A review of the surgical options for the correction of presbyopia

Presbyopia is an age-related eye condition where one of the signs is the reduction in the amplitude of accommodation, resulting in the loss of ability to change the eye's focus from far to near. It is the most common age-related ailments affecting everyone around their mid-40s. Methods for the correction of presbyopia include contact lens and spectacle options but the surgical correction of presbyopia still remains a significant challenge for refractive surgeons. Surgical strategies for dealing with presbyopia may be extraocular (corneal or scleral) or intraocular (removal and replacement of the crystalline lens or some type of treatment on the crystalline lens itself). There are however a number of limitations and considerations that have limited the widespread acceptance of surgical correction of presbyopia. Each surgical strategy presents its own unique set of advantages and disadvantages. For example, lens removal and replacement with an intraocular lens may not be preferable in a young patient with presbyopia without a refractive error. Similarly treatment on the crystalline lens may not be a suitable choice for a patient with early signs of cataract. This article is a review of the options available and those that are in development stages and are likely to be available in the near future for the surgical correction of presbyopia.

Development of a questionnaire to assess the relative subjective benefits of presbyopia correction

Purpose To develop a standardized questionnaire of near visual function and satisfaction to complement visual function evaluations of presbyopic corrections. Setting Eye Clinic, School of Life and Health Sciences, Aston University, Midland Eye Institute and Solihull Hospital, Birmingham, United Kingdom. Design Questionnaire development. Methods A preliminary 26-item questionnaire of previously used near visual function items was completed by patients with monofocal intraocular lenses (IOLs), multifocal IOLs, accommodating IOLs, multifocal contact lenses, or varifocal spectacles. Rasch analysis was used for item reduction, after which internal and test–retest reliabilities were determined. Construct validity was determined by correlating the resulting Near Activity Visual Questionnaire (NAVQ) scores with near visual acuity and critical print size (CPS), which was measured using the Minnesota Low Vision Reading Test chart. Discrimination ability was assessed through receiver-operating characteristic (ROC) curve analysis. Results One hundred fifty patients completed the questionnaire. Item reduction resulted in a 10-item NAVQ with excellent separation (2.92), internal consistency (Cronbach a = 0.95), and test–retest reliability (intraclass correlation coefficient = 0.72). Correlations of questionnaire scores with near visual acuity (r = 0.32) and CPS (r = 0.27) provided evidence of validity, and discrimination ability was excellent (area under ROC curve = 0.91). Conclusion Results show the NAVQ is a reliable, valid instrument that can be incorporated into the evaluation of presbyopic corrections.

Determining which factors influence the optimum multifocal contact lens correction for presbyopia

Presbyopia is a consequence of ageing and is therefore increasing inprevalence due to an increase in the ageing population. Of the many methods available to manage presbyopia, the use of contact lenses is indeed a tried and tested reversible option for those wishing to be spectacle free. Contact lens options to correct presbyopia include multifocal contact lenses and monovision.Several options have been available for many years with available guides to help choose multifocal contact lenses. However there is no comprehensive way to help the practitioner selecting the best option for an individual. An examination of the simplest way of predicting the most suitable multifocal lens for a patient will only enhance and add to the current evidence available. The purpose of the study was to determine the current use of presbyopic correction modalities in an optometric practice population in the UK and to evaluate and compare the optical performance of four silicone hydrogel soft multifocal contact lenses and to compare multifocal performance with contact lens monovision. The presbyopic practice cohort principal forms of refractive correction were distance spectacles (with near and intermediate vision providedby a variety of other forms of correction), varifocal spectacles and unaided distance with reading spectacles, with few patients wearing contact lenses as their primary correction modality. The results of the multifocal contact lens randomised controlled trial showed that there were only minor differences in corneal physiology between the lens options. Visual acuity differences were observed for distance targets, but only for low contrast letters and under mesopic lighting conditions. At closer distances between 20cm and 67cm, the defocus curves demonstrated that there were significant differences in acuity between lens designs (p < 0.001) and there was an interaction between the lens design and the level of defocus (p < 0.001). None of the lenses showed a clear near addition, perhaps due to their more aspheric rather than zoned design. As expected, stereoacuity was reduced with monovision compared with the multifocal contact lens designs, although there were some differences between the multifocal lens designs (p < 0.05). Reading speed did not differ between lens designs (F = 1.082, p = 0.368), whereas there was a significant difference in critical print size (F = 7.543, p < 0.001). Glare was quantified with a novel halometer and halo size was found to significantly differ between lenses(F = 4.101, p = 0.004). The rating of iPhone image clarity was significantly different between presbyopic corrections (p = 0.002) as was the Near Acuity Visual Questionnaire (NAVQ) rating of near performance (F = 3.730, p = 0.007).The pupil size did not alter with contact lens design (F = 1.614, p = 0.175), but was larger in the dominant eye (F = 5.489, p = 0.025). Pupil decentration relative to the optical axis did not alter with contact lens design (F = 0.777, p =0.542), but was also greater in the dominant eye (F = 9.917, p = 0.003). It was interesting to note that there was no difference in spherical aberrations induced between the contact lens designs (p > 0.05), with eye dominance (p > 0.05) oroptical component (ocular, corneal or internal: p > 0.05). In terms of subjective patient lens preference, 10 patients preferred monovision,12 Biofinity multifocal lens, 7 Purevision 2 for Presbyopia, 4 AirOptix multifocal and 2 Oasys multifocal contact lenses. However, there were no differences in demographic factors relating to lifestyle or personality, or physiological characteristics such as pupil size or ocular aberrations as measured at baseline,which would allow a practitioner to identify which lens modality the patient would prefer. In terms of the performance of patients with their preferred lens, it emerged that Biofinity multifocal lens preferring patients had a better high contrast acuity under photopic conditions, maintained their reading speed at smaller print sizes and subjectively rated iPhone clarity as better with this lens compared with the other lens designs trialled. Patients who preferred monovision had a lower acuity across a range of distances and a larger area of glare than those patients preferring other lens designs that was unexplained by the clinical metrics measured. However, it seemed that a complex interaction of aberrations may drive lens preference. New clinical tests or more diverse lens designs which may allow practitioners to prescribe patients the presbyopic contact lens option that will work best for them first time remains a hope for the future.

Accommodating intraocular lenses:a review of design concepts, usage and assessment methods

The correction of presbyopia and restoration of true accommodative function to the ageing eye is the focus of much ongoing research and clinical work. A range of accommodating intraocular lenses (AIOLs) implanted during cataract surgery has been developed and they are designed to change either their position or shape in response to ciliary muscle contraction to generate an increase in dioptric power. Two main design concepts exist. First, axial shift concepts rely on anterior axial movement of one or two optics creating accommodative ability. Second, curvature change designs are designed to provide significant amplitudes of accommodation with little physical displacement. Single-optic devices have been used most widely, although the true accommodative ability provided by forward shift of the optic appears limited and recent findings indicate that alternative factors such as flexing of the optic to alter ocular aberrations may be responsible for the enhanced near vision reported in published studies. Techniques for analysing the performance of AIOLs have not been standardised and clinical studies have reported findings using a wide range of both subjective and objective methods, making it difficult to gauge the success of these implants. There is a need for longitudinal studies using objective methods to assess long-term performance of AIOLs and to determine if true accommodation is restored by the designs available. While dual-optic and curvature change IOLs are designed to provide greater amplitudes of accommodation than is possible with single-optic devices, several of these implants are in the early stages of development and require significant further work before human use is possible. A number of challenges remain and must be addressed before the ultimate goal of restoring youthful levels of accommodation to the presbyopic eye can be achieved.

Surgical correction of astigmatism during cataract surgery

High levels of corneal astigmatism are prevalent in a significant proportion of the population. During cataract surgery pre-existing astigmatism can be corrected using single or paired incisions on the steep axis of the cornea, using relaxing incisions or with the use of a toric intraocular lens. This review provides an overview of the conventional methods of astigmatic correction during cataract surgery and in particular, discusses the various types of toric lenses presently available and the techniques used in determining the correct axis for the placement of such lenses. Furthermore, the potential causes of rotation in toric lenses are identified, along with techniques for assessing and quantifying the amount of rotation and subsequent management options for addressing post-operative rotation.

Patterns of refractive change in myopic subjects during the incipient phase of presbyopia:a preliminary study

Purpose: Changes in refractive error are well documented over the typical human lifespan. However, a relatively neglected period of investigation appears to be during the late fourth decade; this is at the incipient phase of presbyopia (IP), where the amplitude of accommodation is much reduced and approaches the level where a first reading addition is anticipated. Significantly, informal clinical observation has suggested a low incidence of an unexpected abrupt increase in myopia during IP. Methods: We investigated this alleged myopic shift retrospectively by mapping the longitudinal refraction histories of normally-sighted 35-44years old British White patients previously examined in routine optometric practice. The refractive trends in the right eyes of healthy myopic subjects (spherical equivalent refraction, SER =-0.50D: N=39) were analysed relative to that point at which a first near dioptric addition was considered to be clinically useful. Results: A refractive change was evident in some subjects during IP; viz, an abrupt increase in myopic SER of between -0.50 and -0.75D. These individuals (N=8) represented 20% of the study population of myopic incipient presbyopes. Beyond the pivotal point of the first near addition the longitudinal refraction stabilized in these subjects. In contrast, and as the extent of the available longitudinal data would permit, the remaining myopic eyes maintained an approximately stable refractive trend throughout IP and beyond. Conclusions: The anatomical or physiological basis of this specific late (non-developmental) abrupt myopic refractive change is an intriguing issue. Axial (vitreous chamber elongation), corneal (contour) and lenticular (profile and index) power bases, alone or in concert, might be considered candidates for this hitherto unexplored refractive phenomenon. Although necessarily obtained under conventional conditions of central (0deg) fixation, our data might also be a reflection of the recent recognition of the possible influence of the peripheral refraction upon the axial error. Consideration of this material provides an impetus for further research, including ocular biometry, a reappraisal of ciliary zonular functional anatomy, renewed investigation of the AC/A ratio, and the extent of a centripetal refractive influence on myopia development. © 2011 The College of Optometrists.

A longitudinal study of vergence adaptation in incipient presbyopia

Background: To investigate vergence adaptation during the incipient phase of presbyopia, when the amplitude of accommodation approaches the level where the first reading addition is required. The study aimed to assess the ability of the vergence system to counteract changes in the component contributions to the overall vergence response with the decline in the amplitude of accommodation in presbyopia, although previous reports on the nature of changes in accommodative, tonic and proximal vergence are equivocal. Methods: Using a 'flashed' Maddox rod technique, an assessment of vergence adaptation to 6 Δ base-out and 6Δ base-in prism was made for 28 subjects (aged 35-45 years at the commencement of the study). The measurements were taken four times over a 2-year period. Results: Using a repeated measures analysis of variance, the results show that with the decline in amplitude of accommodation, there is a statistically significant reduction in the magnitude of vergence adaptation to both base-out (p < 0.05) and base-in prism (p < 0.01). Conclusions: This study shows that with ageing, there is a decrease in the ability of the slow vergence mechanism to overcome a change in fusional vergence demand and would suggest that either the fast component of fusional vergence must cope with any change in fusional vergence demand or that the sum of the accommodative, tonic and proximal vergence responses are virtually stable with age. © 2003 The College of Optometrists.

The effect of incipient presbyopia on the correspondence between accommodation and vergence

Purpose: To investigate the accommodation-convergence relationship during the incipient phase of presbyopia. The study aimed to differentiate between the current theories of presbyopia and to explore the mechanisms by which the oculomotor system compensates for the change in the accommodation-convergence relationship contingent on a declining amplitude of accommodation. Methods: Using a Canon R-1 open-view autorefractor and a haploscope device, measurements were made of the stimulus and response accommodative convergence/accommodation ratios and the convergence accommodation/convergence ratio of 28 subjects aged 35-45 years at the commencement of the study. Amplitude of accommodation was assessed using a push-down technique. The measurements were repeated at 4-monthly intervals over a 2-year period. Results: The results showed that with the decline in the amplitude of accommodation there is an increase in the accommodative convergence response per unit of accommodative response and a decrease in the convergence accommodation response per unit of convergence. Conclusions: The results of this study fail to support the Hess-Gullstrand theory of presbyopia in that the ciliary muscle effort required to produce a unit change in accommodation increases, rather than stays constant, with age. Data show that the near vision response is limited to the maximum vergence response that can be tolerated and, despite being within the amplitude of accommodation, a stimulus may still appear blurred because the vergence component determines the proportion of available accommodation utilised during near vision.

Requirement for and optimisation of premium intraocular lenses

Premium intraocular lenses (IOLs) aim to surgically correct astigmatism and presbyopia following cataract extraction, optimising vision and eliminating the need for cataract surgery in later years. It is usual to fully correct astigmatism and to provide visual correction for distance and near when prescribing spectacles and contact lenses, however for correction with the lens implanted during cataract surgery, patients are required to purchase the premium IOLs and pay surgery fees outside the National Health Service in the UK. The benefit of using toric IOLs was thus demonstrated, both in standard visual tests and real-world situations. Orientation of toric IOLs during implantation is critical and the benefit of using conjunctival blood vessels for alignment was shown. The issue of centration of IOLs relative to the pupil was also investigated, showing changes with the amount of dilation and repeat dilation evaluation, which must be considered during surgery to optimize the visual performance of premium IOLs. Presbyopia is a global issue, of growing importance as life expectancy increases, with no real long-term cure. Despite enhanced lifestyles, changes in diet and improved medical care, presbyopia still presents in modern life as a significant visual impairment. The onset of presbyopia was found to vary with risk factors including alcohol consumption, smoking, UV exposure and even weight as well as age. A new technique to make measurement of accommodation more objective and robust was explored, although needs for further design modifications were identified. Due to dysphotopsia and lack of intermediate vision through most multifocal IOL designs, the development of a trifocal IOL was shown to minimize these aspects. The current thesis, therefore, emphasises the challenges of premium IOL surgery and need for refinement for optimum visual outcome in addition to outlining how premium IOLs may provide long-term and successful correction of astigmatism and presbyopia.

Higher-order aberrations in amblyopia:an analysis of pre- and post-wavefront-guided laser refractive correction

For more than a century it has been known that the eye is not a perfect optical system, but rather a system that suffers from aberrations beyond conventional prescriptive descriptions of defocus and astigmatism. Whereas traditional refraction attempts to describe the error of the eye with only two parameters, namely sphere and cylinder, measurements of wavefront aberrations depict the optical error with many more parameters. What remains questionable is the impact these additional parameters have on visual function. Some authors have argued that higher-order aberrations have a considerable effect on visual function and in certain cases this effect is significant enough to induce amblyopia. This has been referred to as ‘higher-order aberration-associated amblyopia’. In such cases, correction of higher-order aberrations would not restore visual function. Others have reported that patients with binocular asymmetric aberrations display an associated unilateral decrease in visual acuity and, if the decline in acuity results from the aberrations alone, such subjects may have been erroneously diagnosed as amblyopes. In these cases, correction of higher-order aberrations would restore visual function. This refractive entity has been termed ‘aberropia’. In order to investigate these hypotheses, the distribution of higher-order aberrations in strabismic, anisometropic and idiopathic amblyopes, and in a group of visual normals, was analysed both before and after wavefront-guided laser refractive correction. The results show: (i) there is no significant asymmetry in higher-order aberrations between amblyopic and fixing eyes prior to laser refractive treatment; (ii) the mean magnitude of higher-order aberrations is similar within the amblyopic and visually normal populations; (iii) a significant improvement in visual acuity can be realised for adult amblyopic patients utilising wavefront-guided laser refractive surgery and a modest increase in contrast sensitivity was observed for the amblyopic eye of anisometropes following treatment (iv) an overall trend towards increased higher-order aberrations following wavefront-guided laser refractive treatment was observed for both visually normal and amblyopic eyes. In conclusion, while the data do not provide any direct evidence for the concepts of either ‘aberropia’ or ‘higher-order aberration-associated amblyopia’, it is clear that gains in visual acuity and contrast sensitivity may be realised following laser refractive treatment of the amblyopic adult eye. Possible mechanisms by which these gains are realised are discussed.

A longitudinal study of accommodative changes in biometry during incipient presbyopia

PURPOSE: To profile accommodative biometric changes longitudinally and to determine the influence of age-related ocular structural changes on the accommodative response prior to the onset of presbyopia. METHODS: Twenty participants (aged 34-41 years) were reviewed at six-monthly intervals over two and a half years. At each visit, ocular biometry was measured with the LenStar biometer (www.Haag-Streit.com) in response to 0.00, 3.00 and 4.50 D stimuli. Accommodative responses were measured by the WAM 5500 Auto Ref/Keratometer (www.grandseiko.com). RESULTS: During accommodation, anterior chamber depth reduced (F = 29, p < 0.001), whereas crystalline lens thickness (F = 39, p < 0.001) and axial length (F = 5.4, p = 0.009) increased. The accommodative response (F = 5.5, p = 0.001) and the change in anterior chamber depth (F = 3.1, p = 0.039), crystalline lens thickness (F = 3.0, p = 0.042) and axial length (F = 2.5, p = 0.038) in response to the 4.50 D accommodative target reduced after 2.5 years. However, the change in anterior chamber depth (F = 2.2, p = 0.097), crystalline lens thickness (F = 1.7, p = 0.18) and axial length (F = 1.0, p = 0.40) per dioptre of accommodation exerted remained invariant after 2.5 years. The increase in disaccommodated crystalline lens thickness with age was not significantly associated with the reduction in accommodative response (R = 0.32, p = 0.17). CONCLUSION: Despite significant age-related structural changes in disaccommodated biometry, the change in biometry per dioptre of accommodation exerted remained invariant with age. The present study supports the Helmholtz theory of accommodation and suggests an increase in lenticular stiffness is primarily responsible for the onset of presbyopia.

The effect of ageing on in vivo human ciliary muscle morphology and contractility

Purpose. To assess the effect of ageing on in vivo human ciliary muscle morphology and contractility during accommodation. Methods. Seventy-nine subjects, aged 19–70 years were recruited. High-resolution images were acquired of nasal and temporal ciliary muscle in the relaxed state, and at stimulus vergence levels of -4 and -8 D, using anterior segment optical coherence tomography (AS-OCT). Objective refractions and axial lengths were also recorded. Linear regression analysis was performed to determine the effect of age on nasal and temporal ciliary muscle morphologic characteristics. Results. Ciliary muscle anterior length decreased significantly with age both nasally (R = 0.461, P = 0.001) and temporally (R = 0.619, P < 0.001) in emmetropic eyes. In a subset of 37 participants, ciliary muscle maximum width increased significantly with age, by 2.8 µm/year nasally (R = 0.54, P < 0.001) and 3.0 µm/year temporally (R = 0.44, P = 0.007), while the distance from the inner apex of the ciliary muscle to the scleral spur decreased significantly with age on both the nasal and temporal aspects (R = 0.47; P = 0.004 and R = 0.43; P = 0.009, respectively). During accommodation, changes to ciliary muscle thickness and length remained constant throughout life. Conclusions. The human ciliary muscle undergoes age-dependent changes in morphology that suggest an antero-inwards displacement of muscle mass, particularly in emmetropic eyes. However, the morphologic changes observed appear not to affect the ability of the muscle to contract during accommodation, even in established presbyopes, thus supporting a lenticular model of presbyopia development.

Visual signs and symptoms of Parkinson's disease

Parkinson's disease (PD) is a common disorder of middle-aged and elderly people, in which there is degeneration of the extra-pyramidal motor system. In some patients, the disease is associated with a range of visual signs and symptoms, including defects in visual acuity, colour vision, the blink reflex, pupil reactivity, saccadic and smooth pursuit movements and visual evoked potentials. In addition, there may be psychophysical changes, disturbances of complex visual functions such as visuospatial orientation and facial recognition, and chronic visual hallucinations. Some of the treatments associated with PD may have adverse ocular reactions. If visual problems are present, they can have an important effect on overall motor function, and quality of life of patients can be improved by accurate diagnosis and correction of such defects. Moreover, visual testing is useful in separating PD from other movement disorders with visual symptoms, such as dementia with Lewy bodies (DLB), multiple system atrophy (MSA) and progressive supranuclear palsy (PSP). Although not central to PD, visual signs and symptoms can be an important though obscure aspect of the disease and should not be overlooked.

Canonical solution groups of a homomorphism : manipulator kinematics, nonparametric regression and distributed object systems

The kinematic mapping of a rigid open-link manipulator is a homomorphism between Lie groups. The homomorphisrn has solution groups that act on an inverse kinematic solution element. A canonical representation of solution group operators that act on a solution element of three and seven degree-of-freedom (do!) dextrous manipulators is determined by geometric analysis. Seven canonical solution groups are determined for the seven do! Robotics Research K-1207 and Hollerbach arms. The solution element of a dextrous manipulator is a collection of trivial fibre bundles with solution fibres homotopic to the Torus. If fibre solutions are parameterised by a scalar, a direct inverse funct.ion that maps the scalar and Cartesian base space coordinates to solution element fibre coordinates may be defined. A direct inverse pararneterisation of a solution element may be approximated by a local linear map generated by an inverse augmented Jacobian correction of a linear interpolation. The action of canonical solution group operators on a local linear approximation of the solution element of inverse kinematics of dextrous manipulators generates cyclical solutions. The solution representation is proposed as a model of inverse kinematic transformations in primate nervous systems. Simultaneous calibration of a composition of stereo-camera and manipulator kinematic models is under-determined by equi-output parameter groups in the composition of stereo-camera and Denavit Hartenberg (DH) rnodels. An error measure for simultaneous calibration of a composition of models is derived and parameter subsets with no equi-output groups are determined by numerical experiments to simultaneously calibrate the composition of homogeneous or pan-tilt stereo-camera with DH models. For acceleration of exact Newton second-order re-calibration of DH parameters after a sequential calibration of stereo-camera and DH parameters, an optimal numerical evaluation of DH matrix first order and second order error derivatives with respect to a re-calibration error function is derived, implemented and tested. A distributed object environment for point and click image-based tele-command of manipulators and stereo-cameras is specified and implemented that supports rapid prototyping of numerical experiments in distributed system control. The environment is validated by a hierarchical k-fold cross validated calibration to Cartesian space of a radial basis function regression correction of an affine stereo model. Basic design and performance requirements are defined for scalable virtual micro-kernels that broker inter-Java-virtual-machine remote method invocations between components of secure manageable fault-tolerant open distributed agile Total Quality Managed ISO 9000+ conformant Just in Time manufacturing systems.