presbyopia lens, presbyopia laser

IOLs and PRESBYOND: Putting Pressure on Presbyopia

It’s a simple fact of life that increasing age leads to new challenges and realities — like presbyopia. Presbyopia has affected people since time immemorial, and until recently not many treatments were available.  

The good news is that we are all collectively aging in the future — the year 2021 as of this writing. Perhaps due to years of science fiction indoctrination or perhaps simply due to consistently astounding technological progress, this era just has a “new-y” feel to it. This means we’ve got all sorts of new tools to manage the biological realities that come with age. 

One area of said consistently astounding progress has been in vision correction options — which conveniently brings us back to presbyopia, today’s topic. To discuss some of the best possible options, Media MICE CEO & CAKE magazine Publisher Matt Young hosted an online roundtable discussion with three top-notch refractive and corneal surgeons. Their insights were valuable and eye-opening, and certainly fresher than using puns like “eye-opening” in an ophthalmic article. 

Through the entire discussion, the panelists discussed essentially two options: intraocular lenses (IOLs) and PRESBYOND🄬, a laser vision correction option for presbyopia from Carl Zeiss Meditec (Jena, Germany). 

The three honorable opinionators present were:

  • Dr. Jan Bond Chan, a consultant ophthalmologist and cataract and refractive surgeon at International Specialist Eye Centre in Kuala Lumpur, Malaysia
  • Dr. Andrei Filip, a cataract and refractive surgeon at Ama Optimex Eye Clinic in Bucharest, Romania, and a consultant and speaker for Carl Zeiss Meditec
  • Dr. Amir Hamid, an ophthalmic consultant and surgeon with Optegra Eye Health Care in London, U.K.

With the speakers introduced, let’s get to the meat of the issue. The video is below, and the article continues after.

How Do You Treat and Manage Presbyopic Patients?

IOLs and PRESBYOND: Putting Pressure on Presbyopia

Think outside the glasses.

The above question was the first order of the day, and set the tone for most of the discussion. It’s a broad question, but it opened the door for plenty of more specific questions. 

PRESBYOND came to the fore of the discussion when the question came to Dr. Filip. As he noted, PRESBYOND is a customized laser treatment plan based on micro monovision and spherical aberration. It’s pretty darn neat, and deserves a brief explainer here. 

Essentially, PRESBYOND uses blended vision to help a patient get the benefits of refractive surgery combined with EDoF effects. It’s a software option for ZEISS’s CRS-Master and MEL 90 excimer laser, and relies on spherical aberrations naturally occurring in the eye to sculpt vision. Using it, a surgeon can correct the dominant eye for distance and intermediate vision while correcting the non-dominant eye for intermediate and near vision. 

The brain will combine the stereo vision of both eyes to create a full depth-of-field image. Dr. Filip pointed out that the brain can filter spherical aberration (SA) until a certain threshold. So, to avoid contrast loss, SA has to be below ± 0.6 micrometers. 

One of the best parts of PRESBYOND is it’s completely customizable for each patient. And, because it’s based on LASIK technology, surgeons already have years of experience using the tools. Similarly, as there have been tens of millions of LASIK operations, we can be relatively sure the safety profile is extremely … well, safe. 

Ok, cool. So it looks like it works, and there’s your primer. Let’s get back to the talk. 

Dr. Filip presented the first clinical outcomes from PRESBYOND in Romania totalling 54 patients, and they’re pretty impressive. In the hyperopia group — 47 patients — the mean preoperative spherical equivalent was 1.73 ± 0.79 diopters. After a year? A mean of 0.17 ± 0.84D in the dominant eye and -1.18 ± 0.67D in the non-dominant eye. 

There were similar results from the myopic group. Preoperatively, the mean spherical equivalent was -3.15 ± 2.10D. And after the same year as the other group? A whopping -0.23 ± 0.57D in the dominant eye and -1.55 ± 0.64 in the non-dominant eye. 

Naturally, IOLs were suggested as one of the most important arrows in an ophthalmologist’s quiver when targeting presbyopia. Dr. Hamid specifically pointed out that the AT LISA trifocal and the AT LARA extended depth-of-focus (EDoF) lenses from ZEISS were valuable tools that could be suited to patients depending on their lifestyle.

For example, a patient who has a near-vision dependent lifestyle and doesn’t drive much at night would be well served by the trifocal, such as AT LISA tri,  while a patient who drives at night and has a more active lifestyle might prefer the EDoF lens, such as AT LARA. It’s up to the patient and doctor at that point. 

Dr. Chan astutely pointed out that there is no one perfect IOL that provides all focal points with quality vision without side effects. Such is life, but options still exist. To wit, he suggested the possibility of mixing and matching IOLs to suit a patient’s needs — but cautioned that it shouldn’t necessarily be common practice. For example, if a patient is happy enough with an IOL in one eye, there’s no good reason to go off-reservation and try a different one in the other eye. On the other hand, if a patient isn’t happy with their first IOL, a doctor can consider a different IOL for the other eye to improve the situation. 

There are multiple possibilities of combinations, but the idea is to cover all ranges of vision. For example, a monofocal in the dominant eye can be combined with a trifocal in the non-dominant eye, with the trifocal giving solid near and intermediate-range while the monofocal covers distance vision. An EDoF lens in the dominant eye can be combined with a trifocal in the non-dominant eye, or a trifocal can be combined with a bifocal. It all depends on a patient’s individual needs, but that’s the neat part about mix-and-match: It’s entirely customizable and gives the ophthalmologist a broad palette to paint with. 

Shifting Philosophy on Presbyopia?

IOLs and PRESBYOND: Putting Pressure on Presbyopia

There are all sorts of brilliant new treatments for presbyopia.

An online poll of webinar attendees showed that most respondents answered they treated presbyopia with IOLs. But Dr. Hamid cautioned that there had been some shifts in the philosophy behind presbyopia treatments. For one thing, it’s best to maintain a patient’s clear lens for as long as possible. 

One significant clinical perk of PRESBYOND that Dr. Hamid alluded to was the procedure’s speed. Because the treatment is fast, there’s less chair time per patient — which means a surgeon can treat more patients. In general, he said, patients were very happy with PRESBYOND treatments — they were spectacle independent, with good quality of vision and without invasive surgery. That’s a win all around. 

Presbyopia Treatments for Specific Cases

Just like there’s no one food that takes care of all the body’s demands, there’s no one presbyopia treatment that can be given carte blanche to individuals. A doctor has to do a fair bit of patient counseling and individual decision-making to see just what fits whom. 

Because of that, there is no end to the number of special categories we could cover, but we’ll start with a few. 

Drivers and Pilots

IOLs and PRESBYOND: Putting Pressure on Presbyopia

A laser or a lens? Both offer options. 

People who rely on good vision for work — think truck drivers and pilots — fall into a bit of a special category. Truck drivers (lorry drivers for some) often have to drive at night, and need to know their night vision will be up to par. In that case, Dr. Chan recommended trifocal IOLs, though EDoF lenses could work as well for those who wanted to be extra careful. 

Another interesting case is pilots. In the U.K., for example, pilots are not allowed to fly commercially with presbyopia IOLs. They are, however, allowed to fly commercially after PRESBYOND treatment, which is why, Dr. Hamid said, British Airways pilots are flocking to refractive surgeons. 

Patients with Complications

The panelists all agreed: Problems like dry eye disease (DED) or other eye diseases need to be tackled first before any treatment for presbyopia can begin. For one thing, many conditions can throw off biometry, giving poor readings and potentially leading to an inaccurate refractive surgery. Why get a patient into the surgeon’s chair if you’re not sure your diagnostics are accurate? 

Similarly, for patients who had previous eye surgery, Dr. Chan suggested conducting biometry at least a couple of times on separate occasions — the more the better. As he explained, you have to make sure a patient’s eye has stabilized before you try to correct it. That makes sense to us. 

When it comes to patients with thin corneas, Dr. Hamid again cautioned that a doctor should approach each patient on a case-by-case basis. However, he also gave room for optimism. Corneal thickness doesn’t necessarily limit a surgeon, he said, and pointed out that modern ablative surgeries are very good at preserving tissue. 

Cataracts and PRESBYOND

If a patient who has previously undergone PRESBYOND develops a cataract, it’s not an inconvenience — rather, the patient enters a cataract treatment already a bit prepared. As the doctors suggested, the effects of PRESBYOND will persist through and after a cataract surgery. When using an IOL, they all recommended using monofocals since PRESBYOND takes care of essentially all EDoF effects. 

The More Tools, the Better the Toolbox

IOLs and PRESBYOND: Putting Pressure on Presbyopia

Putting more tools in surgeons’ hands means more options for patients.

One interesting question that came up is this: What should eye surgeons use? Dr. Filip enlightened us that plenty of eye surgeons have had PRESBYOND treatment, whereas few wore multifocal IOLs, such as trifocals. 

The trifocal lenses we have these days are amazing indeed, and they offer huge value to both patients and ophthalmologists. PRESBYOND offers another tool in the toolbox that presents yet another value-add. 

Perhaps best of all — besides the fact that it’s reversible, enhanceable, adjustable, and gives quality vision — is that it’s a minimally invasive surgery. As Dr. Filip stressed, the less invasive a treatment is, the better. This is for many reasons, which surgeons are all likely aware of and needn’t be belabored here. 

One important factor discussed by all panelists was that doctors have to set patient expectations. A good example provided by Dr. Chan was to suggest patients don’t compare their eyes one at a time, since vision doesn’t really work that way. 

We’re born to have stereo acuity. That’s a simple fact of our species. Both PRESBYOND and IOLs can help achieve high quality stereo vision. The more arrows an ophthalmologist has in their quiver, the more targets they can hit. 

There are more treatment options than ever for presbyopia, and that’s a good thing. Doctors should stay apprised of current developments and be able to give as many choices to patients as possible. There’s no one-size-fits-all solution to presbyopia, but the industry is making solid progress. Hopefully, in the future, presbyopia will be a thing of the past. 

Editor’s Note: The news roundtable style webinar, “The Secrets to Happy Presbyopic Patients”, was held on May 10, 2021. Reporting for this story took place during the event.

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