). Ten percent of the cohort had a presbyopia-associated utility of 0.95 or less. Age, gender, level of education, marital status, and the degree of presbyopia did not significantly affect the time trade-off utilities associated with presbyopia.

CONCLUSIONS

Presbyopia corrected with glasses is associated with a nominal decrease in quality of life, similar to that of treated hypertension, for the average person with the condition. Approximately 10% of such patients theoretically may be candidates for an intervention other than spectacles to correct the condition.

Fluid transport phenomena in ocular epithelia

This article discusses three largely unrecognized aspects related to fluid movement in ocular tissues; namely, (a) the dynamic changes in water permeability observed in corneal and conjunctival epithelia under anisotonic conditions, (b) the indications that the fluid transport rate exhibited by the ciliary epithelium is insufficient to explain aqueous humor production, and (c) the evidence for fluid movement into and out of the lens during accommodation. We have studied each of these subjects in recent years and present an evaluation of our data within the context of the results of others who have also worked on electrolyte and fluid transport in ocular tissues. We propose that (1) the corneal and conjunctival epithelia, with apical aspects naturally exposed to variable tonicities, are capable of regulating their water permeabilities as part of the cell-volume regulatory process, (2) fluid may directly enter the anterior chamber of the eye across the anterior surface of the iris, thereby representing an additional entry pathway for aqueous humor production, and (3) changes in lens volume occur during accommodation, and such changes are best explained by a net influx and efflux of fluid.

Volume change of the ocular lens during accommodation

During accommodation, mammalian lenses change shape from a rounder configuration (near focusing) to a flatter one (distance focusing). Thus the lens must have the capacity to change its volume, capsular surface area, or both. Because lens topology is similar to a torus, we developed an approach that allows volume determination from the lens cross-sectional area (CSA). The CSA was obtained from photographs taken perpendicularly to the lenticular anterior-posterior (A-P) axis and computed with software. We calculated the volume of isolated bovine lenses in conditions simulating accommodation by forcing shape changes with a custom-built stretching device in which the ciliary body-zonulae-lens complex (CB-Z-L) was placed. Two measurements were taken (CSA and center of mass) to calculate volume. Mechanically stretching the CB-Z-L increased the equatorial length and decreased the A-P length, CSA, and lens volume. The control parameters were restored when the lenses were stretched and relaxed in an aqueous physiological solution, but not when submerged in oil, a condition with which fluid leaves the lens and does not reenter. This suggests that changes in lens CSA previously observed in humans could have resulted from fluid movement out of the lens. Thus accommodation may involve changes not only in capsular surface but also in volume. Furthermore, we calculated theoretical volume changes during accommodation in models of human lenses using published structural parameters. In conclusion, we suggest that impediments to fluid flow between the aquaporin-rich lens fibers and the lens surface could contribute to the aging-related loss of accommodative power.

Estimation of macular pigment optical density in the elderly: test-retest variability and effect of optical blur in pseudophakic subjects

The reproducibility of macular pigment optical density (MPOD) estimates in the elderly was assessed in 40 subjects (age: 79.1+/-3.5). Test-retest variability was good (Pearson's r coefficient: 0.734), with an average coefficient of variation (CV) of 18.4% and an intraclass correlation coefficient (ICC) of 0.96. The effect of optical blur on MPOD estimates was investigated in 22 elderly pseudophakic subjects (age: 79.9+/-3.6) by comparing the baseline MPOD, obtained with an optimal correction, with MPODs obtained with a +/-1.00-diopter optical blur. This optical blur did not cause differences in the MPOD estimates, its accuracy, or test duration.

Mapping age-related elasticity changes in porcine lenses using bubble-based acoustic radiation force

Bubble-based acoustic radiation force aims to measure highly localized tissue viscoelastic properties. In the current investigation, acoustic radiation force was applied to laser-induced bubbles to measure age-related changes in the spatial distribution of elastic properties within in vitro porcine lenses. A potential in vivo technique to map lens elasticity is crucial to understanding the onset of presbyopia and develop new treatment options. Bubble-based acoustic radiation force was investigated as a technique to measure the spatial elasticity distribution of the lens in its natural state without disrupting the lens capsule. Laser-induced optical breakdown (LIOB) generated microbubbles in a straight line across the equatorial plane of explanted porcine lenses with 1mm lateral spacing. Optical breakdown occurs when sufficiently high threshold fluence is attained at the focus of femtosecond pulsed lasers, inducing plasma formation and bubble generation. A two-element confocal ultrasonic transducer applied 6.5 ms acoustic radiation force-chirp bursts with the 1.5 MHz outer element while monitoring bubble position within the lens using pulse-echoes with the 7.44 MHz inner element. A cross-correlation method was used to measure bubble displacements and determine exponential time constants of the temporal responses. Maximum bubble displacements are inversely proportional to the local Young's modulus, while time constants are indicative of viscoelastic properties. The apparent spatial elasticity distributions in 41 porcine lenses, ranging from 4 months to 5 years in age, were measured using bubble-based acoustic radiation force. Bubble displacements decrease closer to the porcine lens center, suggesting that the nucleus is stiffer than the cortex. Bubble displacements decrease with increasing lens age, suggesting that porcine lenses become stiffer with age. Bubble-based acoustic radiation force may be well-suited as a potential in vivo technique to spatially map elastic properties of the lens and guide therapeutic procedures aimed at restoring accommodation.

Presbyopia: the first stage of nuclear cataract?

Presbyopia, the inability to accommodate, affects almost everyone at middle age. Recently, it has been shown that there is a massive increase in the stiffness(1) of the lens with age and, since the shape of the lens must change during accommodation, this could provide an explanation for presbyopia. In this review, we propose that presbyopia may be the earliest observable symptom of age-related nuclear (ARN) cataract. ARN cataract is a major cause of world blindness. The genesis of ARN cataract can be traced to the onset of a barrier within the lens at middle age. This barrier restricts the ability of small molecules, such as antioxidants, to penetrate into the centre of the lens leaving the proteins in this region susceptible to oxidation and post-translational modification. Major protein oxidation and colouration are the hallmarks of ARN cataract. We postulate that the onset of the barrier, and the hardening of the nucleus, are intimately linked. Specifically, we propose that progressive age-dependent hardening of the lens nucleus may be responsible for both presbyopia and ARN cataract.

Accommodative changes in lens diameter in rhesus monkeys

PURPOSE

Some debate surrounds the accommodative mechanism in primates, particularly whether the lens equatorial diameter increases or decreases during accommodation. This study has been undertaken to measure the relationship between changes in lens diameter and refraction during accommodation in rhesus monkeys.

METHODS

Photorefraction was used to measure accommodation, and goniovideography was used to measure accommodative changes in lens diameter in the iridectomized eyes of two rhesus monkeys. Accommodation was stimulated through the full amplitude available to each eye by stimulation of the Edinger-Westphal nucleus of the brain. Dynamic measurement of refractive changes followed by dynamic measurements of changes in lens diameter for the same stimulus current amplitudes allow the relationship between refraction and lens diameter to be determined.

RESULTS

Lens diameter decreased relatively linearly during accommodation by 0.055 mm/diopter (D), resulting in an overall decrease in lens diameter of approximately 7% of the unaccommodated lens diameter for approximately 12 D of accommodation.

CONCLUSIONS

The rhesus monkey lens diameter decreases systematically with the refractive change during accommodation in accordance with the Helmholtz accommodative mechanism and in contrast to the accommodative mechanism originally proposed by Tscherning.

The relationship between refractive and biometric changes during Edinger-Westphal stimulated accommodation in rhesus monkeys

Experiments were undertaken to understand the relationship between dynamic accommodative refractive and biometric (lens thickness (LT), anterior chamber depth (ACD) and anterior segment length (ASL=ACD+LT)) changes during Edinger-Westphal stimulated accommodation in rhesus monkeys. Experiments were conducted on three rhesus monkeys (aged 11.5, 4.75 and 4.75 years) which had undergone prior, bilateral, complete iridectomies and implantation of a stimulating electrode in the Edinger-Westphal (EW) nucleus. Accommodative refractive responses were first measured dynamically with video-based infrared photorefraction and then ocular biometric responses were measured dynamically with continuous ultrasound biometry (CUB) during EW stimulation. The same stimulus amplitudes were used for the refractive and biometric measurements to allow them to be compared. Main sequence relationships (ratio of peak velocity to amplitude) were calculated. Dynamic accommodative refractive changes are linearly correlated with the biometric changes and accommodative biometric changes in ACD, ASL and LT show systematic linear correlations with increasing accommodative amplitudes. The relationships are relatively similar for the eyes of the different monkeys. Dynamic analysis showed that main sequence relationships for both biometry and refraction are linear. Although accommodative refractive changes in the eye occur primarily due to changes in lens surface curvature, the refractive changes are well correlated with A-scan measured accommodative biometric changes. Accommodative changes in ACD, LT and ASL are all well correlated over the full extent of the accommodative response.

Platelet-derived growth factor D, tissue-specific expression in the eye, and a key role in control of lens epithelial cell proliferation

Platelet-derived growth factor D (PDGF-D), also known as Iris-expressed growth factor, is a member of the PDGF/vascular endothelial growth factor family. The expression of PDGF-D in the eye is tissue-specific. In the anterior segment, it is localized to iris and ciliary body, whereas in the retina, PDGF-D is restricted to the outer plexiform layer. PDGF-D is present in aqueous humor but is not detectable in mature lens or in mouse lens-derived alphaTN4-1 cells. However, it is expressed in rabbit lens-derived N/N1003A cells. N/N1003A cell-conditioned medium stimulates proliferation in rat lens explants, and this is blocked by immunodepletion of PDGF-D. Immunopurified PDGF-D also stimulates cell proliferation in rat lens explants and in NIH 3T3 cells. In organ culture of rat eye anterior segments, anti-PDGF-D strongly inhibits lens epithelial cell proliferation. This finding suggests a major in vivo role for PDGF-D in the mechanisms of coordinated growth of eye tissues. Intervention in the PDGF-D pathway in the eye, perhaps by antibody or blocking peptide, could be useful in the treatment of certain cataracts, including post-operative secondary cataract.

Anterior ciliary sclerotomy for treatment of presbyopia: a prospective controlled study

PURPOSE

To examine the safety and efficacy of anterior ciliary sclerotomy to restore accommodation in the presbyopic eye.

DESIGN

Prospective nonrandomized comparative single-center clinical trial.

PARTICIPANTS

Nine presbyopic subjects with no prior ocular surgery except corneal refractive procedures were enrolled.

METHODS

One eye from each subject was chosen, in consultation with the patient, to undergo anterior ciliary sclerotomy. The contralateral eye of each subject served as a control. Examinations were performed preoperatively, and at 1 day, 1 week, 1 month, and 6 months after surgery.

MAIN OUTCOME MEASURES

(1) Accommodative amplitude, measured by two methods, (2) Jaeger reading vision at 14 inches wearing best distance correction, (3) manifest refraction, (4) assessment of operative complications.

RESULTS

For the nine study eyes, there was no statistically significant change between the average accommodative amplitude at the preoperative visit (1.11 diopter [D]) and the 1-month postoperative visit (1.19 D, P = 0.55) nor at the 6-month postoperative visit (1.31 D, P = 0.21) in the study eyes. There was no significant difference between the study and control eyes' change in accommodative amplitude at 6 months (P = 0.43). Logarithm of the minimum angle of resolution equivalent of Jaeger reading vision in the study eyes at 14 inches wearing best distance correction showed no statistically significant change from the preoperative visit (0.53 [20/70]) at the 1-month postoperative visit (0.41 [20/50], P = 0.07) or at the 6-month postoperative visit (0.48 [20/60], P = 0.22). There was no significant change in manifest refraction spherical equivalent in the study eyes at 1 and 6 months postoperatively. One eye experienced a perforation of the anterior chamber during surgery. A second eye experienced mild postoperative anterior segment ischemia manifested by sectoral iris akinesis.

CONCLUSIONS

Anterior ciliary sclerotomy does not restore accommodation in presbyopic eyes and can cause significant complications.