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Up Front | Sep 2008

Current Options for Presbyopia Correction

As patients increasingly demand surgical treatment for presbyopia, the number of options continues to grow.

To achieve optimum results with multifocal IOLs, it is necessary to fulfill what I call the four essential visual elements of success: (1) relatively high quality distance visual acuity, (2) functional intermediate vision (eg, seeing the computer at arm's length), (3) functional near vision in both bright and moderate light (eg, comfortably reading the newspaper), and (4) acceptable light phenomenon when driving at night.

When the US Food and Drug Administration (FDA) approves the Tecnis Multifocal IOL (Advanced Medical Optics, Inc., Santa Ana, California), our ability to achieve these four goals will significantly increase. Until then, I will wait-list patients in anticipation of the IOL—much as I did from October 2004 to June 2005 when I wait-listed approximately 140 patients in anticipation of the Restor multifocal IOL (Alcon Laboratories, Inc., Fort Worth, Texas). I did not implant any Array IOLs (Advanced Medical Optics, Inc.; no longer available) during this 8-month period because I believed the Restor was the best option for my patients. Similarly, waiting for the Tecnis Multifocal IOL is clearly the best option for the 140 of my patients who are wait-listed for this IOL. Forty of these patients already have a ReZoom IOL (Advanced Medical Optics, Inc.) and 20 already have an Eyeonics Crystalens (Bausch & Lomb, Rochester, New York) implanted in their first eye.

I have firsthand experience with the Tecnis Multifocal, implanting more than 45 IOLs during the FDA trial. There is also a 5-year worldwide experience to learn from, as opposed to the Restor lens, which was brand new in 2005.

After placing 300 Restor lenses bilaterally, unilaterally, and as mix and match with the ReZoom, I eventually abandoned use of the Restor late in 2006; however, I firmly believe that combining a high-quality diffractive multifocal IOL with other styles of presbyopia-correcting IOLs, such as the Crystalens HD and the ReZoom, will offer our patients the highest degree of spectacle independence and patient satisfaction.

The Tecnis Multifocal IOL is superior to the Restor aspheric implant in numerous ways; however, the most critical characteristic is that the Tecnis Multifocal has excellent near UCVA in both bright and dim light versus the Restor, which has poor near reading in dim light. A less known but also significant difference is that the intermediate vision of the Tecnis Multifocal is significantly better than the Restor implant, as documented by European investigators.1-3

After the Tecnis Multifocal is approved, the three most common choices for patients seeking correction of their presbyopia will be (1) Tecnis Multifocal plus Crystalens HD, (2) Tecnis Multifocal plus ReZoom, and (3) Tecnis Multifocal in both eyes. The optimum combination depends on the patient's preoperative characteristics, such as age, culture, visual function, and patient expectations. The halophobia associated with the ReZoom IOL will likely lead to the Tecnis Multifocal/Crystalens being the most popular combination. The ReZoom has greater overall refractive predictability and substantially better near vision than the Crystalens. I currently have six patients with this combination, and they are all 100% free of spectacles and have all neuroadapted past any significant halo-related complaints.

The Tecnis Multifocal/Crystalens HD combination will be popular because it will effectively fulfill the four visual elements of success. The Tecnis Multifocal will provide such excellent near vision in both bright and dim light that it will make up for any near deficiencies of the Crystalens HD. At the same time, the Crystalens HD will provide a nonhaloed image when the patient drives at night and spare the patient any need to neuroadapt in that eye.

Implanting Tecnis Multifocal IOLs in both eyes has achieved excellent results worldwide in relatively older cataract patients. These excellent outcomes are the result of the IOL's outstanding near vision in both dim and bright light, excellent distance vision secondary to the aspheric correction, and better-than-expected intermediate vision. If the target refraction is 0.25 D in each eye, the intermediate vision becomes even stronger without giving away any distance vision.

In summary, the Tecnis Multifocal is an excellent anchor for a number of effective mix-and-match scenarios, and it will finally give us the diffractive multifocal visual performance needed to truly provide our presbyopic patients with what they are really looking for—spectacle independence.

When discussing the treatment of presbyopia, the following six points should be kept in mind.

No. 1: Is the patient interested in presbyopia treatment? Just because the patient may not ask for presbyopia correction does not mean that he will not eventually be interested in it. The surgeon should discuss the possibility of future presbyopic correction and stimulate interest by displaying brochures and handouts as well as show movies or other demos in the office.

Some cataract or refractive patients have never heard about the concept of presbyopia correction. If we do not mention it as an option, our patients may be disappointed when they discover it could have been performed. It is hard for the surgeon to pinpoint patients who can afford the extra cost of presbyopia correction, so it is best to offer it to all patients.

No 2: The surgeon must understand what the patient wants and aim to meet his lifestyle needs. What are the patient's expectations? Does he require spectacle independence, or is some spectacle dependence good enough? Is the patient extremely demanding? What are his hobbies? Does he use a computer regularly? (And what kind? Laptops and desktops have different working distances.) Does he drive a lot at night?

Patient gender is also a determining factor; we have learned from experience that women prefer to work and read at shorter distances than men.

All patients who receive a multifocal IOL may encounter the potential disturbances of halos and glare. We are involved in a multicenter international study, The Happy Patients Program, in which all multifocal IOL candidates are screened with psychological and psychometric tests. Surgical outcomes will be tested against preop data. Hopefully, in the future, similar studies will be undertaken worldwide. We hope that the conclusions will be helpful for future candidates.

No. 3: Who is the ideal candidate? Moderate to high hyperopes between the ages of 50 and 70 years who wish to achieve spectacle independence are the ideal candidates. Without presbyopic correction, these patients are essentially handicapped for all distances. Moderate and high myopic presbyopes are also good candidates; however, emmetropes and low myopes usually have high expectations.

No. 4: What techniques should you advise? Presbyopic treatments include hyperopic LASIK, presby-LASIK, multifocal IOLs, accommodating IOLs, and monovision.

We do not favor monovision as a presbyopic treatment; we have had too many excimer monovision patients come back for a full correction in the nondominant eye. Presby-LASIK always involves a compromise in quality between the near and far vision; however, it is an excellent approach for low hyperopes (1.00 to 3.00 D) and moderate myopes (-3.00 to -6.00 D). The patient must understand and accept that the correction may not last their lifetime. We currently use the MEL 80 excimer laser (Carl Zeiss Meditec AG, Jena, Germany) for presby-LASIK.

Accommodating IOLs are not commonly used in Europe, and our earlier experiences were rather disappointing. Therefore, we prefer multifocal IOLs, such as the Tecnis Multifocal diffractive IOL, (formerly with a silicone optic, now with acrylic), and the ReZoom refractive IOL. We customize the IOL according to the patient's lifestyle. In doing so, more than 95% of our patients are spectacle independent.

No. 5: Age matters. Discussing presbyopia with a 45-year-old moderate hyperope (1.00 to 3.00 D) is completely different from discussing it with a 55-year-old, 4.00 D presbyope. When your patient wants a definite solution for his distance and reading for the remainder of his life, a multifocal IOL is our preferred option; however, the patient must (1) accept some optical compromises, including glare and halos, and (2) undergo enhancement when needed.

In the case of a 45-year-old patient with 1.50 D who wants improved reading capacity and spectacle freedom for distance, we prefer simple hyperopic LASIK or presby-LASIK. In 5 to 10 years, the patient will require a second intervention (ie, real or improved style accommodating IOL). If this patient was 55 years old, the approach would be different.

No. 6: Avoid false expectations. Be honest with your patient. When discussing multifocal IOLs, tell him the whole story. But remember that complaints about ghost images are not as common as they were 5 years ago. Discuss the possibility of enhancements, such as femto-LASIK or limbal relaxing incisions. When a patient undergoes presby-LASIK, make sure he understands that an enhancement or a second treatment (perhaps a truly accommodating IOL when they become available) will be unavoidable because presbyopia is not a stable target.

The ideal presbyopic treatment (1) provides good UCVA for far, near, and intermediate distance, (2) does not cause a marked reduction of contrast sensitivity and does not induce dysphotopsia, and (3) is predictable and long-lasting.

None of the current treatments for presbyopia fulfills these criteria. Multifocal IOLs reduce contrast sensitivity, are essentially bifocal (either intermediate or near vision can be deficient), and may induce some degree of dysphotopsia. The advent of diffractive and aspheric models have raised new hopes for multifocal IOLs; however, they demonstrate only little advantage over time-tested refractive optics.4 Multifocal IOLs remain an option for hyperopes,5 patients for whom night driving is not a concern, and those who can tolerate acceptable vision at two distances only—depending on the IOL, far and intermediate or far and near—despite a loss of contrast sensitivity.

Binocular implantation is problematic when the patient is unhappy with his first eye. In some cases, patients want to wait for the first eye to improve before operating on the second; however, their vision will not improve until the IOL is implanted in the second eye. This is why my favorite multifocal IOL patients are hyperopes because their far vision already improves at the completion of surgery in their first eye.

Scleral expansion techniques, based on the controversial Schachar theory of accommodation,6 are often unpredictable, and their long-term efficacy is uncertain. Regression, cosmetic concerns, and changes in distance refraction are the reasons I do not perform scleral expansion.

Accommodating IOLs have been shown to essentially provide patients with pseudoaccommodation. The ability of the lens to move forward during the contraction of the ciliary muscle is yet to be demonstrated. Additionally, their effect is highly unpredictable, and capsular bag fibrosis prevents movement of the IOL in the long term.7

Monovision, whether achieved using conductive keratoplasty, excimer laser, or refractive lens exchange, is applicable only to approximately 50% of patients. The advantage of this technique is that it is fully predictable with a contact lens trial. Monovision LASIK is easy and completely reversible, with no loss of contrast sensitivity and long-term stability.8 Its drawbacks include halos in the near-corrected eye, which may require driving glasses, and the need for a perfect result in the distance-corrected eye. In emmetropes, I advise it only after a prolonged contact lens trial.

In my opinion, the ultimate frontier for the correction of presbyopia is in the cornea. Many attempts to create a multifocal cornea have been made in the past; however, I have always been concerned about how to reverse outcomes in unhappy patients. Pinelli and colleagues recently developed a customized ablation profile for LASIK or surface ablation in which the distance refractive error is treated in the central cornea and the near addition is created by a more peripheral ablation.9 This profile is not exactly multifocal or bifocal. To date, we have had satisfactory results.

Several surgical options are currently available for the treatment of presbyopia, and a true refractive surgeon cannot choose one single option to treat all of his patients. Additionally, new options are on the horizon, such as corneal inlays, truly accommodating IOLs, and improved scleral procedures.

If we focus on those treatments available today, the two most popular surgical treatments are multifocal corneas created with excimer laser ablation and multifocal IOLs. Other options include conductive keratoplasty, accommodating IOLs (still in development), and scleral expansion procedures, the last of which is currently losing popularity.

My choice of presbyopic treatment is guided by three factors: the patient's age, the patient's occupation, and the magnitude of his accompanying refractive defect. For young presbyopes (ie, under the age of 50 years), my first option is a multifocal cornea created with the excimer laser (Figure 1). Because the patient's pupil size is large at that age, multifocal IOLs may cause visual disturbances, including halos and glare.

For presbyopes over 50 years of age, multifocal IOLs play a role in the list of options to treat the defect; however, if the patient has high astigmatism or the pupil is larger than 6 mm, I prefer to create a multifocal cornea with the excimer laser. In presbyopes over 60 years of age, IOLs may be the more appropriate option.

When I implant a multifocal IOL in an eye with high preoperative astigmatism, I prefer the Restor, Tecnis Multifocal, or the Acri.Tec Acri.LISA (Carl Zeiss Meditec AG) because the WaveScan System (Advanced Medical Optics, Inc.) easily measures these IOLs. Therefore, the patient may receive a customized excimer laser ablation approximately 1 month after the IOL surgery, eliminating the corneal refractive error and allowing the IOL to work properly. We have been successful with this treatment in the last year. The WaveScan unit does not accurately measure the ReZoom.

The main reason I still strongly advocate corneal multifocality instead of multifocal IOLs in the already mentioned indications is that it is totally reversible with a customized excimer laser ablation. Some of my patients with multifocal corneas created in 2001 and 2002 subsequently developed cataracts and have been successfully treated with a multifocal IOL. One month later, a customized ablation was performed, eliminating the residual refractive error and providing spectacle independence.

Calculating IOL power is easier today because of recent software and technology developments, including the Pentacam (Oculus OptikgerŠte GmbH, Wetzlar, Germany) and IOLMaster (Carl Zeiss Meditec AG).

In conclusion, there are many surgical options for presbyopia treatment today. Refractive surgeons must keep an open mind to new technologies. Certainly in the near future we will have a complete portfolio for customized treatments dependent upon the individual characteristics of the patient.

There are several options to treat presbyopia, and although some were developed over the past 10 years, there is not yet a fully effective method to correct it. Because presbyopia involves many factors with interpersonal variations, it is difficult to find a technique or procedure that is effective in every patient. Thus, it appears more logical to choose the best solution according to the patient's habits, his preferences, and the anatomy and physiology of his eyes.

Following this premise, we may consider the classic options of glasses or contact lenses or choose a surgical intervention, such as corneal laser, corneal or scleral implants, and IOLs.

In our clinic, we prefer to attempt a certain grade of monovision. We achieve this in young presbyopes by treating the cornea with an aspheric laser profile.

If the patient's crystalline lens exhibits significant changes, we prefer to use refractive lens exchange, mixing and matching the Tecnis Multifocal in the nondominant eye with the ReZoom in the dominant eye. This approach achieves efficient overall vision.

In our experience, we have had a high rate of success; however, some patients complain of halos or problems while driving at night. To avoid these complications, newer pseudoaccommodating IOLs appear to provide better results than previous designs.

Combination of premium IOLs with excimer laser ablation compensates for accommodation; however, this technique has its own problems, including aberrations and prismatic effects induced by the center of the different optical surfaces. For this reason, we are cautious when we evaluate this possibility.

Frank A. Bucci Jr, MD, is Medical Director of Bucci Laser Vision Institute, Wilkes Barre, Pennsylvania. Dr. Bucci states that he has no financial interest in the products or companies mentioned. Dr. Bucci may be reached at tel: +1 570 825 5949; e-mail: buccivision@aol.com.

Frank J. Goes, MD, is the Medical Director of the Goes Eye Centre, Antwerp, Belgium. Dr. Goes states that he receives travel support from Advanced Medical Optics, Inc., and Carl Zeiss Meditec AG. Dr. Goes may be reached at tel: +32 3 2193925; fax: + 32 3 2196667; e-mail: frank@goes.be.

Antonio Leccisotti, MD, PhD, is a Visiting Professor at the School of Biomedical Sciences, University of Ulster, Coleraine, UK, and Director of the Ophthalmic Department, Casa di Cura Rugani, Siena, Italy. Dr. Leccisotti states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +39 335 8118324; fax: +39 0577 578600; e-mail: leccisotti@libero.it.

Gustavo Tamayo, MD, practices at the Bogota Laser Refractive Institute, Bogotá, Colombia. He states that he is a consultant to Advanced Medical Optics, Inc., and is a paid consultant to Moria. He may be reached at e-mail: gtvotmy@telecorp.net.

Carlos Vergés MD, PhD, is Professor and Head of the Department of Ophthalmology, CIMA, Universitat Politecnica de Catalunya, Spain. Dr. Verges is a member of the CRST Europe Editorial Board. He states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +34 93 551 33 14; fax: +34 93 551 33 14; e-mail: verges@attglobal.net.