Roadmap to presbyopic success Miltos O Balidis MD, PhD, FEBOphth, ICOphth
Early experience with Presbyopic correction 2003 Binocular Distance-Corrected Intermediate and Near Vision Binocular Distance-Corrected Intermediate and Near Vision 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 83% 66% 56% 44% 22% 12% J1 or Better J2 or Better J3 or Better Intermediate Near 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 98% 100% 93% 80% 58% 28% J1 or Better J2 or Better J3 or Better Intermediate Near Crystalens Restor +4
Comparing technologies ReSTOR Array Tecnis Crystalens Distance Daylight Distance Dim light Near Bright light Near Dim light Intermediate
Comparing technologies ReSTOR Array Tecnis Crystalens Night halos Starbusts Contrast Fluctuation Spectacle dependance
Overpromise - underdeliver Ghost Halos Intermediate VA Night Vision Residual astigmatism Common issues
Overpromise Goal IS to reduced dependence on glasses Refractive enhancement may be required IOL exchange may be required Goal ISN T Spectacle independence Vision of youth Adaptation time to new vision
Patient s lifestyle: Work Listen Sports or leisure activities Computer work? Is their job dependent on driving at night? Have they tried monovision in CLs or bifocals?
Photic Phenomena
Aspheric Multifocal IOL Aspheric Multifocal IOL Restor 3D
Aspheric Multifocal IOL Contrast Sensitivity values of the multifocal IOL group were significantly lower than those of the monofocal IOL group for all spatial frequencies tested (p<0.01), Spherical aberration was significantly higher in the multifocal IOL group than in the monofocal IOL group (p<0.001). Alio JL et al J Cataract Refract Surg. 2008 May;34(5):755-62. Montes- Mico et al J Cataract Refract Surg. 2008 Dec;34(12):2036-42. Kim CY et al Yonsei Med J. 2007 Aug 31;48(4):627-33.
Ghosting Uncorrected astigmatism Ocular surface disease Halos at Night Residual refractive error? Short term pharmacologic miosis using brimonidine 0.2% Improves with spectacles with 0.5 D more myopia than refraction
Source Gatinel
IOL curvature determines far point Diffractive grating provides addition Grating variable height = apodiazation
Diffractive apodized steps Step width determines additional power 4,3,or 2.5 D Small step high add Large step lower add
Diffractive apodized steps Step height determines energy repartition between near and far Higher step, higher energy for near vision Lower step higher energy for distance vision
Neuroadaptation The Visual cortex Attempts to compensate for anything influencing normal functioning. Requires a period of adjustment to digest information from multifocal lenses, Short term neuroadaptation (30 to 40 seconds) on all the time. Long term (several weeks to 12 months) to improve image quality.
Neuroadaptation In monovision, (1.50 D), cortex fuses at every distance Simultaneous image formation is difficult to adapt The greater the disparity between images, the more time to adapt Younger patients adapt more quickly Personality profile
Biometry Biometry is the key for success IOL MASTER / Biograph Holladay Hoffer Q SRK/T Haigis a0 a1 a2 Charman et al Problems in the measurement of wavefront aberration for eyes implanted with diffractive bifocal and multifocal intraocular lenses. J Refract Surg. 2008; 24(3):280-286. Gatinel D. Limited accuracy of Hartmann-Shack wavefront sensing in eyes with diffractive multifocal IOLs [letter]. J Cataract Refract Surg 2008;34:528 Jendritza BB, Knorz MC, Morton S. Wavefront-guided excimer laser vision correction after multifocal IOL implantation. J Refract Surg 2008;24:274-279.
Unhappy patient stepwise approach IOL position Residual astigmatism Laser Vision Cor Capsular opacity Cystoid Macular Edema Endothelium assessment Dry Eye Possibly different IOL or target in second eye
Important aspects Gender Female more near work Male aim for better distance Astigmatism Topography Endothelial cell rate Scotopic - photopic pupil
IOL SELECTION Restor 4,3,or 2.5 Diffractive aspheric technology Additional refractive power +3.0D or 2.5 (2.25 or 1.85D at the spectacle plane). Near or intermediate dominant IOL mix and match the same IOL design platform and multifocal optic technology
IOL SELECTION Restor toric Two trusted technologies Essential even for 0.75 diopter of astigmatism Work on steep axis Aim 0.5 D higher than corneal astigmatism / compensate for minimal rotation Use intraoperative keratoscope if available
Avoid High demands Irregular astigmatism Dry eye Retinal disease Glaucoma
My approach Multiple options, same technology Same technology less neuroadaptation Limited monovision (0.5-1.0D) OR different addition well accepted Easy to re-adjust (refractive-astigmatic correction)
Πανελλήνιο Συνεδριο 2014