Eyeworld

101 April 2016 EW REFRACTIVE SURGERY consists of a 20-mm polycarbonate scleral contact lens that is placed, for presbyopia-correcting purposes, on the bulbar conjunctiva 3.5 mm from the corneal limbus. This lens has 4 electrodes connected to a power source, which will emit electricity at a low voltage to passively con- tract the ciliary muscle for about 8 minutes. Dr. Gualdi's study, which involved 20 eyes and emmetropic presbyopia patients ranging from 40–50 years old, measured pre- and postoperative uncorrected visual acuity using both objective and sub- jective tests, ultrasound biomicros- copy, aberrometry, and the AR-1A accommodation module. Dr. Gualdi found patients im- proved in uncorrected near (40 cm) and intermediate (70 cm) distance and reading speed time, maintained their distance vision, and had no negative side effects. The negatives of this treatment for the patient, he said, are that it requires maintenance and it is not as effective on older presbyopic pa- tients. He recommends 4 treatments within the first 2 months, followed by 1 treatment every 3 months to sustain it. Dr. Berdahl said he "loves outside-of-the-box ideas," such as electrostimulation of the ciliary body to address presbyopia. "I love that companies are willing to take risks on ideas that are unconventional as long as they are studied well," he said. "The question, of course, is 'Is the lens What do his colleagues have to say about this drop? "My good friends congratulate me, but [others say it] doesn't work, but the best thing is when I apply the drops, then they're convinced," he said. Dr. Vejarano is not alone on the drop front. The search for a topical solution has been on for decades. In the past year alone there was a report out of Al-Azhar University in Cairo regarding the safety and efficacy of a carbachol-brimonidine solution, 1 another that EV06—a lipoic acid choline ester—by Encore Vision (Fort Worth, Texas) enrolled its first subject in its phase 1 and 2 clinical trials, and yet another that Presbyopia Therapies (Coronado, California) presented the phase 2 results for its Liquid Vision drop, just to name a few. Dr. Berdahl said presbyopia- correcting drops in general have produced "very promising anecdot- al reports," but ultimately, "what's going to drive the profession to adopt them are well-controlled trials that show good data on efficacy and safety." Stimulating the ciliary muscle Another nonsurgical option could be electrostimulation of the ciliary muscle. Luca Gualdi, MD, Rome, recently presented the results of a small, preliminary study involving Ocufit (SOOFT, Montegiorgio, Italy). The device—patented in 2009 by Massimo Filippello, MD, for treat- ment of glaucoma and presbyopia— than 20 years ago. "I think we are past the era of testimonials and more into the era of real science, educating our patients, and having them decide what the best solution is," Dr. Kanellopoulos said. Dr. Chang thinks that good patient education and understand- ing of the misconceptions as well as good marketing techniques will help increase LASIK in areas where it may have declined. "Ultimately, good patient experience, low complica- tion rates, and excellent results [are] the recipe for patients referring their friends and relatives," he said. EW he said. They may sleep with their lenses in but then balk at the idea of having surgery on their eyes. "I think that we as an ophthal- mic community need to propagate the data and the truth," he said. "I have personally taken the road of being very honest with my patients, speaking openly about complica- tions, and not trying to 'sell' the procedure, and I think this has helped me to have a tremendous turnaround in my patients in regard to how many of them decide to have surgery." Dr. Kanellopoulos thinks that people are far more educated today efficacy record when properly and appropriately delivered." Dr. Kanellopoulos sees the primary difference between people who wish they had LASIK done and those who had it done as fear rather than finances. "Creating public awareness that this is an extreme- ly safe procedure—perhaps safer than wearing contact lenses—will increase the number of LASIK cases performed," he said. "It still amazes me that patients wear everyday contact lenses, and they are very casual about it in regard to how old their lenses are and the hygiene that they use," Editors' note: Dr. Chang has no finan- cial interests related to this article. Dr. Cummings has financial interests with Alcon (Fort Worth, Texas). Dr. Kanellopoulos has financial interests with Alcon, Allergan (Dublin), Kera- Med (Orange, California), Optovue (Fremont, California), i-Optics (The Hague, the Netherlands), and Carl Zeiss Meditec (Jena, Germany). Contact information Chang: johnchang@hksh.com Cummings: abc@wellingtoneyeclinic.com Kanellopoulos: ajk@brilliantvision.com LASIK continued from page 99 flexible enough to change its shape in someone who is presbyopic by increasing the ability of the ciliary muscle to pull on the lens?' I think that has yet to be shown, but I like the thought process behind it." Other options Drops and electrostimulation are not all that's going on in the field of noninvasive presbyopia research. Noninvasive laser thermal kerato- plasty (LTK) called optimal kerato- plasty (Opti-K) with the Opti-K System (NTK Enterprises, Austin, Texas) is another option. This procedure, according to a 2011 study published by Rogers et al. in the Proceedings of SPIE Ophthalmic Technologies, involves "laser heating of the cornea to change its shape." 2 While the paper acknowledged that the history of LTK has been "unsat- isfactory" in the past, Opti-K, which is currently in clinical trials as a hyperopia treatment, was found to be "simple, rapid, comfortable, and repeatable." Conductive keratoplasty (CK) is a non-laser thermal treatment that could be used to correct presbyopia. As Rogers et al. said, "CK remains the most widely used technology for presbyopia treatment with over 200,000 procedures completed." Dr. Berdahl said advances in accommodating contact lenses could provide another avenue as well. With all the work and research being done to create newer presby- opia treatments, Dr. Berdahl said it is a condition that will be solved. "With the amount of effort that people are putting in, it's going to be a solvable problem and we're making more progress toward it now than we ever have," he said. "I'm all for safe and effective surgical options. I'm all for safe and effective pharmaceutical options. I love having new tools in my toolkit because some patients might be able to take drops, for example, others may be averse to surgery or not good candidates for surgery, so the more tools we have in our bag, the better," Dr. Berdahl said. "I'm mostly con- cerned about solving the problem for our patients, and the more tools we have, the more likely we're going to solve it for more people." EW References 1. Abdelkader A. Improved presbyopic vision with miotics. Eye Contact Lens. 2015 Sep;41(5):323–7. 2. Rogers JK, et al. Improved method of laser thermal keratoplasty to overcome presbyopia. Proc. SPIE 7885, Ophthalmic Technologies XXI, 78850N, 12 February 2011. Editors' note: Dr. Vejarano has finan- cial interests with PresbV Tears. Dr. Berdahl has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Bausch + Lomb (Bridgewater, New Jersey), and Alcon (Fort Worth, Texas). Dr. Gualdi has no financial interests related to his comments. Contact information Berdahl: johnberdahl@gmail.com Gualdi: luca@gualdi.it Vejarano: felipev@fov.com.co

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