SPS-401 Presbyopia Correction | ASCRS
2020 ASCRS Virtual Annual Meeting

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Papers in this Session
Expand each tab below to view the paper abstract for each paper within this session.
Correction of Presbyopia for Commercial and Military Pilots Requiring Class 1 Medical Certification
Author
Dan Z. Reinstein, MD, FRCS

Methods
This was a retrospective study of 21 commercial and military pilots who underwent PRESBYOND Laser Blended Vision treatments using the MEL 90 excimer laser and VisuMax femtosecond laser (Carl Zeiss Meditec). Postoperative follow-up visits were conducted at 1 day, 1 month, 3 months and 12 months. Standard outcomes analysis was performed using the data at the last visit. A questionnaire of cockpit functional vision was given to each patient after surgery.

Results
Mean age was 55±8 years (42 to 79 years). Attempted SEQ was -0.22±2.41D (-4.00 to +4.88D), cylinder was -0.65±0.52D (0.00 to -2.75D). Binocular UDVA was 20/20 in 100% and 20/16 in 57%. Binocular UIVA was J3 in 79%, J5 in 89% and J10 in 100%. Binocular UNVA was J1 in 86% and J2 in 100%. Postop SEQ relative to target was -0.01±0.37D (-0.63 to +0.75D), 90% within ±0.50D. There was 1 line loss CDVA in 10%, and no eyes lost 2 lines. Contrast sensitivity was increased at 3, 6, 12, and 18 cpd. All pilots reported improved functionality compared to before surgery.

Conclusion
Treatment by PRESBYOND Laser Blended Vision enabled presbyopic commercial pilots to continue to fly without the need for spectacles, even within the visually challenging environment of a cockpit where vision is required at near, intermediate, and far distance.
Analysis of Defocus Curve of Emerging Presbyopic Patients
Authors
Brian M Shafer, MD
John P. Berdahl, MD
Vance M. Thompson, MD
Mitch J. Ibach, OD
Larae L. Zimprich, OD
Justin A. Schweitzer, OD

Methods
Non-randomized, prospective study of thirty phakic emerging presbyopic patients ages 37-42 that have 20/20 best-corrected distance visual acuity (BCDVA) on an EDTRS chart at 20 feet. Minus lenses in increments of -0.50 D will be added to each subjects BCDVA until reaching -3.0 D. The subjects BCDVA will be recorded at each -0.50 increment on an ETDRS chart at 20 feet. A Plus lens of +0.50 D will be added to each subjects BCDVA. The subjects BCDVA will be recorded at +0.50 D on an ETDRS chart at 20 feet. The results will be plotted to obtain a defocus curve. This defocus curve will be compared to the defocus curve present in the label of all currently available US presbyopic IOLs.

Results
Of the 29 subjects, 55.1% were female. 48.3% of subjects were between the ages of 37-39 and 51.7% were between the ages of 40-42. Binocular visual acuity with the best-corrected distance refraction at different defocus steps ranging from +0.5 D to 3 D were measured in the 37-39 year old group and the 40-42 year old group. Visual acuity significantly decreased from plano to -3 D defocus steps in both the younger and older groups (p<0.0002 and p=0). The younger group had statistically significantly better acuity starting at the -2.5 D defocus step (p=0.004) and continued through the -3 D step (p=0.0003).

Conclusion
The defocus curves of emerging presbyopic individuals demonstrates the expected visual acuity at different defocus steps. Therefore, defocus curves at different age ranges can be compared to the published defocus curves for known intraocular lenses to provide patients with enhanced guidance on visual expectations following cataract surgery.
Hyperopia and Presbyopia: A New Nomogram Using the Q Factor Modulation
Authors
Nesrine Rahmania Jr., MD, MSc
Imene Salah, PhD, MSc
Damien Gatinel, MD, PhD

Methods
Prospective interventionnal superiority study including presbyopic hyperopic patients led between January 2018 and February 2019 comparing a sample with monofocal correction using a classical monovision with a sample in whom multifocality was aimed at using Presbylasik with Q factor modulation. Visual acuities and high order aberrations such as primary and secondary spherical aberrations, and coma were compared in both groups. Classical monovision was simulated with contact lenses aiming at myopic defocus in Non Dominant Eye (NDE) whereas an emmetropic correction was targeted in Dominant Eye (DE).

Results
28 patients (mean age: 56,03 ±4,31 years) were included. Distance Visual Acuity (DVA) in Log Mar was statistically different with contact lenses and 6 months after surgery in NDE (0,69± 0,09versus 0,04± 0,18; p<0,00001). Corneal asphericity was equal to 0,66± 0,24 and to -0,12± 0,37; (p< 0,00001), corneal Δc(4,0) to -0,07± 0,15 microns versus 0,01± 0,08 microns; p=0,013, corneal Δc(6,0) to -0,008± 0,02 microns versus -0,004± 0,03 microns; p=0,589 respectively for NDE and DE.

Conclusion
Our study shows significant improvement in visual scores by changing corneal asphericity with PresbyLasik Custom Q compared to monovision and enhances the benefit of Q factor modulation in both DE and NDE. A dedicated software is being developed to facilitate its routine clinical use by ophthalmologists worldwide.
Novel Simulation of Accommodation & Ciliary Muscle Movements Using Finite Element Model Animation (FEMA)
Authors
AnnMarie Hipsley, PhD
Katie R. Knaus
Silvia S. Blemker, PhD
Daniel B. Goldberg, MD, ABO
Brad Hall, PhD

Methods
A 3-D model of the eye was constructed using meshing and FEM analysis was performed using advanced multi-physics simulation (AMPS) technology on representative 3D models of ocular structures. The CM groups were activated and accommodative power was analyzed as a function of the resulting CM excursion and lens displacement which were then calibrated with published data images (OCT/UBM/MRI) in young(30yrs) and presbyopic(50yrs) eyes. CM fiber groups were activated in isolation to quantify each’s contribution to accommodation biomechanics. The FEM was translated into a FEMA to show 3D dynamic movements using a proprietary method and Autodesk Maya.

Results
The FEM demonstrated multiple components of the accommodative apparatus behave biomechanically to result in CM excursion inward and forward. These accommodative biomechanics are also affected by extralenticular structures such as the sclera, choroid, and zonular geometry. The model also revealed specific contributions of ciliary fiber groups to lens changes. Sensitivity analysis of the differences in accommodation between the “young/healthy” and “old/presbyopic” eye identified the age-related changes that contribute most to symptoms of presbyopia. The FEMA demonstrated the dynamic movements of the ciliary muscle, zonules, lens, sclera, choroid, and vitreous during accommodation.

Conclusion
Age-related changes in the ocular tissues impede normal CM function as well as capability for lens deformation required for normal accommodative biomechanical function. We were capable in our lab to translate the FEM into Maya to give unique insights into dynamic accommodation movements.
New Polynomial Decomposition to Enhance the Benefits of a Nomogram Using Q Factor Modulation
Authors
Nesrine Rahmania Jr., MD, MSc
Imene Salah, PhD, MSc
Damien Gatinel, MD, PhD

Methods
Superiority retrospective study comparing High Order Aberrations (HOAs) among which primary and secondary spherical aberrations and coma using Zernike polynomial decomposition to HOAs obtained by using a new polynomial decomposition introduced by Gatinel and Malet. HOAs were analyzed in hyperopic and presbyopic patients who underwent bilateral presbylasik with a Q factor modulation using a new nomogram.

Results
Changes in defocus and modified spherical aberration polynomials were better correlated with keratometric and asphericity changes respectively.

Conclusion
Our results suggest better accuracy of this new polynomial decomposition compared to Zernike's to reflect changes in High order aberrations variations when altering both target Q factor and defocus.
Evaluation of Accommodation & OCT Guided Depth Control after Laser Scleral Microporation in Presbyopic Non Human Primates
Authors
Luca Gualdi, MD
AnnMarie Hipsley, PhD
Jodhbir S. Mehta, MBBS, FRCSEd, PhD
Yu-Chi Liu, MD
Brad Hall, PhD

Methods
Six non-human primates (n = 12 eyes) at presbyopic age underwent LSM. The LSM treatment utilized a 2.94um Erbium Yttrium Aluminum Garnet (Er:YAG) laser in 4 oblique quadrants on the sclera to rejuvenate age-related ocular rigidity reduce biomechanical stiffness, and improve efficiency of the ciliary muscles in 5 critical zones of anatomical and functional significance. Slit lamp, anterior segment optical coherence tomography (ASOCT), intraocular pressure (IOP) measurements, and accommodation were performed postoperatively. Wound healing profiles were also characterized at 1, 6, and 9 months postoperatively and examined for stability.

Results
On ASOCT evaluation, the margin of the micropores was clearly visible. The mean laser ablation depth was 81.2 ± 5.8% at 1 month postoperatively, which decreased to 72.7 ± 11.5% at 6 months postoperatively. Average preoperative IOP of 13.0 ± 0.8 mmHg was significantly reduced to an average of 10.2±0.8mmHg postoperatively and was sustained through 7 months postoperatively (p=0.000076). At 7 months postoperatively, EROF was increased by approximately 8D on average, which corresponded to a 5D increase in true accommodation and a 3D increase in pseudoaccommodation. At 9 months, there was minimal scleral fibroblast migration into the micropores.

Conclusion
OCT is a useful tool in characterization of scleral micropores for depth, pore quality, pore density and evaluation of microporation patterns. LSM at approximately 80% depth of the sclera appears to not only improve accommodative ability, but also to reduce IOP.
The Use of Objective Evaluation of Patients’ Daily Life in Guiding Surgeon Selection of Presbyopic IOLs
Author
Arthur B Cummings, MD

Methods
This study sought to determine if the effect of VBM results influenced the surgeons’ decision-making process. The study compared IOL selection following the VBM results, compared to historical IOL implantation for the primary surgeon at this site (AC). Patients were randomly selected for enrollment and were not screened for a pre-existing interest in a premium IOL. The VBM is a unique wearable that can track a patient’s visual lifestyle using a combination of sensors measuring working distances, ambient light, head movement and position, resulting in an objective evaluation of the patient’s visual activities.

Results
35 patients (N=48 eyes) were enrolled at this site. Historically, 92% of patients received a monofocal IOL with 4% receiving a presbyopic IOL and 4% a toric IOL. During the study, using the VBM results a part of the IOL selection process, 66% of eyes received a presbyopic correcting IOL (N=30) and 31% (N=14) receiving a monofocal IOL.

Conclusion
In this initial feasibility study, relying on the results from the VBM objective data, patients opted for a presbyopic-correction IOL at almost 15 times the previous rate seen at this clinical site.
Range of Vision and Spectacle Independence with a New Trifocal IOL
Authors
Vance M. Thompson, MD
Satish S. Modi, FRCS, MD

Methods
Prospective, non-randomized, vision assessor-masked, multicenter (twelve sites in the USA), parallel-group study to support a PMA submission for the TFNT00 IOL. To evaluate the DoF depth of focus, binocular defocus curves were generated between +1.50 D and -2.50 D in 0.50 D steps (0.25 D steps from +0.50 to -0.50 D). All testing was performed on an electronic visual acuity test system (CTS, M&S Technologies). The assessment of need for eyeglass/contact lenses wear was performed with the PRO instrument (IOLSAT).

Results
A total 243 subjects with a mean age of 67.3 years were implanted in at least 1 eye and 241 (127 in the T group and 114 in the S group) completed the study. The T IOL provided superior mean performance of 0.1 logMAR or better DoF from -2.5D to 0.00D (40 cm to infinity). The T IOL was superior in the % of subjects (80.5%) who responded “never to the need of wearing eyeglasses to see” VS the S IOL group (8.2%). There were 91.8% of subjects in the T group and 11.8% of subjects in the S group reported rarely to never needing glasses to see up close and 99.2% of subjects in the T group VS 67.3% of subjects in the S group reporting rarely to never needing glasses to see at arms’ length.

Conclusion
The AcrySof IQ PanOptix Trifocal provided a superior range of vision from distance to 40cm (~16 inches) and spectacle independence compared to the monofocal SN60AT IOL.
Does Pre-Operative Objective Visual Assessment Impact Patient Satisfaction?
Authors
Bojan Pajic, MD, PhD
H. Burkhard Dick, MD, PhD
Arthur B Cummings, MD
Zeljka Cvejic, PhD

Methods
Patients were randomly selected to take part in this feasibility study to wear the VBM for 36-hours prior to scheduling of surgery. The VBM is a wearable that can track a patient’s lifestyle using a combination of sensors resulting in an objective evaluation of patient’s activities. Following enrollment in the study, patients completed a modified Cat-Quest9 questionnaire and then were instructed on the use of the VBM, sent home and returned 1 week later to see the results and schedule surgery. Approximately 1 month after surgery, patients completed a post-operative version of the Cat-Quest 9. The results were compared with the pre-operative results, as well as published cataract IOL studies.

Results
129 patients were enrolled and completed the Cat Quest9 questionnaire pre-operatively. For the final analysis, 101 patients completed the questionnaire. Pre-operatively, 81% of patients indicated that they had at least some difficulty with their vision in daily life, with 72% indicating they were very dissatisfied to rather dissatisfied with their vision. At the final post-operative visit, 85% reported that their vision matched expectations or exceeded their expectations. 10 percent indicated that their vision was not quite what they had expected.

Conclusion
The results suggest that the use of the VBM does help improve patients’ level of satisfaction following cataract or refractive lens exchange surgery. A new study that our center is participating in will more fully explore the impact of the VBM on surgeon decision making.

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