Femtosecond lasers may now also be used to treat presbyopia. This minimally invasive approach is available in several countries outside the United States (but is not currently FDA approved) and does not involve incisions or flap creation. In this procedure, known as IntraCor, the femtosecond laser makes 5 concentric rings within the stroma, starting in the center with a ring diameter of 1.8 mm, and proceeding with subsequent rings toward the periphery. The formation of these rings produces a localized biomechanical change that reshapes the cornea to correct presbyopia. The procedure is normally performed only in the nondominant eye. Studies have demonstrated that this procedure has the potential to provide a solution for patients with hyperopic presbyopia (+0.50 D to +1.25 D), with a potential gain of 4–5 lines of near vision. However, to date, some studies have shown that 7%–15% of treated eyes have lost 2 or more lines of corrected distance visual acuity (CDVA; also known as bestcorrected visual acuity, BCVA).
Holzer MP, Knorz MC, Tomalla M, Neuhann TM, Auffarth GU. Intrastromal femtosecond laser presbyopia correction: 1-year results of a multicenter study. J Refract Surg. 2012;28(3): 182–188.
Menassa N, Fitting A, Auffarth GU, Holzer MP. Visual outcomes and corneal changes after intrastromal femtosecond laser correction of presbyopia. J Cataract Refract Surg. 2012; 38(5):765–773.
Ruiz LA, Cepeda LM, Fuentes VC. Intrastromal correction of presbyopia using a femtosecond laser system. J Refract Surg. 2009;25(10):847–854.
Thomas BC, Fitting A, Auffarth GU, Holzer MP. Femtosecond laser correction of presbyopia (INTRACOR) in emmetropes using a modified pattern. J Refract Surg. 2012;28(12):872–878.
Corneal Inlays
Corneal inlays, which are not currently FDA approved but are available outside the United States, improve near vision by changing corneal curvature, increasing depth of field via a small central aperture, or changing the refractive index of the cornea. Because the procedure is performed only in the nondominant eye, some adverse visual effects (night halos) may be less perceptible in binocular viewing conditions. These devices can be removed or combined with other refractive procedures, such as LASIK. (See Chapter 4 for more details.)
Bouzoukis DI, Kymionis GD, Limnopoulou AN, Kounis GA, Pallikaris IG. Femtosecond laser–assisted corneal pocket creation using a mask for inlay implantation. J Refract Surg. 2011;27(11):818–820. Epub 2011 Jul 18.
Garza EB, Gomez S, Chayet A, Dishler J. One-year safety and efficacy results of a hydrogel inlay to improve near vision in patients with emmetropic presbyopia. J Refract Surg. 2013; 29(3):166–172.
Limnopoulou AN, Bouzoukis DI, Kymionis GD, et al. Visual outcomes and safety of a refractive corneal inlay for presbyopia using femtosecond laser. J Refract Surg. 2013;29(1):12–19.
Tomita M, Kanamori T, Waring GO IV, et al. Simultaneous corneal inlay implantation and laser in situ keratomileusis for presbyopia in patients with hyperopia, myopia, or emmetropia: six-month results. J Cataract Refract Surg. 2012;38(3):495–506.
Waring GO IV. Correction of presbyopia with a small aperture corneal inlay. J Refract Surg. 2011;27(11):842–845.
Accommodative Treatment of Presbyopia
Scleral Surgery
Several scleral surgical procedures have been evaluated for use in the reduction of presbyopia. They share the objective of attempting to increase zonular tension by weakening or altering the sclera over the ciliary body to allow for its passive expansion. Thornton first proposed weakening the sclera by creating 8 or more scleral incisions over the ciliary body (anterior ciliary sclerotomy, or ACS). Results were mixed, and any positive effect appeared short-lived. A prospective study of ACS using a 4-incision technique was discontinued because of significant adverse events, including anterior segment ischemia. In 2001, the American Academy of Ophthalmology stated that ACS was ineffective and a potentially dangerous treatment for presbyopia. Another method involves the placement of scleral expansion bands, but this surgical option has had mixed results for safety, efficacy, and patient satisfaction (Fig 9-7).
Figure 9-7 A, The scleral expansion band is inserted in a scleral tunnel over the ciliary body parallel to the limbus. B, The appearance of the band after placement, prior to conjunctival closure. C, The appearance of the well-healed band. (Courtesy of
Refocus Group.)
Despite some initial encouraging results in recent FDA trials of scleral expansion, it remains unclear whether any of these procedures produces real and lasting results with an acceptable safety profile.
Hamilton DR, Davidorf JM, Maloney RK. Anterior ciliary sclerotomy for treatment of presbyopia: a prospective controlled study. Ophthalmology. 2002;109(11):1970–1977.
Kleinmann G, Kim HJ, Yee RW. Scleral expansion procedure for the correction of presbyopia. Int Ophthalmol Clin. 2006;46(3):1–12.
Femtosecond Lens Relaxation
Accommodation restoration through photodisruption of the crystalline lens using an ultra-short-pulse femtosecond laser has been proposed. This procedure was proven relatively safe and theoretically possible.
Reggiani Mello GH, Krueger RR. Femtosecond laser photodisruption of the crystalline lens for restoring accommodation. Int Ophthalmol Clin. 2011;51(2):87– 95.
Accommodating IOLs
Accommodating IOLs attempt to restore a significant amount of true accommodation to patients with surgically induced pseudophakia. Accommodating IOLs were designed after it was observed that some patients who received silicone-plate IOLs reported near vision beyond that expected from their refractive result. Investigations revealed that, during ciliary muscle contraction, forward displacement of the IOL led to an increase in the IOL’s effective power and thus an improvement in near vision. However, some studies have questioned the amplitude of true accommodation that can be expected solely on the basis of anterior displacement of the IOL optic. Other factors, such as pupil size, with-the-rule astigmatism, and mild myopia, may also contribute to unaided near visual acuity.
Some IOLs that use this accommodative approach are modified silicone, plate-haptic lenses (Fig 9-8). Potentially, these lenses allow anterior movement of the lens during accommodation. Another possibility is that ciliary body contraction causes a steepening of the anterior optic surface, allowing for better near vision. Although the exact cause of the movement is unclear, it appears to be a combination of posterior chamber pressure on the back surface of the IOL and ciliary body pressure on the IOL that vaults the optic forward. The anterior displacement is postulated to result in an effective increase in optical power and near vision.
