Mechanism and outcomes of PRESBYOND Glenn I Carp MBBCh, FC Ophth (SA)1 Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth FEBO 1,2,3,4 Timothy J Archer, MA(Oxon), DipCompSci(Cantab) 1 1. London Vision Clinic, London, UK 2. Columbia University Medical Center, New York, USA 3. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France 4. Biomedical Science Research Institute, Ulster University, Coleraine, Northern Ireland
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Mechanism and outcomes
of PRESBYOND
Glenn I Carp MBBCh, FC Ophth (SA)1 Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth FEBO1,2,3,4
Timothy J Archer, MA(Oxon), DipCompSci(Cantab)1
1. London Vision Clinic, London, UK
2. Columbia University Medical Center, New York, USA
3. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France
4. Biomedical Science Research Institute, Ulster University, Coleraine, Northern Ireland
©DZ Reinstein 2016
Financial Disclosure
The author (GI Carp) receives travel expenses
from Carl Zeiss Meditec AG (Jena, Germany)
The author (DZ Reinstein) is a consultant for
Carl Zeiss Meditec AG (Jena, Germany)
The author (DZ Reinstein) acknowledges a
financial interest in Artemis™ VHF digital
ultrasound (ArcScan Inc., Golden, CO)
©DZ Reinstein 2016
Objective
PRESBYOND is….
not monovision!
not micro/modest monovision!
not a multifocal treatment!
It’s PRESBYOND!!!!!
©DZ Reinstein 2016
Monovision Disadvantages: Low Tolerance
Dominant eye:
mainly corrected
for distance
Non-dominant eye:
mainly corrected
for near Brain merges two
images to see near and
far without glasses
59-67%
Patients Tolerate
Evans BJ. Monovision: a review.
Ophthalmic Physiol Opt.
2007;27:417-439.
©DZ Reinstein 2016
Monovision: Challenges
3. Distance vision loss 1. Intermediate vision loss 2. Tolerance
4. Summation loss 5. Stereo acuity loss
(unrecoverable)
©DZ Reinstein 2016
Modest Monovision
** Pardhan et al., The Effect of Monocular Defocus on Binocular Contrast
Sensitivity, Ophthal. Physiol. Opt., 1990, Vol. 10, January
Literature suggests a defocus value of -1.3D delivers the best balance of
summation and near acuity
Summation
Subtraction Suppression
©DZ Reinstein 2016
Monovision: Challenges
3. Poor distance vision in
the near eye
1. Blur zone at intermediate
distances
2. Anisometropia not
tolerated by many
4. Loss of binocular distance
vision (rivalry/suppression)
5. Loss of stereo acuity
(unrecoverable)
Improves on
these challenges
Modest
Monovision
Graham Barrett
©DZ Reinstein 2016
Stereoacuity and anisometropia
Up to -1.25 D
-1.50 D or more
Minimal stereopsis impairment for
anisometropia <1.5D
©DZ Reinstein 2016
Stereoacuity and anisometropia
Up to -1.25 D
-1.50 D or more
Minimal stereopsis impairment for
anisometropia <1.5D
However, near visual acuity is
compromised as max -1.25 add!
©DZ Reinstein 2016
Monovision: Challenges
3. Distance vision loss 1. Intermediate vision loss 2. Tolerance
4. Summation loss 5. Stereo acuity loss
(unrecoverable)
4. Loss of binocular distance
vision (rivalry/suppression)
5. Loss of stereo acuity
(unrecoverable)
Improves on all
of these Presbyond
Increased Depth of Field by
controlling
Spherical Aberration
• Naturally occurring aberration
• Increases with age
• Increases during accommodation
©DZ Reinstein 2016
Influence of Spherical Aberration on Depth of Field
without spherical aberration
with spherical aberration
courtesy Hartmut Vogelsang, PhD
©DZ Reinstein 2016
Influence of Spherical Aberration on Depth of Field
0.00 D -0.50 D -1.00 D -1.50 D -2.00 D
without
spherical
aberration
@ 7 mm
with
spherical
aberration
@ 7 mm
Slides courtesy Hartmut Vogelsang, PhD
©DZ Reinstein 2016
Simulation for -1.50 D defocus
-1.50 D @ 7 mm
Add spherical aberration Reduce pupil size to 4 mm
With spherical
aberration and @ 4 mm
Central neural processing
Spherical Aberration Increases Depth of
Field: Confirmed by Adaptive Optics
©DZ Reinstein 2016
Spherical Aberration Increases Depth of Field
Depth of field increases with both negative and positive
spherical aberration
PRESBYOND Laser Blended Vision for
Myopia, Hyperopia, and Emmetropia (Non-linear Aspheric Presbyopic Micro-monovision LASIK)
©DZ Reinstein 2016
Current Possible Depth of Field Increase
Near
Intermediate
Distance
Far Distance
Right Eye Left Eye
1.50 D 1.50 D
Loss of contrast
©DZ Reinstein 2016
Depth of Field by SA: Myopia S
ph
eri
cal A
berr
ati
on
+ve
-ve
0
Low High High Pre SA
Threshold
©DZ Reinstein 2016
Depth of Field by SA: Hyperopia S
ph
eri
cal A
berr
ati
on
+ve
-ve
0
Low High
Threshold
Threshold
©DZ Reinstein 2016
Depth of Field by SA: Emmetropia S
ph
eri
cal A
berr
ati
on
+ve
-ve
0
Dist Eye Near Eye
Threshold
Threshold
©DZ Reinstein 2016
Laser Blended Vision – Micro-Monovision
Near
Intermediate
Distance
Far Distance
Dominant Eye Non-Dominant Eye
“Blend Zone”
DO
F 1
.50 D
DO
F 1
.50 D
©DZ Reinstein 2016
Laser Blended Vision – Micro-Monovision
Near
Intermediate
Distance
Far Distance
Dominant Eye Non-Dominant Eye
Nominal Rx: plano
Nominal Rx: -1.50 D
DO
F:
1.5
0 D
DO
F:
1.5
0 D
-2.25 D
“Blend Zone”
-0.75 D
PRESBYOND Laser Blended Vision for
Myopia, Hyperopia, and Emmetropia (Non-linear Aspheric Presbyopic Micro-monovision LASIK)
©DZ Reinstein 2016
Blended Vision: Methods
Myopia Hyperopia Emmetropia
# Patients 136 111 148
SEQ -3.58 ± 1.80 D
up to -8.50 D
+2.58 ± 1.17 D
up to +5.75 D
+0.25 ± 0.43 D
-0.88 to +1.00 D
Cylinder -0.83 ± 0.64 D
up to -2.50 D
-0.49 ± 0.50 D
up to -3.25 D
-0.44 ± 0.31 D
up to -1.25 D
Age median 49 yrs
43 to 63
median 56 yrs
44 to 66
median 55 yrs
44 to 65
• >90% follow up at 1 year
• Results presented including enhancements
©DZ Reinstein 2016
Blended Vision: Enhancement Rate
Myopia
-8.50
Hyperopia
+5.75 Emmetropia
All 19% 22% 12%
Distance eyes
(20/25 or worse) 9% 9% 6%
Near eyes
(J3 or worse) 8% 9% 7%
©DZ Reinstein 2016
Laser Blended Vision: Results
Myopia to -8.50D
20/20 & J2
95%
Hyperopia to +5.75 D
20/20 & J2
77%
Emmetropia
20/20 & J2
95%
20/20
J2
upto -8.50 D upto +5.75 D
J5
-0.88 to +0.88 D
©DZ Reinstein 2016
Safety: Laser Blended Vision
All 395 Patients: Range: -8.50 D – plano – +5.75 D
©DZ Reinstein 2016
Laser Blended Vision: Contrast Sensitivity
*
Statistically significant improvement (p<0.05)
* * *
* *
Myopia Upto -8.50D, n=272
Hyperopia Upto -8.50D, n=222
Emmetropia n=292
©DZ Reinstein 2016
Monovision: Challenges
3. Distance vision loss 1. Intermediate vision loss 2. Tolerance
4. Summation loss 5. Stereo acuity loss
(unrecoverable)
©DZ Reinstein 2013
Intermediate Vision: Myopic Patients
• 238 Patients
• SEQ: up to -12.00 D
• Age: 40 to 70 years
• Follow-up: 3 mo to 5 yrs
Computer
font size 12
©DZ Reinstein 2013
Intermediate Vision: Hyperopic Patients
• 334 Patients
• SEQ: up to +6.00 D
• Age: 40 to 70 years
• Follow-up: 3 mo to 5 yrs
Computer
font size 12
©DZ Reinstein 2013
Monovision: Challenges
3. Poor distance vision in
the near eye
1. Blur zone at intermediate
distances
2. Anisometropia not
tolerated by many
4. Loss of binocular distance
vision (rivalry/suppression)
5. Loss of stereo acuity
(unrecoverable)
©DZ Reinstein 2013
Monovision Disadvantages: Low Tolerance
Dominant eye:
mainly corrected
for distance
Non-dominant eye:
mainly corrected
for near Brain merges two
images to see near and
far without glasses
59-67%
Patients Tolerate
Evans BJ. Monovision: a review.
Ophthalmic Physiol Opt.
2007;27:417-439.
©DZ Reinstein 2013
Correcting Presbyopia: Laser Blended Vision
Brain merges two
images to see near and
far without glasses
Dominant eye:
mainly corrected
for distance
Non-dominant eye:
mainly corrected
for near
~97%
Patients Tolerate
Reinstein DZ et al. LASIK for Hyperopic
Astigmatism and Presbyopia Using Micro-
monovision With the Carl Zeiss Meditec
MEL80. JRS. 2009;25(1):87-93
©DZ Reinstein 2013
Monovision: Challenges
3. Distance vision loss 1. Intermediate vision loss 2. Tolerance
4. Summation loss 5. Stereo acuity loss
(unrecoverable)
©DZ Reinstein 2013
Binocular Vision: Neural Summation
20/12.5or better
20/16 orbetter
20/20 orbetter
20/25 orbetter
20/32 orbetter
20/40 orbetter
20/63 orbetter
Near Eyes 0.0055096 0.0330579 0.1460055 0.2369146 0.3636364 0.446281 0.8044077
Distance Eyes 0.0931507 0.4465753 0.9232877 0.9780822 0.9945205 0.9972603 1
Binocular 0.1315068 0.5342466 0.9616438 0.9808219 1 1 1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cu
mu
lati
ve
Pe
rce
nta
ge E
ye
s
Distance UCVA After All Treatments
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Distance UCVA After All Treatments
Cu
mu
lati
ve
Pe
rce
nta
ge
Ey
es
Near Eyes 1% 3% 15% 24% 36% 45% 80%
Distance Eyes 9% 45% 92% 98% 99% 100% 100%
Binocular 13% 53% 96% 98% 100% 100% 100%
20/12.5 or
better
20/16 or
better
20/20 or
better
20/25 or
better
20/32 or
better
20/40 or
better
20/63 or
better
-1.50 D refraction expect 20/80
n=395
©DZ Reinstein 2013
Monovision: Challenges
3. Distance vision loss 1. Intermediate vision loss 2. Tolerance
4. Summation loss 5. Stereo acuity loss
(unrecoverable)
©DZ Reinstein 2013
71%
94%100%
89%
100% 100%
66%
97% 100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
≤100 sec ≤200 sec ≤400 sec
Emmetropes
Myopes
Hyperopes
Stereo Acuity: Efficacy (near-corrected pre vs near-uncorrected post)
• All eyes retained uncorrected stereo acuity of
400 arcsec or better post-operatively
©DZ Reinstein 2013
Monovision: Challenges
3. Distance vision loss 1. Intermediate vision loss 2. Tolerance
4. Summation loss 5. Stereo acuity loss
(unrecoverable)
©DZ Reinstein 2013
Summary
• PRESBYOND Laser Blended Vision
– Correction of pure presbyopia (distance normal)
– Wide range of refractive error: +5.00 to -9.00
– Based on induction of ‘natural aberrations’
– Simultaneous accurate correction of cylinder
– Easily enhanced in future if required
– Centration on visual axis
– Minimal compromise to contrast sensitivity and night
vision disturbances
– Tolerated by >95% of patients
– Functional stereo acuity maintained
– Performed as bilateral simultaneous 10 minute
procedure with fast recovery
Mechanism and outcomes
of PRESBYOND
Glenn I Carp MBBCh, FC Ophth (SA)1
Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth FEBO1,2,3,4
Timothy J Archer, MA(Oxon), DipCompSci(Cantab)1
1. London Vision Clinic, London, UK
2. Columbia University Medical Center, New York, USA
3. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France
4. Biomedical Science Research Institute, Ulster University, Coleraine, Northern Ireland
Thank You
©DZ Reinstein 2016
Modest Monovision vs Multifocals
>>
>>
Near eye target: -1.00 to -1.50 D
Achieved: -0.92 ±0.65
2.5x
©DZ Reinstein 2016
Eccentric Visual Function
• Adler’s Physiology of the Eye
Wertheim T. Uber die indirekte Sehschärfe,
Z. Pyschol 7:172, 1894
20/63
5
©DZ Reinstein 2013
Visual Function
20/200
20/63
20/20
30 10 5 0 5 10 30
Normal
Traditional Monovision
Blended Vision
Vis
ual A
cu
ity
Eccentricity (degrees)
©DZ Reinstein 2013
Visual Function
20/200
20/63
20/20
30 10 5 0 5 10 30
Normal
Traditional Monovision
Blended Vision
Vis
ual A
cu
ity
Eccentricity (degrees)
Summation
Suppression
©DZ Reinstein 2016
Slit Lamp Examination in OR
• Take patient to the slit-lamp in the operating room to redistribute any redundant cap to the periphery
• Use Fluorescein stain to review the cap tension
• Minor cap adjustment can be carried out at the slit-lamp using a sterile spear-tip sponge if necessary
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