GHENESSIA isop paris septembre corrigé 2...13 Isop2019 –Paris, France Our Studyon 100 patients...

Equivision Presbylasik vs Iol with EDOF:Selection criteria and Results

Charles Ghenassia, M.D. Nice- France.

Presbylasik

Iol EDOF

Presbyopia surgery, considered challenging twenty years ago, has now madesignificant technological advances, which explain its success and interest.

Presbylasik or Miol?

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□ This is a controversial subject, as the current trend is to immediatelyrecommend implants

□ The results of Presbyopia treatment is dependent on the quality of the pre-op exam and patient expectations.

□ Whatever technique is used requires some brain plasticity and a period of adaptation.

□ I will briefly explain these two techniques with their advantages and disadvantages.

Isop 2019 – Paris, France

3 Isop 2019 – Paris, France

Before indicating a technique, a full pre-op exam is required

• Refraction + Binocular vision• Age, Topography, keratometry• Pre-op axial length (IOL calculation)• I tracey : Aberrations

• OQAS exams:• Residual Accommodation• Tear film analysis• Visual quality• Scattering index OSI


Different Presbylasik approaches using Alcon EX 500 or similar

StandardMonoVision

Custom-QMonoVision

Blended Vision EquiVision

DV / NV DV / IV-NV DV-IV / IV-NV Bilateral DV-IV-NV

Anisometropia2.00D

Anisometropia1.50D

Anisometropia0.75/1.00D

No Anisometropia0.00/0.25D

Accommodation

- Standard Monovision- Advanced Monovision: modifying asphericity on the dominated eye- Blended Vision : modifying asphericity, differently in each eye, - Equivision: bilateral asphericity treatment with the same increase in depth of field in both eyes


How does Presbylasik work?

Presbylasik is based on several optical principles

• Corneal multifocality

• Modifying corneal asphericity (shape factor)

• Creating spherical aberration

• Increasing visual quality (retinal image)

• Increasing depth of field

• Reusing residual accommodation


Corneal mutifocality post-myopic and hyperopic PresbylasikSame Increase in central curvature radius for NV

Central island for NV post myopia Presbylasik central island for NVpost hyperopia Presbylasik

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Q < 0

Prolate shape

Large axis

Change in corneal asphericity post Presbylasik

Asphericity target delta Q -0,60.to improve the quality of vision and depth of field7


Modulating asphericity with the F-cat software changes spherical aberration

Spherical Aberration

Corneal Asphericity and Spherical Aberration. Antonio Calossi, DipOptomJournal of Refractive Surgery. 2007;23(5):505-514

Spherical Aberration


Based on my own case (operated more than 12 years ago) and our studies, we noticed an improvement in accommodation and visual quality (OQAS)

Pre op RE Post op RE 10 months


Why improve depth of field?Because average depth of field is only 0.30 D as reported in the literature

-2.2D45cm

-2.8D35cm

-2.5D40cm

focal pointf’1 f’2retina

5 cm 5 cm


The decrease in pupillar diameter tied to aging improves depth of field(Pin-hole effect) – Werner et al.

Werner W, Roth EH. http://www.dok.de/ipo/asphaer_iol.html :

Wilhelm B, Wilhelm H (1996) based on original data from Lowenstein O und Loewenfeld I E private communication

Over 60 the average pupillar diameter is 5 mm

To calculate the exact correction for the target asphericity

With Alcon I use my own PresbyCor Equivision software

Isop 2019 – Paris, France12


Our Study on 100 patients With OQAS showsSignificant improvement in post-op accommodation: from 0.69 to 2 D

0,69

1.752.1 2.08 2.04 2.02

0.

0.55

1.1

1.65

2.2

2.75

Pré-op Post-op Post-op post-op Post-op Post-op

1 month 3 months 6 months 9 months 12 months

OQAS accommodation curve

20] Duane A. Normal values of the accommodation at all ages. JAMA, 1912 ; LIX : 1010-3.[25] Hamasaki D., Ong J., Marg E. The amplitude of accommodation in presbyopia. Am J Optom Arch Am Acad Optom, 1956 ; 33 : 3-14[4] Anderson H.A., Hentz G., Glasser A. et al. Minus-lens-stimulated accommodative amplitude decreases sigmoidally with age:a study of objectively measured accommodative amplitudes from age 3. Invest Ophthalmol Vis Sci, 2008 ; 49 : 2919- 26.


We can now calculate the thickness of the lens duringaccommodation with the new Anterion high-resolution device

No accommodation: thickness lens 3,79 mm Accommodation: thickness lens 4,13 mm

We are conducting an FMRI study to evaluate brain plasticity and the creation of new connections post presbylasik

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Refractive surgery inanisometropic adult patientsinduce plastic changes inprimary visual cortexElisa Vuori,1Simo Vanni,2Linda Henriksson,2Timo M. T. Tervo1and Juha M. Holopainen11Department of Ophthalmology, University of Helsinki, Helsinki, Finland2Brain Research Unit and Advanced Magnetic Imaging Centre, LowTemperatureLaboratory, Aalto University, School of Science and Technology, Espoo, Finland. Acta Ophthalmologica 2012

What about IOL with EDOF?

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□ New EDOF implants reached the market 5 years ago, with differents approaches and characteristics.

□ Bifocal and trifocal implants give satisfactory resultsin NV, despite a loss of contrast due to photic effects.

□ Patients today expect a perfect correction of theirinitial ametropia and presbyopia.


Classification of EDOF by design type

□ EDOF - mainly by changing asphericity : Miniwell (ophta France) or Liberty (Medicontour)(Hanita)

□ EDOF -apodized diffractive refractive lenses : Symfony (Johnson & Johnson)

□ EDOF - quadrifocal (trifocal function) lenses: Fine vision (Physiol),

□ EDOF - trifocal (bifocal function) lenses with : At-Lara Tri (Zeiss)

a change in asphericity

□ EDOF Pin-hole technology: IC-8® Small Aperture IOL (Autofocus USA)17

What is an EDOF Iol?« Extended Depth Of Field »

□ An implant that would allow continuous vision at any distance (like physiological accommodation)

□ The term EDOF has created a marketing effect, with names like Full range, Extended range


Light distribution on foci depending on pupillar dynamics

19 (courtesy of Medicontur)

Major Edof Iols available on the market


Example of an EDOF Iol commonly used in FranceBiflex M or Liberty (Medicontur) : apodized diffractive implant


Liberty Iol with PAD optical design:reduction in steps from the center to the periphery

22

1.4micron

2.2micro

n

PAD technology:

Every diffractive step has a change in aspherical curvature. Spherical aberration on the refractive part of the diffractive steps improve depth of field


The Liberty Iolhas ahigh Abbe number(58)to decreasethe incidence of chromaticaberration

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• Abbenumber: define the dispersion propertiesof the material depending on wavelength

• A high Abbe number decreases the incidence of chromatic aberration

Without chromatic aberration

With chromatic aberration: loss of quality

Abbe numberLiberty: 58

We conducted a study on 11 patients (22 eyes) implanted after Presbylasik (liberty Iol)

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0102030405060708090

100

Distance Vision IntermerdiateVision

Near Vision

Post-op Visual AccuracyVA ≥ 6/10 (+0,20 logMAR)VA ≥ 7/10 (+0,15 logMAR)VA ≥ 8/10 (+0,1 logMAR) VA ≥ 9/10 (+0,05 logMAR)VA ≥ 10/10 (+0,00 logMAR)

77.5

88.5

99.510

0.25 0

-0.25 -0.

5-0.

75 -1-1.

25 -1.5-1.

75 -2-2.

25 -2.5-2.

75

Visu

al a

ccur

acy

Defocus

Liberty Defocus curve


Generally, there is no contraindication for Miol or EDOF post Presbylasik


61-yr old patient, Presbylasik operation fév. 2009.OD: +4,75 (-1,50) 90°.

Cataract operation jan. 2013:OD: +0,50 (-0,50) 135°16/20 add +0,75 J2.Corneal asphericity pre cataract: -1,23.

Result post op:(SRK T ou Haigis)UCVA RE: 20/20 J2, IV 16/20.Depth field aided by corneal asphericity.

Topo pre op Presbylasik. Topo pre op cataract.

What are the selection criteria for indication: Presbylasik or EDOF?


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The choice of technique should depend on the Scattering index (OSI) and Residual Accommodation


A scattering index of over 3.5 requires MIOL surgery

Residual accommodation over 0.75 Dallows Presbylasik surgery

Lens Opacities Classification System III: Cataractgrading variability between junior and senior staffat a Singapore hospitalAnna C. Tan, MBBS, Seng Chee Loon, FRCS, MBBS, Harold Choi, MBBS,Lennard Thean, FRCS, MBBS

What technique should be used for presbyopia management?

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□ Training in laser techniques and cataract surgery must be adequate for success

□ Advantages of Presbylasik : non-invasive surgery, fast treatment, no hospital stay, high satisfaction rate,natural continuous vision, ulterior MIOL implantation possible(SRKT, Haigis L, Barett…)

□ Few or no post op complications

□ Disadvantages: transitory discomfort in DV, high cost of surgery. Shorter-lasting vs MIOL, possible enhancements


What technique should be used for presbyopia?

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□ EDOF Advantages: longer-lasting treatment vs Presbylasik, targetpost op result reached immediately

□ Disadvantages: invasive surgery, expensive surgery if clear lens, lossof accommodation, photic phenomena risk of infection, capsularrupture, Vitreous posterior or retinal detachment, cystoid oedema, secondary cataract…


What is the take-home message?

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□ In managing presbyopia, complications with Miol implantation are better accepted vs corneal surgery

□ I would tend to suggest laser surgery first, as age is not a determining factor when there is a low scatteringindex and sufficient residual accommodation

□ These two types of surgery should not be opposed but complementary. There are few problems for the lens calculation post-Presbylasik with the new formulas

□ The shape factor post Presbylasik is complementary to the EDOF Iol in terms of extended depth of field

□ Warning: in France, a BCVA >10/20 is not legally considered as a cataract (no coverage).

□ Managing presbyopia requires clear and complete information from the surgeon, according to patient expectations; indication and results will depend on the surgeon’s experience.


GHENESSIA isop paris septembre corrigé 2...13 Isop2019 –Paris, France Our Studyon 100 patients...

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