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Up Front | Apr 2010

CHIEF MEDICAL EDITOR’S PAGE: The Holy Grail of Ophthalmology: Treatment of Presbyopia

I would like to introduce myself as the newest Chief Medical Editor of CRST Europe, effective as of this issue. I am delighted to transition into this role from my prior post as Associate Chief Medical Editor. My position as the Medical Director of Medipolis in Antwerp, Belgium, provides background that will allow me to serve my latest role well. This journal transfers ideas and concepts and introduces new technologies directly into the scope of every European ophthalmologist. The how-to format of CRST Europe keeps readers aware of the never-ending evolution in our specialism. I am eager to learn new technologies and bring them into daily use to benefit my patients—a message I will continue to infuse into my contributions to this publication.

I would like to highlight a few topics from this month's interesting cover focus on presbyopia. The correction of presbyopia was a difficult task in the past, but recently new approaches are available to our portfolio. Although this series of articles describes the advantages and disadvantages of each approach, patient selection and setting expectations are even more critical in the treatment of presbyopia. I am going to adopt the term environmental vision, as described by Claes Feinbaum, MSc, ECS, FAAO from Sweden, because this is really what we should take into account when treating patients.

I have always taken great care in listening to patients and trying to understand their motivation and expectations for surgical intervention. I have learned through the years that what we surgeons think is the best option for our patients does not always coincide with their needs. Perhaps we should all adopt the motto: Customize the best overall solution for each patient.

Is changing the corneal curvature to enhance near vision the best approach for the correction of presbyopia even though only pseudoaccommodation is achieved? Several laser manufactures have developed presbyopic LASIK algorithms such as presby-LASIK (Technolas Perfect Vision, Munich, Germany), PresbyMAX (Schwind eye-tech-solutions, Kleinostheim, Germany), PresBvis (CustomVis, Balcatta, Australia), and laser blended vision (Carl Zeiss Meditec, Jena, Germany). LASIK surgery has been well established and has proven its safety and efficacy. Different asymmetric laser ablation profiles extend corneal presbyopia correction to laser centers around the world.

Antonio Calossi, Dip Optom, FBCLA, FIACLE, writes of a customizable reverse geometry lens that induces negative spherical aberration while the patient sleeps. Orthokeratology is well known to correct myopia, but in experienced hands and with motivated patients, it now can be a reversible alternative for presbyopes.

IntraCOR flapless presbyopia treatment is a relatively new approach in presbyopia reversal. The Technolas femtosecond laser alters the biomechanical properties of the cornea without removing corneal tissue or disturbing Bowman's layer and Descemet's membrane. Sinan Goker, MD, describes the indications and advantages compared with other presbyopic laser techniques. I have been using this approach in my own clinic for more than 6 months. The results have been excellent so far with very high patient satisfaction.

Corneal inlays are gaining momentum with newer designs. In the past, most needed to be explanted due to deposits around the inlay, decentration, or disturbance in the corneal flow. Now a flap or a pocket is created with the femtosecond laser, and smaller inlays with newer materials such as the PresbyLens (ReVision Optics, Inc., Lake Forest, California) or Flexivue Micro- Lens (Presbia Coöperatief UA, Amsterdam, Netherlands), are available, as described by Ioannis Pallikaris, MD, PhD, and colleagues. My clinic is also involved in the study of the PresbyLens, with clinical trials starting soon.

Corneal approaches mean the natural lens remains untouched and will continue to undergo changes. Refractive lens exchange with premium lenses such as multifocal and accommodating IOLs are performed regularly and were discussed extensively in the January issue. Elizabeth A. Davis, MD, FACS; and Francesco Carones, MD, revisit lens-based strategies for presbyopia correction. I certainly expect many new presbyopia- correcting procedures to emerge in the near future. In the end, the most successful presbyopia treatment will be the one providing good near vision with only a minimal compromise in distance. You will certainly be updated through future issues of Cataract and Refractive Surgery Today Europe.