Laser Eye Surgery

Laser vision correction and other surgeries for presbyopia

10 Dec 2021

From what age and when it is recommended to undergo laser vision correction for presbyopia?

By getting elder the lens of the eye loses its elasticity, which makes it difficult to focus vision at close range. At the same time, a person cannot see the fine print or small objects. All older people are at risk of presbyopia, mostly from 45 years of age. Clinical research and patient demand has resulted in more and more individualized treatments for presbyopia in recent years 1 2 3 4 5. Presbyopic corneal correction techniques (not intraocular lenses) can be categorized as 6 7:
  • monovision,
  • laser multifocal vision correction,
  • intracorneal multifocality,
  • corneal segments (implants).
Laser multifocal vision correction for presbyopia has significantly increased interest in itself in recent years. The use of excimer lasers in the surgical correction of presbyopia is not new, but only recently refractive surgeons have begun to effectively combine this method of treating refractive anomalies of presbyopia. Basically, the type of laser correction of presbyopia comprises Presby-LASIK (see LASIK) and less often Presby-LASEK operations (see LASEK). When the flap is created with a femtosecond laser, this group is called Prebi-Femto-LASIK, but that doesn't change the meaning. Next, we will analyze in more detail why Presby-LASEK is not so popular.

How is the Presby-LASIK surgery type done ?

The essence of all laser refractive surgery for presbyopia is multifocal ablation, i.e. based on the creation of two or more areas of different optical power in which the greatest visual acuity is achieved. This can be achieved by creating different cornea curvatures for distance visual acuity and near reading in different eyes (monovision) or in one eye. In monovision, the dominant eye is usually corrected for distance.

In the second case, basically, a small central optical region is created with a steeper curvature for reading and a less steep region for distance vision (see Fig. below). The number of areas can be more than 2. Here visual acuity depends on the size of the pupil 8,9. It is necessary to understand that each person has a dominant eye, which is operated so that the distance visual acuity is maximum on it. One such ablation profile for presbyopic patients has been performed with AMARIS lasers since 2007.

Presby-LASIK and other types of surgeries for presbyopia correction

One such module for Presby-LASIK with two areas of vision is PresbyMAX® of three surgeries (µ-Monovision, Hybrid, Monocular), which differ in the degree of difference in refraction between the eyes (anisometropia). There are other multifocal surgeries of this type from other manufacturers of surgeries with commercial names such as Presbyond®, Supracor ™ and CustomVue ™ VISX, however in the case of Presbyond® the central cornea is left for distance vision 10. It should be understood that a high degree of anisometropia can lead to loss of stereoscopic (spatial) vision and contrast sensitivity.

Here we can add that such operations with Presby-PRK or Presby-LASEK are rare, because there is a possibility that multifocality on the cornea may be partially covered by the processes of overgrowing of the removed epithelium (re-epithelialization). Hence, the presence of a flap excludes this possibility.

Other surgery types to correct presbyopia

Recently, IOL implantation has been chosen by an increasing number of refractive surgeons and patients due to its reversibility and a wider range of vision error correction. IOLs are considered to be more accurate and safer than laser presbyopia 11, but laser vision correction is worth considering as well. Patients undergoing posterior IOL surgery should be counseled about the risk of cataracts and the potential need for further surgery 11. Surgeons and patients should make decisions carefully according to specific situations 12.

There are the following most popular alternative treatments for presbyopia:

  • Reading glasses
This is a monofocal vision correction for only one specific working distance.

  • Progressive glasses
This is a multifocal vision correction, but here not all patients adapt to such glasses. These glasses have areas for near (reading) and distance visual acuity.

  • Contact lenses
This is both multifocal and monofocal vision correction. Glare and ghosting is possible with multifocal lenses.

  • Monofocal vision with Presby-LASIK or by replacing the lens of the eye with an intraocular lens (IOL)
In this case, both eyes are corrected for distance or near vision. Reading glasses are often needed if the patient has been operated for distance vision.

  • Monovision with Presby-LASIK
  • Monovision when replacing the eye lens by an IOL
In monovision, the visual acuity of the eyes is corrected at one distance only. As mentioned above, there is a possibility that not all patients get used to the significant difference in visual acuity of the distance and the near eye.

  • Multifocal methods for Presby-LASIK and IOL
There is also the likelihood of the above, i.e. not all patients can get used to it. One of the advantages is that this treatment covers the entire range of distances due to the different curvature of areas on the cornea. The disadvantages may include discomfort, because the quality of vision depends on the size of the pupil.

The advantage of using inlay inserts is that they can eliminate and reverse the results of treatment. Although the inserts in the cornea are located in only one eye, they differ from monovision in that they do not affect distance vision. For some inserts, light entering the eye is limited, which can reduce contrast and night vision, i.e. optical side effects may occur.

  • Conductive keratoplasty
Complete correction of the far eye in combination of multifocality and monovision for reading in the other eye 6.

Results after laser vision correction of prebiopia

Let's consider clinical results after applying PresbyMAX® technique and its three modes: monocular, hybrid and µ-monovision. They differ from each other in the magnitude of refraction into the distance and must be selected individually. We will not delve into the theory, but compare the results of recent positive studies.

The results of clinics in Holland in 2020 showed that even 6 years after surgery, presbyopic treatment using hybrid and µ-monovision modes is safe and effective. Postoperative results indicate improved binocular vision for distance, near, and mid-range. To improve patient satisfaction, 8% of patients had to resort to a second course of surgery 9. Binocular Uncorrected Distance Visual Acuity (BUDVA, i.e. by two eyes)> 20/20, or one (0 according to the logMAR table), was achieved in 100% of patients. Although individually 16% of the eyes lost more than 2 lines of visual acuity compared to vision with glasses before surgery, no line was lost in the case of binocular vision after 6 years.

One of the latest studies 8 of the same 2020 of the same PresbyMAX® technique for patients from 42 to 62 years old in the People's Republic of China, but a monocular mode, has shown its safety and efficacy for correcting presbyopia and that it can improve vision both at far and near distance. However, deterioration in the quality of vision can occur at an early stage, but gradually recover to the preoperative level. All patients had binocular vision (vision with two eyes) more than 100% at a distance of more than 100% after 12 months (≥ 20/20 according to Snellen chart or  ≤ 0.0 according to the logMAR table, or more than 10 lines according to the Sivtsev’s table). Binocular near visual acuity of more than 100% was achieved in almost 78% of patients. Preservation of visual acuity after eye correction remained at a high level, because no one has lost more than 2 lines.

The PresbyMAX® monocular mode in study 13 of the same year 2020 showed that it can provide a quick recovery of vision, and therefore is recommended for people with increased demands for distance vision. Patients over 40 years old showed stable refraction during the following 2 years. Binocular uncorrected distance visual acuity (BUDVA) remained ≥ 20/25 or 80% (0.1 acc. the logMAR table), and binocular uncorrected near visual acuity (for reading) (BUNVA) > 20/25 remained in 90.9% of patients. Here, too, none of the patients lost more than 2 lines of visual acuity compared to visual acuity with glasses before the operation.

The study results 14 of 2019 from clinic in Spain using one of the currently popular PresbyMAX® modes (µ-Monovision) showed a good stability of eye refraction after three months and three years (deviation 0.25 D).

There is also a less successful study 15 of patients over 40 years old after one year using PresbyMAX® technology (µ-Monovision and Hybrid) from Germany, dating back to 2020. Although the indicators of the achieved refraction remained quite high, i.e. a change of no more than 1 diopter was in 89% of the eyes in the dominant eye (reading vision), and 86% in the dominant eye (distance vision), but about 31% of patients lost more than 2 lines of visual acuity compared to vision with glasses before surgery.

However, the Hybrid and µ-Monovision methods with PresbyMAX® technology in 2020 showed higher results 16 after 1 year in patients from 41 to 51 years old in China. So in 99% of patients, the change in refraction was less than 1 diopter. None of the patients lost more than 2 lines of visual acuity compared to vision with glasses before surgery.

There are also results of studies from Russia after 4 years using the µ-Monovision mode in patients aged from 40 to 59, presented at an international congress in 2019 17. It was shown that the average binocular visual acuity significantly improves after surgery, stabilizes within 6 months after surgery and remains stable for at least 4 years of the follow-up.

As it has already become clear, monocular surgery with PresbyMAX® has an advantage over classical monovision in that it uses intermediate vision in the non-dominant eye and restoration of distance vision is usually achieved after about 3 months. By other PresbyMAX® modes this period is even faster.

Prospects for treating presbyopia

Implantation of a refractive lenticule can be an effective alternative to the treatment of presbyopia or to eliminate complications of LASIK 18. Despite the leading development of materials with increased biocompatibility with the cornea, the implantation of natural donor tissue, that is a refractive lenticule, can provide better diffusion of nutrients through the cornea than presbyopic inserts (implants). Implantation of the lenticule can provide an inexpensive alternative to synthetic material that is associated with subsequent opacification, fibrosis (proliferation of connective tissue), or abnormal corneal shape 18. After natural tissue implantation, the corneal shape remains more natural compared to laser treatment.
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