This article is more than 5 years old. Information may no longer be current.

Presbyopia therapies revisited

More correction choices are becoming available as more people start to experience this age-related refractive error.

Issue: November 10, 2018

ByMitchell A. Jackson, MD

Add topic to email alerts

Receive an email when new articles are posted on

Please provide your email address to receive an email when new articles are posted on .

Subscribe

Added to email alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

Back to Healio

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

Back to Healio

There is that one moment that happens to even premium surgeons when you wake up sometime in your early 40s and you can no longer read the print on your smartphone. It is an inevitable future for all of us — presbyopia — and already 11% of the world’s population experiences it, with this figure doubling by 2050. There are many surgical, and soon medical, options for presbyopia, which traditionally have been separated into corneal, scleral and lenticular approaches to treatment.

Based on Dan Goldberg’s recent publication and additional research from Mary Ann Croft and others, accommodation and presbyopia involve both lenticular and extralenticular mechanisms of action. Based on these new theories, pseudoaccommodation procedures involve presbyLASIK, monovision, corneal inlays, and multifocal, trifocal and extended depth of focus IOLs. True dynamic accommodation restorative type procedures include accommodating IOLs, presbydrops, femtosecond lens softening and scleral procedures. Diagnostic testing such as the HD Analyzer (Visiometrics) utilizes a double-pass retinal image technique to quantitate a true objective scatter index to help determine if a cornea- or lens-based procedure should be performed in the first place.

Current IOL presbyopia options

When utilizing the Crystalens or Trulign family of IOLs (Bausch + Lomb), best results are achieved when a target of –0.25 sphere is aimed for in each eye, yielding on average 20/25 uncorrected distance vision, 20/20 uncorrected intermediate vision and J2+ uncorrected near vision. With low add multifocals with the Tecnis family of IOLs (Johnson & Johnson Vision), implantation of the ZKB00 in the dominant eye is recommended, and if more near is needed, place a ZLB00 in the nondominant eye. With the EDOF Symfony and Symfony toric IOLs (Johnson & Johnson Vision), it is suggested to shoot for plano in the dominant eye and –0.25 sphere in the nondominant eye to yield the best visual outcomes and the least amount of spider halo side effects, especially with night driving. The ReSTOR +2.5 ActiveFocus and ActiveFocus toric IOL options (Alcon) are distance dominant with excellent intermediate vision and a low distance side effect profile. A ReSTOR +3.0 in the nondominant eye may be needed for more near vision.

Future IOL presbyopia options

The At Lisa IOL (Carl Zeiss Meditec) is a non-apodized, pupil-independent, aspheric diffractive trifocal in non-toric and toric versions. This hybrid lens divides usable light 65% for distance and 35% for near with 3.33 D near add and 1.66 D intermediate add. The Lentis Mplus (Oculentis) is a segmental bifocal design that can be implanted upside down to help with night vision complaints. It is a one-piece zonal refractive lens with a large aspheric distance vision zone and sector-shaped 3 D near add embedded on the posterior surface. The FineVision (PhysIOL) is a true trifocal with a 3.5 D near add and 1.75 D intermediate add, but it is pupil dependent and becomes distance dominant at a 4.5-mm aperture. The PanOptix (Alcon) is a non-apodized diffractive trifocal with intermediate add +2.7 D and near add +3.25 D; it is pupil independent, and its intermediate focal add works best at 60 cm, unlike other trifocal designs at 80 cm. The Light Adjustable Lens (RxSight) was FDA approved in November 2017 and will be commercially released soon. Presbyopia correction can be achieved with this lens by adjustable blended vision with zero to minimal net spherical aberration in the dominant eye and induced controlled amount of negative spherical aberration in the nondominant eye to extend depth of focus. The IC-8 (AcuFocus) is a 1.36-mm aperture at the nodal point of the eye vs. 1.6 mm for the Kamra corneal counterpart (CorneaGen). It works by a pinhole effect to increase depth of focus and is an excellent option in eyes with highly aberrated or irregular corneas.

Scleral options

The VisAbility scleral implants (Refocus Group) are currently in FDA trials and utilize a two-piece PMMA interlocking implant outside of the visual axis in the sclera. A conjunctival peritomy is required and may lead to unwanted dry eye side effects in the postoperative period. A laser scleral microporation procedure (Ace Vision Group) utilizes current Er:YAG laser technology to create four quadrants of diamond-like 225-µm spots over five ciliary body scleral locations in a 2-minute delivery simultaneously. Initial data outside of the U.S. have been promising, and this fast procedure is performed transconjunctivally.

Presbydrops

EV06 (Novartis) is a lens-softening eye drop and works as a lipoic acid choline ester to weaken the oxidation-induced disulfide bond formation between crystalline proteins in the human lens. Phase 1 and 2 FDA studies have shown a mean increase of two more lines of near vision in 32% of cases by day 91 in the nondominant treated eye. Liquid Vision PRX-100 (Presbyopia Therapies) is a drop using both aceclidine as a muscarinic antagonist to create a strong pinhole effect and short-acting low-dose tropicamide with restored accommodation of at least 4 to 7 hours, and it is reversible. It currently is in phase 2b FDA trials. Other non-presbyopia potential uses of these presbydrop formulations include multifocal IOL rescue, decentered IOLs and irregular astigmatism in keratoconus, as these drops reduce pupil size and indirectly can reduce spherical aberration almost 16-fold.

Despite all of us incurring this lovely condition as part of aging, the good news is that we have many current and future ways to combat presbyopia.

• References:
• Artal P, et al. PLoS One. 2011;doi:10.1371/journal.pone.0016823.
• Croft MA, et al. Invest Ophthalmol Vis Sci. 2013;doi:10.1167/iovs.12-10847.
• Croft MA, et al. Exp Eye Res. 2009;doi:10.1016/j.exer.2009.07.009.
• Fishkind WJ. Phacoemulsification and Intraocular Lens Implantation: Mastering Techniques and Complications in Cataract Surgery. 2nd ed. Thieme; 2017:374-386.
• Goldberg DB. Clin Ophthalmol. 2011;doi:10.2147/OPTH.S25983.

• For more information:
• Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.

Disclosure: Jackson reports he is a consultant for Bausch + Lomb, Johnson & Johnson, Alcon and Visiometrics and is a shareholder in Ace Vision Group.