Presbyopic LASIK using hybrid bi-aspheric micro-monovision ablation profile for presbyopic corneal treatments

Purpose: To evaluate distance and near image quality after hybrid bi-aspheric multifocal central presbyLASIK treatments. Design: Consecutive case series. Methods: Sixty-four eyes of 32 patients consecutively treated with central presbyLASIK were assessed. The mean age of the patients was 51 ± 3 years with a mean spherical equivalent refraction of-1.08 ± 2.62 diopters (D) and mean astigmatism of 0.52 ± 0.42 D. Monocular corrected distance visual acuity (CDVA), corrected near visual acuity (CNVA), and distance corrected near visual acuity (DCNVA) of nondominant eyes; binocular uncorrected distance visual acuity (UDVA); uncorrected intermediate visual acuity (UIVA); distance corrected intermediate visual acuity (DCIVA); and uncorrected near visual acuity (UNVA) were assessed pre- and postoperatively. Subjective quality of vision and near vision was assessed using the 10-item Rasch-scaled Quality of Vision and Near Activity Visual Questionnaire, respectively. Results: At 1 year postoperatively, 93% of patients achieved 20/20 or better binocular UDVA; 90% and 97% of patients had J2 or better UNVA and UIVA, respectively; 7% lost 2 Snellen lines of CDVA; Strehl ratio reduced by ~-4% ± 14%. Defocus curves revealed a loss of half a Snellen line at best focus, with no change for intermediate vergence (-1.25 D) and a mean gain of 2 lines for near vergence (-3 D). Conclusions: Presbyopic treatment using a hybrid bi-aspheric micro-monovision ablation profile is safe and efficacious. The postoperative outcomes indicate improvements in binocular vision at far, intermediate, and near distances with improved contrast sensitivity. A 19% retreatment rate should be considered to increase satisfaction levels, besides a 3% reversal rate.

Randomized crossover trial of silicone hydrogel presbyopic contact lenses

PURPOSE: To assess the performance of four commercially available silicone hydrogel multifocal monthly contact lens designs against monovision. METHODS: A double-masked randomized crossover trial of Air Optix Aqua multifocal, PureVision 2 for Presbyopia, Acuvue OASYS for Presbyopia, Biofinity multifocal, and monovision with Biofinity contact lenses was conducted on 35 presbyopes (54.3 ± 6.2 years). After 4 weeks of wear, visual performance was quantified by high- and low-contrast visual acuity under photopic and mesopic conditions, reading speed, defocus curves, stereopsis, halometry, aberrometry, Near Activity Visual Questionnaire rating, and subjective quality of vision scoring. Bulbar, limbal, and palpebral hyperemia and corneal staining were graded to monitor the impact of each contact lens on ocular physiology. RESULTS: High-contrast photopic visual acuity (p = 0.102), reading speed (F = 1.082, p = 0.368), and aberrometry (F = 0.855, p = 0.493) were not significantly different between presbyopic lens options. Defocus curve profiles (p <0.001), stereopsis (p <0.001), halometry (F = 4.101, p = 0.004), Near Activity Visual Questionnaire (F = 3.730, p = 0.007), quality of vision (p = 0.002), bulbar hyperemia (p = 0.020), and palpebral hyperemia (p = 0.012) differed significantly between lens types, with the Biofinity multifocal lens design principal (center-distance lens was fitted to the dominant eye and a center-near lens to the nondominant eye) typically outperforming the other lenses. CONCLUSIONS: Although ocular aberration variation between individuals largely masks the differences in optics between current multifocal contact lens designs, certain design strategies can outperform monovision, even in early presbyopes.

Investigating the utility of clinical assessments to predict success with presbyopic contact lens correction

PURPOSE: To determine the utility of a range of clinical and non-clinical indicators to aid the initial selection of the optimum presbyopic contact lens. In addition, to assess whether lens preference was influenced by the visual performance compared to the other designs trialled (intra-subject) or compared to participants who preferred other designs (inter-subject). METHODS: A double-masked randomised crossover trial of Air Optix Aqua multifocal, PureVision 2 for Presbyopia, Acuvue OASYS for Presbyopia, Biofinity multifocal and monovision was conducted on 35 presbyopes (54.3±6.2years). Participant lifestyle, personality, pupil characteristics and aberrometry were assessed prior to lens fitting. After 4 weeks of wear, high and low contrast visual acuity (VA) under photopic and mesopic conditions, reading speed, Near Activity Visual Questionnaire (NAVQ) rating, subjective quality-of-vision scoring, defocus curves, stereopsis, halometry, aberrometry and ocular physiology were quantified. RESULTS: After trialling all the lenses, preference was mixed (n=12 Biofinity, n=10 monovision, n=7 Purevision, n=4 Air Optix Aqua, n=2 Oasys). Lens preference was not dependent on personality (F=1.182, p=0.323) or the hours spent working at near (p=0.535) or intermediate (p=0.759) distances. No intersubject or strong intrasubject relationships emerged between lens preference and reading speed, NAVQ rating, halo size, aberrometry or ocular physiology (p>0.05). CONCLUSIONS: Participant lifestyle and personality, ocular optics, contact lens visual performance and ocular physiology provided poor indicators of the preferred lens type after 4 weeks of wear. This is confounded by the wide range of task visual demands of presbyopes and the limited optical differences between current multifocal contact lens designs.

Réactivité posturale et inconfort subjectif induits par un stimulus visuel

Il est bien connu des professionnels de la vision que l’ajustement des verres progressifs sur un patient presbyte peut induire de l’inconfort et des difficultés posturales (Timmis, Johnson, Elliott, & Buckley, 2010). Ces plaintes sont directement associées à l’information visuelle perçue à travers les verres progressifs. Le principal objectif de cette thèse est d’identifier quels sont les paramètres d’un stimulus visuel (p.ex. fréquence temporelle ou vélocité) à l’origine de la perturbation posturale et de l’inconfort. Les distorsions dynamiques perçues à travers des verres progressifs s’apparentent aux mouvements d’un bateau qui roule de droite à gauche ou qui tangue d’avant en arrière. Ce type de stimulation visuelle a été reproduit dans une voute d’immersion en réalité virtuelle avec un sol à texture de damier noir et blanc qui oscillait périodiquement de droite à gauche et d’avant en arrière à différentes fréquences et amplitudes. Les études qui portent sur ce sujet montrent que la réponse posturale induite visuellement augmente avec la vélocité de stimulation et diminue lorsque la fréquence augmente. Cette information peut paraitre contradictoire, car ces deux variables sont liées entre elles par l’amplitude et covarient dans le même sens. Le premier objectif de cette thèse était de déterminer les causes possibles de cette contradiction. En faisant varier la fréquence temporelle de stimulation visuelle, on retrouve deux domaines de réponse posturale. Le premier domaine correspond aux fréquences inférieures à 0,12 Hz. Dans ce domaine, la réponse posturale est visuodépendante et augmente avec la vélocité du stimulus. Le second domaine postural correspond aux fréquences supérieures à 0,25 Hz. Dans ce domaine, la réponse posturale sature et diminue avec l’augmentation de la fréquence. Cette saturation de la réponse posturale semble causée par des limitations biomécaniques et fréquentielles du système postural. D’autres études ont envisagé d’étudier l’inconfort subjectif induit par des stimuli visuels périodiques. Au sein de la communauté scientifique, deux théories principales se confrontent. La théorie sensorielle repose sur les conflits sensoriels induit par le stimulus visuel tandis que la théorie posturale suggère que l’inconfort est la conséquence de l’instabilité posturale. Nos résultats révèlent que l’inconfort subjectif induit par une stimulation visuelle dynamique dépend de la vélocité du stimulus plutôt que de sa fréquence. L’inconfort peut être prédit par l’instabilité naturelle des individus en l’absence de stimulus visuel comme le suggère la théorie posturale. Par contre, l’instabilité posturale induite par un stimulus visuel dynamique ne semble pas être une condition nécessaire et suffisante pour entrainer de l’inconfort. Ni la théorie sensorielle ni la théorie posturale ne permettent à elles seules d’expliquer tous les mécanismes à l’origine de l’inconfort subjectif. Ces deux théories sont complémentaires, l’une expliquant que l’instabilité intrinsèque est un élément prédictif de l’inconfort et l’autre que l’inconfort induit par un stimulus visuel dynamique résulte d’un conflit entre les entrées sensorielles et les représentations acquises par l’individu.

Comparative analysis of the visual performance and aberrometric outcomes with a new hybrid and two silicone hydrogel multifocal contact lenses: a pilot study

Background: The aim was to evaluate the visual performance achieved with a new multifocal hybrid contact lens and to compare it with that obtained with two other currently available multifocal soft contact lenses. Methods: This pilot prospective comparative study comprised a total of 16 presbyopic eyes of eight patients ranging in age from 43 to 58 years. All patients were fitted with three different models of multifocal contact lens: Duette multifocal (SynergEyes), Air Optix AQUA multifocal (Alcon) and Biofinity multifocal (CooperVision). Fittings were performed randomly in each patient according to a random number sequence, with a wash-out period between fittings of seven days. At two weeks post-fitting, visual, photopic contrast sensitivity and ocular aberrometry were evaluated. Results: No statistically significant differences were found in distance and near visual acuity achieved with the three different types of multifocal contact lens (p ≥ 0.05). Likewise, no significant differences between lenses were found in the monocular and binocular defocus curve (p ≥ 0.10). Concerning contrast sensitivity, better monocular contrast sensitivities for 6, 12 and 18 cycles per degree were found with the Duette and Air Optix multifocal compared to Biofinity (p = 0.02). Binocularly, differences between lenses were not significant (p ≥ 0.27). Furthermore, trefoil aberration was significantly higher with Biofinity multifocal (p < 0.01) and Air Optix (p = 0.01) multifocal compared to Duette. Conclusions: The Duette multifocal hybrid contact lens seems to provide similar visual quality outcomes in presbyopic patients with low corneal astigmatism, when compared with other soft multifocal contact lenses. This preliminary result should be confirmed in studies with larger samples.

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.

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.

Accommodative amplitude required for sustained near work

Purpose: Many practitioners base the prescription of near vision additions on the assertion that only one half or two-thirds of an individual’s amplitude of accommodation is sustainable for a prolonged period. To better understand how much eye focus needs to be restored for presbyopic corrections to be adequate, this study investigated the robustness of the pre-presbyopic human accommodative system during a sustained and intensive near vision task. Methods: Twenty-one pre-presbyopic volunteers (aged 26.1 ± 4.7 years) participated in the study. Binocular subjective amplitude of accommodation was measured before and after a prolonged reading exercise, using the RAF rule. During the 30 min reading task, the subject’s closest comfortable eye-to-text distance and pupil size was monitored. Accommodative accuracy to 0.2, 1.0, 2.0, 3.0 and 4.0 D stimuli was determined objectively using a validated binocular open-view autorefractor immediately before, and after the reading task. Results: Amplitude of accommodation (p = 0.09) and accommodative accuracy (p > 0.05) were statistically unchanged following the intensive near task. The mean proportion of accommodation exerted throughout the near exercise was 80.6% (range 45.3 ± 3.7 to 96.6 ± 4.3%), which increased as the task progressed (F = 2.24, p = 0.02). The mean percentage of accommodation utilised increased with subject age (r = 0.517, p = 0.016). Conclusion: The pre-presbyopic human accommodative system is robust to fatigue during intense and prolonged near work. A greater proportion of one’s amplitude of accommodation may be continuously exerted than previously suggested.

Comparison of near visual acuity and reading metrics in presbyopia correction

PURPOSE: To provide a consistent standard for the evaluation of different types of presbyopic correction. SETTING: Eye Clinic, School of Life and Health Sciences, Aston University, Birmingham, United Kingdom. METHODS: Presbyopic corrections examined were accommodating intraocular lenses (IOLs), simultaneous multifocal and monovision contact lenses, and varifocal spectacles. Binocular near visual acuity measured with different optotypes (uppercase letters, lowercase letters, and words) and reading metrics assessed with the Minnesota Near Reading chart (reading acuity, critical print size [CPS], CPS reading speed) were intercorrelated (Pearson product moment correlations) and assessed for concordance (intraclass correlation coefficients [ICC]) and agreement (Bland-Altman analysis) for indication of clinical usefulness. RESULTS: Nineteen accommodating IOL cases, 40 simultaneous contact lens cases, and 38 varifocal spectacle cases were evaluated. Other than CPS reading speed, all near visual acuity and reading metrics correlated well with each other (r>0.70, P<.001). Near visual acuity measured with uppercase letters was highly concordant (ICC, 0.78) and in close agreement with lowercase letters (+/- 0.17 logMAR). Near word acuity agreed well with reading acuity (+/- 0.16 logMAR), which in turn agreed well with near visual acuity measured with uppercase letters 0.16 logMAR). Concordance (ICC, 0.18 to 0.46) and agreement (+/- 0.24 to 0.30 logMAR) of CPS with the other near metrics was moderate. CONCLUSION: Measurement of near visual ability in presbyopia should be standardized to include assessment of near visual acuity with logMAR uppercase-letter optotypes, smallest logMAR print size that maintains maximum reading speed (CPS), and reading speed. J Cataract Refract Surg 2009; 35:1401-1409 (C) 2009 ASCRS and ESCRS

Optimizing measurement of subjective amplitude of accommodation with defocus curves

PURPOSE: To determine whether letter sequences and/or lens-presentation order should be randomized when measuring defocus curves and to assess the most appropriate criterion for calculating the subjective amplitude of accommodation (AoA) from defocus curves. SETTING: Eye Clinic, School of Life & Health Sciences, Aston University, Birmingham, United Kingdom. METHODS: Defocus curves (from +3.00 diopters [D] to -3.00 D in 0.50 D steps) for 6 possible combinations of randomized or nonrandomized letter sequences and/or lens-presentation order were measured in a random order in 20 presbyopic subjects. Subjective AoA was calculated from the defocus curves by curve fitting using various published criteria, and each was correlated to subjective push-up AoA. Objective AoA was measured for comparison of blur tolerance and pupil size. RESULTS: Randomization of lens-presentation order and/or letter sequences, or lack of, did not affect the measured defocus curves (P>.05, analysis of variance). The range of defocus that maintains highest achievable visual acuity (allowing for variability of repeated measurement) was better correlated to (r = 0.84) and agreed best with ( 0.50 D) subjective push-up AoA than any other relative or absolute acuity criterion used in previous studies. CONCLUSIONS: Nonrandomized letters and lens presentation on their own did not affect subjective AoA measured by defocus curves, although their combination should be avoided. Quantification of subjective AoA from defocus curves should be standardized to the range of defocus that maintains the best achievable visual acuity.

Development of a near activity visual questionnaire to assess accommodating intraocular lenses

Purpose: To develop a questionnaire that subjectively assesses near visual function in patients with 'accommodating' intraocular lenses (IOLs). Methods: A literature search of existing vision-related quality-of-life instruments identified all questions relating to near visual tasks. Questions were combined if repeated in multiple instruments. Further relevant questions were added and item interpretation confirmed through multidisciplinary consultation and focus groups. A preliminary 19-item questionnaire was presented to 22 subjects at their 4-week visit post first eye phacoemulsification with 'accommodative' IOL implantation, and again 6 and 12 weeks post-operatively. Rasch Analysis, Frequency of Endorsement, and tests of normality (skew and kurtosis) were used to reduce the instrument. Cronbach's alpha and test-retest reliability (intraclass correlation coefficient, ICC) were determined for the final questionnaire. Construct validity was obtained by Pearson's product moment correlation (PPMC) of questionnaire scores to reading acuity (RA) and to Critical Print Size (CPS) reading speed. Criterion validity was obtained by receiver operating characteristic (ROC) curve analysis and dimensionality of the questionnaire was assessed by factor analysis. Results: Rasch Analysis eliminated nine items due to poor fit statistics. The final items have good separation (2.55), internal consistency (Cronbach's α = 0.97) and test-retest reliability (ICC = 0.66). PPMC of questionnaire scores with RA was 0.33, and with CPS reading speed was 0.08. Area under the ROC curve was 0.88 and Factor Analysis revealed one principal factor. Conclusion: The pilot data indicates the questionnaire to be internally consistent, reliable and a valid instrument that could be useful for assessing near visual function in patients with 'accommodating' IOLS. The questionnaire will now be expanded to include other types of presbyopic correction. © 2007 British Contact Lens Association.

Predicting prescribed magnification

Aim: To determine the best method of estimating the optimum magnification needed by visually impaired patients. Methods: The magnification of low vision aids prescribed to 187 presbyopic visually impaired patients for reading newspapers or books was compared with logMAR distance and near acuity (at 25 cm) and magnification predicted by +4 D step near additions. Results: Distance letter (r = 0.58) and near word visual acuity (r = 0.67) were strongly correlated to the prescribed magnification as were predictive formulae based on these measures. Prediction using the effect of proximal magnification resulted in a similar correlation (r = 0.67) and prediction was poorer in those who did not benefit from proximal magnification. The difference between prescribed and predicted magnification was found to be unrelated to the condition causing visual impairment (F = 2.57, p = 0.08), the central visual field status (F = 0.57, p = 0.57) and patient psychology (F = 0.44, p = 0.51), but was higher in those prescribed stand magnifiers than high near additions (F = 5.99, p < 0.01). Conclusions: The magnification necessary to perform normal visual tasks can be predicted in the majority of cases using visual acuity measures, although measuring the effect of proximal magnification demonstrates the effect of stronger glasses and identifies those in whom prescribed magnification is more difficult to predict.

Visual comparison of multifocal contact lens to monovision

Purpose. To compare visual function with the Bausch & Lomb PureVision multifocal contact lens to monovision with PureVision single vision contact lenses. Methods. Twenty presbyopic subjects were fitted with either the PureVision multifocal contact lens or monovision with PureVision singlevision lenses. Aftera 1-month trial, the following assessments of visual function were made: (a) distance, intermediate, and near visual acuity (VA); (b) reading ability; (c) distance and near contrast sensitivity function (CSF); (d) near range of clear vision; (e) stereoacuity; and (f) subjective evaluation of near vision ability with a standardized questionnaire. Subjects were then refitted with the alternative correction and the procedure was repeated. All measurements were compared between the two corrections, whereas the ``low addition'' multifocal lens was also compared with the ``high addition'' alternative. Results. Distance and near VA were significantly better with monovision than with the multifocal option (p < 0.05). Intermediate VA (p = 0.13) was similar with both corrections, whereas there was also no significant difference in distance and near CSF (p = 0.29 on both occasions). Reading speeds (p = 0.48) and the critical print size (p = 0.90) were not significantly different between the two contact lens corrections, but stereoacuity (p < 0.01) and the near range of clear vision (p < 0.05) were significantly better with the multifocal option than with monovision. Subjective assessment of near ability was similar for both types of contact lens (p = 0.52). The high addition multifocal lens produced significantly poorer distance and near CSF, near VA, and critical print size compared with the low addition alternative. Conclusions. Monovision performed better than a center-near aspheric simultaneous vision multifocal contact lens of the same material for distance and near VA only. The multifocal option provides better stereoacuity and near range of clear vision, with little differences in CSF, so a better balance of real-world visual function may be achieved due to minimal binocular disruption. (Optom Vis Sci 2009;86:98-105)

An analysis of progressive addition spectacles lens design by the use of interferometry

Progressive addition spectacle lenses (PALs) have now become the method of choice for many presbyopic individuals to alleviate the visual problems of middle-age. Such lenses are difficult to assess and characterise because of their lack of discrete geographical locators of their key features. A review of the literature (mostly patents) describing the different designs of these lenses indicates the range of approaches to solving the visual problem of presbyopia. However, very little is published about the comparative optical performance of these lenses. A method is described here based on interferometry for the assessment of PALs, with a comparison of measurements made on an automatic focimeter. The relative merits of these techniques are discussed. Although the measurements are comparable, it is considered that the interferometry method is more readily automated, and would be ultimately capable of producing a more rapid result.

Physical and psychophysical analysis of progressive addition lens embodiments

The extent to which the surface parameters of Progressive Addition Lenses (PALs) affect successful patient tolerance was investigated. Several optico-physical evaluation techniques were employed, including a newly constructed surface reflection device which was shown to be of value for assessing semi-finished PAL blanks. Detailed physical analysis was undertaken using a computer-controlled focimeter and from these data, iso-cylindrical and mean spherical plots were produced for each PAL studied. Base curve power was shown to have little impact upon the distribution of PAL astigmatism. A power increase in reading addition primarily caused a lengthening and narrowing of the lens progression channel. Empirical measurements also indicated a marginal steepening of the progression power gradient with an increase in reading addition power. A sample of the PAL wearing population were studied using patient records and questionnaire analysis (90% were returned). This subjective analysis revealed the reading portion to be the most troublesome lens zone and showed that patients with high astigmatism (> 2.00D) adapt more readily to PALs than those with spherical or low cylindrical (2.00D) corrections. The psychophysical features of PALs were then investigated. Both grafting visual acuity (VA) and contrast sensitivity (CS) were shown to be reduced with an increase in eccentricity from the central umbilical line. Two sample populations (N= 20) of successful and unsuccessful PAL wearers were assessed for differences in their visual performance and their adaptation to optically induced distortion. The possibility of dispensing errors being the cause of poor patient tolerance amongst the unsuccessful wearer group was investigated and discounted. The contrast sensitivity of the successful group was significantly greater than that of the unsuccessful group. No differences in adaptation to or detection of curvature distortion were evinced between these presbyopic groups.