Eyeworld

EW FEATURE 66 "If I have a young person whose lenses look fine and if the patient has some accommodation, presby- LASIK is a good option," Dr. Weiss said. "For people in their early to mid-40s who are not reasonable can- didates for lens-based procedures, I think it's great. There will continue to be a niche for presbyLASIK for the foreseeable future." Dr. Nichamin is more cautious, saying "a priori, I have a little bit of a problem etching a multifocal pat- tern on a cornea, but I've been February 2011 Challenging refractive cases October 2011 Presbyopia continued from page 64 The AkkoLens accommodating IOL uses the ciliary muscle to move sliding aspheric surfaces laterally Source: AkkoLens International BV wrong about other technologies more than I've been right." Clear lensectomy "remains a little margin- alized," he added, but the corneal inlays in development "show prom- ise and are really exciting." Dr. Koch said the KAMRA (AcuFocus, Irvine, Calif.) is "a very intriguing option; it's promising be- cause it's also removable." Both the KAMRA and an inlay from ReVision Optics (Lake Forest, Calif.) have had "some good data" to date, he added. Another cornea-based proce- dure, the INTRACOR with the fem- tosecond laser (Technolas Perfect Vision, Munich, Germany) "uses femtosecond corneal treatments with a series of cylindrical cuts that cause a central steepening of the cornea," Dr. Nichamin said. "Michael Holzer, M.D., has pre- sented data that's reasonably prom- ising. But there's a narrow patient population that will initially be con- sidered for INTRACOR." Dr. Koch added presbyLASIK "might be a reasonable option, but I've not seen data on treating em- metropes." He cited potential advan- tages as preserving some distance vision, "recognizing, of course, that there is going to be some contrast loss as you have with the intra- corneal lenses." He has concerns with any procedure—such as the INTRACOR—"that weakens the cornea to engender an effect." Creat- ing cylinders in the cornea to allow it to bulge forward a little bit cen- trally "makes me slightly uneasy," he said. "Some superb people are doing it, both internationally and in the U.S., so I know their data is going to be reliable and helpful. Personally, I want to watch a little closer before I jump on board." Dr. Weiss said the newer fem- tosecond lasers for cataract surgery "have the potential to be game changers in this area. We're not there yet, but if we can produce rou- tine caps and rarely go through pos- terior, we've decreased the risk again." All the surgeons agreed, how- ever, that their holy grail would be accommodating lenses that could consistently provide between 3.0 and 5.0 D or more of accommoda- tion, could be implanted in safe pro- cedures, and have minimal complications. Upcoming technologies Several companies are actively work- ing on new accommodative lenses, and some have promising early re- sults. "What we have now is better than what we had 8-10 years ago, but there's always something better being developed," Dr. Weiss said. "I constantly tell patients if they wait for the next best technology, they'll never have the surgery." The Synchrony dual-optic lens (Visiogen, Irvine, Calif.) "intrigues me because it's its own encapsulated system that might transfer ciliary forces better," Dr. Harton said. Lens refilling technologies are also promising, he said. "With those, you don't take away the anterior capsule. Instead, a synthetic polymer is injected that has the potential to restore accommodation," but human trials have not yet begun. Dr. Nichamin said proof of concept has been shown for the FluidVision (PowerVision, Belmont, Calif.), a fluid-filled device "that can emulate the natural accommodative process and has the potential of somewhere between 5-6 D, where we currently are, up to perhaps as much as 10 D of accommodative power through technology that looks very similar to contemporane- ous implant technology." (Dr. Nichamin is the original medical advisor for the lens.) The lens is cur- rently in human trials in S. Africa and the company is "working through newer iterations that will allow us to implant it through an in- jector delivery device through a con- temporary small incision." Dr. Nichamin expects European trials to begin shortly. He said surgeons' learning curves would be short on the lens "because there's nothing particularly unusual about the appearance of the lens or the way it's implanted—it goes in the bag through a small inci- sion. And unlike the NuLens tech- nology [Herzliya Pituach, Israel], which is based upon a reverse ac- commodative process opposite of Mother Nature, this lens emulates or replicates the natural processes of how the crystalline lens provides us with near vision." The NuLens is comprised of two lens elements; as the ciliary body re- laxes, one element is pushed up into the other to cause a bulge that pro- vides for near reading, Dr. Koch ex- plained. Any accommodating IOL "that truly accommodates" is eagerly awaited, "not only for this group of patients, but for our cataract pa- tients as well," Dr. Lane said. "Tech- nology like the NuLens is not yet in full-fledged clinical trials, but if any accommodating technology be- comes available that lives up to what it should do, we'd all embrace it." Registration and Housing Now Open! Save the Date Back in 2012 Administrator Program Track With Expanded Program 52-67 Feature_EW October 2011-DL33_Layout 1 9/29/11 4:52 PM Page 66

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