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MONOVISION, PRESBYLASIKW. Bruce Jackson, MD, FRCSC

W. Bruce Jackson, MD, FRCSC

University of Ottawa Eye Institute

Ottawa, Canada

IC-47 Course : Matching Surgical Presbyopic Correction Technologies to the Patient

MONOVISION

Monovision

•Correcting presbyopia with one eye focused for distance and the other for near – myopic eye (-1.25 to -2.50D)

•Mini-monovision – correction for intermediate range (-0.50 to -0.75D)

•Micro-monovision or blended vision – increased range of binocular vision from distance to near usually from multifocality – adjust Spherical Aberration in both distance and near eye1, 2

Why Monovision LASIK?

•Works for myopes and hyperopes

•Results in functional decrease in dependence on glasses

•Small impact on stereopsis, contrast sensitivity and binocular VA

•Does not add additional aberrations to the cornea for future surgery – MF IOL’s

•Easily supplemented by glasses

•High satisfaction rate3 – if proper selection

•Reversible

Optical Effects of Monovision

•Vision is corrected for only 1 focal point

•Slightly decreased binocular distance visual acuity

•Decreased stereopsis for distance and near

•Normal peripheral visual fields

Monovision

•Best accepted in people with casual and intermittent near visual demands

•Not well accepted in people who need precise binocular close-range vision or stereopsis or precise binocular distance vision

•Best accepted in optimistic, adaptable people

•Avoid people who cannot understand the trade-offs and compromises

Monovision LASIK

•Braun EH, Lee J, Steinert RF: Monovision in LASIK4

  • 172 patients treated with monovision
  • Up to 66% of LASIK pts >45 chose monovision
  • More women than men 60:40
  • 20% already using monovision – CL or glasses
  • Goal for the near eye -1.32 ± 0.22 SE – mean post op was -1.26 ± 0.65 SE
  • Hyperopic pts do as well as myopic – tend to select the more hyperopic eye for near
  • 93 % chose their dominant eye for distance
  • Crossed monovision worked well but lower success rate
  • Patients most concerned with achieving best distance vision – need perfect distance vision
  • 27.9% had distance eye enhanced – 16.9% for near eye – 1.6X more likely
  • 7% chose to forgo monovision and enhanced for distance
  • Overall success rate 86-97%
  • Contact lens trial strongly recommended
  • Correction may still be needed for distance especially at night and for fine near work

•VISX Wavefront-guided Monovision Trial

  • 202 myopic presbyopes had a CL trial with 79% having monovision
  • Myopia of -6D and cylinder of 3D
  • Non-dominant eye under-corrected for near
  • At 12 months 67% binocular UCVA of 20/16, 92% 20/20
  • 99% satisfied with their depth perception compared to 90% with correction preop
  • 98% would have the surgery again
  • No reversal of monovision

•Garcia-Gonzalez M, Teus MA, Hernandez-Verdejo JL: Visual outcomes of LASIK-induced monovision in myopic patients with presbyopia5

  • 37 consecutive pts >45 yrs old, myopic
  • Evaluated dist/near VA, CS, stereopsis at 6 mos
  • Mean residual SE of -0.97D (-0.25 to -1.50D) in non-dominant eye
  • Mean binocular UNVA 0.74 (20/30+), mean reading test of 0.88 (20/25+) and binocular UDVA 1.08 (20/20)
  • Slight decrease in CS and stereopsis
  • 16% used glasses for driving

Monovision Pearls

•Patient selection critical

  • Realistic expectation – may require glasses – distance or near
  • Distance acuity must be good OU

•Ideal correction -1.50 D

•Patient satisfaction 72-96%

•Enhancement of distance eye more frequent ~20%

•May be combined with adjustment of SA (<0.40 µm) to enhance depth of field and create a blend zone

•Contact lens trial always good if patient is unsure of monovision

MULTIFOCAL LASIK OR PRESBYLASIK

Why the Increased Interest in PresbyLASIK?

•Baby boomers want to get rid of glasses

•Familiar with LVC – disappointed with current options - monovision not acceptable to many

•Patients not ready for IOL’s

•Over 10 yrs of experience – good results and patient satisfaction

•Bilateral treatment or monocular in non-dominant eye (blended vision or advanced monovision)

•Micro-monovision – distance and near eyes with residual SA to ↑ depth of field

•Off label use increasing – frustration - no FDA approval

How does PresbyLASIK Work?

•Lasers can create an aspheric shape – smooth transition - enhances near vision

•Induce negative or positive spherical aberration to ↑ depth of field (pseudoaccommodation)

•More near vision – more compromise of distance and optical quality

•Higher corrections – more near effect

•Vertical coma and other aberrations can hinder near performance and patient satisfaction (decentered ablations)

Advantages of PresbyLASIK

•Young presbyopes: -4 to +4 D custom ablation

•Retain existing accommodation and clear lens

•Uses proven LV technology – no increased risk from surgery

•Surgery time is short and low cost

•Can enhance or remove the correction

•Can be performed bilaterally

•Causes few undesirable optical effects

•Minimal lines lost of CDVA or CNVA

•Vision at 6 months in most series

–Distance 20/20 to 20/30

–Near J1 to J3

•PresbyLASIK can improve near vision in monofocal pseudophakes

Disadvantages PresbyLASIK

•No FDA but now CE approved commercial programs – in US off-label ablations - double carding

•Multiple approaches – need good training on laser used

•Limited effect – chose patients wisely – patient often would like stronger add

•Some loss of “quality of vision” trade off – it is a compromise

•More enhancements needed – up to 30% usually to improve distance vision

•Near vision dependent on pupil size

•Not permanent – refraction, lens, accommodation - change with age

•Changes the corneal shape – induces aberrations – may be a problem for future cataract surgery with MF IOLs

•Ocular surface problems will affect patient’s vision and satisfaction

–Manage meibomian gland dysfunction and tear dysfunction

–Lubricants

–Plugs

–Cyclosporine

Issues with Multifocal IOL’s Similar to PresbyLASIK

•Reduced quality of vision

•Performance - pupil dependant

•Reduced contrast sensitivity

•Night vision symptoms

•Ocular surface instability affects vision

PresbyLASIK Techniques6

•Inferior Off Centered

  • Transitional ablations7

•Center Near8, 9

  • Aspheric ablation profile for distance and near
  • Pupil size dependent
  • Central 3 mm more prolate

•Peripheral Near10-13

  • Delayed stabilization of patient’s final distance vision – 6 mos after surgery
  • More neuroadaptation required – distance vision
  • Easier to perform – double cardwith current lasers – myopic and hyperopic treatment
  • Longer treatments, more tissue removed
  • Enhancements 2-30%

Current Status of PresbyLASIK

•AMO VISX SYSTEM

  • Center near – hyperopic treatments
  • Not available in North America
  • 100% 20/25 and J3 at 1 year – Jackson (mean 1.97 D)8
  • 64% 20/25 and J3 at 6 mos – Jung (mean 1.16 D)9
  • Assil used photopic pupillometry to treat hyperopes for presbyopia in the nondominant eye14.
  • Tamayo and Epstein developed algorithms for – peripheral near treatments for myopia, emmetropia and hyperopia15

•MEL 80 Carl Zeiss Meditec System

  • Laser blended vision: Presbyopic correction
  • Developed by Dan Reinstein1, 2 - incorporated in CRS-Master
  • Combines nonlinear aspheric ablation profiles with micro-monovision
  • Can treat myopes, hyperopes and emmetropes (+5.75 to -9.00 D)
  • Profile optimizes induction of spherical aberration for each patient while avoiding excessive SA to prevent visual disturbances or loss of CS
  • Dominant eye plano with non-dominant eye -1.50 D with adjusted SA
  • 95% myopes, 80% hyperopes and 92% emmetropes see 20/25 and J2
  • No change or improvement in CS
  • Blurred nondominant eye added for binocular distance vision the vision improved from 92% monocularly to 96% binocularly 20/20

•WaveLight System

  • Allegretto Eye-Q F-CAT profile
  • Nondominant eye targeted with more negative Q-value and myopic defocus
  • Hyperopes more satisfied than myopes

•Schwind Amaris System

  • PresbyMAX software developed by Dr. J Alio6
  • Bi-aspheric central PresbyLASIK ablation profile with a minimum of aberrations at the near and distance foci
  • Multicenter Study Reported in Eurotimes Jan 2011 of 52 patients
  • Range -7.00 to +3.5 D of sphere and up to 3.0 D of cylinder
  • At 6 months 78% had distance and near uncorrected VA of 20/40 or better and J5 or better
  • 75% of hyperopes, 67% of emmetropes and 85% of myopes achieved J2 UNVA

•Technolas Perfect Vision (TPV) System

  • SupraCOR – a “IntraCOR for Excimer”
  • New presbyopic algorithm for myopic, hyperopic and emmetropic eyes as well as post-LASIK cases
  • Performed using the Technolas Excimer Workstation 217P
  • Central near approach
  • Chaubard conducted a multicenter trial with 46 eyes of 23 presbyopic hyperopic patients
  • Bilateral treatments with 6.0 optical zone aiming for slight myopia
  • Preop SE +1.67 at 6 mos -0.41 D
  • 87% 20/25 and J2, 2 eyes losing 1 line of CDVA at 6 mos.
  • Good patient satisfaction, most required no glasses

•Nidek System

  • EC-5000 CXIII laser
  • Distance-dominant central cornea algorithm called pseudoaccommodative cornea (PAC) for treatment of myopic, hyperopic and emmetropic presbyopia10
  • Inclusion of the OPA (Optimized Prolate Ablation) software
  • 119 eyes treated by Uy assessed out to 3 months11, 12
  • Preop MSE was -3.80 D for myopes and +1.00 for hyperopic or emmetropic presbyopes
  • At 3 mos MSE was -0.40 for myopes and +0.15 D for hyperopes and emmetropes
  • 0/30 UDVA and JE achieved in 83% of myopes and 87% of hyperopes and emmetropes.
  • All corneas became increasingly steeper from center to periphery with induction of positive SA of 0.312 um in myopes and 0.016 in hyperopes.
  • Retreatment rate less than 2%

Conclusion PresbyLASIK

•PresbyLASIK continues to show promise for correcting young presbyopes

•More high quality scientific evidence needed

•Most studies report short term results

•Custom algorithms are being used in centers worldwide – difficult to compare results

•All laser manufacturers are developing software for either central or peripheral PresbyLASIK creating either negative SA for central or positive SA for peripheral near

•Limited effect as presbyopia increases with age as well as changes in the crystalline lens– chose patients wisely

•Retreatment rate ~30% - some pts. not content to compromise distance vision for near

•Some loss of “quality of vision” trade off

•Management of the ocular surface key to best results

•Blended vision with increased depth of field in both eyes good option

References

1. Reinstein DZ, Archer TJ, Gobbe M: LASIK for Myopic Astigmatism and Presbyopia Using Non-Linear Aspheric Micro-Monovision with the Carl Zeiss Meditec MEL 80 Platform. J Refract Surg 27:23-37, 2011.

2. Reinstein DZ, Couch DG, Archer TJ: LASIK for hyperopic astigmatism and presbyopia using micro-monovision with the Carl Zeiss Meditec MEL80 platform. J Refract Surg 25:37-58, 2009.

3. Miranda D, Krueger RR: Monovision laser in situ keratomileusis for pre-presbyopic and presbyopic patients. J Refract Surg 20:325-8, 2004.

4. Braun EH, Lee J, Steinert RF: Monovision in LASIK. Ophthalmology 115:1196-202, 2008.

5. Garcia-Gonzalez M, Teus MA, Hernandez-Verdejo JL: Visual outcomes of LASIK-induced monovision in myopic patients with presbyopia. Am J Ophthal 150:381-6, 2010.

6. Alio JL, Amparo F, Ortiz D, et al: Corneal multifocality with excimer laser for presbyopia correction. Curr Opin Ophthalmol 20:264-71, 2009.

7. Bauerberg JM: Centered vs. inferior off-center ablation to correct hyperopia and presbyopia. J Refract Surg 15:66-9, 1999.

8. Jackson WB, Tuan KM, Mintsioulis G: Aspheric Wavefront-Guided LASIK to Treat Hyperopic Presbyopia: 12-Month Results with the VISX Platform. J Refract Surg 1-11, 2011.

9. Jung SW, Kim MJ, Park SH, et al: Multifocal corneal ablation for hyperopic presbyopes. J Refract Surg 24:903-10, 2008.

10. El Danasoury AM, Gamaly TO, Hantera M: Multizone LASIK with peripheral near zone for correction of presbyopia in myopic and hyperopic eyes: 1-year results. J Refract Surg 25:296-305, 2009.

11. Telandro A: The pseudoaccommodative cornea multifocal ablation with a center-distance pattern: a review. J Refract Surg 25:S156-9, 2009.

12. Uy E, Go R: Pseudoaccommodative cornea treatment using the NIDEK EC-5000 CXIII excimer laser in myopic and hyperopic presbyopes. J Refract Surg 25:S148-55, 2009.

13. Pinelli R, Ortiz D, Simonetto A, et al: Correction of presbyopia in hyperopia with a center-distance, paracentral-near technique using the Technolas 217z platform. J Refract Surg 24:494-500, 2008.

14. Assil KK, Chang SH, Bhandarkar SG, et al: Photopic pupillometry-guided laser in situ keratomileusis for hyperopic presbyopia. J Cataract Refract Surg 34:205-10, 2008.

15. Epstein RL, Gurgos MA: Presbyopia treatment by monocular peripheral presbyLASIK. J Refract Surg. 25:516-23, 2009.

June 21, 2011