Ординатура / Офтальмология / Английские материалы / Hyperopia and Presbyopia_Tsubota, Boxer Wachler, Azar_2003
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Future Developments
BRIAN S. BOXER WACHLER
Boxer Wachler Vision Institute, Beverly Hills, California, U.S.A.
Presently, there are several viable treatments for the correction of hyperopia and presbyopia. In order to broaden the scope of patient acceptance, current and investigative techniques will continue to develop in the future as the clinicians and researchers strive for greater efficacy, safety, and visual quality. Each area within refractive surgery will bring improvements specific unto itself.
A. HYPEROPIA
1. LASIK and PRK
Hyperopic laser-assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) have the advantage of directly reshaping the cornea with high safety in low to moderate degrees of correction. There is growing interest in where hyperopic ablations should be centered on the eye. Conventional teaching is to center treatments on the pupillary center. This paradigm has developed from a 1987 article by Uozoto and Guyton(1) that demonstrated, through mathematical analysis, the rationale for pupil centration of refractive procedures. An opposing article by Pande and Hillman(2) used another set of analyses to show that the corneal sighted light reflex (which best approximates the visual axis of the eye) is the best location for centering refractive procedures. Positive angle kappa (corneal sighted light reflex located nasal to pupilary center) is not nearly as common in myopes as it is in hyperopes(3). Therefore, since the excimer was used initially for myopia, the potential for decentered ablations due to pupilary centration was low. I believe that the combination of delayed hyperopic excimer capability and the lower number of such patients undergoing treatments has obscured the issue that hyperopic ablations and perhaps myopic ablations as well may be better centered on the corneal sighted light reflex. Over 2 years ago, I began to question the recommendation of the Uozoto and Guyton
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Figure 1 Decentration of the treatment zone is seen in the right eye compared to the left eye in the hyperopic patient will bilateral angle kappa. The laser ablation was centered on the pupil in the right eye and on the coaxially sighted corneal light reflex in the left eye.
article after noting the decentrations of hyperopic LASIK was not uncommon in my practice. In one hyperopic patient with angle kappa, I centered the hyperopic treatment on the pupil on the first eye; on the second eye, the treatment was centered on the corneal sighted light reflex(4). The postoperative topographies demonstrate decentration of the treatment in the eye where the laser was centered on the pupil, while the fellow eye showed a centered ablation (Fig. 1). This area will undergo further study, evaluating not only topography but also visual acuity, contrast sensitivity, and higher-order aberrations.
The dioptric limits of hyperopic excimer correction are not entirely clear. Therefore, there will be better definitions of the limitations of hyperopic ablations, which may be defined by acceptable degrees of induced higher-order aberrations. The pupil is the guardian of the aberrations of the eye. Based on individual pupil-dependent aberrations, future studies will likely determine the limits of hyperopic treatments.
In myopic LASIK, the flap itself has been shown to be a source of higher-order aberrations, specifically spherical aberrations(5). In hyperopic LASIK, it is unknown what role flap-induced aberrations play. We can expect to see such evaluations in the future for hyperopic LASIK compared to hyperopic PRK.
2. Thermokeratoplasty
Laser thermokeratoplasty (LTK)has the advantage of being very safe due to its noncontact modality, which also avoids surgery in the central cornea. As an indirectly acting procedure, one of its limitation is that the variable corneal steepening may occur with the same
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degree of treatment, also that some eyes have more instability of the effect than others. The future of LTK lies in the ability to perform intraoperative, real-time refractive monitoring using wavefront analysis during the treatment. This may allow the surgeon to stop the treatment when the desired refractive effect is achieved, making the treatment independent of corneal physiology, dehydration, stiffness, and surgeon technique. Preliminary results of lower-energy treatments hold promise for more stable postoperative effects.
Like LTK, conductive keratoplasty (CK) offer the advantage of avoiding the central cornea. CK will be evaluated for additional uses, as for astigmatism, by steepening the flat axis (opposite to astigmatic keratotomy, whereby the steep axis is flattened). The ability of the probe to be used selectively may make this device useful for treating irregular astigmatism, as in keratoconus. Focal heat treatments of keratoconus have been evaluated in the past, but the controlled temperature gradient of CK may lead to more stability than previous probe technologies.
3. Intraocular Lenses
Phakic intraocular lenses offer the advantage of high-quality of vision in higher corrections as well as being removable. Phakic lenses will continue to undergo safety evaluation with longer-term follow-up. Such lenses have the ability to treat higher degrees of hyperopia than excimer lasers. Wavefront analysis will help determine the optical advantages of phakic implants compared to excimer laser treatments. Adjustability of lens power may be achieved in the future through exchangeable optic with a haptic carrier or thoroughly laser adjustments of the optic postimplantation.
B. PRESBYOPIA
1. Scleral Expanding Bands
Scleral expansion surgery, although not without controversy, has been slowly gaining credibility. The data from international and preliminary U.S. Food and Drug Administration clinical trial results demonstrate improved reading ability postoperatively. As a result, there will be greater attention paid to refining this technique and improving accommodative predictability. Ultrasound will be used to elucidate the relationship to segment positioning relative to zonules and lens capsule and how this affects postoperative accommodative amplitudes. Surgical intrumentation will improve, thus decreasing the duration of what is now an approximately 45-min procedure. The new device, called the “Focal One,” is an automated blade that creates the belt loops and has already improved efficiency in performing the procedure.
2. Multifocal LASIK and Intraocular Lenses
Presbyopic LASIK has the advantage of improving near vision in carefully selected patients. Wavefront analysis will be an important adjunct to help elucidate the acceptable induced aberrations that maximize near vision without compromising quality of vision. Some monofocal intraocular lenses made with wavefront optic profiles have been reported to improve near vision with distance as well. Accomodating endocapsular intraocular lenses will continue to be evaluated for longer-term safety and efficacy.
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C. Conclusions
We are beginning a new era as refractive surgery now embraces the challenge of correcting presbyopia. Through the creativity and determination of many ophthalmic care providers and investigators, greater numbers of patients are experiencing the increased freedom that comes with treating hyperopia and presbyopia. The future is very bright for the surgical correction of hyperopia and presbyopia.
References
1.Uuzoto H, Guyton DL. Centering corneal surgical procedures. Am J Ophthalmol 1987; 103: 264–275.
2.Pande M, Hillman JS. Optical zone centration in keratorefractive surgery. Entrance pupil center, visual axis, coaxially sighted corneal reflex, or geometric corneal center? Ophthalmology 1993; 100:1230–1237.
3.Burian HM. The sensorial retinal relationships in comitant strabismus. Arch Ophthalmol 1947; 37:336–340.
4.Korn T, Chandra N, Boxer Wachler BS. Visual outcomes of hyperopic LASIK: centration based on pupil center versus visual axis. American Society of Cataract and Refractive Surgery Annual Meeting, April 2001.
5.Roberts C. Flap-induced spherical aberrations. Videorefractiva Italy Ophthalmology Congress. February 2001.
Index
Aberrations defined, 151
hyperopia vs. myopia, 159 Ablation zone decentration, 294
Accommodating and adjustable intraocular lens (IOL), 279–285
results, 283–284 Accommodation
defined, 30–31 Fincham, 40–42 Gullstrand, 39–40
Helmholtz description, 32–33 measurement, 36–38
near vision, 19–20 optical changes, 30–32
scleral expansion surgery, 44 Accommodative amplitude, 20, 213
after surgery for presbyopia, 287–290 dynamic retinoscopy, 287–288 increased depth of focus, 289 measuring accommodation, 289–290 multifocal crystalline lens, 289 retinoscopic reflexes, 288–289 wavefront analysis, 290
Accommodative apparatus, anatomy, 27–28 Accommodative intraocular lens (IOL)
finite-element computer simulation, 10
Accommodative mechanism, debate, 34 Accommodative tone, 211 Accommodative triad, 31
ACS (See Anterior ciliary sclerotomy (ACS)) ACS-SEP, 214
Age-related cataract (ARC), 58 Aging
crystalline lens, 55–63 size and shape, 56–57
oxidative stress, 58–59 presbyopia, 57–58 refractive error, 57 zonule, 60
AIS, 223–224, 232 ALK, 5, 164
Alternating-vision bifocal contact lenses, 68 American Optical vectographic test, 195 Ametropia
correctable modeling, 272 correction, 261
simultaneous within Phaco-Ersatz, 269 AMO ARRAY, 238, 239
foldable silicone multifocal intraocular lens, 250
Amplitude of accommodation, 19 simultaneous ametropia correction
Phaco-Ersatz, 263–264
319