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Hyperopia and

Presbyopia
edited by
Kazuo Tsubota
Tokyo Dental College
Ichikawa City, Chiba, Japan

Bn'an S. Boxer Wachler


Boxer Wachler Vision Institute
Beverly Hills, California, U.S.A.

Dimitri T. Azar
Massachusetts Eye and Ear Infirmary
Schepens Eye Research Institute
and Harvard Medical School
Boston, Massachusetts, U.S.A.

Douglas D. Koch
Cullen Eye Institute
Baylor College of Medicine
Houston, Texas, U.S.A.

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REFRACTIVE SURGERY

Series Editors

Dimitri T. Azar, M.D.


Massachusetts Eye and Ear Infirmary
Schepens Eye Research Institute
and Harvard Medical School
Boston, Massachusetts

Douglas D. Koch, M.D.


Cullen Eye Institute
Baylor College of Medicine
Houston, Texas

1. LASIK: Fundamentals, Surgical Techniques, and Complications, edi-


ted by Dimitri T. Azar and Douglas D. Koch
2. Hyperopia and Presbyopia, edited by Kazuo Tsubota, Brian S. Boxer
Wachler, Dimitri T. Azar, and Douglas D. Koch

ADDITIONAL VOLUMES IN PREPARATION


Preface

Heil dir, Sonne!


Heil dir, Licht!
With the explosion of refractive surgical technologies and techniques we have wit-
nessed increased success in the treatment of hyperopia, but we still stand restrained in our
ability to free our patients from presbyopic spectacles. We eagerly await the moment
of overcoming the seemingly insurmountable obstacles of presbyopic correction to echo
Brunhildes greetings of the sun and of the light in the third act of Wagners opera Siegfried,
at the time of her resurrection after decades of slumber:
Long was my sleep.
Who is the hero who awakened me?
Siegfried forged Nothung, the famous sword that could be forged only by a man
who did not know fear, and used it to slay the dragon Fafner (and recover the magical
Ring and Tarnhelm). He defied the gods and entered Loges impenetrable circle of flames
to rescue the sleeping Brunhilde.
We are on the verge of facing a similar success story in refractive surgery. Many
unsung heroes are paving the way for the next discovery that will change the way we
treat hyperopia and revolutionize the surgical correction of presbyopia. The wide range
of investigations covered in this book indicates that it will not be long before we will be
able to fulfill our quest to conquer these two frontiers in refractive surgery.
This book is the second of a series of books dedicated to refractive surgery published
by Marcel Dekker, Inc. The focus of the first volume in this series was LASIK fundamen-
tals, surgical techniques, and complications, a topic that has received a lot of coverage in
both the peer- and non-peer-reviewed literature. For this book, we asked Drs. Tsubota
iii
iv Preface

and Boxer Wachler to edit the manuscripts, and they have worked diligently with the
contributors to ensure maximal coverage and minimal redundancy.
It may come as no surprise to the reader that the methods of treatment of hyperopia
and presbyopia are grouped in a single refractive surgical textbook. The classical teachings
of physiological optics separate these two areas, but many of the surgical techniques
employed for the correction of hyperopia may have applications for presbyopia.
The introductory section is written by experts in the fields of basic optics, mecha-
nisms of accommodation, aging of the lens, and contact lens basics. Among topics dis-
cussed in the section on hyperopia are LASIK and PRK for hyperopia and hyperopic
astigmatism, laser thermokeratoplasty, conductive keratoplasty, hyperopic intracorneal
segments, phakic IOLs. The section on presbyopia includes discussions of monovision
refractive surgery, multifocal corneal approach, scleral relaxation, scleral expansion bands,
multifocal IOLs, refractive lens exchange with a multifocal intraocular lens, Phaco-Erstaz,
and accommodating and adjustable IOLs. The topographical changes, corneal surface
profiles, wavefront contrast sensitivity changes, and wound healing after hyperopic surgery
are discussed in a separate section with special emphasis on clinical applications. The
contributors draw on first-hand experiences with the aim of providing an engaging book
covering these important topics.
We are indebted to the coeditors, students, residents, and colleagues who have made
valuable contributions to this book. We are grateful for their effort in integrating the
sometimes limited information in peer-reviewed literature with the knowledge derived
from their clinical experiences and interactions with colleagues. We hope that this provides
a text that is both clinically relevant and as evidence-based as possible.
We thank Dr. Geoffrey Greenwood and Elizabeth Curione of Marcel Dekker, Inc.,
for their commitment to this project. Special thanks go to Leona Greenhill, for her editorial
assistance, and to Rhonda Harris, who managed this project with care and precision. Her
attention to detail and her dedication have enabled us to work coherently in the face of
adversity.
We take the opportunity to acknowledge the pioneering surgeons and researchers
in the field of refractive surgery. Their work and vision have provided the basis not only
for current advances in hyperopia and presbyopia that we can offer to our patients, but
also for future advances to be made by the next generation of thoughtful contributors to
this important field.

Dimitri T. Azar
Douglas D. Koch
Contents

Preface iii
Contributors ix

1. Introduction 1
Kazuo Tsubota

2. Basic Optics of Hyperopia and Presbyopia 17


Michael K. Smolek and Stephen D. Klyce

3. The Helmholtz Mechanism of Accommodation 27


Adrian Glasser

4. Schachars Theory of the Mechanisms of Accommodation 47


Jay S. Pepose and Moonyoung S. Chung

5. Aging and the Crystalline Lens: Review of Recent Literature (19982001) 55


Leo T. Chylack, Jr.

6. Hyperopia 63
Ivo John Dualan and Penny A. Asbell
v
vi Contents

7. Surgical Treatment Options for Hyperopia and Hyperopic Astigmatism 69


Paolo Vinciguerra and Fabrizio I. Camesasca

8. Laser Thermokeratoplasty and Wavefront-Guided LTK 83


Shahzad I. Mian and Dimitri T. Azar

9. Conductive Keratoplasty for the Correction of Low to Moderate Hyperopia 95


Marguerite B. McDonald, Jonathan Davidorf, Robert K. Maloney,
Edward E. Manche, Peter Hersh, and George M. Salib

10. Intracorneal Segments for Hyperopia 107


Laura Gomez and Arturo S. Chayet

11. Anterior Chamber Phakic Intraocular Lenses in Hyperopia 115


Georges Bakoff

12. Hyperopic Phakic Intraocular Lenses 119


Thanh Hoang-Xuan and Francois Malecaze

13. Hyperopia and Presbyopia: Topographical Changes 129


Stephen D. Klyce, Michael K. Smolek, Michael J. Endl, Vasavi Malineni,
Michael S. Insler, and Marguerite B. McDonald

14. Corneal Surface Profile After Hyperopia Surgery 141


Damien Gatinel

15. Wavefront Changes After Hyperopia Surgery 151


Maria Regina Chalita and Ronald R. Krueger

16. Contrast Sensitivity Changers After Hyperopia Surgery 163


Lavinia C. Coban-Steflea, Tommy S. Korn, and Brian S. Boxer Wachler

17. Wound Healing After Hyperopic Corneal Surgery: Why There Is Greater
Regression in the Treatment of Hyperopia 173
Renato Ambrosio, Jr., and Steven E. Wilson

18. Monovision Refractive Surgery for Presbyopia 189


Dimitri T. Azar, Margaret Chang, Carolyn E. Kloek, Samiah Zafar,
Kimberly Sippel, and Sandeep Jain

19. Multifocal Corneal Approach to Treat Presbyopia 201


Janie Ho and Dimitri T. Azar

20. Scleral Relaxation to Treat Presbyopia 209


Hideharu Fukasaku

21. The Scleral Expansion Procedure 219


Chris B. Phillips and Richard W. Yee
Contents vii

22. Multifocal IOLs for Presbyopia 237


Hiroko Bissen-Miyajima

23. Refractive Lens Exchange with a Multifocal Intraocular Lens 249


I. Howard Fine, Richard S. Hoffman, and Mark Packer

24. The Limits of Simultaneous Ametropia Correction in Phaco-Ersatz 259


Arthur Ho, Fabrice Manns, Viviana Fernandez, Paul Erikson, and
Jean-Marie Parel

25. Accommodating and Adjustable IOLs 279


Sandeep Jain, Dimitri T. Azar, and Rasik B. Vajpayee

26. Accommodative Amplitude Measurements After Surgery for Presbyopia 287


David L. Guyton

27. Complications of Hyperopia and Presbyopia Surgery 291


Liane Clamen Glazer and Dimitri T. Azar

28. Future Developments 315


Brian S. Boxer Wachler

Index 319
Contributors

Renato Ambrosio, Jr., M.D. Department of Ophthalmology, University of Washington,


Seattle, Washington, U.S.A., University of Sao Paolo, Sao Paolo, and Department of
Cornea and Refractive Surgery, Clinica e Microcirurgia Oftalmologica Renato Ambrosio,
Rio de Janeiro, Brazil

Penny A. Asbell, M.D. Mount Sinai Medical Center, New York, New York, U.S.A.

Dimitri T. Azar, M.D. Corneal and Refractive Surgery Services, Massachusetts Eye
and Ear Infirmary, Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

Georges Bakoff, M.D. Clinique Montecelli, Marseille, France

Hiroko Bissen-Miyajima, M.D., Ph.D. Department of Ophthalmology, Tokyo Dental


College, Suidobash Hospital, Tokyo, Japan

Brian S. Boxer Wachler, M.D. Boxer Wachler Vision Institute, Beverly Hills, Califor-
nia, U.S.A.

Fabrizio I. Camesasca, M.D. Department of Ophthalmology, Istituto Clinico Humani-


tas, Milan, Italy

Maria Regina Chalita, M.D. Department of Refractive Surgery, Cole Eye Institute,
Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.
ix
x Contributors

Margaret Chang, M.S. Corneal and Refractive Surgery Services, Massachusetts Eye
and Ear Infirmary, Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

Arturo S. Chayet, M.D. Codet Aris Vision Institute, Tijuana, B.C., Mexico

Moonyoung S. Chung, M.D. Pepose Vision Institute, Chesterfield, Missouri, U.S.A.

Leo T. Chylack, Jr., M.D. Department of Ophthalmology, Harvard Medical School and
Center for Ophthalmic Research, Brigham and Womens Hospital, Boston, Massachusetts,
U.S.A.

Lavinia C. Coban-Steflea, M.D. Department of Ophthalmology, Bucharest University


Hospital, and Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

Jonathan Davidorf, M.D. Davidorf Eye Group, West Hills, and Maloney Vision Insti-
tute, Los Angeles, California, U.S.A.

Ivo John Dualan, M.D. Mount Sinai Medical Center, New York, New York, U.S.A.

Michael J. Endl, M.D. Department of Ophthalmology, Louisiana State University


Health Sciences Center, New Orleans, Louisiana, U.S.A.

Paul Erickson, O.D., Ph.D. Cooperative Research Centre for Eye Research and Tech-
nology, The University of New South Wales, Sydney, New South Wales, Australia

Viviana Fernandez, M.D. Ophthalmic Biophysics Center, Bascom Palmer Eye Institute,
University of Miami Medical School, Miami, Florida, U.S.A.

I. Howard Fine, M.D. Department of Ophthalmology, Casey Eye Institute, Oregon


Health and Science University, Portland, Oregon, U.S.A.

Hideharu Fukasaku, M.D. Fukasaku Eye Centre, Yokohama, Japan

Damien Gatinel, M.D. Fondation Ophthalomogique Adolphe de Rothschild and Bichat


Claude Bernard Hospital, Paris, France

Adrian Glasser, Ph.D. College of Optometry, University of Houston, Houston, Texas,


U.S.A.

Liane Clamen Glazer, M.D. Massachusetts Eye and Ear Infirmary, Schepens Eye Re-
search Institute, and Harvard Medical School, Boston, Massachusetts, U.S.A.

Laura Gomez, M.D. Codet Aris Vision Institute, Tijuana, B.C., Mexico

David L. Guyton, M.D. Department of Ophthalmology, The Wilmer Institute, The Johns
Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.
Contributors xi

Peter Hersh, M.D. Cornea and Laser Vision Center, Teaneck, New Jersey, U.S.A.

Arthur Ho, M.Optom., Ph.D. Cooperative Research Centre for Eye Research and Tech-
nology, The University of New South Wales, Sydney, New South Wales, Australia

Janie Ho, M.D. Department of Ophthalmology, University of California at San Fran-


cisco, San Francisco, California, U.S.A.

Thanh Hoang-Xuan, M.D. Fondation Ophthalomogique Adolphe de Rothschild and


Paris University, Paris, France

Richard S. Hoffman, M.D. Department of Ophthalmology, Casey Eye Institute, Oregon


Health and Science University, Portland, Oregon, U.S.A.

Michael S. Insler, M.D. Department of Ophthalmology, Louisiana State University


Health Sciences Center, New Orleans, Louisiana, U.S.A.

Sandeep Jain, M.D. Corneal and Refractive Surgery Service, Massachusetts Eye and
Ear Infirmary, Schepens Eye Research Institute, and Harvard Medical Schoool, Boston,
Massachusetts, U.S.A.

Carolyn E. Kloek, B.A. Corneal and Refractive Surgery Service, Massachusetts Eye
and Ear Infirmary, Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

Stephen D. Klyce, Ph.D. Department of Ophthalmology, Louisiana State University


Health Sciences Center, New Orleans, Louisiana, U.S.A.

Tommy S. Korn, M.D. University of CaliforniaSan Diego, and Sharp Rees-Stealy


Medical Group, San Diego, California, U.S.A.

Ronald R. Krueger, M.D. Department of Refractive Surgery, Cole Eye Institute, Cleve-
land Clinic Foundation, Cleveland, Ohio, U.S.A.

Francois Malecaze, M.D. Hopital Purpan, Toulouse, France

Vasavi Malineni, M.D. Department of Ophthalmology, Louisiana State University


Health Sciences Center, New Orleans, Louisiana, U.S.A.

Robert K. Maloney, M.D. Maloney Vision Institute, Los Angeles, California, U.S.A.

Edward E. Manche, M.D. Stanford University School of Medicine, Palo Alto, Califor-
nia, U.S.A.

Fabrice Manns, Ph.D. Ophthalmic Biophysics Center, Bascom Palmer Eye Institute,
University of Miami Medical School, Miami, and Department of Biomedical Engineering,
University of Miami College of Engineering, Coral Gables, Florida, U.S.A.
xii Contributors

Marguerite B. McDonald, M.D. Department of Ophthalmology, Louisiana State Uni-


versity Health Sciences Center, New Orleans, Louisiana, U.S.A.

Shahzad I. Mian, M.D. Corneal and Refractive Surgery Service, Massachusetts Eye
and Ear Infirmary, Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

Mark Packer, M.D. Department of Ophthalmology, Casey Eye Institute, Oregon Health
and Science University, Portland, Oregon, U.S.A.

Jean-Marie Parel, Ph.D. Ophthalmic Biophysics Center, Bascom Palmer Eye Institute,
University of Miami Medical School, Miami, Department of Biomedical Engineering,
University of Miami College of Engineering, Coral Gables, Florida, U.S.A., and University
of Liege, CHU Sart-Tilman, Liege, Belgium

Jay S. Pepose, M.D., Ph.D. Department of Ophthalmology and Visual Sciences, Wash-
ington University School of Medicine, St. Louis, and Pepose Vision Institute, Chesterfield,
Missouri, U.S.A.

Chris B. Phillips, M.D. Department of Ophthalmology, Hermann Eye Center and Uni-
versity of Texas Health Science Center at Houston Medical School, Houston, Texas,
U.S.A.

George M. Salib, M.S., M.D. Department of Ophthalmology, Tulane University School


of Medicine, New Orleans, Louisiana, U.S.A.

Kimberly Sippel, M.D. Massachusetts Eye and Ear Infirmary, Schepens Eye Research
Institute, and Harvard Medical School, Boston, Massachusetts, U.S.A.

Michael K. Smolek, Ph.D. Department of Ophthalmology, Louisiana State University


Health Sciences Center, New Orleans, Louisiana, U.S.A.

Kazuo Tsubota, M.D. Department of Ophthalmology, Tokyo Dental College, Ichikawa


City, Chiba, Japan

Rasik B. Vajpayee, M.D. Corneal and Refractive Surgery Service, Massachusetts Eye
and Ear Infirmary, Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

Paolo Vinciguerra, M.D. Department of Ophthalmology, Istituto Clinico Humanitas,


Milan, Italy

Steven E. Wilson, M.D. Department of Ophthalmology, University of Washington, Se-


attle, Washington, U.S.A.
Contributors xiii

Richard W. Yee, M.D. Department of Ophthalmology, Hermann Eye Center and Uni-
versity of Texas Health Science Center at Houston Medical School, Houston, Texas,
U.S.A.

Samiah Zafar, M.B.B.S. Corneal and Refractive Surgery Service, Massachusetts Eye
and Ear Infirmary, Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.
1
Introduction

KAZUO TSUBOTA
Tokyo Dental College, Ichikawa City, Chiba, Japan

SUMMARY

A new era of refractive surgery is on the horizon in the field of hyperopia and presbyopia
correction. Corneal intervention, corneal implants, corneal rings, intraocular lenses, and
scleral intervention are the major treatment strategies. Although this field is new and some
of the novel surgeries may not endure into the future, this book covers all of the clinical
and basic research activities available as of the year 2003.

A. OVERVIEW

Refractive surgery is currently evolving toward a new stage. Although high myopia and
irregular astigmatism cannot be corrected fully, laser-assisted in situ keratomileusis
(LASIK) for myopia and myopic astigmatism has already become an established technol-
ogy, with millions of patients benefiting from LASIK every year all over the world. The
next challenge will be the correction of hyperopia and presbyopia. In most advanced
countries, life spans have been increasing annually and have now passed the 80-year mark.
Baby boomers in the United States, Japan, Europe, and other countries are getting older,
with an expected mean age of 50 to 60 years by the year 2005. Although the ratio of
hyperopia cases is lower at younger ages, hyperopia becomes increasingly significant in
the later stages of life. It has been estimated that around 20% of the U.S. population are
hyperopic at the age of 40, and the rate is above 60% at age 65. Even in Japan, where
myopia is the dominant refractive error, the ratio increases from 15% at age 40 to 30%
at age 65. People may develop cataracts, possibly indicating phacoemulsification and
intraocular lens implantation, but the majority of the elderly still do not have cataract
1
2 Tsubota

Table 1 Medical and Surgical Correction of Hyperopia


Medical correction Surgical correction

Glasses Photorefractive keratectomy (PRK) or laser-


assisted in situ keratomileusis (LASIK)
Contact lenses Phakic intraocular lenses (IOLs)
Clear lens extraction with IOLs
Laser thermal keratoplasty (LTK)
Conductive keratoplasty (CK)
Diode laser keratoplasty
Corneal implant
Intracorneal ring (ICR) modification

surgery. It is well known that nearly everyone develops presbyopia with age. Thus, in an
aging society, correction of hyperopia and presbyopia is anticipated to become more impor-
tant than it currently is.
This book covers the current medical and surgical treatments for the correction of
hyperopia and presbyopia. An effort is also made to cover new technologies, although
these are still preliminary and controversial. In this sense, this is no ordinary textbook
based only on authority and established principles. Rather, it is a new comprehensive
information book introducing current technology and developmental trials. The emerging
innovation of thermal or conductive keratoplasty as well as corneal implants for
hyperopic correction now provide exciting potential. Furthermore, the new Schachar
theory of presbyopia is now attracting attention as a strategy for the treatment of
presbyopia. Scleral relaxation, using a diamond knife or laser, and scleral expansion
rings are also potential technologies. All of the established as well as the new medical
and surgical treatments are described in this book, with the relevant theoretical back-
grounds, clinical results, and possible complications indicated (Tables 1 and 2, Figs.
1 and 2).

Table 2 Medical and Surgical Correction of Presbyopia


Medical correction Surgical correction

Bifocal and multifocal glasses Monovision by LASIK


Bifocal and multifocal HCL Multifocal LASIK
Bifocal and multifocal SCL IOL with multifocal
Bifocal disposable SCL Hinged IOL
Scleral expansion ring
Scleral incision
Scleral relaxation by laser
Small-diameter corneal lens
Key: HCL, hard contact lens; SCL, soft contact lens; LASIK, laser-assisted in situ
keratomileusis; IOL, intraocular lens.
Introduction 3

Figure 1 Surgical correction of hyperopia.

Figure 2 Surgical correction of presbyopia.


4 Tsubota

B. HISTORY OF MEDICAL AND SURGICAL CORRECTION OF


HYPEROPIA
The most commonly used corrective devices for hyperopia are glasses and contact lenses.
Since surgical correction is still in its preliminary stages, most patients around the world
still use glasses or contact lenses. Before discussing the current technology, let us broadly
review some older ideas. In the history of surgical correction, there have been several
methods that are no longer popular. One technology was keratomileusis as originally
proposed by Jose Barraquer in Colombia (13). He developed a technique in which a
central lamellar keratectomy is performed and a resected disk is shaped using a Barraquer
cryolathe (4). The shaped disk is then sutured in place. For hyperopic correction, more
tissue is removed from the periphery of the disk, producing a steepening of the central
portion of the cornea (5,6). In order to minimize the complexity of the procedure, a donor
disk is also used. This is called keratophakia. The corneal lenticule is obtained from a
donor cornea, frozen, and shaped with a cryolathe into a refractive disk with central
thickness (2). A lamellar flap is made on the host cornea, the disk is inserted intrastromally,
and the lamellar cut is replaced. Kaufman and Werblin further developed this technique
of epikeratoplasty (7,8). Donor corneal tissue is prelathed into the proper shape and sutured
onto a recipient, de-epithelialized cornea in which Bowmans layer and the stroma are
intact. This technique is described by the term living contact lens. The change in curvature
of the anterior surface produced by the lenticule provides the refractive correction. First,
the corneal epithelium of the host cornea is removed and an annular keratectomy is per-
formed. A partial lamellar dissection peripheral to the trephine is used as a groove for
lenticule suturing. Interrupted and running 100 nylon sutures are used to secure the tissue
and are removed 10 weeks later (Figs. 3 and 4). This technique was originally developed
for aphakia and keratoconus (7,9). The results were slightly disappointing relative to
predictions, and the technique was abandoned. (10)
Hexagonal keratotomy is another refractive procedure formerly employed for hyper-
opia. The procedure consists of making a series of paracentral incisions in a hexagonal
pattern with subsequent steepening of the central cornea (11). This curvature change is
due to weakening of the central cornea, which has been incised and separated from the
peripheral cornea, resulting in bulging of the center due to intraocular pressure. The initial
results seemed promising, but this procedure was later found to frequently be associated
with glare, photophobia, fluctuating vision, and irregular astigmatism (12). Thus, this

Figure 3 Diagram of epikeratophakia. Donor corneal lens is placed on the Bowmans layer with
stromal pockets sutured with 100 nylon.
Introduction 5

Figure 4 Photograph of epikeratophakia. Note the corneal lens on the top of the cornea.

technique was abandoned. Predictability was not adequate, such that the procedure did not
gain popularity. In the specific situation of postoperative hyperopia after radial keratotomy,
suturing of the corneal incision is useful for the correction of hyperopia up to 2 diopters. It
is believed to stabilize refractive status, thus minimizing corneal shape fluctuation (13,14).
Automated lamellar keratoplasty is another method for the correction of hyperopia.
Historically, the idea for this also came from keratomileusis. Steepening of the central
cornea was observed to occur with lamellar keratotomy alone. Recently, ectasia of the
cornea after myopic LASIK has become a major long-term safety concern. Progressive
ectasia in a significant percentage of eyes, another major concern, also renders this tech-
nique unattractive. When the cut is deep, more ectasia unavoidably occurs with this proce-
dure. The amount of ectasia depends on the optical zone. When the optical zone is small,
the curvature is relatively high. When the optical zone is large, the curvature is low. The
nomogram was developed on the basis of this observation (15,16). When the optical zone
is 6.6 mm, the correction is 1.0 D; whereas the correction is 6.5 D with an optical zone
of 5.0 mm. The cut should be deepe.g., 65%. The initial results were promising, but
the nomogram is not always predictable. With the development of hyperopic LASIK, use
of this procedure is now limited (17).
The mechanical corneal contouring device invented by Eiferman and Nordquist is
another means of correcting hyperopia (18). The principle is based on the observation that
when the peripheral cornea is flattened, the central optical power is increased. The instru-
ment consists of a vacuum chamber and steel blades positioned at orthogonal angles. When
a Teflon stopper is added to the blade and the stopper pressed down on the eye, the
peripheral cornea bulges, such that the blades can remove more tissue in the periphery
than at the central cornea. The clinical results remain unknown.

C. CURRENT SURGICAL CORRECTION OF HYPEROPIA


Photorefractive keratectomy (PRK) for hyperopia is useful for the correction of hyperopia
up to 3.0 to 4.0 D; however, healing of the corneal epithelium has effects on the final
6 Tsubota

result, such as regression and/or haze (1923). Predictability is still poor for moderate to
high myopia. LASIK, which was originally developed for the correction of myopia
(2426), is considered theoretically to be more advantageous for the correction of hyper-
opia because it is possible to ablate the corneal midperiphery by stromal photorefractive
ablation and to prevent strong epithelial regression with an overlying flap (2729). With
the expansion of optical zone treatment, LASIK has now become an acceptable treatment
for hyperopia of up to 5 D (3036). This method is fully discussed in Chapters 7, 1315.
The Phakic IOL has also been used for the correction of hyperopia as well as for
aphakia and high myopia (3740). The use of posterior chamber phakic IOL, such as the
Staar Collamer implantable contact lens (Staar Surgical, AG, Nidau, Switzerland) appears
to be promising, although there is a risk of cataract formation. The recent development
of very light floating lenses, such as the Medennium (Ciba Vision, Duluth, GA), may be
another innovation. The lens is very light, almost floating, and does not touch the patients
own lens. Iris-claw lenses in phakic eyes, to correct hyperopia, are also promising (Fig.
5), despite the risks of glaucoma and corneal degeneration. Very thin anterior chamber
phakic IOLs, angle support lenses such as Nuvita (Bausch & Lomb Surgical, Rochester,
NY), and new foldable lenses designed by Bakoff (fully discussed in Chapter 11) are
other promising technologies. These are discussed in detail in Chapters 11 and 12. Clear
lens extraction can produce cystoid macular edema and retinal detachment and is less
accurate and predictable for hyperopia below 3.0 D (41,42).
Reshaping the corneal curvature by heating of the peripheral cornea is another major
approach for hyperopic correction. Currently, there are three ways to do this. One is laser
thermal keratoplasty (LTK) (4346). This employs a holmium laser technique, called the
Sunrise LTK Procedure (Sunrise Technologies International, Inc. Fremont, CA), to heat
the corneal collagen in several spots in the periphery. The resulting thermal contraction
steepens the central corneal curvature, thus correcting hyperopia. This procedure has re-
ceived approval from the U.S. Food and Drug Administration (FDA). The treatment range
will be up to 2.5 D. The second method is conductive keratoplasty (CK) (Refractec, Inc,

Figure 5 Artisan hyperopia 5 mm, phakic intraocular lens (IOL) for the correction of hyperopia.
(Figure provided courtesy of OPHTEC BV, Groningen, The Netherlands.)
Introduction 7

Figure 6 Conductive keratoplasty for the correction of hyperopia. (Figure provided courtesy of
Refractec, Inc., Irvine, CA, USA.)

Irvine, CA) (Fig. 6). This method uses a radiofrequency generator as the energy source
instead of a holmium:YAG laser. The energy is delivered through a microtip inserted deep
into the stroma. The procedure is considered to minimize regression relative to LTK
because the energy is applied deep in the cornea, thereby creating an affected spot that is
uniform in depth. The CK was approved by the FDA in April 2002. Diode laser treatment
is a third approach (4749). This procedure uses a 1.8-U diode laser as an energy source
(Rodenstock, Munich, Germany). The application is similar to CK in that the probe is in
contact with the peripheral cornea. The diode laser has not yet obtained FDA approval.
All three technologies are described in detail in Chapters 8 and 9.
The ICS (Intrastromal Corneal Segments) or Hyperopia Segments is a variation
of the INTACS Prescription Inserts (Addition Technology, Inc., Fremont, CA) under
investigation in the United States, Europe, Brazil, Mexico, Singapore, and the U.K. While
INTACS inserts correct for myopia by flattening the central portion of the cornea, the
ICS is designed to correct hyperopia by steepening the anterior corneal curvature by the
insertion of the ring materials at the limbal area, instead of inserting at the 7-mm central
zone as for myopic correction. The ICS may also be used for hyperopia concurrent with
astigmatism or hyperopic astigmatism. Clinical investigations have been initiated in both
Mexico and Europe for the treatment of hyperopia using the ICS clinical product. The
results are most encouraging, with stability achieved around the Month 3 exam and hyper-
opic corrections of up to 4.63 D (based MRSE) at Month 6 (n43) and slightly less than
3.0 diopters of hyperopic correction (2.75 D) at the Month 12 exam. Manifest Refraction
stability is demonstrated through the Month 12 time point. Clinical trials in Europe are
ongoing.
Corneal implants have long been an attractive idea, but lack of suitable materials has
inhibited the development of this technology. New materials have again made it attractive.
Historically, Barraquer, who inserted glass materials into the corneal stroma in animals,
developed the intracorneal technique. There was always a loss of transparency, with vascu-
larization and extrusion of lenses. It was not known at that time that nutrients such as
8 Tsubota

amino acids and glucose come from the aqueous humor and that oxygen is supplied from
the ambient air. The glass lens interfered with the exchange of these components through
the corneal stroma. Then, fenestrated intracorneal polysulfone lenses were developed to
enhance the exchange of metabolic components. However, opacification was associated
with these fenestration techniques. This was a major obstacle to the implementation of
this technology. The recent development of a small-diameter lens made of a hydrogel
copolymer (Chiron Corporation, Emeryville, CA), with a water content of 45%, for correc-
tion of presbyopia, has paved a new pathway for this technology (53). Since the lens is small
in diameter (1.82.2 mm), nutrient diffusion is not impaired (54). Lindstrom suggested the
usefulness of this technology for a select group of patients (53). Anamed, Inc., recently
developed novel biocompatible, clear, and permeable hydrogel materials with substantially
higher permeability than typical hydrogels with similar water content. The refractive index
of the material is essentially identical to that of corneal tissue (1.376 D), and has a water
content exceeding 70%. The lens diameter ranges from 4.5 to 6.0 mm, depending on the
diopter correction needed. The meniscus design includes a central thickness of 50 m
and an edge thickness of 20 m. A preliminary animal study showing the safety and
efficacy of this lens and a limited clinical trial were both performed by Dr. Stephen G.
Slade, M.D., Director of the Laser Center of Houston, Texas. He reported that there was
no haze formation except in one patient with minimal haze (1), which later resolved.
No lines of best-corrected visual acuity were lost and the refractive correction was accurate.
A flap is made with a microkeratome and the lens is placed in the center of the pupil.
Since making a flap with a microkeratome is now a standard technique in refractive
surgery, this technique is relatively simple for most surgeons currently performing LASIK.
In LASIK, it is necessary for the correction of hyperopia to remove twice as much tissue
as the same myopic diopter correction with certain regression, such that the intracorneal
approach is reasonable. The FDA approved Phase I of the clinical trial for the PermaVisi-
on intracorneal lens, involving 10 eyes, which began in November 2001 (Fig. 7). An
interim clinical analysis has been completed and submitted to the FDA, along with a

Figure 7 PermaVision intracorneal lens for the correction of hyperopia. (Figure provided cour-
tesy of Anamed Inc., Lake Forest, CA, USA.)
Introduction 9

request to move into Phase II of the clinical protocol. As of November 2002, Anamed is
awaiting FDA approval to begin Phase II. This is considered to be a promising technology.
However, the long-term complicationssuch as corneal stromal and epithelial thinning
as well as endothelial changemust be evaluated in terms of safety.

D. CURRENT MEDICAL AND SURGICAL CORRECTION OF


PRESBYOPIA
The major means of correction are simple glasses or simple contact lenses (55). The
development of bifocal glasses provided the first convenience, allowing the use of only
one pair of glasses throughout the day. Bifocal contact lenses are another popular method
for the correction of presbyopia (56). According to the 1999 contact lens spectrum reader
profile survey, 21.5% were fit with monovision, 9% with soft multifocals, 3% with rigid
gas permeable (RGP) multifocals, and 5% with single-vision contact lenses and reading
glasses. The remainder had spectacles only. A major disadvantage of this method is com-
promised visual quality (57). Success depends on the patient having a realistic expectation.
Monovision contact lenses are also used (58,59). The increasing prevalence of dry eye in
the elderly might be an obstacle to the application of this technique for many patients.
Since the introduction of disposable bifocal contact lenses (Vistakons Acuvue Contact
Lenses, Jacksonville, FL) in 1999 (60), use of bifocal contact lenses for the correction of
presbyopia has been increasing. With further development of materials and designs from
companies such as Ciba Vision and Bausch & Lomb, Inc., bifocal contact lenses have
apparently become the major corrective method for presbyopia.
The intraocular lens with multifocal optics is another method for correcting presby-
opia. This method is based on a theory termed the simultaneous vision principle, whereby
separate images of near and distant objects are formed and, if the power difference between
the two optical systems is more than 3.0 D, the images are dissimilar enough for the brain
to interpret them as separate. The brain therefore selects the highly focused image and
suppresses the other. This IOL can be achieved with two distinct optical elements (bifocal
IOL) (61) or by means of diffractive optics (62), in which concentric diffractive zones
are applied to the posterior surface of the implant in order to focus light from near objects.
Both types of IOLs require central fixation and are relatively successful in younger patients.
Monovision intraocular lenses are also the choice for presbyopic correction (61).
The IOL with real accommodative power has long been studied by Japanese and
other researchers. The gel technology reached a certain level, using monkey eyes, in which
the lens capsule was filled with soft gel. However, clinical application has not yet begun.
Recently, a hinged haptic accommodative lens was developed and has attracted considera-
ble attention. The proper functioning of the lens is dependent on movement of the remain-
ing lens capsule, contracted by the ciliary muscle. When the lens capsule expands, the
lens changes position and focuses. There are now several companies working on this
technology (Fig. 8).
Like the multifocal intraocular lens, LASIK can also offer the multifocal effect by
means of changing the corneal shape. It was first observed that regional variation in corneal
curvature in the eyes of patients 45 years of age or older sometimes provides good near
vision without correction (63). The regional variation in corneal power apparently ex-
plained how the multifocal lens effect could be achieved. Thus, intentional multifocal
LASIK is a potential technology, which is still under investigation (64). Another practical
method is monovision LASIK. Monovision is defined as providing optical correction of
10 Tsubota

Figure 8 Finite-element computer simulation of accommodative intraocular lens (IOL), a flexible


micro-optic with accommodative features. (Figure provided courtesy of Human Optics AG, Erlangen,
Germany.)

one eye for distance vision and of the other eye for near vision. This is usually achieved
with contact lenses or intraocular lenses after cataract extraction, but can be achieved by
LASIK as well (65). The ideal diopter difference necessary for both distant and near vision
has not yet been determined. Since most patients with presbyopia undergoing LASIK still
have some accommodative ability, there are several components that should be evaluated
and determined for mass application of LASIK monovision. This is fully discussed by
Azar in Chapter 18.
The concept of anterior ciliary sclerotomy (ACS) is a new challenge in the treatment
of presbyopia (66). This surgery is based on the theory that the lens is ectodermal in origin
and constantly grows throughout life, gradually filling the eye and leaving no space for
accommodation (67,68). Loss of lens elasticity might contribute to the mechanism of
presbyopia, and this theory raises the possibility that reduced space is the cause of the
reduced accommodative power of the lens. Thus, somehow expanding the globe by ciliary
sclerotomy can provide space for the ciliary body and lens for accommodation. Along
this line, the original anterior sclerotomy as well as Fukasaku incisional surgeries have
been developed (69). Since there is regression of the results due to wound healing, Fuka-
saku recently developed a method of inserting silicon plugs for the maintenance of the
incision (69). Furthermore, the erbium:YAG laser has also been applied to making a wide
scleral incision that may not heal quickly, thus maintaining the effect (Figs. 9 and 10). I
have personal experience of two patients who had previously undergone LASIK. Both
were Japanese males, aged 58 and 48 years. Both had 1.0 far vision without correction
and near vision of 0.3 without correction, and both were having difficulty with reading.
I applied the laser to a limbal-scleral area 4.0 mm in length. A total of 8 lasers were
applied in a radial configuration. One day after surgery, both patients had 0.6 to 0.7 near
Introduction 11

A B

C
Figure 9 (A) Scleral relaxation by laser. The eight incisions at the sclera. The incision is 4 mm
in length and 0.5 mm from the limbus. The parallel incisions are 2 mm apart. (B) Possible mechanism
of scleral relaxation for the treatment of presbyopia. (C) Scleral incision by Erbium:YAG laser.
Optics are applied directly to the sclera where the conjunctiva is opened.
12 Tsubota

Figure 10 Slit-lamp view of the sclera incision by Erbium:YAG. The arrow indicates the incision
fully covered by the conjunctiva.

vision without correction, reporting that they could read the newspaper without glasses.
The technique must be evaluated in regard to long-term safety and efficacy, but the results
appear to be promising. Recently, Schachar et al. proposed a new surgical treatment using
a scleral expansion ring based on the same theory (Fig. 11) (67). Since several negative
reports have been published on this theory and surgery (70,71), this area is discussed in
Chapters 3, 20, and 21.

Figure 11 Slit-lamp view of the Schachar scleral band. Note that the scleral band is visible and
slightly elevated.
Introduction 13

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2
Basic Optics of Hyperopia and
Presbyopia

MICHAEL K. SMOLEK and STEPHEN D. KLYCE


Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A.

A. INTRODUCTION

It normally comes as a surprise that there are more hyperopes than myopes in the general
population. The reason for this is that hyperopes can hide behind their accommodative
capacity until at least age 40, when the aging process takes away the ability to alter the
power of the natural lens. In this chapter, we examine the optical basis and interrelation-
ships between hyperopia and presbyopia.

B. FAR POINT

The simplest and preferred clinical method of determining the refraction of the eye is still
the far point method, in which the patient subjectively determines the furthest distance at
which he or she can clearly see a target without using any accommodation. The far point
location of the eye can also be determined objectively by an examiner using a retinoscope,
an automated refractor, or similar method. By definition, the far point is the focal point
in object space that is conjugate to the focus at the retina and is, therefore, seen clearly
by the subject. Again, because of the spherical aberration (multifocality) of the eyes optics
and the physical size of the pupil, there may actually be a distance range that appears to
be in focus simultaneously (i.e., a depth-of-field effect), but a single far point is specified.
The far point of the eye is distinct from the near point of the eye, which is the location
at which one can maximally accommodate in order to clearly see the closest possible
target to the eye.
17
18 Smolek and Klyce

For the emmetrope, the far point is located at optical infinity, and no power correction
is needed to image a distant target onto the retina (Fig. 1). In myopia, the far point lies
close to and a finite distance in front of the eye, so that light from the far point target
enters the eye with a certain amount of negative vergence. The amount of negative vergence
cancels the excess power inherent within the myopic eye, and the light comes to a focus
at the retina. The specific location of the far point for the nearsighted myope depends
on the level of myopic error; the higher the error, the nearer the far point will be to the
eye. In order for the myope to clearly see a target located at optical infinity, negative
power must be added to reduce the vergence of the distant light to a negative amount
before it enters the eye; otherwise the excessive power of the eyes optics must be reduced,
as through flattening of the cornea by laser surgery. Myopic error is always expressed
with a negative sign indicative of the negative power that must be added to achieve
correction for viewing distant targets.
In hyperopia, the far point is commonly said to exist beyond infinity, because
only converging rays can be brought to a focus onto the retina in the uncorrected hyperope
(Fig. 1). Actually, it is more accurate to say that the far point of the hyperope is a virtual
object that is located a finite distance behind the retina. The far point of the hyperope can
be found by noting the location where the converging rays entering the eye would come
to a focus if the eye were not present to intercept the light.
Because hyperopic eyes have insufficient plus power to see targets clearly at infinity,
positive vergence must be added to the light entering the eye and the refraction is signified
by a plus sign. Plus power can be added to the light entering the eye or the eye itself can
be made to have relatively more power by making the cornea steeper through laser surgery.
However, many young to middle-aged hyperopes can fully correct their distance vision
error by adding enough plus power through accommodation to shift the far point to infinity.
This ability to self-correct their refractive error gives these hyperopes a distinct advantage
over myopes, who cannot disaccommodate to move the far point away from the eye.
It also explains why these hyperopes can be considered to be farsighted, because they in
fact become self-corrected for far vision. Unfortunately, as hyperopes age, the ability to

Figure 1 Far point location specified for three refractive states. R is the location of the far point,
defined as the most remote distance at which the unaccommodated eye can see clearly. R is the
conjugate focus of the far point, which is always located at the retina. D refers to the vergence
power entering the eye to bring light to a focus on the retina: zero for emmetropia, negative for
myopia, and positive for hyperopia.
Basic Optics of Hyperopia and Presbyopia 19

Figure 2 Graphic representation of the decline in accommodative amplitude with age (2).

accommodate diminishes (Fig. 2); thus they lose their ability to see clearly at any distance,
while older myopes still retain at least a portion of their ability to see clearly at some
distance.

C. ACCOMMODATION FOR NEAR VISION


The closer an object is to the cornea, the greater the divergence of light entering the eye
and the greater the need for more plus power to make the near object conjugate with the
retina. In youth, accommodation allows viewing at a variety of distances from infinity to
very near targets. As a person ages, however, the accommodative ability decreases, and
the near point moves away from the eye. Because uncorrected hyperopes often use a
portion of their accommodative ability to correct their refractive error for distance, the
near point is located farther from the eye; therefore hyperopes often experience near vision
problems at an earlier age than myopes or emmetropes. It should be noted that some
myopes may not experience any near vision problems in the uncorrected state if their
refractive error maintains a clear image within a comfortable working distance that is
neither too close nor too far from their eyes.
It is important to appreciate that there is a limited and diminishing amount of accom-
modation available at any given age and that the amount available depends in part on
whether accommodation is being used to correct for a hyperopic error. This amount of
accommodation in play is specified by the amplitude of accommodation, which is defined
as the vergence difference between the far point and the near point. The relationship
between age and accommodative amplitude was established by Donders (1) and later
refined by Duane (2), who presented what has since become the classic representation of
accommodative amplitude as a function of age (Fig. 2). Duanes data show that accommo-
dation begins to decrease in early adulthood, well before the decline is noticed during
the performance of near vision tasks, such as reading. For adolescents, accommodative
amplitude is approximately 14 D, which corresponds to a near point of approximately 7
20 Smolek and Klyce

cm for an emmetrope. By age 45, this accommodative amplitude drops, due to changes
in the accommodative apparatus controlling the crystalline lens power, to about 4 D and
results in at best a 25-cm near point distance for that same emmetrope. Normal reading
distance is considered to be around 15 in. or 37 cm, which is still within the range of a
person in his or her mid- to late forties. However, it must be remembered that a continuous
and excessive need to accommodate can be tiring and uncomfortable, so the decline in
accommodative amplitude will be noticed by many subjects who are only in their mid-
forties and who still have a fair amount of accommodative amplitude in reserve.
If the eye has insufficient accommodative amplitude, which normally occurs with
advancing age and requires a plus lens addition for comfortable near vision, the condition is
called presbyopia. There are no specific values that define the absolute onset of presbyopia,
because its effects are dependent on a number of factors including the refractive error,
age, amplitude of accommodation, and the near vision tasks and lifestyle of a particular
patient. Because using accommodation to correct for distance vision is often tiring in itself,
the hyperope will be more likely to complain of tired eyes, eyestrain, and diplopia, and
may do so at an earlier age. Children do not normally experience vision problems
from mild amounts of hyperopia because their accommodative reserve is large. However,
those with moderate to high levels of hyperopia may experience visual problems
ranging from mild eyestrain and headaches after near work to more severe problems
such as strabismus and amblyopia (3). Some of these complaints are associated specifi-
cally with the ability of the two eyes to fuse images binocularly, because the accommoda-
tive process is neurologically tied to the convergence of the eyes.
There is a clinical distinction made between accommodative amplitude, which is
the optical difference between the near and far point measured in diopters, and the range
of accommodation, which is the linear difference between the far point and the near point
in terms of physical distance. In the uncorrected myope, the far point may be located very
close to the eye. The myopes range of accommodation is thus very limited, whereas
prepresbyopic low hyperopes may have a range that allows vision to infinity, just as in
emmetropia (Fig. 3).

D. MANIFEST VERSUS LATENT HYPEROPIA


The refractive state of the eye is measured at rest with respect to the far point, but achieving
a totally unaccommodated state can be problematic, especially in the uncorrected hyperope
who uses accommodation to self-correct for distance vision. Consequently, refractions are
separated into two basic typesmanifest and latent refractionswhich can give different
refraction values for the same eye. A manifest refraction is the obvious, nonhidden part
of the refraction that is based on the elimination of any natural stimulus to accommodate.
Generally this is best accomplished by providing additional positive vergence of a known
amount to the incoming light to the extent that the eye is made artificially myopic. The
process is referred to as fogging. The far point thus moves to a finite distance in front of
the eye, which in itself is beneficial with respect to interacting with and measuring the
location of the far point. Of course, once the myopia-shifted far point is measured, the
added vergence power is subtracted to provide the true far point location.
While fogging a patient removes the manifest portion of the total accommodation
that may be in play, it does not necessarily remove the latent or hidden portion of accommo-
dation that may still exist. Latent accommodation is that part which cannot be relaxed due
to excessive, spastic tonicity of the ciliary apparatus controlling accommodation. Self-
Basic Optics of Hyperopia and Presbyopia 21

C
Figure 3 Example of the possible range of accommodation for three refractive states at three
different ages. R is the far point and P is the near point. The dark line refers to the theoretical region
in which unaided clear vision is possible. (A) In emmetropia, objects at optical infinity can be seen
at any age. (B) In myopia, objects seen clearly are always located a finite distance in front of the
eye, but objects at optical infinity cannot be seen clearly. (C) In hyperopia, objects at optical infinity
can usually be seen clearly in youth and middle age; by the time late presbyopia occurs, however,
no objects can be seen clearly at any distance unless the hyperopic error is corrected.
22 Smolek and Klyce

correcting hyperopes tend to be prone to accommodative excess because they are constantly
demanding additional plus power from the lens for both near and far tasks, and this effort
builds up a constant level of spastic tonicity in the ciliary muscle. Therefore a cycloplegic
drug is used to completely relax the spastic tonicity of the ciliary muscle, after which a
refraction is performed to determine the full latent refractive error. Typically, the latent
accommodation may account for approximately 1 D of total accommodation, so the differ-
ence between manifest and latent refractions may be clinically significant.

E. MAGNIFICATION AND VISUAL ACUITY


A refractive error can be fully corrected and image blur eliminated, but the retinal image
may be smaller or larger than it would be in the uncorrected state; therefore the ability
to resolve details in the image may be harder or easier to accomplish. Suppose we have
a hyperope with a 5 D correction in a spectacle plane 1.2 cm from the cornea. The
apparent image size will be reduced by 6% if the correction is moved to the corneal plane,
as in the case of laser refractive surgery or contact lens wear (Table 1). If the spectacle
correction is increased to 10 D, the amount of minification for a corneal plane correction
likewise doubles to 12%. The general rule of thumb is that spectacle magnification in
percent equals the power of the spectacle lens in diopters multiplied by the distance
between the spectacle plane and the cornea in centimeters. Because we are considering
an image projected from the eye in order to assess the apparent visual angle change
experienced by the subject, distances are considered positive when measured from the
cornea to the spectacle plane and negative when moving from the spectacle plane back
to the cornea. Thus, moving a correction from the cornea to a spectacle plane in the
hyperope causes magnification of the retinal image, and the further the spectacle plane is
from the eye, the greater the change in the magnification. However, when the correction
is moved from the spectacle plane back to the cornea, the retinal image becomes physically
smaller in the hyperope. Therefore, Snellen letters subtend a relatively smaller angle in
the visual field and appear smaller to the patient and harder to distinguish. The opposite
relationship holds true for the myope; moving the correction from the spectacle plane to
the cornea causes Snellen letters to appear slightly larger to the myope corrected by
refractive surgery or a contact lens.
Applegate and Howland calculated the effects of magnification on Snellen visual
acuity and, as expected, showed that the effective change in acuity was nonlinear and
greater for myopes than for hyperopes (4). Whereas myopes had a positive effect of
gaining more letters of visual acuity, hyperopes lost letters of acuity. For example, a 5

Table 1 Magnification Effect of Moving a Correction from the Spectacle Plane to the Cornea
Spectacle Spectacle plane Spectacle Loss of letters for Snellen
power (D) distance (cm) magnification (%) distance visual acuity

2 1.2 2.4 1
2 1.5 3.0 1
5 1.2 6.0 2
5 1.5 7.5 2
10 1.2 12.0 3
Basic Optics of Hyperopia and Presbyopia 23

D hyperope wearing glasses who has successful refractive surgery is expected to lose two
to four letters of acuity as a result of moving the correction to the cornea, depending on
the exact distance of the spectacle plane from the cornea (Table 1).

F. HYPEROPIA AND BIOMETRIC CHANGES DURING LIFE


Based on spherical equivalent data obtained during cycloplegic refractions, the average
eye is hyperopic through most of life (Fig. 4). The average refraction is approximately
2.25 D at birth and reaches a hyperopic peak around 8 years of age, after which the
refraction becomes increasingly less hyperopic during adolescence and comes close to
being emmetropic during early adulthood (5). In the Beaver Dam Eye Study of adults,
hyperopia was more prevalent than myopia in age-matched subjects (49 vs 26.2%, respec-
tively, p 0.0001) (6). Hyperopia increases in later adulthood from 22.1% between ages
43 and 54 to 68.5% at age 75 and above; however, Slataper noted that the refraction
tends to drift back toward myopia with very advanced age (5). The hyperopic shift
for older adults between the ages of 45 and 65 has been attributed to reductions in
the axial length of the eye and changes in the focal power of the lens (7). The cause
of the myopic drift in advanced age may be attributed to a shrinking radius of
curvature of the cornea, which leads to a higher corneal power (8). This effect occurs
predominantly in females (9).
Passive growth of the eye during childhood tends to be a correlated, uniform expan-
sion of ocular dimensions (7,10). By correlated we mean that as eye growth causes the
retina to recede from the optical elements of the eye, we also see changes in the lens and
cornea that ideally allow emmetropia to be achieved if the eye is hyperopic or retained
if the eye is already emmetropic. Furthermore, it must be remembered that as axial length
increases, there is a reduction in the vergence power required to focus an image on the

Figure 4 Graph based on Slatapers data (5) of average refractive error during life. Note that the
error tends to be hyperopic throughout life and relatively stable from young adulthood to middle
age. N 34,570 eyes assessed by cycloplegic refractions.
24 Smolek and Klyce

retina. During childhood, corneal power decreases by about 2 D because the radius
of curvature of the cornea increases as part of the expansive growth of the corneoscleral
shell (11). In addition, the anterior chamber depth decreases, which reduces the effective
power of the lens, and the lens itself decreases in power as the radius of curvature
of the front and back surfaces increases by up to 1 mm (11). Sorsby noted lens power
to be on average 23 D at age 3 and only 20 D at age 14 (12). The lens also thins
from an average of 3.6 mm at age 6 to about 3.4 mm at age 10, after which thinning
essentially halts (11). The overall lens thinning can be attributed to a compression of
the nucleus, even though the cortex grows and thickens at this time.
There appears to be an active growth mechanism that uses feedback from the blur
of the retinal image to make corrective growth changes to the ocular component dimensions
(7,10). A defect in an active growth feedback pathway might be responsible for a runaway
increase in axial length, which is often seen with myopia; but the active growth mechanism
does not adequately explain hyperopic error. Hyperopia seems more likely to be a failure
of the passive growth mechanism, such that the eye retains slightly immature globe dimen-
sions into adulthood. Hyperopic eyes tend to be smaller in all dimensions (not just in axial
length) compared to corresponding age-matched emmetropic eyes. Using high-resolution
magnetic resonance imaging to measure dimensions in the major axes of the eye, Cheng
and coworkers found that, on average, the hyperopic eye is consistently smaller overall
than the mean emmetropic eye and significantly smaller than the mean myopic eye (Fig.
5) (13). Strang et al. used biometric data from 53 human subjects with refractive errors
of up to 10 D and found that there was a strong correlation between the mean hyperopic

Figure 5 Data based on the findings of Cheng et al. (13) of eye size relative to refractive error.
Error bars indicate standard deviations. The general trend is that myopic eyes are larger and hyperopic
eyes smaller than eyes with no refractive error. The differences in globe dimension between hyperopic
and myopic eyes are significant.
Basic Optics of Hyperopia and Presbyopia 25

error and the axial length of the globe (r2 0.611, p 0.0001) (14). There was also a
weak but significant correlation between mean corneal radius and mean refractive error
(r2 0.128, p 0.009). Grosvenor also found that hyperopic eyes were smaller and
tended to have flatter corneas than emmetropic eyes (15).

G. OPTICS OF THE CRYSTALLINE LENS


The lens has an average index of refraction that higher than the index of corneal stroma
(1.427 vs. 1.376) (16). However, the contribution of the lens to the total power of the eye
is about half that of the anterior corneal surface, because the lens is surrounded by fluid
with an index near 1.336, whereas the cornea is exposed to air with an index of 1.0, which
greatly increases its refractivity. While a single index of refraction of the lens is useful
for simple calculations, in reality, the lens cannot be defined by a single value. Mapping
the gradient index of the lens has proved difficult. Simple models using concentric shells
of varying index gradients do not yield accurate ray-tracing results, and the models do
not agree with refractive index measurements made by tissue probes (17). It is interesting
to find that significant levels of transient hyperopia have been attributed entirely to changes
in the refractive index of the lens. Saito and coworkers noted hyperopia peaking between
1 to 2 weeks after abrupt decreases in plasma glucose and attributed this effect to water
influx into the lens (18). Okamoto et al. also noted hyperopia after treatment for hyperglyce-
mia and found no changes in lens thickness or anterior chamber depth, thus implicating
a change entirely due to the refractive index of the lens (19).
Although the lens is the primary component associated with accommodation for near
vision, the contribution of depth of focus of the eye should not be discounted, particularly in
presbyopic eyes. Brighter viewing conditions or the use of miotics that constrict the pupil
increase the depth of focus and help to extend the effective range of accommodation.

H. OPTICAL ABERRATIONS
The shape of the gradient index profile across the lens as well as shape changes due to
accommodation alter not only effective power but also the spherical aberration of the eye
(20). By accommodating to approximately 3 D (a 33-cm viewing distance), the negative
spherical aberration of the lens corrects for much of the positive spherical aberration
induced by the cornea (21). Further accommodation tends to give the eye an overall
negative spherical aberration, but the exact amount varies among individuals (22). In
general, near accommodation tends to increase the monochromatic wavefront aberrations
of the eye (23). Fourth-order aberrations can either increase or decrease with increasing
accommodation, but higher-order aberrations tend to increase (22). It has been suggested
that there is no correlation between the change in aberration during accommodation and
the total amount of aberration for the relaxed eye (22). It can be concluded that any
clarity of vision provided by refractive surgery must diminish by a measurable extent with
accommodation, but certainly more work needs to be done to ascertain the significance
of aberration change on visual performance.

REFERENCES
1. Donders FC. On the Anomalies of Accommodation and Refraction of the Eye. London, 1864.
2. Duane A. Normal values of accommodation at all ages. JAMA 1912; 59:10101013.
26 Smolek and Klyce

3. Moore B, Lyons SA, Walline J. A clinical review of hyperopia in young children. The Hyper-
opic Infants Study Group, THIS Group. J Am Optom Assoc 1999; 70:215224.
4. Applegate RA, Howland HC. Magnification and visual acuity in refractive surgery. Arch
Ophthalmol 1993; 111:13351342.
5. Slataper FJ. Age norms of refraction and vision. Arch Ophthalmol 1950; 43:466481.
6. Wang Q, Klein BEK, Klein R, Moss SE. Refractive status in the Beaver Dam Eye Study.
Invest Ophthalmol Vis Sci 1994; 35:43444347.
7. Brown NP, Koretz JF, Bron AJ. The development and maintenance of emmetropia. Eye 1999;
13:8392.
8. Hayashi K, Hayashi H, Hayashi F. Topographic analysis of the changes in corneal shape due
to aging. Cornea 1995; 14:527532.
9. Goto T, Klyce SD, Zheng X, Maeda N, Kuroda T, Ide C. Gender and age related differences
in corneal topography. Cornea 2001; 20:270276.
10. van Alphen GWHM. On emmetropia and ametropia. Ophthalmologica Suppl 1961; 142:192.
11. Zadnik K, Mutti DO, Fusaro RE, Adams AJ. Longitudinal evidence of crystalline lens thinning
in children. Invest Ophthalmol Vis Sci 1995; 36:182187.
12. Sorsby A, Benjamin B, Sheridan M. Refraction and Its Components During the Growth of
the Eye from the Age of Three. MRC special report series no. 301. London: Her Majestys
Stationery Office, 1961.
13. Cheng H-M, Singh OS, Kwong KK, Xiong J, Woods BT, Brady TJ. Shape of the myopic eye
as seen with high-resolution magnetic resonance imaging. Optom Vis Sci 1992; 69:698701.
14. Strang NC, Schmid KL, Carney LG. Hyperopia is predominantly axial in nature. Curr Eye
Res 1998; 17:380383.
15. Grosvenor T. High axial length/corneal radius ratio as a risk factor in the development of
myopia. Am J Opt Physiol Opt 1988; 65:689696.
16. Mutti DO, Zadnik K, Adams AJ. The equivalent refractive index of the crystalline lens in
childhood. Vis Res 1995; 35:15651573.
17. Pierscionek BK. Refractive index contours in the human lens. Exp Eye Res 1997; 64:887893.
18. Saito Y, Ohmi G, Kinoshita S, Nakamura Y, Ogawa K, Harino S, Okada M. Transient hyperopia
with lens swelling at initial therapy in diabetes. Br J Ophthalmol 1993; 77:145148.
19. Okamoto F, Sone H, Nonoyama T, Hommura S. Refractive changes in diabetic patients during
intensive glycaemic control. Br J Ophthalmol 2000; 84:10971102.
20. Smith G, Pierscionek BK, Atchison DA. The optical modelling of the human lens. Ophthalmic
Physiol Opt 1991; 11:359369.
21. Koomen MJ, Tousey R, Scolnik R. The spherical aberration of the eye. J Opt Soc Am 1949;
39:370376.
22. He JC, Burns SA, Marcos S. Monochromatic aberrations in the accommodated human eye.
Vis Res 2000; 40:4148.
23. He JC, Marcos S, Webb RH, Burns SA. Measurement of the wave-front aberration of the eye
by a fast psychophysical procedure. J Opt Soc Am A Opt Image Sci Vis 1998; 15:24492456.
3
The Helmholtz Mechanism of
Accommodation

ADRIAN GLASSER
College of Optometry, University of Houston, Houston, Texas, U.S.A.

There is no other portion of physiological optics where one finds so many differing and
contradictory ideas as concerns the accommodation of the eye, where only . . . in the most
recent time have we actually made observations where previously everything was left to the
play of hypotheses.
H. Von Helmholtz (1909)

A. INTRODUCTION
In 1853 Hermann von Helmholtz described the mechanism of accommodation of the
human eye. This was not the first description of how the human eye accommodates. Many
descriptions of and much research on accommodation preceded the work of Helmholtz
(1), yet the accommodative mechanism of the human eye is still generally referred to as
the classic Helmholtz accommodative mechanism. Helmholtz succeeded where others
had failed at providing a comprehensive and consistent explanation of how accommodation
occurs. It was comprehensive in that he described the functions of all of the major elements
of the accommodative apparatus, and it was consistent in that it required no significant
modifications of what was known with certainty at the time regarding how accommodation
occurs.

B. THE ANATOMY OF THE ACCOMMODATIVE APPARATUS


In order to understand how accommodation occurs, it is necessary to have a clear under-
standing of the accommodative apparatus and the relationships of the accommodative
structures to each other. While in recent years there has been some limited debate over
27
28 Glasser

Figure 1 Hermann Ludwig Ferdinand von Helmholtz (b, 1821; d, 1894) was not the first to
describe the accommodative mechanism of the human eye, but he provided the first comprehensive
and most accurate description based on the experiments he had performed and on the work done
by many preceding him. Helmholtz succeeded where others had failed at providing a consistent and
harmonious description of how accommodation occurs. Although the description that Helmholtz
provided was largely accurate, subsequent experimental studies have shown that some aspects of
the accommodative mechanism are not as Helmholtz described. For example, Helmholtz believed
that the posterior surface of the lens did not move with accommodation and that the iris played an
important role in mediating the accommodative changes in the lens.

the gross anatomy of the accommodative apparatus, in general there is a consensus, and
has been for some time (2). The primary accommodative structures of the eye consist of
the ciliary body, the ciliary muscle, the posterior and anterior zonular fibers, the lens
capsule, and the lens substance.

C. THE CILIARY MUSCLE


The ciliary muscle consists of three subgroups of muscle fiber cells differentiated by their
positions and orientations within the ciliary body (3). The muscle fibers group are (1) the
longitudinal fibers, sometimes referred to as meridional fibers or Bruckes muscle (4); (2)
the radial or reticular fibers; and (3) the equatorial or circular fibers. The longitudinal
fibers are located most peripherally in the eye, just inside the sclera at the ciliary region.
Inward of the longitudinal fibers and closer to the vitreous are the radial fibers, and inside
these are the circular fibers, located most anteriorly in the ciliary body and closest to the
lens (5). The ciliary muscle is located within the ciliary body, bounded externally by the
The Helmholtz Mechanism of Accommodation 29

sclera of the eye and the collagen fibers, fibroblasts, and melanocytes of the outer surface
of the ciliary body (3). The inner surface of the ciliary muscle is bounded anteriorly by
the pars plicata and posteriorly by the pars plana of the ciliary body. Anteriorly, the
ciliary muscle inserts into the scleral spur and the trabecular meshwork, which serve as
a relatively fixed anterior anchor point against which the ciliary muscle contracts (3).
Posteriorly, the ciliary muscle attaches via the elastic tendons to the stroma of the choroid.

D. THE ZONULAR FIBERS


The zonular fibers of the eye can broadly be broken down into two subgroups. The posterior
zonular fibers or the pars plana zonule and the anterior zonular fibers. The pars plana
zonule extends from the posterior insertion of the zonule at the posterior attachment of
the ciliary muscle near the ora serrata of the retina to the ciliary processes.(6) The anterior
zonular fibers span the circumlental space between the ciliary processes and the equatorial
region of the lens (Fig. 2). From their posterior origin, the posterior zonular fibers extend
longitudinally toward the pars plicata of the ciliary body as a mat or meshwork of interlac-
ing fibers, following a straight path toward the tips of the ciliary processes (7). The majority
of the posterior zonular fibers course forward to the pars plicata region of the ciliary body
and enter the valleys between the ciliary processes, inserting into the walls of the valleys
of the ciliary processes (8). The pars plicata region of the ciliary body separates the

Figure 2 Early anatomists had an excellent knowledge of the anatomy of the crystalline lens (A)
and the ciliary region of the eye. The lens is composed of lens fiber cells arranged in concentric
layers. New lens fibers develop from the germinative zone at the anterior equatorial region of the
lens. The lens capsule surrounds the lens. The anterior surface of the lens is to the left. (From Ref.
2.) (B) Similarly, investigators whose work preceded that of Helmholtz (1) had already provided
excellent anatomical information on the structure and relationships of various elements of the accom-
modative apparatus to each other. In particular, the arrangement of the zonular fibers passing from the
ciliary body to the lens equator shows a picture remarkably consistent with subsequent descriptions of
this tissue, but quite unlike that postulated in recent controversial and anatomically inaccurate theories
(i.e., Refs. 9 and 43). (From Ref. 2.)
30 Glasser

posterior zonule from the anterior zonule (8). Some zonular fibers pass from the pars
plana through the valleys between the ciliary processes and on toward the lens (6,8). A
spanning or tension fiber system of many finer strands forms the zonular plexus, which
attach the zonule to the ciliary epithelium in the valleys of the ciliary processes (6). This
serves to anchor the anterior and pars plana zonule to the ciliary epithelium of the ciliary
body. As the anterior zonular fibers near the lens equator, they fan out to insert into the
lens capsule around the equatorial region of the lens. The individual zonular fibers termi-
nate within zonular lamellae of the lens capsule (6). No discrete zonular fiber bundles can
be seen to selectively insert specifically to the lens anterior, equatorial, and posterior
surfaces, as suggested by Schachar (9); instead, the zonular fibers form a uniform distribu-
tion or meshwork of fibers inserting all around the equatorial region of the lens (10,11).

E. THE LENS AND CAPSULE


The lens capsule is a thin, acellular, elastic membrane surrounding the lens. It is principally
composed of type IV collagen with some glycosaminoglycans (12). The capsule is not of
uniform thickness. Fincham, in 1937, found it to be thickest at the peripheral anterior
surface and thinner toward the lens equatorial region. On the lens posterior surface, the
capsule is thinnest at the region of the posterior pole of the lens but thicker toward the
periphery (13).
The lens consists of a monolayer of epithelial cells on the anterior surface beneath
the capsule, with elongated lens epithelial cells at various stages of maturation. The lens
fiber cells are arranged in layers to form the younger peripheral cortex and the more
mature central lens cortex (Fig. 2). The human lens does not shed any of its cells and
grows throughout life by adding lens fibers at its outer equatorial zone. Isolated lenses
show a linear increase in mass with age (1416). The axial thickness of the lens increases
with increasing age. Its axial thickness can readily be measured in vivo in the living eye
with A-scan ultrasound or Schiempflug (1719). Since the lens thickness increases with
accommodation, it is important to measure this dimension in unaccommodated eyes to
draw conclusions about changes due to aging. As the lens grows, there is an increase in
the anterior and posterior surface curvatures of the unaccommodated lens as measured
with Schiempflug slit-lamp photography (20,21). While the axial thickness and surface
curvatures of the lens can readily be measured in the living eye, lens diameter, until
recently, could not. Based on the observation that the diameter of lenses removed from
postmortem human eyes increases with increasing age (22), it has been suggested that
there is a growth-related increase in the lens equatorial diameter throughout life (2325).
However, Smith (22) recognized that his measurements of isolated lenses did not reflect
a growth-related increase in diameter. When lenses are removed from the eye, the outward-
directed zonular tension on the lens equator is removed. Isolated lenses are therefore in
an accommodated form, rather more so for the younger than the older lenses (3). Advances
in magnetic resonance imaging (MRI) have recently allowed lens diameter to be measured
in the living eye. The MRI measurements do not show an increase in lens diameter with
age (26).

F. OPTICAL CHANGES WITH ACCOMMODATION


1. Increased Optical Power of the Eye
Accommodation is defined as a dioptric change in power of the eye (27). The increase
in refractive power or the change in refractive state of the eye is the predominant optical
The Helmholtz Mechanism of Accommodation 31

change of accommodation and is readily measured. The cornea, the anterior and posterior
lens surfaces, and the lens gradient refractive index provide optical refractive power to
the eye. In the unaccommodated, emmetropic eye, the optical refracting power allows the
image of a distant object to be focused on the retina. In this case, parallel rays of light
from the distant object enter the eye and become convergent to focus the image on the
retina. A near object, closer to the eye than optical infinity, however, has diverging light
rays entering the cornea. In order for the divergent rays to be drawn to a focus on the retina,
the optical power of the eye must increase. During accommodation, this is accomplished
primarily by an increase in curvature of the anterior and posterior lens surfaces. In addition,
lens thickness increases and anterior chamber depth and, to a lesser degree, vitreous cham-
ber depth decreases during accommodation. All these changes contribute to an increase
in optical refracting power. If the optical power or the refraction of a young eye is measured
with an objective refractometer during accommodation, it is clear that the optical power
increases, resulting in a myopic shift in the refraction.

2. Depth of Field
The accommodative triad describes the neuronally coupled accommodation, convergence,
and pupil constriction that occur with an accommodative effort. Both accommodation and
pupil constriction contribute to near visual acuity. Depth of field is the distance an object
can be moved in object space without appreciably altering image focus or, in the case of
the eye, without appreciably altering the eyes visual acuity. This plays an important role
in the perception of a sharply focused image on the retina. An eye with a large pupil
diameter has a small depth of field. This means that the eye can detect a change in focus
of the retinal image with small movements of the object toward or away from the eye.
An eye with a small pupil diameter has a large depth of field. In this case, the object can
be moved a greater distance toward or away from the eye without appreciably altering
the retinal image focus. The pupillary constriction that occurs with accommodation results
in an increased depth of field, which also contributes to maintaining a clear image of a
near object on the retina. Pupillary constriction can also occur without accommodation,
as with increased illumination. This too improves depth of field and hence near reading
ability, but without accommodation. Pupillary constriction and increased depth of field
are important for improving near reading ability but are very different from the refractive
change that accompanies accommodation.

3. Aberrations of the Eye


The imperfect optics of the eye mean that the eye suffers from optical aberrations. The
low-order aberrations, such as defocus and astigmatism, can be corrected with optical
prescriptions, but higher-order aberrations cannot. These higher-order aberrations include
spherical aberration and coma, for example. While the presence of aberrations in the eye
reduces retinal image quality, they also have important implications for accommodation.
Ocular aberrations result in decreased retinal image quality and contribute to a larger depth
of field of the eye due to its inability to detect small changes in image focus as an object
is moved closer or further from the optimal point of focus. Before the accommodative
mechanism was fully understood, Sturm (2) proposed that astigmatism could explain how
the eye could see at different distances. An optical system with astigmatism has two line
foci at orthogonal meridians separated by a distance called the interval of Sturm. No
perfect image focus is attained anywhere between the two line foci, so if an object is
32 Glasser

moved such that the interval of Sturm remains on the retina, only a modest change in
image quality occurs, but without a distinct perception of a change in focus. Thus subjective
accommodation testing may suggest the presence of accommodation in an individual with
ocular aberrations even when no functional accommodation occurs. This illustrates the
importance of considering of the optical aberrations of the eyehow they can contribute
to near vision but yet are clearly distinct from active accommodation.

G. THE HELMHOLTZ DESCRIPTION OF ACCOMMODATION


Helmholtz (2) provided the first accurate description of the eyes accommodative anatomy
and mechanism. He described that in the unaccommodated state, resting tension on the

Figure 3 Sections of the (A) unaccommodated and (B) accommodated ciliary muscle. Eyes were
placed in a fixative after maximal contraction of the ciliary muscle with eserine or maximum
relaxation of the ciliary muscle with atropine. These histological diagrams illustrate that the inner
apex of the ciliary body moves forward and toward the axis of the eye with accommodation. Notice
that in the unaccommodated state, the inner apex of the ciliary muscle resides behind the scleral
spur; but in the maximally accommodated state, this portion of the ciliary muscle has moved forward
of the scleral spur. (From Ref. 2.) (C) The Helmholtz accommodative mechanism. In the left half
of the diagram, the eye is shown in the unaccommodated state, focused for far (F), and the right
half, in the accommodated state, focused for near (N). A contraction of the ciliary muscle moves
the ciliary body closer to the lens equator. Resting zonular tension is released. The anterior lens
surface is shown to move forward with accommodation and the posterior lens position to remain
unchanged. (From Ref. 2.)
The Helmholtz Mechanism of Accommodation 33

zonular fibers at the lens equator pull and hold the lens in a flattened and unaccommodated
state. The zonular fibers extend from the ciliary processes to their insertion on the lens
capsule at the lens equatorial region. When the ciliary muscle contracts with an accom-
modative effort, it undergoes a forward redistribution of its center of mass (Fig. 3).
This moves the anterior-inward apex of the ciliary body toward the lens equator to
release the resting zonular tension. When the zonular tension is released, the elastic
lens capsule molds the lens to decrease equatorial diameter, increase thickness, and
allow the lens anterior and posterior surfaces to undergo an increase in curvature (Fig. 3).

H. TSCHERNINGS THEORY OF ACCOMMODATION


Tscherning (28) challenged the Helmholtz theory of accommodation, believing that with
accommodation there is an increase in traction of the zonular fibers at the lens equator
and that the curvatures of the central lens increase while those at the periphery flatten on
account of the greater resistance and steeper curvatures of the lens nucleus (Fig. 4). In
other words, with a traction of the zonular fibers, the softer cortex is molded around
the harder nucleus, so that the central lens surface curvatures more closely resemble
the steeper central curvatures of the lens nuclear surface. Tscherning also believed
that the vitreous provided a force on the lens posterior surface to aid in the accom-
modative mechanism. Tscherings accommodative mechanism required no significant
modification of the anatomy of the accommodative apparatus as Helmholtz had de-
scribed it.

Figure 4 Tscherning (Ref. 28.) proposed an alternative mechanism of lenticular accommodation.


(A) The unaccommodated lens is shown as a solid line with the accommodated lens superimposed
as a dashed line. Tscherning believed that the accommodative change in the form of the lens occurred
as a consequence of an increase in traction of the zonular fibers at the lens equator. Thus, as depicted
by Tscherning, the unaccommodated lens has a larger diameter, but the lens undergoes no change
in axial thickness. The anterior surface of the lens is to the left. (B) Tscherning believed this change
in form of the lens occurred as a consequence of the relatively softer cortex being molded around
the relatively hardened nucleus. He believed the surfaces of the nucleus to be more steeply curved
than the surfaces of the lens. With an increase in traction of the zonular fibers at the lens equator
the peripheral lens surfaces are flattened while at the middle of the lens the curvatures increase.
The cornea and anterior lens surface are on the left of the diagram. (From Ref. 28.)
34 Glasser

I. SCHACHARS THEORY OF ACCOMMODATION

Schachar too has proposed that accommodation occurs through an increase in zonular
tension, essentially restating Tschernings theory. Unlike Tschernings theory, however,
Schachars theory requires significant modification of the accommodative anatomy. Scha-
char requires that the zonular fibers insert into the anterior face of the ciliary muscle,
which Schachar believes moves backward in the eye with an accommodative effort. Scha-
chars theory also requires that separate and discrete zonular fiber bundles insert to that
lens anterior, equatorial, and posterior surfaces and that the tension on these discrete
subgroups be differentially adjusted with accommodation. Like Tscherning, Schachar pro-
poses that when the ciliary muscle contracts with accommodation, there is an increase in
zonular tension at the lens equator, but that the tension of the zonular fibers on the lens
anterior and posterior surfaces relax during accommodation. Schachar believes that the
increased zonular tension at the lens equator results in an increase in lens equatorial
diameter, but that the release of zonular tension on the lens anterior and posterior surfaces
results in a flattening of lens peripheral surfaces and an increase in curvature at the center
of the lens.

J. DEBATE OVER THE ACCOMMODATIVE MECHANISM

Central to the debate over the Helmholtz and Schachar theories of accommodation is the
mechanism by which the ciliary muscle/zonular complex acts on the lens. Cramer (29),
by observing minification of Purkinje images reflected off the anterior lens surface with
accommodation, first unequivocally demonstrated that the crystalline lens anterior surface
undergoes an increase in curvature with accommodation (see appendix in Ref. 29). Cram-
ers belief that this was mediated by a contraction of the iris sphincter was later disproved
by von Graefe (31), who observed that an aniridic patient had normal accommodation.
Helmholtz, apparently unaware of Cramers work, subsequently and independently also
observed minification of Purkinje images of the anterior lens surface with accommodation.
It is beyond debate that for accommodation to occur, the lens power must increase, and
that this is accomplished in part through an increase in the lens anterior surface curvature.
However, the Helmholtz accommodative mechanism on the one hand and the Tscherning/
Schachar theories on the other are at odds as to how this occurs.

K. TSCHERNINGS STUDIES

Young (32) stated that the amplitude of accommodation diminishes toward the periphery
of the pupil. Tscherning observed in his own eye that, with accommodation, the refraction
at the center of his pupil increased more than the refraction at the periphery. Tscherning
arrived at this conclusion from observations of the change in the appearance of the point-
spread of his eye and by positioning Youngs double-slit optometer in the center and toward
the periphery of his pupil during accommodation. Tscherning believed the Helmholtz
accommodative mechanism to be incorrect because it provided no obvious explanation
for this observation. Tscherning believed that this could be explained only by a steepening
of the central lens and a flattening of the peripheral lens.
The Helmholtz Mechanism of Accommodation 35

In an attempt to prove his accommodative mechanism, Tscherning studied the behav-


ior of bovine lenses (Fig. 5). He observed that when inward pressure was applied at the
lens equator, the anterior and posterior surface curvatures flattened; but when outward
zonular tension was applied at the lens equator, the anterior surface curvature increased.
Schachar also performed similar experiments on bovine lenses to provide experimental
support for his accommodative mechanism and recorded an increase in optical power of
the lens with outward-directed zonular tension at the lens equator (33). The bovine eye
and lens bear little resemblance to that of the primate. The bovine eye is unlikely to
accommodate, since it has a diminutive ciliary muscle (34) and a lens that is considerably
thicker, more spherical, and harder than the primate lens. The paradoxical optical results
that Tscherning and Schachar et al. (28,35) observed from tests on bovine lenses may be
due to the fact that the bovine lens is structurally and functionally quite different from the
primate lens. It is inappropriate to draw conclusions on the accommodative performance of
the primate lens or on the primate accommodative mechanism from observations of the

Figure 5 Tscherning (Ref. 28.), like Schachar et al. (33), performed experiments on bovine lenses.
(A) When Tscherning applied a squeezing force to the equator of the bovine lens, a peripheral
flattening and central steepening resulted (solid line) relative to unstressed lens (dashed line). (B)
Tscherning believed that the nucleus was harder and had steeper curvatures than the surfaces of the
lens and so provided a resistive force around which the cortex is molded. (C) When Tscherning
applied a stretching tension to the lens equator (solid line), the softer lens cortex was molded around
the hardened nucleus such that there is an increase in curvature at the center of the lens relative to
the unstretched lens (dashed line). Note that there is no change in thickness of the lens with either
squeezing or stretching. While this may be an accurate depiction of the behavior of the bovine lens,
this lens is harder and more spherical than that of the primate lens and is from an animal that
probably has no accommodation. Results from studies on bovine lenses cannot be extrapolated to
prove anything about the accommodative performance of the human lens or the accommodative
mechanism of the human eye. It is well established, for example, that there is an increase in axial
thickness of the human lens during accommodation. (From Ref. 28.).
36 Glasser

performance of bovine lenses. Tscherning found no change in axial thickness of the bovine
lens with stretching, and Schachar (33) does not mention lens thickness. It is well estab-
lished that the lens thickness increase by 10% with accommodation in the human eye
(35,36). Our recent results show a 23% increase in lens thickness with 12D of accommoda-
tion in young rhesus monkey eyes (unpublished observations). When accommodation tests
are performed on primate lenses known to be capable of accommodation, very different
results from those of Tscherning and Schachar are found. Outward-directed zonular tension
applied to young primate lenses causes a decrease in power due to flattening of the lens
surface curvatures, in accordance with the Helmholtz accommodative mechanism (11).
The extent of change in lens power at any age matches the expected accommodative
amplitude (11). It is possible to demonstrate paradoxical optical effects of mechanical
stretching on bovine lenses (33), artificial fluid-filled lenses (3739), or air-filled Mylar
balloon lenses (40). However, these lenses bear little resemblance to the primate lens, so
there is little that can be concluded about accommodation in primates from tests on such
lenses.
Both Tschernings and Schachars theories require some part of the anterior-internal
aspect of the ciliary muscle to recede to increase zonular tension at the lens equator
during accommodation. Subsequent to Helmholtzs description of accommodation, even
Tscherning (28) himself was aware of reports that described how, in aniridic patients, the
ciliary processes could be observed to move (swell) toward the lens equator and that
the lens diameter was observed to decrease with accommodation. Lens diameter is observed
to decrease with accommodation in human eyes (41). Ultrasound biomicroscopy and gonio-
videography shows similar accommodative movements in monkey eyes (Fig. 6) (42).
These observations contradict the mechanistic descriptions of Tscherning and Schachar.
Schachar has postulated how the ciliary muscle contracts to increase zonular tension based
on an analysis of a histological section (43). However no direct evidence exists to support
the proposed movements of the ciliary muscle, and ultrasound biomicroscopy of the accom-
modative movements of the ciliary body (42) does not support the mechanism of action
required by Schachar.

L. MEASUREMENT OF ACCOMMODATION
Tscherning begins his chapter on the accommodative mechanism with a section on the
measurement of the amplitude of accommodation, in which he writes to determine [the
near point] exactly is generally of little practical importance. The significance of this
misconception is no more certain than today. Despite claims that accommodation is re-
stored in presbyopes, there are no published objective measurements to demonstrate this.
Subjective near reading tests used to determine if scleral expansion restores accommoda-
tion (44) are inaccurate and unreliable and do not unequivocally measure accommodation.
The only documented attempt to measure accommodation postoperatively in scleral expan-
sion patients using objective methods found none (45). Accurate, objective measurement
of accommodation is imperative to establish the efficacy of surgical procedures claimed
to restore accommodation. Tscherning did not have access to infrared optometers and
other objective instruments that are available today to measure accommodation. Unlike
the push-up test that is used clinically, these instruments are capable of unequivocally
measuring accommodation dynamically and objectively. While the push-up test provides
an indication of near reading ability, in some cases this may have no relationship to
accommodative ability. For example if the push-up test were used to measure accommoda-
The Helmholtz Mechanism of Accommodation 37

Figure 6 Recent experiments on iridectomized rhesus monkeys using Edinger-Westphal stimu-


lated accommodation are in agreement with the Helmholtz accommodative mechanism (42). (A) A
gonioscopy lens placed on the temporal cornea allows visualization of the ciliary processes and lens
equator. (B) The movements of these structures can be observed during accommodation. (C) The
subtracted image pair shows that the eye remains relatively stable during accommodation, but there
is a pronounced movement of the ciliary processes and lens equator away from the sclera with
accommodation. (D) The ciliary muscle and lens equator can be observed with ultrasound biomicros-
copy (UBM). (E) The apex of the ciliary muscle and the lens equator move away from the sclera
during accommodation. (F) The subtracted image pair shows that while the eye is relatively stable,
the ciliary muscle and lens equator move away from the sclera during accommodation. (G) The
entire equatorial diameter of the lens can be seen when a Goldman lens is placed on the cornea.
(H) With accommodation, there is a concentric decrease in equatorial diameter of the crystalline
lens and an inward movement of the ciliary processes. (I) The subtracted image pair shows that the
eye remains relatively stable relative to the pronounced accommodative movements that are ob-
served. Each of the movements observed are in accordance with the Helmholtz accommodative
mechanism and opposite to those proposed by Schachar. The accommodative movements observed,
such as a concentric decrease in lens diameter (GI), cannot be explained by eye movements. (From
Ref. 42.)
38 Glasser

tion in a presbyope wearing multifocal contact lenses, one might erroneously conclude
that active accommodation is present. The multifocal contact lenses may provide functional
distance and near reading ability but obviously without restoring accommodation. Clearly
the push-up test does not unequivocally measure accommodation and cannot differentiate
multifocality from functional accommodation. An objective optometer that dynamically
measures the refraction of the eye is the appropriate method to unequivocally demonstrate
the presence of accommodation.
While Tscherning may not have appreciated the importance of accurate measurement
of accommodation, he was aware of good methods to stimulate accommodation. Tschern-
ing described the use of topical instillation of a muscarinic agonist to stimulate accommoda-
tion. Muscarinic agonists such as pilocarpine and carbachol act directly on the acetylcho-
line receptors of the ciliary muscle and cause it to contract. If the optical refractive power
of the eye is measured with an objective optometer before and after the instillation of
topical pilocarpine, for example, the optometer will record a change in refraction as accom-
modation occurs. Depending on the drugs concentration, its penetration into the eye, and
the amount absorbed by the ciliary muscle, the accommodative response may vary. While
pharmacological stimulation may not stimulate maximal accommodation and would there-
fore not provide an accurate measure of the full accommodative amplitude, it will provide
an objective demonstration of whether accommodation is present.

M. HELMHOLTZS CONTRIBUTION
From his observations of the eye during accommodation, Helmholtz noted that the anterior
surface of the crystalline moves forward and that the anterior lens surface curvature in-
creases (a decrease in the radius of curvature). This latter observation was demonstrated
by observing the minification of the third Purkinje image reflected from the anterior lens
surface. Helmholtz also observed an apparent minification of the posterior lens surfaces
Purkinje images and concluded from calculations that the curvature of the posterior lens
surface increases slightly with accommodation but without appreciable movement of the
posterior lens surface. Helmholtz suggested that these observations meant that the lens
axial thickness increased by about 0.5 mm with accommodation and, that since the lens
volume is constant, the equatorial diameter of the lens must be reduced with accommoda-
tion.
As to the mechanism by which the observed accommodative changes occur, Helm-
holtz was less certain due to the difficulties in observing the accommodative movements
of the ciliary body directly.
Prior to Helmholtz, Cramer and Donders believed that the iris and the ciliary muscle
induced accommodation of the lens. They supposed that the iris pushed backward on the
peripheral anterior surface of the lens and that the ciliary muscle increased the vitreous
pressure behind the lens. Helmholtz recognized that this was inconsistent with the increase
in lens thickness that he had observed. Helmholtz believed that the mechanism proposed
by Cramer and Donders would tend to decrease lens thickness and flatten the posterior
lens surface.
Helmholtz believed that when the eye is focused at distance, the lens is stretched
by the zonule attached to the lens equator. Based on an understanding of the anatomical
attachment of these zonular fibers to the ciliary body, Helmholtz hypothesized that with
a contraction of the ciliary muscle, the zonular insertion in the ciliary body is moved
toward the lens to release the tension at the lens equator, allowing a decrease in lens
diameter, an increase in lens thickness, and an increase in both lens surface curvatures.
The Helmholtz Mechanism of Accommodation 39

Observations of accommodation in a patient with a paralyzed iris and in another with a


completely detached iris convinced Helmholtz that the iris did not cause the accommoda-
tive change in the lens.
Helmholtz also observed that the form of the lens is changed and that it becomes
thicker on cutting the zonule. He did not believe that the lens was composed of a lens
muscle (musculus crystallinus), as others had suggested, but, in describing the accommoda-
tive mechanism, he also failed to provide an explanation why this change in the form of
the lens occurs.
From his observations, Helmholtz ultimately concluded that the ciliary muscle was
responsible for inducing accommodation. Helmholtz was aware of Mullers (5) description
of circular fibers of the ciliary muscle and appreciated that it acted as a sphincter muscle
in conjunction with the meridional and radial fibers. In particular, a contraction of the
circular and meridional fibers moves the tip of the ciliary processes toward the lens equator
to release zonular tension. Helmholtz was unsure if the ciliary processes push directly on
the lens equator, as occurs in birds eyes with accommodation, since he could not directly
observe the edge of the lens. Although this is unlikely to occur in human eyes, it is observed
to occur at maximum accommodation in iridectomized monkey eyes (42).
Thus, Helmholtz recognized that, at rest, zonular tension pulls outward on the lens
equator and that a contraction of the ciliary muscle moved the ciliary processes toward
the lens equator and released tension on the zonule, allowing an increase in lens anterior
and posterior surface curvatures, an increase in lens thickness, a decrease in lens diameter,
a forward movement of the lens anterior surface, and little or no movement in the posterior
lens surface.
Although Helmholtz provided a comprehensive and accurate description of how
accommodation occurs, he gave no indication of how or why the lens becomes accommo-
dated, simply assuming that it did this through its supposed elasticity. He made no mention
of a role for the lens capsule, the posterior zonular fibers, or the elasticity of the posterior
attachment of the ciliary muscle to the choroid, all anatomical structures now known to
play important roles in accommodation. Helmholtz also believed that the posterior lens
surface does not move with accommodation, but this is now well documented to occur
(46,47).

N. GULLSTRANDS CONTRIBUTION
Gullstrand also contributed to our current understanding of accommodation in the appendix
to Helmholtzs posthumous third edition of the Treatise on Physiological Optics.
Gullstrands descriptions built on the groundwork that Helmholtz had laid.
On summarizing the knowledge concerning the lens posterior surface, Gullstrand
wrote: The only definitive conclusions that can be drawn from these investigations is
that as yet there is no proof of a change in position of the posterior surface of the lens in
accommodation, and that the curvature of the posterior surface of the lens increases in
accommodation, though to a very slight extent.
Gullstrands investigations suggested that with accommodation, the anterior lens
surface radius of curvature decreased from 10.0 to 5.33 mm and that the anterior lens
surface moved forward by 0.4 mm. More recent measurements suggest forward movement
of the anterior lens surface of between 0.2 to 0.3 mm with accommodation (46).
Gullstrand inferred a role for the lens capsule in describing the intracapsular accom-
modative mechanism. He described that the lens undergoes accommodative changes as a
consequence of the extracapsular accommodative changes.
40 Glasser

Helmholtz had correctly postulated that zonular tension at the lens equator is released
during accommodation. Gullstrand showed that evidence for this had been presented by
Hess (48), who demonstrated that, with a strong accommodative effort, the lens sags
downward in the direction of gravity, that there is an increase in amplitude of accommoda-
tion when the head is bent forward and a decrease when the head is bent backward, and
that the lens sags sagittally downward in the frontal plane after administration of eserine
to induce accommodative spasm.

O. FINCHAMS CONTRIBUTION
Fincham (13) made significant contributions to what we understand about accommodation
today. He showed that the zonule is an elastic tissue and repeated observations made
by Tscherning, Helmholtz, and others on the accommodative changes in curvature, lens
thickness, anterior chamber depth, and vitreous chamber depth. Fincham identified that
the lens thickness increases to a greater degree than the anterior chamber decreases with
accommodation and therefore that the lens posterior surface moves backward with accom-
modation. From his measurements of accommodation in an eye with traumatic aniridia,
Fincham observed centripetal movement of the ciliary processes and a smaller decrease
in lens diameter. He also observed that with accommodation, both the lens nucleus and
lens surface undergo similar change in curvature, demonstrating that the whole of the lens
substance rather than just the lens cortex is involved in accommodation. Together with
Graves (49), Fincham observed that in the empty capsular bag of a patient with traumatic
aphakia, the anterior and posterior capsular surfaces were flattened and parallel to each
other in the unaccommodated state but became flaccid, widely separated, and wrinkled
during an accommodative effort. Fincham concluded that the capsule is held under tension
in the unaccommodated state and that the tension is released with accommodation. Fincham
also measured greater changes in the anterior chamber depth with accommodation when
a subject is looking down than when looking forward, supporting an accommodative
release of zonular tension. He observed, in a young enucleated eye, that the lens takes on
a more accommodated form, with increased anterior surface curvature, when the zonule
is cut and the lens freed from the zonular suspension and that when the capsule is removed,
the lens substance tends to take on the unaccommodated form. All these observations led
Fincham to the inevitable conclusion that accommodation is caused by capsular molding
of the plastic lens substance into an accommodated form. Fincham studied the capsules
of various animal species in histological section and found them to be of relatively uniform
thickness in nonaccommodating mammals, but in humans it was thinnest at the posterior
pole and of maximum thickness on the anterior surface about 2 mm from the equator and
on the posterior surface about 1 mm from the equator. Fincham described how these
variations in capsular thickness allow the lens polar surfaces to undergo steeper changes
in curvature with accommodation than the peripheral lens surfaces, thus allowing the
accommodated lens to take on a conoidal form. Finally, Fincham restates the Helmholtz
accommodative mechanism, but now with the recognition that resting zonular tension
pulls the lens into a flattened and unaccommodated form and that the capsular forces mold
the lens into an accommodated form when zonular tension is released. Fincham recognized
that presbyopia and the loss of accommodative amplitude can be explained simply by the
lens substance losing its elasticity and the capsule failing to be able to mold the hardened
lens. In accordance with Smiths (22) observation that the equatorial diameter of isolated
lenses does not reflect the diameter of the lens in the living eye, Fincham stated that when
The Helmholtz Mechanism of Accommodation 41

Figure 7 (A) Fincham (13) showed that the primate lens capsule is not of uniform thickness. A
diagram of the capsule, in which thickness is exaggerated relative to size, shows the posterior surface
to be thinner than the anterior surface and regions of increased thickness on the anterior and posterior
peripheral surfaces. The elasticity of the capsule provides the force to mold the lens substance into
an accommodated form. In the absence of the capsule, the lens substance is in a flattened and
maximally unaccommodated form. When outward-directed zonular tension is released with accom-
modation, the capsule molds the lens to increase the lens anterior and posterior surface curvatures.
(B) In support of this capsular theory of accommodation, Fincham cites the evidence from Graves
(49) of the behavior of the empty capsular bag in a patient with traumatic aphakia. In the unaccommo-
dated state, the anterior and posterior capsular surfaces were flat against each other. With a voluntary
accommodative effort, the two surfaces became more flaccid and separated slightly. After the iris
was dilated and accommodation was stimulated with eserine, the two surfaces of the capsule separated
widely and the posterior surface (P) moved backward in the eye, becoming flaccid and wrinkled,
while the anterior surface (A) showed a forward curve. (From Ref. 13.)
42 Glasser

removed from the eye and isolated from external zonular forces, younger lenses tend to
become accommodated while older presbyopic lenses do not undergo a change in shape.

P. EVIDENCE AGAINST SCHACHARS THEORY OF


ACCOMMODATION
While Schachars theory of accommodation has been widely discussed, when scrutinized
with results from the nearly 150 years of research on accommodation since Helmholtz,
numerous inconsistencies appear. Schachars theory requires that accommodation occur
through an increase in the lens surface curvatures consequent to an increase in zonular
tension at the lens equator, but without any significant change in the lens thickness. If
anything, increased tension on the zonule at the lens equator would be expected to decrease
its thickness. However, the lens is well documented to undergo an increase in axial thick-
ness with accommodation. This is readily documented by A-scan ultrasonography (50)
but has most convincingly been documented by studies in which an ultrasound transducer
was vacuum suctioned to the sclera of the eye to ensure that the transducer did not move
with respect to the axis of the eye when accommodation occurred (36). In addition, in-
creases in lens thickness have also been measured during accommodation to an aligned
optical target with partial coherence interferometry, a noncontact, high-precision measure-
ment technique (46). These studies show a 0.5-mm increase in the lens axial thickness
with accommodation. An increase in thickness of this magnitude could not occur under
Schachars theory, with an increase in zonular tension. These studies of accommodative
changes in the lens also show that the lens posterior surface moves backward in the eye
to decrease vitreous chamber depth and that the lens anterior surface moves forward to
decrease anterior chamber depth. It is impossible, under Schachars theory, to explain how
lens thickness can increase and anterior chamber depth and vitreous chamber depth de-
crease during accommodation with an increase in zonular tension at the lens equator.
Schachars theory requires that that the zonule at the lens equator be composed of
three separate and distinct subgroupsanterior, posterior, and equatorial bundles (43,51).
Scanning electron micrographic studies (6) and direct examination of the zonule in enucle-
ated human eyes (11) do not support this view. Further, Schachars theory requires that
the equatorial zonular fibers be attached to the anterior face of the ciliary muscle just
beneath the root of the iristhe region of the ciliary muscle that Schachar believes to
move outward to selectively increase the tension on the equatorial zonular bundle (43).
Direct examination of the ciliary body shows that the zonular fibers attach all along the
pars plicata and not to the anterior face of the ciliary muscle, as required by Schachars
theory. Ultrasound biomicroscopy shows this anterior face of the ciliary muscle to move
forward with accommodation (42) rather than backward, as required by Schachars theory.
Schachars theory requires that the lens equator move toward the sclera by 50 m
with accommodation (52). Independent experiments have imaged movements of the lens
equator in several different ways during centrally or pharmacologically stimulated accom-
modation in iridectomized monkey eyes (42). Swan-Jacob gonioscopy and ultrasound
biomicroscopy showed a 0.25-mm movement of the lens equator away from the sclera
during accommodation. Imaging with a Goldman lens showed a concentric decrease in
the crystalline lens diameter with accommodation. Pharmacologically stimulated accom-
modation, not subject to the systematic convergent eye movements that occur with centrally
stimulated accommodation, also showed movement of the lens equator away from the
The Helmholtz Mechanism of Accommodation 43

sclera and a concentric decrease in lens diameter. The lens was also observed to sag
downward under the influence of gravity during accommodation irrespective of the orienta-
tion of the head, thus demonstrating that zonular tension is reduced rather than increased
as required by Schachars theory. Sutures were placed beneath the medial and lateral rectus
muscles to reduce eye movements that occur with centrally stimulated accommodation.

Q. EVIDENCE AGAINST SCHACHARS THEORY OF PRESBYOPIA

Schachars theory of presbyopia also fails on scrutiny at many levels. Fundamental to


Schachars theory of presbyopia is his claim that the lens grows throughout life, increasing
in equatorial diameter by 20 m per year. It is this increased lens diameter that Schachar
suggests results in crowding of the posterior chamber with a consequent loss of resting
zonular tension. Schachars claims for an increase in lens diameter come from a single
study in which lens diameter was measured in isolated human lenses (22). Rafferty (23)
cites this study when stating that the lens undergoes an increase in diameter of 0.02 mm/
year. Rafferty (23) is the single source cited by Schachar to support the notion that the
lens grows in equatorial diameter (24,25,40,5153). Smith (22) recognized that his mea-
surements of the diameter of the isolated lens do not reflect the diameter of the lens in
the living eye. Smith (22) states that when the lens is removed from the eye, it undergoes
a change in shape becoming more accommodated, relatively more so for the younger than
the older lenses. These data do not reflect equatorial growth of the lens. Only recently
has technology become available to measure lens diameter in vivo in living human eyes.
Lens diameter measured with MRI in living eyes shows no increase with increasing age
(26). The MRI study does show an age-dependent decrease in circumlental space or dis-
tance between ciliary processes and lens equator. However; this is clearly not due to
increased lens diameter but may be due to an age-related change in configuration of the
ciliary body (54).
Based on his theory of accommodation and presbyopia, Schachar has suggested that
accommodation can be restored by scleral expansion (24). Setting the numerous problems
with Schachars theory of accommodation aside, under the classic notion that presbyopia
occurs due to an increased hardness or sclerosis of the lens, it is hard to understand
how accommodation could be restored by scleral expansion. Mechanical stretching experi-
ments of human eye bank eyes suggests that the presbyopic lens is incapable of being
made to undergo accommodative changes (11). These experiments show that young lenses
can be made to undergo accommodative changes in focal length matching accommodative
amplitudes in youth, but that when lenses over the age of 60 years are subjected to the
same mechanical tests, they fail to undergo any change in focal length. This result is
supported by the MRI studies showing that in presbyopes, accommodative movements of
the ciliary body occur, but without changes in the lens (26). The human lens undergoes
a fourfold increase in hardness over the human life span (16). Scleral expansion cannot
restore the accommodative capacity to the crystalline lens. While scleral expansion possi-
bly may increase resting zonular tension or even enhance the efficacy of ciliary muscle
contraction, this is unlikely to provide sufficient force to enable presbyopic lenses to
accommodate. In any event, whatever serendipitous beneficial consequences scleral expan-
sion surgery may have would be undermined by the inevitability of cataract and the
required removal of the crystalline lens in cataract surgery.
44 Glasser

R. DOES SCLERAL EXPANSION SURGERY RESTORE


ACCOMMODATION?
Regardless of the accommodative mechanism or the causes of presbyopia, it is theoretically
possible that scleral expansion surgery may restore accommodation through some un-
known mechanism. However, the only published objective measurements of accommoda-
tion in patients with postoperative scleral expansion show that no accommodation is re-
stored (45). Subjective tests suggest that near reading distance may be temporarily
improved following scleral expansion (44). It is not clear why this would occur. The push-
up or near reading test that is typically used to assess accommodation postoperatively is
inappropriate to determine if accommodation occurs. The push-up test does not unequivo-
cally measure accommodation and is subject to errors due to depth of focus of the eye
and ocular aberrations. By definition, accommodation is a dioptric change in optical power
of the eye. If accommodation occurs, this can be measured with objective instrumentation
designed to measure the optical power of the eye. Unilateral scleral expansion surgery
reportedly improves near vision bilaterally. A physiological explanation for this is unlikely,
but it may reflect the inadequacy of subjective accommodation testing. It is possible, for
example, that scleral expansion surgery may inadvertently introduce corneal or lenticular
aberrations or some degree of multifocality to the eye. While this may prove beneficial
to provide some degree of functional near vision, it is clearly not accommodation. Schachar
has suggested that this is not the cause of the improved near vision, since keratometry is
unaltered by scleral expansion (24). However, this does not address the possibility of
aberrations in the lens. In addition to instrumentation available to measure accommodation
objectively, excellent wavefront technology exists to objectively measure the aberrations
of the eye. These measurements should be made pre- and postoperatively, in conjunction
with objective and appropriate measurements of accommodation to demonstrate if there
are any benefits to scleral expansion.

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46 Glasser

38. Schachar RA, Cudmore DP, Torti R, Black TD, Huang T. A physical model demonstrating
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45. Mathews S. Scleral expansion surgery does not restore accommodation in human presbyopia.
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4
Schachars Theory of the Mechanisms
of Accommodation

JAY S. PEPOSE
Washington University School of Medicine, St. Louis, and Pepose Vision Institute,
Chesterfield, Missouri, U.S.A.
MOONYOUNG S. CHUNG
Pepose Vision Institute, Chesterfield, Missouri, U.S.A.

A. KEY FEATURES THAT DIFFERENTIATE HELMHOLTZS VERSUS


SCHACHERS THEORIES

The term accommodation refers to the change in the refractive power of the eye that allows
images of near objects to be focused on the retina. The most widely accepted theory to
account for the mechanism of accommodation was proposed by Hermann von Helmholtz
in 1855 in his Treatise on Physiological Optics. He observed that accommodation involves
pupillary constriction and anterior movement of the iris. Helmholtz carefully observed the
Purkinje images of the crystalline lens during accommodation using crossed glass plates
placed between the subjects eye and the observer viewing the eye with a telescope. He
observed an increase in curvature of the anterior and posterior surfaces of the lens, although
the anterior surface became more convex than the posterior surface. He noted that the
sagittal thickness of the lens increased and hypothesized that the equatorial diameter of
the lens decreased during accommodation. He proposed that these events occurred through
contraction of the ciliary muscle. This anterior and axial movement of the muscle results
in relaxation of zonular tension, which allows the lens (which is surrounded by its elastic
capsule) to round up and increase in optical power, with the lens equator moving away
from the sclera (1,2).
Helmholtzs universally accepted theory has recently been challenged by Ronald
Schachars new theory of the mechanisms underlying accommodation. Schachar (2) pro-
47
48 Pepose and Chung

Figure 1 Effect of equatorial stretch on a deformable lens.

poses that in the unaccommodative state (i.e., when there is minimal optical power), the
equatorial zonules are under minimal tension. He suggests that during accommodation,
the anterior radial muscle fibers of the ciliary muscle move toward the sclera, with in-
creased tension exerted on the lens exclusively via the equatorial zonules. There is relaxa-
tion of the anterior and posterior zonules as the posterior longitudinal and posterior radial
fibers are displaced anteriorly. The increase in equatorial zonular tension causes the lens
equator to move toward rather than away from the sclera. Schachar proposes that this
transduction in the force of the ciliary muscle to the lens via the equatorial zonules results
in steepening of the central lens and flattening at its periphery. This causes an increase
in optical power along with a reduction in spherical aberration.
To illustrate this type of lens deformation, Schachar utilizes a Mylar balloon to
demonstrate his theory (Figs. 1 and 2). If the equator of a biconvex air-filled Mylar balloon
is stretched, the reflections from the center of the balloon minify while the reflections
from its periphery enlarge, demonstrating that the center of the balloon is steepened with
equatorial stretching while the periphery is flattened. Schachar also states that since the
effective working distance between the ciliary muscle and the equator of the lens decreases
throughout life secondary to normal lens growth, the force that the ciliary muscle can

Figure 2 Effect of equatorial stretch on periphery of a deformable lens.


Schachars Theory of Accommodation 49

apply to the lens equator decreases linearly with age, resulting in a linear decrease in the
amplitude of accommodation (i.e., presbyopia).

1. Schachars Supporting Data


Schachar first showed experimental support of his theory by progressively stretching the
sclerae and ciliary bodies of bovine eyes and then measuring the change in focal length
and equatorial diameter of the lens. All eyes showed a decrease in focal length and therefore
an increase in the optical power as well as an increase in equatorial diameter (3). Schachar
(4) has also constructed a physical model of the variable-focus lens using a gelatin-filled
balloon that can change optical power to 10 D, simulating an aspect of his theory of
accommodation. Profile photographs were taken of a gelatin-filled balloon relaxed and
stretched at the equator. He was able to prove, both with the photographs and mathemati-
cally, that with equatorial stretching, the central anterior lens becomes steeper, the periph-
eral anterior lens becomes flatter, and there is no change in the posterior radius of curvature.
Schachar (5) used a vertical scanning interference microscope to measure the mean radius
of curvature of both anterior and posterior surfaces of constant-volume, deformable, water-
filled lenses prior to and during stepwise equatorial stretching. Central steepening and
peripheral flattening of the lens was again demonstrated.
In another study, high-frequency, high-resolution anterior segment ultrasound biomi-
croscopy was used to measure in vivo changes occurring at the lens equator in 12 young
human subjects during pharmacologically controlled accommodation (6). The patients
ranged in age from 20 to 34 years with a mean age of 26 years and a standard deviation
of 5 years. The patients had a correctable visual acuity of 20/20 and accommodative mean
amplitude of 9.5 D. One drop of 1% tropicamide was placed in the right eye. The pupil
and the near point without correction were measured 25 min later using four-point print.
Ultrasound biomicroscopy (UBM) was performed using the Humphrey Instruments biomi-
croscope to image the lens equator in the unaccommodated state. A video recording was
made of the UBM images. Later, one drop of 2% pilocarpine was administered in the
right eye, and 1 h later the pupil and the near point without correction were measured.
Ultrasound biomicroscopy was then performed, after which a video recording was made
of the UBM images. The induced accommodation was the difference between the near
point measurements after pilocarpine and tropicamide.
A frame-by-frame comparison was made between the two videos for each patient,
using a video mixer and computer subtraction techniques. Over 20,000 images of each of
the 12 subjects were compared. Separate and different images of the same patient in the
unaccommodated and the accommodated states were superimposed. The cornea and sclera
were used as positional references, which provided a reliable method to avoid errors that
accompany misalignment and rotation, since the cornea and sclera do not change position
during accommodation. In this study it was demonstrated that, during accommodation,
the lens equator moves toward the sclera. The mean displacement of the lens equator
toward the sclera was 6.81 m for each diopter of increase in accommodation (6). This
confirmed predictions of previous mathematical and physical models (4,7,8) and was
consistent with the increase in the optical power of the bovine lens with equatorially
stretching that occurred in Schachars previous study (3).
Schachar and his colleagues mathematically modeled the human crystalline lens to
approximate both the Schachar and the Helmholtz theories of accommodation (9). They
used nonlinear finite-element analysis that included the material properties and proper
50 Pepose and Chung

boundary conditions approximating the human crystalline lens. They used ANSYS 5.6, a
general-purpose, nonlinear, finite-element computer program to perform their analysis.
They calculated the amount of force necessary to produce a given amount of equatorial
displacement. The thick-lens formula was used to establish the optical power of the crystal-
line lens. Then the longitudinal spherical aberration of various levels of crystalline lens
accommodation was investigated using Zemax EE, an optical computer program.
The results of nonlinear finite-element analysis by Schachar et al. demonstrated that
only the tension produced solely by the equatorial zonules was able to produce the known
properties of the accommodative process, which include an increase in central optical
power, and also accounts for the physiological force limitations of the ciliary muscle.
They also demonstrated that the increase in equatorial diameter associated with the tension
produced by the equatorial zonules was consistent with the ultrasound biomicroscopy
measurements showing that the lens equator moves toward the sclera during pharmacologi-
cally controlled accommodation. The analysis demonstrated that when the anterior and
posterior zonules or all three sets of zonules totally relax, the central optical power of the
crystalline lens would decrease, not increase. These results contradict Helmholtzs theory
of accommodation.

2. Clinical and Experimental Data Supporting Helmholtzs Theory


Schachars hypothesis of accommodation has recently been challenged. Glasser and Camp-
bell (11,12) isolated human lenses from 27 human eyes aged 10 to 87 years. An in vitro
scanning laser technique was used to measure the focal length and spherical aberration
of the lenses as the lenses were exposed to increasing and decreasing radial stretching
forces through the ciliary bodyzonular complex. They demonstrated that for the three
youngest lenses (11,31, and 39 year old), the focal length did change with stretch. On the
other hand, the older lenses, 54 and the 87 years old, demonstrated no change in focal
length over the extent of stretch applied. These results contradict Schachars hypothesis
of accommodation, which maintains that the lens remain malleable even with increasing
age. In a different investigation by Glasser and Campbell (12,13), another group of 19
lenses 5 to 96 years of age were studied. In this group, which included older lenses with
signs of early cataract, the focal length increased up to approximately age 65, but then
their focal length decreased. Both studies demonstrated that over the years when accommo-
dation is gradually lost due to presbyopia, the focal length of the unstretched lenses gradu-
ally increased linearly, supporting a lens/capsule compliance and elasticity-based theory
of presbyopia.
Glasser and Kaufman (14) studied the accommodative mechanism in six cynomolgus
monkeys (10 to 13 year old) and eight rhesus monkeys (6 to 17 years old) with stimulated
accommodative amplitudes ranging from 7 and 18 D. The monkeys had complete bilateral
iridectomies. Stimulating electrodes surgically implanted in the Edinger-Westphal nucleus
were used to induce varying amplitudes of accommodation. Accommodation was also
induced and reversed in several other cynomolgus and rhesus monkeys. Carbachol chloride
iontophoresis, topical pilocarpine hydrochloride, and systemic pilocarpine hydrochloride
were the agents used to stimulate accommodation, and topical and systemic atropine sulfate
was used to reverse the accommodation.
Goniovideography of the iridectomized eyes was performed, demonstrating the tips
of the ciliary processes, the anterior zonular fibers, and the lens equator. Ultrasound biomi-
croscopy was also performed using the Humphrey Instruments biomicroscope. Gonioscopy
Schachars Theory of Accommodation 51

was imaged and recorded at the slit lamp. Measurements of the movement of the lens
equator and ciliary processes were taken from image analysis of the goniovideography
sequences. The refractive state of the eye during accommodation was recorded using the
Hartinger coincidence refractometer (Jenoptik, Jena, Germany). Refractions at baseline
and with accommodation were recorded at each stimulus amplitude. The accommodative
amplitude at each stimulus was the difference between the two refractions. The results of
these studies of dynamic accommodation showed that the ciliary body and the lens equator
moved away from the sclera during both centrally and pharmacologically stimulated ac-
commodation, contrary to Schachars theory of accommodation, which states that the lens
equator moves toward the ciliary processes.
Schachar has claimed that the experiments by Glasser and Kaufman were flawed
(15). He states that because the sutures placed in the cornea as a reference point and the
corneal Purkinje images did not subtract out, there was eye movement between the imaging
device and the eye. He then states that Glasser and Kaufman did not have any controls
to prove that the small amount of eye movement seen in their experiments did not account
for the changes in the crystalline lens size. In Glasser and Kaufmans experiments, when
they fixated the lateral rectus to reduce eye movement, the crystalline lens equator moved
toward the sclera with anterior and posterior zonular relaxation. The authors state that this
movement of the lens was secondary to lateral translation of the crystalline lens, but
Schachar has argued that this mechanism is mechanically impossible. He states that with
anterior and posterior zonular relaxation, because the crystalline lens is denser than water
and vitreous, the crystalline lens equator can only move toward the temporal sclera by an
active force generated by the equatorial zonules.
Wilson and Merin (1618) also demonstrated, using infrared videophotography in
a young human subject with ocular albinism, that the lens equator moved away from the
sclera and that its diameter decreased during accommodation. However, Schachar (15)
has challenged their study. He states that since the measurements were taken only when
the circular light was concentric with the pupil and that, in order to keep the light concentric
with the pupil, the alignment between the eye and the camera must have changed between
the measurements made of the unaccommodated and accommodated states, since the pupil
moves nasally during pupillary constriction. He also notes the presence of rotation of the
eye relative to the axis of the camera, which is demonstrated by measuring the horizontal
diameter of the cornea in the unaccommodated and accommodated states.
Strenk et al. used high-resolution magnetic resonance imaging (MRI) to examine
changes in the human ciliary muscle and crystalline lens during minimal and maximal
accommodation (18). Magnetic resonance images from 25 subjects, ranging from 22 to
83 years of age, were taken. Measurements of the ciliary muscle rings diameter, lens
thickness, and equatorial diameter of the lens under minimum and maximal accommoda-
tion were obtained from the magnetic resonance images. A nonmagnetic accommodative
stimulus device was used to provide a minimal (0.1 D) or a strong (8.0 D) binocular
accommodative stimulus during magnetic resonance imaging. They found that ciliary
muscle contractile activity remained active in all the subjects and was reduced only slightly
with advancing age. They did find a decrease in the diameter of the unaccommodated
ciliary muscle ring and retrolenticular space that correlated highly with advancing age.
There was an age-related increase in the unaccommodated lens thickness, but the lens
thickness under accommodative effort was only modestly age-dependent. Of note, the lens
equatorial diameter did not show any significant change with advancing age in either
accommodative state. This latter finding appears to directly challenge one of Schachars
52 Pepose and Chung

basic tenetsi.e., that a primary mechanism underlying presbyopia is crowding of the


ciliary muscle because of a linear increase in lens diameter with age. [Others (12) have
argued that the early studies of the diameter of isolated lenses of enucleated eyes did not
reflect the diameter of the unaccommodated lens in the living eye, because the younger
lenses rounded up when the zonules were cut.] This stresses the importance of being able
to make reliable in vivo measurements using techniques such as MRI.
As to the subject of reliable measurements, Schachar contends that the results of
the MRI study by Strenk et al. were caused by artifact (15). He states that an MRI image
of their patients eye during accommodation showed that the eye was turned nasally and
that there was a change in configuration of the orbital bones, demonstrating that the head
and the eye moved during accommodation. He further attests that the measurements of
the transverse diameter of the globe, the corneal diameter, and the equatorial diameter of
the lens all decrease during accommodation, demonstrating that the image plane of the
eye in the unaccommodated and accommodated states was not the same.

3. Studies of Scleral Expansion Surgery to Improve Near Vision

Based upon his theory of accommodation and presbyopia, Schachar has developed a num-
ber of surgical techniques to expand the sclera, using bands or segments (22), in an effort
to increase the effective working distance between the ciliary muscle and the equator of
the crystalline lens. Others have attempted to expand the sclera by incisions or laser
treatment (15), and these cumulative studies have shown some significant albeit nonuni-
form improvement in near vision using standard subjective testing.
Whether such surgical methods truly restore accommodation has recently been chal-
lenged by Matthews (10), who examined three presbyopic patients shortly after scleral
expansion surgery and three young control subjects. The presbyopic patients ranged be-
tween 50 and 58 years of age. The control subjects were 22, 27, and 29 years of age. All
of the patients were asked to focus on an approaching target while accommodation was
monitored with a high-speed infrared optometer. The accommodative targets used were
either the Maltese cross or a reduced Snellen chart presented monocularly in a Badal
optical system. The target luminance was 100 cd/m. The accommodative stimulus changed
in increments of 1 D every 10 s, ranging from 0 to 4 D. The investigator concluded that
scleral expansion surgery did not restore accommodation in the presbyopic patients tested
with this optometer device, which monitors the central 2.2 mm of the pupil. There was
no difference in accommodative responses between the two preoperative presbyopic pa-
tients and the three postoperative presbyopic patients tested at each incremental accommo-
dative stimulus level. There was also no accommodative response in either presbyopic
group. This is in contrast to the three young control subjects, in whom the accommodative
response increased by about 450 A/D values per diopter of accommodative stimulus
change.
Schachars response to Matthews study can be summarized as follows. First, this
group of patients was independently examined by Yang and coworkers (20), who docu-
mented a significant improvement in near vision without a change in distance refraction,
axial length, or corneal power. Matthews study with the optometer did not include any near
vision measurements using standard testing methods. The patients had an early prototype of
the scleral expansion band (rather than segments) not currently in use, and they were all
tested in the very early postoperative period, when tear film abnormalities and superficial
punctate keratitis were present. In addition, the infrared optometer, which is generally
Schachars Theory of Accommodation 53

operated in a darkened room, does not offer the usual accommodative stimulus but relies
purely on defocus. The instrument, which requires the subject to use a bite plate for
stability and alignment, generally takes practice to obtain reliable data, and it was unclear
if this level of training and reproducibility was achieved. Glasser and colleagues (12) have
speculated that the possible restoration of near vision via scleral expansion could function
via nonaccommodative mechanisms, such as inducing multifocality of the crystalline lens.
A number of patients in the phase I clinical trial of scleral expansion in the United States
are now undergoing wavefront analysis to provide an objective measurement and assess
mechanisms that may underlie improvement in near vision after this procedure.

B. CONCLUSION
There are few subjects in ophthalmology capable of generating as much lively debate as
that of accommodation and presbyopia. The processes of accommodation and disaccom-
modation are complex, to say the least, and involve changes in muscular, lenticular, and
extralenticular components. At some time, almost every one of these components has been
proposed as a factor in the development of presbyopia.
We have tried in this chapter to present a balanced view of Schachars versus Helm-
holtzs theory of accommodation, along with experimental evidence and arguments that
have been espoused by proponents of both sides. In a number of key respects, the proposed
mechanisms are antithetical. The universal nature of presbyopia and the intense interest
in its reversal justifies further research in this area to elucidate its pathophysiology.

ACKNOWLEDGMENT
Supported by the Midwest Corneal Research Foundation, Inc.

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accommodation. Ann Ophthalmol 1993; 25:404409.
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Rolland JP. Paradoxical optical power increase of a deformable lens by equatorial stretching.
Ann Ophthalmol 1998; 30(1):1018.
6. Schachar RA, Tello C, Cudmore DP, Liebmann JM, Black TD, Ritch R. In vivo increase of
the human lens equatorial diameter during accommodation. Am J Physiol (United States) 1996;
271(3 pt 2): R670R676.
7. Schachar RA, Cudmore DP, Torti R, Black TD, Huang T. A physical model demonstrating
Schachars hypothesis of accommodation. Ann Ophthalmol 1994; 26:49.
8. Schachar RA, Huang T, Huang X. Mathematical proof of Schachars hypothesis of accommo-
dation. Ann Ophthalmol 1993; 25:59.
9. Schachar RA, Bax AJ. Mechanism of accommodation. Int Ophthalmol Clin 2001; 41(2):1732.
54 Pepose and Chung

10. Mathews S. Scleral expansion surgery does not restore accommodation in human presbyopia.
Ophthalmology 1999; 106:873877.
11. Glasser A, Campbell MCW. Presbyopia and the optical changes in the human crystalline lens
with age. Vis Res 1998; 38:209229.
12. Glasser A, Croft MA, Kaufman PL. Aging of the human crystalline lens and presbyopia. Int
Ophthalmol Clin 2001; 41(2):115.
13. Glasser A, Campbell MCW. Biometric, optical and physical changes in the isolated human
crystalline lens with age in relation to presbyopia. Vis Res 1999; 39:1991.
14. Glasser A, Kaufman PL. The mechanism of accommodation in primates. Opthalmology 1999;
106(5):863872.
15. Schachar RA. Presbyopia: Cause and Treatment. In: Schachar RA, Roy FH eds. Presbyopia:
Cause and Treatment. The Hague, The Netherlands: Kugler, 2001:120.
16. Wilson RS. Does the lens diameter increase or decrease during accommodation? Human ac-
commodation studies: a new technique using infrared retro-illumination video photography
and pixel unit measurements. Trans Am Ophthalmol Soc 1997; 95:261270.
17. Wilson RS, Merlin LM. Infrared video photographic analysis of human accommodation. Invest
Ophthalmol Vis Sci 1997; 38(suppl):S986.
18. Wilson RS, Merlin LM. Infrared video photographic analysis of the lens-zonular-ciliary space
in human accommodation. Invest Ophthalmol Vis Sci 1998; 39(suppl):S312.
19. Strenk SA, Semmlow JL, Strenk LM, Munoz P, Gronlund-Jacob J, DeMarco JK. Age-related
changes in human ciliary muscle and lens: a magnetic resonance imaging study. Invest Ophthal-
mol Vis Sci 1999; 40(6):11621169.
20. Yang GS, Yee RW, Cross WD, Chuang AZ, Ruis RS. Scleral expansion: a new surgical
technique to correct presbyopia. Invest Ophthalmol Vis Sci 1997; 38(suppl):S497.
21. Smith P. Disease of the crystalline lens and capsule: on the growth of the crystalline lens.
Trans Ophthalmol Soc UK 1883; 3:79.
22. Schachar RA. Cause and treatment of presbyopia with a method for increasing the amplitude
of accommodation. Ann Ophthalmol 1992; 24:445452.
5
Aging and the Crystalline Lens
Review of Recent Literature (19982001)

LEO T. CHYLACK, JR.


Harvard Medical School and Brigham and Womens Hospital,
Boston, Massachusetts, U.S.A.

This chapter on aging and the crystalline lens is based on a review of the literature between
1998 and 2001. Due to the limits on the length of this chapter and the numerous recent
publications in this field, I have not been able to cite many important earlier works. I
extend my apologies to the authors of these works.
Bron et al. (1) published an excellent general summary of the aging lens in 2000.
The avascular lens grows throughout life. Being enclosed by a capsule and lacking a
means of shedding cells, the lens is an excellent organ in which to study aging. There are
changes in lens size, shape, and mass throughout life that occur at different rates. The
sagittal diameter of the lens is approximately constant at 9.0 mm., but the anteroposterior
distance varies from 2.5 to 3.5 mm. These dimensions may increase in the mature/hyperma-
ture cataract. In spite of decreases with age in the radius of the anterior surface of the
lens and changes in the points of zonular insertion, the clear lens retains its ability to focus
an image clearly on the retina. Although the central epithelial cells divide rarely, they
survive throughout life. The germinative epithelial cells are actively dividing cells, and
the equatorial epithelial cells undergo terminal differentiation. As lens fibers form, they
lose their nuclei and other intracellular organelles; in the deeper cortex, fiber cells are
essentially organelle-free. The slightly tortuous course of the long fiber cells as they arch
over the equator and meet near the opposite pole to form sutures has been illustrated in
elegant studies by Kuszak et al. (24). The complexity of these sutures increases with
age and may account for the increased light scattering in the zones of disjunction seen
biomicroscopically. Lens protein synthesis in the epithelium and superficial cortex contin-
ues throughout life, but these proteins undergo several posttranslational changes, among
55
56 Chylack

which are chemical and photochemical oxidation, glycation, and racemization. Antioxidant
defense mechanisms may ameliorate some of these posttranslational changes. Also, with
increasing age monomeric proteins associate in covalently bound aggregates to form high-
molecular-weight aggregates whose hydrodynamic radii approach in size the wavelengths
of visible light. As size increases, light scattering also increases to the point of lens opacifi-
cation and frank cataract. Changes with age in protein conformation and phospholipid
composition of fiber membranes increase nuclear rigidity and contribute to presbyopia.
This chapter considers many of these changes in more detail.
In the past 15 years, epidemiological research on age-related cataracts (ARCs) has
revealed risk factors that pertain to behavior (e.g., diet, smoking, lifestyle, drug use) and
suggested that ARC may be a preventable disease (5,6). This is most encouraging, for
each year increasing percentages of public and private health care budgets are used to
provide surgical care for ARC.

A. AGING AND CHANGES IN LENS SIZE AND SHAPE


Several authors (712) have documented the growth of the lens throughout life. Koretz
et al. analyzed (24) Scheimpflug photographs of the unaccommodated lens in 100 subjects
from 18 to 70 years of age to determine the regions that changed with time. With Scheimp-
flug optics the lens image is in focus from the anterior to posterior pole. The geometric
distortion of Scheimpflug images can be corrected (14), so that accuratemeasures of the
lens can be obtained. Koretz et al. measured the lens with Hough transforms and other
image analysis methods. The radii of the anterior and posterior surfaces of the whole lens
decrease, but the volume increases with increasing age. In contrast, neither the shape nor
the volume of the nucleus changes with age. The central clear zone and center of mass
of the nucleus move anteriorly with age. The correlation between lens shape and location
(relative to the cornea) is very high, confirming earlier results. Also, the anterior movement
of the lens with age increases the likelihood of phakic IOLlenticular touch and complica-
tions.
Another study (15) explored the relationship of accommodative convergence per
unit of accommodative response (AC/A ratio), refractive error, and age to determine if
the AC/A ratio was a risk factor for myopia. A high AC/A ratio was associated withand
a risk factor forrapid onset of myopia. A higher AC/A ratio, associated with a flatter
crystalline lens, increased the effort to accommodate, or pseudocycloplegia. Accommo-
dative deficits in myopia may be the functional consequence of myopic enlargement of
the eye. This enlargement was documented in a study (16) of changes in biometric measure-
ments and refractive errors over a 3-year period in eyes of university students. After 3
years, the mean change in refractive error (in OD) was 0.52 / 0.45D (p 0.05).
The mean lens thickness increased by 0.07 / 0.10 mm (p 0.05), and the mean
elongation of the vitreous chamber was 0.27 / 0.30 mm (p 0.05). Regardless of
the original refractive error, the change in refractive error over the 3-year period was
toward myopia. There were no statistically significant changes in the curvature of the
cornea or depth of the anterior chamber. The authors concluded that the myopic shift was
due to an elongation of the vitreous chamber.
In a study of 1-year-old chickens (17), form deprivation vision such as is obtained
through translucent glass or eyelids that have been sutured closed, even in fully grown
birds, was associated with a myopic shift that was similar but not as large as that in
neonatal chicks. The decreases in retinal dopamine seen in neonatal chicks were also seen
Aging and the Crystalline Lens 57

to a lesser degree in 1-year-old chickens. These studies suggest that form deprivation is
one of the mechanisms controlling eye growth and causing myopia.

B. AGING AND CHANGES IN REFRACTIVE ERROR


The modulation transfer function (MTF) has been used (18) to estimate the overall optical
performance of the eye with increasing age. In qualitative terms, the MTF is used to assess
optical quality of lens combinations by measuring the degree to which a point source of
light is dispersed to a spot, in this case on the retina. The average MTF was determined
as a function of age and pupillary size. Not surprisingly, the MTF declined in an approxi-
mately linear fashion with age, but it did not vary with gender. The decline in MTF may
account for the decline in contrast sensitivity function (CSF) with age.

C. PRESBYOPIA
In an important paper appearing in 1988 (19), Fisher recounted the classic argument that
presbyopia was related to the force of contraction of the ciliary muscle and the resistance
to deformation of the crystalline lens. He recounted the view of Donders (20), that presby-
opia was caused by a decrease in the force of contraction of the ciliary muscle with age,
and the opposing view of Helmholtz (21), that the lens became more difficult to deform
with age due to lenticular sclerosis. Fisher found that, in fact, the ciliary muscle undergoes
a compensatory hypertrophy as accommodative amplitude decreases with age. The force
of contraction is about 50% greater at the onset of presbyopia than in youth. However,
because of increased lenticular resistance, its effect on the amplitude of accommodation
is small. Fisher claimed that the lens becomes more difficult to deform not because of
lenticular sclerosis, since the lens substance does not lose water, but because the capsule
loses its elastic force with age and the lens fibers, particularly in the nucleus, become
more compacted with age. In fact, the nuclear fiber mass becomes more rigid with age,
as was shown in subsequent studies.
Since Fishers work, considerable progress has been made in our understanding of
the mechanisms of presbyopia. In 1991 (22), Pau and Kranz used a fine conical probe
and a dynamometer to measure the resistance to penetration of various layers of the lens.
The resistance to penetration increased with age, due primarily to a hardening of the
nucleus. The cortex did not show this hardening. In an interesting study of the dynamic
aspects of accommodation (23), Heron et al. showed that accommodation gain decreased
and the phase lag increased with age. Reaction time, response time, and accommodative
velocity did not change with age for a target oscillating sinusoidally in a predictable
manner at modest amplitude. The main aging effect was a longer than predicted phase
lag. In spite of decreasing amplitude of accommodation, other aspects of accommodative
function were quite robust in the middle-aged eye.
In a very elegant study of accommodation in vivo using magnetic resonance imaging
(MRI) in humans, Strenk et al. (24) showed that the muscles contraction decreased only
slightly with increasing age. A decrease in the diameter of the unaccommodated ciliary
muscle ring was highly correlated with advancing age. Unaccommodated lens thickness
increased with age, but the thickness of the lens under accommodative effort was only
slightly age-dependent. Their data shed light on what has been a lens paradoxnamely,
the decrease in the ciliary muscles diameter and an increase in lens thickness in the
unaccommodated eye. These changes showed the greatest correlation with increasing age.
58 Chylack

They concluded that presbyopia was actually due to the loss in ability to disaccommodate
due to increases in lens thickness, the inward movement of the ciliary ring, or both.
The issue of whether the changes in the human lens are due to changes in the lens
fiber mass or changes in the lens capsule were addressed directly in a recent study (25)
of the biometric, optical, and physical properties of capsulated and decapsulated lenses.
Lens focal lengths, thicknesses, surface curvatures, and spherical aberrations were mea-
sured for paired eye-bank lenses. Decapsulating the lens caused changes in focal length
similar to those occurring in lenses stretched into an unaccommodated state. These phe-
nomena were attributed to nonsystematic changes in lens curvatures. These data support
the concepts that lens hardening is an important factor in presbyopia and that aging changes
in the lens are not limited to the loss of accommodation and cataract. In addition there
are substantial changes in the optical and physical properties of the lens with aging.
It is known that myopes have shallower accommodative stimulus/response functions
(26), due possibly to reduced sensitivity to defocus. Jiang and White showed that a near
task caused a small increase in the static accommodative response. In both emmetropes
and late-onset myopes, near tasks also increased the interval for relaxing accommodation.
These data suggest the existence of two subsystems that adapt differently to prolonged
accommodative effort.
Heron et al. studied dynamic accommodation responses to small, abrupt changes in
an accommodation stimulus (27). They concluded that for small stimuli within the ampli-
tude of accommodation, the response dynamics (reaction and response times) over the
adult age range (16 to 48 years) remained remarkably constant even though the amplitude
of accommodation decreased progressively with age.

D. AGING, OXIDATIVE STRESS, LENS OPACIFICATION AND


CATARACT
Considerable evidence has accumulated implicating oxidative stress as a major risk factor
in age-related cataract (ARC) formation. Both chemical oxidation (H2O2) and photo-oxida-
tion (secondary to UV irradiation) have been implicated. In addition to a cumulative
increase with age in the oxidative damage to lens proteins and lipids, there is also a gradual
reduction in the potency of the lens antioxidant defenses. In a recent study (28), the thiol
and carbonyl contents of 62 cataractous (age-related idiopathic, diabetic, and myopic)
lenses and age- and sex-matched clear lenses from patients undergoing vitrectomy or giant
retinal tear surgery were compared. There was a statistically significant (p 0.01), age-
associated inverse relationship between the contents of P-SH and protein carbonyls. The
changes were greater in cataractous than clear lenses and greater in diabetic and myopic
cataracts than in age-related cataracts. The decrease in P-SH occurred earlier in diabetic
and myopic cataracts than in ARCs. An increase in protein carbonyls 2 nmol/mg protein
and a decrease in P-SH of 10 to 12 nmol/mg protein were always associated with lens
opacification.
The tripeptide glutathione (GSH) is present at high concentrations (4 to 6 mM) (29)
in the young lens and in the cortex of older lenses. It has been identified as one of the major
antioxidant defenses in the lens. The GSH-redox cycle is very active in lens epithelium and
cortex. Via this cycle, the lens detoxifies hydrogen peroxide, other active oxygen species,
and dehydroascorbic acid. There appear to be separate mechanisms in LECs for the detoxi-
fication of hydrogen peroxide and hydroxyl radical. Recently, Truscott (30) and Moffat
et al. (31) demonstrated a barrier to free diffusion of GSH within the lens that increases
Aging and the Crystalline Lens 59

with age. The low ratio of GSH/P-SH and the relatively inactive GSH-redox cycle in the
nucleus make the nucleus more susceptible to oxidative stress than the cortex. That, indeed,
this is the case has been demonstrated in animal models with hyperbaric oxygen (32),
UVA irradiation (33,34), and the glutathione peroxidase knockout mouse (3537). With
increased oxidative stress in nuclei of lenses in these animal models, there is an increase
in protein disulfides and light scattering. Also with reduced activity of the GSH-redox
cycle, there is damage to Na, K-ATPase (an enzyme involved with many of the active
transport mechanisms in LECs), to cytoskeletal proteins, and to membrane proteins in-
volved in regulating membrane permeability. An excellent review of these topics has
recently been published (38).
As oxidative stress increases and the size of the GSH pool decreases, some proteins
thiols (P-SH) are converted to protein-thiol mixed disulfides (29), either protein-S-S-
glutathione (PSSG) or protein-S-S-cysteine (PSSC). The formation of PSSG precedes the
formation of PSSP (29) and increases insolubilization of lens proteins. Lou et al. (29)
discovered that the early oxidative damage could be reversed if the oxidant was removed
in time. This reversal is mediated by the enzyme thiol transferase (TTase), recently found
in the lens. Lou et al. showed that recombinant TTase, although requiring GSH for activity,
was much more efficient in dethiolating lens proteins than GSH alone. TTase favored
PSSG over PSSC and gamma-crystallin-S-S-G over alpha-crystallin-S-S-G. TTase was
also remarkably resistant to oxidation. The TTase dethiolase activity reactivates enzymes
deactivated by S-thiolation. It is this ability to regulate and repair SH-dependent enzymes
that suggests that TTase plays an important role in ARC formation.
In a study (39) of ascorbate oxidation and advanced glycation in the lens, the major
advanced glycation end product (AGE), N(epsilon)-carboxymethyl-L-lysine (CML), was
found to have an EDTA-like (chelator) structure that might bind copper. Ascorbylation
led to increased CML formation, copper binding, and free radical formation in the lens.
These results suggested that there is a vicious cycle in the lens between AGE formation,
lipoxidation, metal binding, and oxidative damage. It is possible that chelators may play
a role in the therapy of ARC.
In another interesting study of the possible value of antioxidants in the treatment of
ARC (40), it was shown that chronic administration of vitamin E, but not of sodium
ascorbate, restored the age-associated decrease in GSH content in rat lenses to levels
comparable to those in younger rats. The age-associated decrease in lenticular glutathione
peroxidase, glutathione reductase, and glucose-6-phosphate dehydrogenase was not re-
versed by chronic administration of either vitamin E or sodium ascorbate (40).
In addition to the age-associated change in lens proteins, there are age-associated
changes in lens lipids. The percentage of sphingolipid nearly doubles with age, and there
is also an increase in hydrocarbon chain saturation with age. These increases were much
greater in the deeper layers of the lens (41). These data support the idea that the degree
of lipid hydrocarbon order is determined by the amount of lipid saturation, and this, in
turn, is regulated by the content of saturated sphingolipid. Hyperbaric oxygen treatment
increases the lipid disorder in the nucleus and the levels of lipid hydroxyl, hydroperoxyl,
and aldehydes. The transparency of the nucleus is also reduced as these lipid oxidation
products accumulate in the lens.
The Roche European-American Cataract Trial (REACT) (42,43), the first prospec-
tive, randomized, placebo-controlled clinical trial of oral vitamins E and C, and beta-
carotene suggested that antioxidant treatment might slow the progression of ARC. A small
but statistically significant deceleration of ARC was found after 3 years of treatment in
60 Chylack

a cohort of American and British patients. In this study, the beneficial effect was seen in
the entire cohort and in the subgroup of American patients but not in the subgroup of
British patients. The basis for the different responses of American and British patients to
the antioxidant treatment was not clear but may have been due to the fact that the British
patients had slightly more advanced cataracts at entry.

E. AGING AND THE ZONULE


There has been very little research on the effects of aging on the zonule. Recently, however,
a light and electron microscopic study of the human ciliary zonule has been published
(44). The organization of the zonule as it inserts into the ciliary body was studied. Fibrillin
is the major constituent of the zonule and also of microfibrils. Mutations in the fibrillin
gene are thought to underlie the zonular abnormalities of Marfans syndrome. With aging,
the zonular fiber becomes more fragile, increasing the risk of ocular pathology.

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17. Papastergiou GI, Schmid GF, Laties AM, Pendrak K, Lin T, Stone RA. Induction of axial eye
elongation and myopic refractive shift in one-year-old chickens. Vis Res 1998; 38:18831888.
18. Guirao A, Gonzalez C, Redondo M, Geraghty E, Norrby S, Artal P. Average optical perfor-
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22. Pau H, Kranz J. The increasing sclerosis of the human lens with age and its relevance to
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35. Spector A, Kuszak JR, Ma W, Wang RR, Ho YS, Yang Y. The effect of photochemical stress
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40. Campisi A, Di Giacomo C, Russo A, Sorrenti V, Vanella G, Acquaviva R, Li Volti G, Vanella


A. Antioxidant systems in rat lens as a function of age: effect of chronic administration of
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41. Borchman D, Giblin FJ, Leverenz VR, Reddy VN, Lin LR, Yappert MC, Tang D, Li L. Impact
of aging and hyperbaric oxygen in vivo on guinea pig lens lipids and nuclear light scatter.
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42. Chylack Jr LT, Wolfe JK, Friend J, Tung W, Singer DM, Brown NP, Hurst MA, Kopcke W,
Schalch W. Validation of methods for the assessment of cataract progression in the Roche
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6
Hyperopia

IVO JOHN DUALAN and PENNY A. ASBELL


Mount Sinai Medical Center, New York, New York, U.S.A.

A. CONTACT LENS VS REFRACTIVE SURGERY


1. History of Contact Lens
Why would anyone choose contact lenses over refractive surgery? Contact lenses have
been around for decades and are therefore true, tried, and tested. Surgical procedures, on
the other hand, are still considered innovative, and no long-term follow-up data are yet
available. Contact lenses were first described and used well over a century ago but came
into popular use after World War II, where the first hard contact lenses, made of polymeth-
ylmethacrylate (PMMA), were introduced. In the 1960s the advent of soft lens materials
made of hydroxy-ethyl methacrylate (HEMA) led to the widespread use of contact lenses
in the United States. In the 1970s rigid gas-permeable lenses were introduced, and in the
1980s astigmatic and presbyopic connecting lenses became available. Flexibility of lens
use increased with the introduction of extended-wear contact lenses in the 1980s and
disposable lenses that can be replaced weekly, monthly, and even daily. The last decade has
seen advances in contact lenses for correcting presbyopia, including bifocal and multifocal
contact lenses.

2. Market Information
Currently, it is estimated in the United States that over 30 million people use contact
lenses. Some 80% are using soft lenses and approximately 20% are using rigid gas-permea-
ble lenses.
Contact lenses offer individuals a readily available method of correcting refractive
errors that can be personalized to their individual needs. Excellent visual acuity is routinely
attained with contact lenses; 100% likely see 20/40 or better and well over 95% achieve
20/20 or better, though visual results with contact lenses are rarely reported. Contact
63
64 Dualan and Asbell

lenses are relatively inexpensive, and though there are ongoing costs in terms of replacing
the lenses, the lens care solutions, and having follow-up care, the expenditures are modest
compared to the significant initial outlay for refractive surgery. Contact lenses can easily
be exchanged as patients refractive error changes and so allows children and young adults
to be fitted even before the refractive error has completely stabilized. In addition, older
individuals have an option to change to presbyopic contact lenses as the need for additional
correction for good near vision increases. Perhaps the key to the success of contact lenses
is their flexibility: the ability to change lenses to meet patients changing visual needs
and even give them the ability to return to spectacles or other vision correction method
at any time. Most refractive surgery procedures are permanent and irreversible. If for any
reason a patient is unhappy or dissatisfied with the surgical results, he or she cannot go
back again.

B. REFRACTIVE SURGERY VERSUS CONTACT LENSES FOR THE


CORRECTION OF REFRACTIVE ERRORS

1. The Contact Lens Candidate

As with any patient seeking correction of a refractive error, a complete eye exam is
indicated. This would include obtaining a good history. It is important to determine how
the patient will be using the refractive correction and whether it is to be used for a specific
activity such as skiing, swimming, computer use, etc. Medical problems that might increase
the risk of wearing contact lenses could include diabetes mellitus, immunosuppression,
severe allergies, and possibly occupational hazards such as exposure to volatile gases. The
eye examiner needs must be particularly attentive to lid function, since spreading of a tear
film by blinking is central for the good fit of a contact lens. Evaluation for possible dry
eyes is essential, since a poor tear film can interfere with the patients ocular health and/
or comfort with lenses.
Relative contraindications to contact lens wear are not different from those being
considered when a patient is being evaluated a patient for refractive surgery: the inability
to understand the risks and benefits of the correction modality, immunosuppressed patients,
patients with only one functional eye, history of previous ocular problems including her-
petic keratitis, previous ocular surgery such as glaucoma filtering procedures, chronic use
of topical medications such as steroids, severe dry eyes, neovasclarization of the cornea,
corneal dystrophies, and pregnancy. The key issues regarding more of contraindications
that are specific to the fitting of contact lenses include patients who are unable or not
willing to participate in appropriate lens care and follow-up care, patients who are unable
to learn to insert and remove contact lenses or do not have a family member who can
assist with this process, and patients who may have poor hygiene, which may put them
at increased risk for infections associated with contact lens use.

C. SOFT CONTACT LENSES

Soft contact lenses are made of a plastic called hydrogel that can be shaped into lenses
but maintains its flexibility and provides immediate quality vision and comfort for most
patients.
Hyperopia 65

1. Advantages of Soft Contact Lenses


Immediate comfort is clearly the advantage of these lenses. Soft contact lenses are generally
large in diameter and extend beyond the cornea and limbus and fit under the upper lid
margin. Though there is slight movement with each blink because of the size of the lens
and the flexibility of the material, little sensation is associated with soft contact lens use.
Adaptation to soft contact lenses is rapid and patients can begin enjoying quality vision
almost from the moment the lenses are placed.
Key advantages of soft contact lens use are
Adaptation
Comfort
High-quality visual acuity
Ability to use on an intermittent basis
Ease of fitting
Ease of contact lens care
Correction of a wide range of refractive errors
Soft contact lenses can usually be fitted in one visit, with a brief follow-up to ensure
that they continue to provide excellent comfort and vision. Few unscheduled visits are
required, and patients typically return every 6 to 12 months for a follow-up that includes
evaluation for other ocular diseases, such as glaucoma and to ensure the general ocular
health as well continued proper use of the contact lenses.

2. Disadvantages of Soft Contact Lenses


Unlike myopes, hyperopes may have difficulties with visualization of contact lenses during
handling, since these patients do not have any near point in focus. Deposits can develop
on the lenses, which can interfere with comfort and vision. Patients who may be exposed
to environmental hazards such as volatile chemicals and those who have poor or inadequate
tear film are presently not good candidates for the use of soft contact lenses.

3. Lens Selection
There are a variety of things to be considered in picking a soft contact lens for a particular
patient. Most soft lenses come in predetermined parameters from the manufacturer, though
some can be custom-ordered for a particular prescription, such as lenses for patients with
high astigmatism. Soft contact lenses vary in water content: low range (30 to 45% water),
medium content (40 to 58% water), and high content (60 to 80% water). The amount of
water is a factor in the oxygen permeability of the lens and also influences comfort and
ease of handling. Contact lens parameters include the base curve of the central optic zone
and the diameter of the lens. Typically, a trial lens will be placed to evaluate the fit and
determine the refractive correction needed to account for the reduced vertex distance and
residual astigmatism. Many manufacturers supply practitioners with trial lenses that can
then be dispensed on the initial visit. Replacement lenses can then be sent directly to the
patients home or work for added convenience.
Another key consideration in fitting a soft lens is the wear schedule. For patients
who might need intermittent correction, as for social events or sports, one-day disposable
lenses may very well be suitable. Other patients do well with daily-wear disposable lenses
that are replaced weekly or biweekly. Soft lenses can also be used on a flexible replacement
66 Dualan and Asbell

schedule: weekly, monthly, or quarterly. They can also be dispensed as extended-wear


lenses, typically being left in place for 6 to 7 days and then removed and disposed of and
replaced by new contact lenses. Past studies suggest that the use of extended-wear contact
lenses significantly increases the risk of corneal infections. However, new lens materials
have become available that have significantly increased oxygen permeability and dispos-
ability of lenses and possibly may have reduced the risks of extended-wear usage. Conven-
tional lenses that are used day in and day out are still available but are less commonly
prescribed, since they offer none of the advantages of disposable lenses, including the
regular use of a Fuch sterile lens offering assured quality vision and comfort with each
new lens.

D. RIGID GAS PERMEABLE CONTACT LENS


The original cosmetic lenses made of a hard material (PMMA) and are still available today
but are rarely used in new fittings in the United States. Newer materials afford increased
oxygen to the cornea and greater comfort while providing better rigidity than soft contact
lenses. Several rigid gas-permeable (RGP) materials are available, including silicone acry-
late and fluorine copolymers as well as others.

1. Key Advantages of RGP


The key advantages of RGP contact lenses are that they are manufactured to order,
allowing for adjustments for an individuals visual needs to achieve the best fit. RGPs
allow for sharp, excellent visual quality and lens durability.
The advantages of rigid gas permeable lenses are
Quality of vision
Durability of lens material
Ability to correct astigmatism
In-office modification possible
Resistance to formation of lens deposit
Increased suitability in patients with poor tear film
Ease of lens handling

2. Disadvantages of Gas-Permeable Contact Lenses


A period of adaptation is needed for the patient to become comfortable with the lenses.
This varies from patient to patient but usually is about 2 weeks long. Comfort is not
instantaneous, and these lenses are less likely to provide the wow factor, which may
be routine with soft contact lenses. Fitting RGP lenses can be more challenging, but
modifications can allow for the best fit for an individual patient. Possible corneal thinning
with long-term contact lens wear is another disadvantage.

3. Lens Selection (RGP)


Lens selection criteria for RGP materials will include choosing the material based on its
oxygen permeability and its ability to resist deposit formation. Other parameters that need
to be considered are the base curve and the peripheral (secondary and tertiary) curves to
provide a good fit. Aspheric lenses are also available; these can provide less optical distor-
tion and better-quality visual acuity. As with other lens modalities, wear schedules will
Hyperopia 67

depend the material chosen and patients visual needs, whether these involve daily wear
or extended-wear use. More recently, frequent lens replacement has been introduced even
for rigid gas permeable lenses. Intermittent use is inadvisable, since an adaptation period
is needed to achieve maximum comfort with RGP lenses.

E. ASTIGMATISM
Soft contact lenses can be used in patients needing astigmatic corrections. If the patients
refractive error demonstrates only a small amount of astigmatism (under 1.00 D) and the
astigmatism is a small amount of the spherical correction (less than one-third), a soft
spherical contact lens will adequately correct vision. However, greater degrees of astigma-
tism can easily be corrected with toric soft contact lenses. RGP lenses can be used to
correct astigmatism whether it is corneal or lenticular in origin. Various methods have
been developed to stabilize the soft lens to match the orientation of the astigmatic correc-
tion. These include prism ballast (weighting the lens more heavily on the bottom), trunca-
tion (removing a section of the upper and/or lower part of the lens), or a combination of
the two methods, and slab off (a change in the lens periphery using pressure from the
eyelids to maintain the position).
The fitting of soft toric lenses usually involves using a trial set and then ordering
the appropriate lenses for an individual patient. These lenses have a surface orientation
mark to demonstrate whether there is lens rotation, indicating that the astigmatism might
not be corrected. One must observe the orientation mark on the soft contact lens when it
is fitted on the eye. Typically, the mark is located at the 6 oclock position, and one must
observe whether the rotation is clockwise or counterclockwise. A mnemonic that can help
the fitter to remember how to order the appropriate lens is LARS: left add, right subtract.
This means that if the lens rotates to the left, one adds to the amount of trial lens rotation
to the axis from the spectacle refraction. However, if the rotation, is to the right, then one
subtracts the amount of lens rotation from the axis obtained in the spectacle refraction.
Soft lenses come in a variety of astigmatic corrections, which are available in disposable
or frequent lens replacement styles, for correcting 2 to 3 D. These lenses are not indicated
for greater amounts of astigmatism and irregular astigmats. RGP contact lenses, on the
other hand, easily correct corneal astigmatism. Typically a spherical RGP contact lens
may correct up to 3 D of astigmatism. For greater amounts of astigmatism, a toric RGP
lens can be made. Most manufacturers provide customer service information over the
telephone or by e-mail through the Internet. This procedure can help in fitting patients
who have significant astigmatism that may not be adequately corrected with standard lens
materials.

F. PRESBYOPIA
1. Monovison
Currently refractive surgery also offers presbyopic correction primarily with the use of
monovison, where one eye is corrected for distance and the other eye for near use. This
procedure has been used successfully for many years with contact lens patients. In fact,
before refractive surgeries, often a trial monovison using contact lenses is indicated to
help a patient decide if this is appropriate for the planned permanent refractive procedure
to be done. Monovision offers simplicity both for the patient and the contact lens fitter.
68 Dualan and Asbell

However, some patients do not get used to the 2 D of anisometropia induced with monovi-
sion fitting and note reduced stereopsis; they sometimes need an overrefraction in specta-
cles for driving and other demanding visual tasks. Another option in such patients is to
reduce the anisometropia to approximately 1.25 D, which usually resolves symptoms, but
by doing so the patient should understand there will be an increased need for glasses for
closer vision compared to midrange vision.

2. Bifocal Contact Lenses


There are basically two designs in bifocal contact lenses. Alternating-vision bifocal contact
lenses provide for a slight range movement of the patients gaze from distance to near.
A slight twist of the lens provides an altered path for the light rays into the eye and how
it is refracted. The lenses can be made in a segmented bifocal-style, similar to bifocal
spectacles, or they can be made in a concentric bifocal style. The distance vision is in the
central part of the lens and the peripheral portion of the lens is for near vision. In both
styles, the lens must move slightly for patients to have good vision as they change their
focus from distance to near.
An alternative bifocal contact lens design provides simultaneous vision, whereby
light rays from both distant and near object pass through the lens and pupil. The patients
brain then selects the object to regard and bring into focus. This type of lens is available
in several different types, including the concentric bifocal which has an annular design,
with distance vision in the center and the near vision in the peripheral part of the contact
lens; an aspheric multifocal design, where there is an increase in plus power as one
moves from the center to the periphery of the lens as a result of the changing curvature
of the lens as oppose to a single based curve; and the diffractive bifocal type, which has
small concentric circular facets of varying refractive ability that are alternated to provide
the appropriate additional power needed for near vision near the center of the lens. Lenses
differ in their ability to be fitted, requiring careful attention to centering of the lens and
the relationship of the lens size to the patients pupil size. Typically, a practitioner becomes
expert in one or two bifocal lens types and acquires the experience and knowledge to pick
patients appropriately and fit them quickly. The availability of soft bifocal contact lenses,
which may also disposable, allows for an easier fit with the use of trial lenses. As with
refractive surgery, however, monovision probably continues to be the mainstay, consider-
ing the presbyopic patient today.

G. CONCLUSION
In conclusion, we will probably always have patients who prefer to use contact lenses and
spectacles for their refractive correction. These modalities offer quality visual acuity as
well as stability and affordability. In addition, the development of new materials for contact
lenses, particularly those offering extended wear, may very likely present a competitive
alternative to refractive surgery. This is especially true if the material for extended wear
demonstrates increased safety and comfort compared to older lens materials. It remains
to be seen whether this goal of extended wear and comfort can in fact be associated normal
corneal physiology and the maintenance of a risk-free use of contact lenses. With further
research and an increasing number of people seeking hassle free vision correction, we
may yet see the emergence of permanent contact lenses.
7
Surgical Treatment Options for
Hyperopia and Hyperopic Astigmatism

PAOLO VINCIGUERRA and FABRIZIO I. CAMESASCA


Istituto Clinico Humanitas, Milan, Italy

A. TREATMENT OF HYPEROPIA

With initial experience, the refractive surgeon may more or less consciously consider the
treatment of hyperopia as a situation opposite to but similar to myopia. Disappointingly,
laser refractive surgery for hyperopia has often led to more unsatisfactory results and
complications than for myopia (13). If we examine carefully a corneal surface after
hyperopic ablation, we may notice several important peculiarities.
The main concern is the transition zone: in treating myopia we create just one
transition zone; while in the treatment of hyperopia, central corneal curvature is increased
and two transition zones are needed, featuring double change in curvature and a median
flexus point (Fig. 1). This double transition zone is the most critical point of hyperopia
treatment (4). The most central of these two transition zones cannot be considered as part
of the optical zone (Fig. 2). This portion of the induced curvature is used to generate a
refractive effect but features a flexus with variation in curvature and is connected to the
peripheral corneal curvature through the second curvature zone. Therefore, in comparing
myopic and hyperopic treatments with the same ablation diameter, the hyperopic optical
zone will be smaller than the myopic one.
With the hyperopic ablation, the corneal curvature is changed, but the corneal physi-
ology is maintained up to the middle periphery. The ablation diameter must be planned
to fit the zone of curvature inversion right where the normal peripheral cornea flattens.
Using the elevation map, the surgeon must calculate the maximal corneal diameter and
place the flexus on the flat peripheral cornea, thus preserving the normal corneal physiology
(Fig. 3). If the flexus area is positioned centrally, far from this peripheral area of physiologi-
cal corneal flattening, multifocality and high-order optical aberrations will be induced.
69
70 Vinciguerra and Camesasca

Figure 1 Hyperopic ablation. Central corneal curvature is increased and two transition zones are
induced, leading to a double change in curvature.

Figure 2 Hyperopic ablation. The central part of the transition zone (A to B) cannot be considered
part of the optical zone.
Surgical Treatment Options 71

Figure 3 Importance of corneal diameter in hyperopic refractive surgery.

Also, hyperopic ablation generates a negative longitudinal spherical aberration with worse
vision quality, due to the fact that para-axial light rays will pass through the first curvature
flexus, which imparts a hyperopic shift (Figs 4 and 5).
However, it is important to remember that these problems are sometimes reduced
by the anatomical characteristics of hyperopic eyes. Generally speaking, the size of the
optical zone is less important for a hyperopic patient than for a myopic one. The hyperopic
eye features smaller axial length, anterior chamber, and corneal diameter. Given the same
ablation diameter, an eye with a shallow anterior chamber will enjoy a larger optical zone
than one with a deep chamber (Fig. 6), and will have a larger percentage of corneal surface
involved by the treatment. Moreover, the two transition zones mentioned above will lie
peripherally, positioned in a corneal area with lesser curvature and lesser influence on
refraction. In a hyperopic eye with a shallow anterior chamber, the treatment results will
be less influenced by pupil diameter: even an optical zone of small size may cover the
pupillary area sufficiently, since the treated corneal arc will be closer to the pupillary area
and thus able to cover the pupil halos during mydriasis (Fig. 6). What is really important
is that the optical zone be truly homogeneous.

Figure 4 Myopic ablation. With a wide ablation area, the optical zone is wide and uniform,
without aberrations induced on para-axial rays.
72 Vinciguerra and Camesasca

Figure 5 Hyperopic ablation. When the optical zone is small, para-axial light rays will pass
through the first curvature flexus, with consequent hyperopic shift, negative longitudinal spherical
aberration, and worse vision quality.

These and the following observations can be assumed to be valid both for photore-
fractive keratectomy (PRK) and laser-assisted in situ keratomileusis (LASIK) treatment.
Therefore, with some important exceptions, we henceforth refer to refractive treatment as
including both PRK and LASIK.

1. Keratorefractive Indexes
Several parameters may be taken into account in evaluating the quality of an ablation.
1. Corneal eccentricity. A concept of foremost importance is that of corneal eccen-
tricity. Eccentricity is the measure of corneal asphericity; therefore it expresses

Figure 6 Given a 6.5-mm optical zone ablation, an eye with a low chamber will enjoy a larger
optical zone than one with a deep chamber, and even a small optical zone may sufficiently cover
the pupillary area.
Surgical Treatment Options 73

the way the cornea changes from a flatter periphery to a more curved central
portion. Eccentricity values (e values) are positive when the cornea is prolate,
negative when it is oblate. Normal eccentricity values range between 0.5 and
0.6 (normally prolate cornea, curved in the center, flat in the periphery). A
hyperopic treatment increases the e value; Figures 7 through 11 show cases
with progressively higher e values, approaching a keratoconus-like situation.
Central keratoconus, featuring a high eccentricity, with e values of 1.5 or
more, amplifies the physiological situation of transition from a curved central
cornea to a flat periphery. On the contrary, a myopic treatment induces negative
eccentricity, inverting the normal morphology.
2. Longitudinal spherical aberration (LSA). LSA expresses the aberration induced
by corneal multifocality. It is a measure of spherical aberration; its increase
indicates a decrease in contrast sensitivity.
3. Root mean square (RMS). RMS is a measure of the irregularity of curvature,
expressing the amount of deviation from a regular corneal curvature.
4. Surface asymmetry index (SAI). SAI is a measure of corneal symmetry in the
pupillary area. Its increase leads to an increase in coma.
In the past, it was generally thought that excessively high corneal curvature values
would lead to a keratoconus-like situation. From our studies, it appears that an important
factor for this complication is the corneal curvature gradient (eccentricity). Interestingly,

Figure 7 through 11 Eyes with progressively higher e values, approaching a keratoconus-like


situation.
74 Vinciguerra and Camesasca

Figure 8.

Figure 9.
Surgical Treatment Options 75

Figure 10.

Figure 11.
76 Vinciguerra and Camesasca

we may observe patients with corneal curvature values of 46 D who show good visual
acuity, while others with, for example, 45 D do not enjoy such good vision. In a patient
with 46 D and normal eccentricity, there is no marked peripheral flattening and visual
acuity will be good. Another patient, with a keratoconus and a corneal curvature within
normal values, such as 45 D, will inevitably show a high eccentricity and therefore a
marked (e.g., spherical) optical aberrations, a very small homogeneous optical zone, and
reduced vision quality.
Highly positive eccentricity values (above 1.0 to 1.2) are typical of keratoconus and
some cases of hyperopic ablations. A whitish scar may occur in the stroma following PRK
or LASIK. This scar correspond topographically to the point of maximal corneal curvature
(Figs. 12 and 13). In these cases there is always a high eccentricity value. At present, the
etiology of this scar remains uncertain; there is an inhomogeneous tear film as well as lid
trauma to the centrally steepened area. For photorefractive treatments, the scar was
believed to be the result of denervation of the central corneal area due to the depth
of the peripheral ablation. This hypothesis is no longer held, however, because the
scar is observed at the point of greatest corneal curvature and not at that of maximal
corneal ablation. Furthermore, the scar is not observed with a greater frequency in
LASIK eyes, where central corneal denervation is more complete. However, a similar
scar is present in posttraumatic corneal leukomas, always at the point of greatest
corneal curvature. In these cases of corneal leukoma, topographic analysis may very
often be misleading due to problems with the elaboration of the map. Keratoscopy
must always be obtained and examined.
Correction of hyperopia with LASIK is more successful, even in the presence of
high e values. As a matter of fact, the flap does not follow the new shape of the stromal
bed, perfectly thus reducing the eccentricity created by the ablation. In PRK, corneal
epithelium follows the newly imparted morphology faithfully. However, above certain
values of eccentricity, even LASIK fails.
Retreatment with PTK of these fibrotic areas in hyperopia leads to limited or no
result at all, if corneal eccentricity remains positive (e 1.0 1.5), with recurrence of

Figure 12 Keratoscopy of an eye with a subepithelial (PRK) whitish scar, corresponding topo-
graphically to the point of maximal corneal curvature.
Surgical Treatment Options 77

Figure 13 Topography of same eye as in Figure 12.

the scar at the point of greatest corneal curvature. On the other hand, when eccentricity
is decreased, as with corneal excimer laser smoothing, recurrence is prevented. A key
point of hyperopic ablation is thus to maintain a corneal eccentricity as much as possible
close to physiological values.
Corneal topography offers the advantage of an accurate evaluation of the quality of
hyperopic ablation. A wide, homogeneous central area is necessary for improved visual
quality, and the surgeon must strive to achieve it as well as to monitor the result topographi-
cally. The aberrometric map allows evaluation of central corneal dioptrical homogeneity
as well as detection of irregularities that may generate aberrations. The wider the central
treatment, the less important is the second, peripheral part of the transition zone (Figs. 1 and
2). Our experience with the Nidek OPD aberrometer shows that, with good topographical
indexes, we have a satisfactory aberrometric map: more than 80% of optical aberrations
are caused by the first corneal surface.
The future is represented by a larger optical zone (in relation to corneal diameter),
of 6.5 mm or greater, with a first, more smooth and homogeneous transition zone up to
9 mm, and a second, limbal transition zone, of more than 9 mm. Let us remember that
the corneal periphery offers also the advantage of a greater thickness (Fig. 14).
8
Laser Thermokeratoplasty and
Wavefront-Guided LTK

SHAHZAD I. MIAN and DIMITRI T. AZAR


Cornea and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary,
Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

The use of thermokeratoplasty in order to change corneal curvature has been evaluated
extensively but has shown limited success due to significant regression of refractive effect.
With an improved understanding of corneal response to thermal injury and technological
advances that have allowed for better control of thermal injury to the cornea, real-time
wavefront-guided thermokeratoplasty may become a safe and effective surgical technique
for the management of hyperopia.

A. HISTORY
Lans first demonstrated the use of thermal energy to change corneal curvature (1). He
applied electrocautery to the peripheral corneas of rabbits to induce central corneal steepen-
ing. Corneal cautery was later used to treat patients with high astigmatism, but with limited
stability of results (2,3). Thermokeratoplasty has also been used to treat patients with
keratoconus, but with poor predictability and a high incidence of regression (46). There
have also been reports of complications, including delayed epithelial healing, corneal
scarring, recurrent erosions, corneal neovascularization, and iritis (79). However, thermo-
keratoplasty may have a role in the management of patients with keratoconus in countries
with limited availability of corneal tissue (10). Radiofrequency energy has also been used
to induce corneal steepening with collagen shrinkage, but with poor predictability and
scarring (11).
Fyodorov first used thermokeratoplasty to treat hyperopia by developing radial ther-
mokeratoplasty (12). He used a retractable nichrome thermal probe to coagulate the midper-
ipheral cornea at a depth of 85 to 90% with temperatures up to 600C for 0.3 s. The
83
84 Mian and Azar

corneal burns were made in a radial pattern with eight rows and comprised of three or
four applications, each up to a premarked optical zone. Trials with radial thermokera-
toplasty showed limited clinical benefit because of regression of refractive effect and
poor predictability (1315). Like previous methods of thermokeratoplasty, there were also
reports of endothelial damage, corneal decompensation, and corneal necrosis.
Improvement in laser technology has led to advancement in thermokeratoplasty
techniques. Prior to the use of infrared laser sources, the complications with thermokera-
toplasty techniques were partly related to nonuniform heating of corneal stroma at high
temperatures. Laser thermokeratoplasty (LTK) allows for controlled delivery of heat to
the corneal stroma while preventing excessive injury to the epithelium and endothelium.
Several lasers have been investigated to induce stromal injury. The carbon dioxide
laser (CO2, wavelength: 10.6 m) leads only to superficial retraction of collagen, with
early regression of effect (16,17). The yttrium-erbium-glass laser (Yt-Er-glass, wavelength:
1.54 m) allows for deep penetration of corneal stroma with good refractive results, but
its use may lead to corneal tissue necrosis and iris damage (18). The cobalt:magnesium
fluoride laser (wavelength: 1.85 to 2.25 m) and the continuous-wave hydrogen fluoride
chemical laser (wavelength: 2.61 m) have also been evaluated in animal studies, with
stable results (19,20).
Initial trials with a pulsed holmium:yttrium-aluminum-garnet laser (Ho:YAG, wave-
length: 2.06 m) in human eyes resulted in a hyperopic shift of up to 5 D, which remained
stable for 4 months (21). The advantages of the Ho:YAG laser include a corneal stromal
penetration depth of about 400 to 450 m and a cone-shaped profile. Unlike the cylindrical
profile of thermal probes, the Ho:YAG laser produces a cone-shaped coagulation, allowing
for greater shrinkage of anterior stromal collagen compared to the posterior stroma (22).
Controlling the magnitude and depth of stromal coagulation allows for greater refractive
effect and increased stability of results. In addition, the Ho:YAG laser uses solid-state
technology, which is relatively inexpensive to manufacture and maintain.

B. MECHANISM
The basic mechanism of thermokeratoplasty involves change in corneal curvature through
heat-induced injury of stromal collagen. Stringer and Parr first reported that the temperature
required to shrink corneal collagen is 55 to 58C (23). Heating above 65 to 70C causes
collagen relaxation, while even higher temperatures lead to stromal collagen necrosis (24).
Refractive outcome with LTK is based on optimal corneal stromal shrinkage, determined
by the following parameters (25):
1. Temperature. Collagen shrinkage without destruction of collagen fibrils occurs
in a narrow temperature range between 55 and 58C. When the corneal stroma
is heated to 55 to 60C, the tropocollagen helical structure collapses due to
dissociation of interpeptide hydrogen bonds, unwinding of the triple helix, cross-
linkage between tropocollagen molecules, and dehydration of the stroma. This
causes the corneal collagen to shrink maximally, to one-third of its original size.
The temperature threshold increases with age due to a greater number of ther-
mally stable cross-linked hydrogen bonds (26). Increasing the temperature to
78C or more leads to relaxation of contracted collagen and loss of tissue elastic-
ity (24).
2. Tissue elasticity. The refractive effect is dependent on tissue resistance to colla-
gen shrinkage (24). In younger patients, rigid corneal tissue will lead to limited
initial response; greater elasticity of corneal tissue will increase regression of
effect (25).
Laser Thermokeratoplasty 85

3. Keratocyte response. Keratocyte injury occurs when stromal collagen is heated


to 79C, which induces wound healing, including extracellular matrix remodel-
ing and keratocyte activation (27). These changes contribute to postoperative
regression of induced refractive effect.
4. Stability of corneal collagen. Normal replacement of treated collagen by newly
synthesized collagen may also contribute to regression of refractive effect. Colla-
gen turnover in the cornea is very slow, with a half-life of 10 years; the stability
of corneal collagen after LTK is unknown (28,29).

C. CONTACT AND NONCONTACT LTK


The Ho:YAG laser delivery system can be used with a contact probe (Summit Technology,
Waltham, MA, and Technomed, Baesweiler, Germany) or a noncontact device (Sunrise
Technologies, Fremont, CA) (22,30). The contact probe allows for sequential delivery of
laser pulses into premarked spots using a fiberoptic handpiece brought into direct contact
with the cornea. The spot size is variable and dependent on the diameter of the fiber
optic handpiece (Summit Technology, Waltham, MA, 0.7 mm; Technomed, Baesweiler,
Germany, 0.55 mm). Depending on the degree of hyperopia, rings of eight spots are applied
with a treatment zone of 6.5 and 9.0 mm, 7.0 and 9.0 mm, and 7.5 mm with the Summit
Ho:YAG LTK and 6, 7, or 8 mm with the Technomed Ho:YAG LTK.
The noncontact Ho:YAG laser device allows for simultaneous delivery of eight laser
pulses using a slit-lamp, with a fixed spot size of 0.60 mm. One, two or three radial or
staggered concentric octagonal rings are placed at 6-to 8-mm ring diameters. This technol-
ogy can be coupled with real-time wavefront measurements to minimize the unpredictabil-
ity of the surgery.

D. PATIENT SELECTION
The noncontact Ho:YAG laser (Hyperion, Sunrise Technologies, Freemont, CA) was ap-
proved by the U.S. Food and Drug Administration (FDA) in June 2000 for the temporary
reduction of hyperopia in patients with the following indications:
1. Age 40 years
2. Manifest refraction spherical equivalent of 0.75 to 2.5 diopters
3. Cylindrical correction 0.75 diopters
4. Stable refraction 6 months prior to the procedure
LTK is contraindicated in patients:
1. During pregnancy or while nursing
2. With keratoconus
3. With clinically significant corneal dystrophy or scarring in the 6-or 7-mm central
zone
4. With a history of herpetic keratitis
5. With an autoimmune disease, collagen vascular disease, clinically significant
atopic syndrome, insulin-dependent diabetes or an immunocompromised state
Patient evaluation includes visual assessment with both uncorrected and best-cor-
rected visual acuity with cycloplegic refraction. Intraocular pressure should be measured
to exclude narrow-angle glaucoma in hyperopic patients. A poor LTK effect is observed in
patients with high intraocular pressure (31). Corneal topography is performed to determine
86 Mian and Azar

presence of irregular astigmatism. Pachymetry is helpful, because thinner corneas have


greater effect with LTK. Systemic anti-inflammatory medications should be avoided 2
months preoperatively and 3 months postoperatively due to their contribution to regression
of refractive effect. Wavefront-guided LTK studies are underway, but have not been ap-
proved as of yet by the FDA.

E. SURGICAL PROCEDURE
1. Contact LTK
With the contact Ho:YAG laser (Summit Technology, Waltham, MA, and Technomed,
Baesweiler, Germany), energy is delivered through a quartz fiberoptic probe handpiece
and focused by a disposable tip at the corneal surface with a cone angle of 120 (32).
Preoperatively, patients are given topical tetracaine anesthesia and the pupil is constricted
with 1% pilocarpine. The optical zone center is located using coaxial fixation and marked
over the center of the pupil. Probe placement is guided by using a specially designed
marker with radial and arcuate marks. The probe tip is applied perpendicular to the corneal
surface at the intersection of the radial and arcuate marks. The laser energy is set at 19
mJ per pulse for 25 pulses, pulse duration of 300 ms, with a repetition rate of 15 Hz. The
patients receive either 8 or 16 spots at variable optical zones. Loose epithelium is debrided
with a weck-cell sponge from the treatment areas after and the eye is patched after adminis-
tering antibiotic/steroid ointment. Postoperatively, patients receive tobramycin 0.3%/dexa-
methazone 0.1% ointment five times daily until re-epithelialization.

2. Noncontact LTK
The noncontact Ho:YAG laser (Hyperion, Sunrise Technologies, Fremont, CA) is a solid-
state, pulsed laser connected to a slit-lamp delivery system (Nikon) capable of projecting
eight uniform beams in an octagonal ring (33). Each beam has an individual shutter with
adjustable optical zone diameters, allowing for different treatment patterns. The laser
energy is set from 21 to 25 mJ per pulse for 5 to 10 pulses with a repetition rate of 5 Hz
applied over several seconds. Two HeNe laser beams are used for alignment, centration,
and coaxial focusing. Preoperatively, topical anesthetic drops (0.5% proparacaine solution)
are administered, starting 20 min before treatment, for a total of four drops. A lid speculum
is inserted to allow the eyelids to be held open for 3 min before laser application to dry
the tear film. This helps standardize the effects of epithelial swelling and corneal hydration
on delivery of laser energy to the corneal stroma. The patient is instructed to fixate on a
flickering red light during laser application. The ring diameter and number of rings applied
depends on the desired correction. Postoperatively, patients are given 0.3% tobramycin
and diclofenac sodium drops four times daily until the epithelium is healed. Patients may
also take acetaminophen or acetaminophen with codeine for pain management. In real-
time wavefront-guided LTK, the energy per pulse can be adjusted to improve the surgical
outcomes.

F. VISUAL OUTCOMES
1. Contact LTK
The safety of contact Ho:YAG LTK was initially established in 33 human cadaver and 4
blind human eyes (21). Sixteen coagulations on two concentric rings, with diameters of
6 and 9 mm, were applied. This resulted in central corneal steepening with a refractive
Laser Thermokeratoplasty 87

change that increased with the applied pulse energy above a threshold of 10 mJ per pulse,
remaining constant between 15 and 35 mJ per pulse. Hyperopic shifts of up to 5.00 D
were obtained, decreasing linearly with increasing diameter of treatment zone, which
remained stable for 4 months.
Durrie et al. conducted FDA phase I and II trials for contact Ho:YAG LTK for low
to moderate hyperopia (32). Patients in phase I had a mean spherical equivalent of 4.17
D (2.25 to 6.62 D). However, because of limited efficacy with higher refractive
corrections, phase II included patients with a mean spherical equivalent of 1.50 D (0.00
to 4.25 D). One or two ring treatments with eight spots were applied at 7.0, 7.5, 7.0,
and 9.0 and 6.5 and 9.0 mm. No patients saw J2 or better preoperatively, and 75% saw
J2 or better 6 months postoperatively. In phase II, 79% of patients were within 1 D of
emmetropia, and 89% of patients had uncorrected visual acuity of 20/40 or better at 1
year follow-up. After initial regression, the refractive results were stable at the 6-month
follow-up for patients in both phase I and phase II. The phase I patients were followed
for 1 year with further regression of effect. Tutton et al. treated 22 eyes by placing two
rings with eight laser spots at 6.5 and 9.0 mm to produce a 4-D correction (34). Only
25% of patients were within 1.00 D of intended correction. In addition, 1.25 to
2.50 D astigmatism was induced with 50% regression of refractive effect at 2 years
postoperatively. Eggink et al. treated 55 hyperopic eyes with one ring of eight spots with
a treatment diameter of 6, 7, or 8 mm (35). The 6- and 7-mm-diameter treatments were
more effective than the 8-mm-diameter treatment zone. Twelve-month follow up did not
show stability, and there was limited additive effect of retreatment.
Contact Ho:YAG LTK has also been used for correction of astigmatism (3638).
Corneal coagulation produces flattening in the peripheral cornea, accompanied by central
steepening. This can be an effective treatment for steepening the flat axis in astigmatism.
There is also a myopic shift in the spherical equivalent equal to one-half the steepening
of the flat axis. Thompson et al. treated 30 eyes with four coagulation treatments with
two spots placed on either side of an 8.5-mm ablation zone in the flat axis of the cylinder
(38). The preoperative cylinder ranged from 1.50 to 4.00 D, with the average astig-
matic correction obtained being 1.69 D (0.4 to 3.98 D). Uncorrected distance visual
acuity improved by two or more lines in 18 eyes and remained unchanged in the other 8
eyes. There was a trend toward more astigmatic correction with increasing age as well as
a trend toward a myopic shift in spherical equivalent. With limited efficacy of results
and a high rate of regression of refractive effect, the FDA trials for contact LTK were
discontinued.

2. Noncontact LTK

The safety of noncontact Ho:YAG LTK was initially established in humans with poorly
sighted eyes. Ariyasu et al reported no evidence of endothelial cell loss, corneal thinning
or neovascularization, persistent epithelial defects or change in intraocular pressure. (39)
Table 1 summarizes the clinical trials conducted for noncontact Ho:YAG LTK. In the
United States, the FDA phase II trial for low hyperopic correction by noncontact Ho:YAG
LTK was conducted with 1-year follow-up (40). Twenty-eight patients with a preoperative
spherical equivalent of 2.21 0.89 D (0.5 to 3.88 D) were treated with either one or
two symmetrical staggered rings of eight spots per ring, with a diameter of 6 mm (one
ring) or 6 and 7 mm (two rings). Ten pulses of laser light were applied at 5-Hz pulse
frequency, with pulse energy ranging from 208 to 242 mJ. At 1 year postoperatively,
88

Table 1 Noncontact Ho: YAG LTK Clinical Studies


LTK Treatment parameters One-Year Postoperative results
Reference Follow-up,
no. months Patients n D (mm) N M Ep (mJ) UDVA SE (D) Cyl (D) Stability

40 12 17 6 8 10 208242 20/6320/32 0.550.33 0.250.29 0.54


8 6/7 8/8 10/10 224240 20/12520/50 1.640.61 0.470.53 0.43
42 24 15 6 8 10 160199 20/12520/50 0.790.65 0.160.49 0.59
43 18 15 6 8 10 208242 20/6320/40 0.520.35 0.300.37 0.49
7 6/7 8/8 10/10 224240 20/12520/63 1.410.53 0.250.29 0.38
44 12 8 6/7/8 8/8/8 7/7/7 NA 20/10520/36 2.15 0.15 0.41
8 6/7/81 8/8/8 7/7/7 20/11820/47 1.50 0.15 0.29
46 12 6 5/6 8/8 5/5 240 20/16020/80 2.081.13 0.921.46 0.62
6 6/7 8/8 5/5 240 20/20020/40 1.830.88 0.170.38 0.62
18 6.5/7.5 8/8 5/5 240 20/20020/50 1.220.88 0.150.58 0.46
47 15 57 6/7 or 8 8/8 10/10 215255 20/3020/40 2.070.11 NA 0.58
49 12 182 5 to 7.5 8/88 5/55 240 20/8020/40 1.25 NA 0.60

Key: n, number of patient eyes; D, centerline ring diameter(s); N, number of spots; M, number of pulses; Ep, pulse energy; UDVA, change in uncorrected distance visual acuity
(prepost); SE, change in spherical equivalent; Cyl, change in cylinder; Stability, ratio of mean change in spherical equivalent values for 1 day to 1 month postoperatively
divided by 1 year postoperatively; NA, not available.
Mian and Azar
Laser Thermokeratoplasty 89

uncorrected distance visual acuity improved in all patients. The mean change in spherical
equivalent was 0.55 0.33 D (one-ring treatment) and 1.64 0.61 D (two-ring
treatment). After initial regression, there was good stability of refractive effect after 6
months. The mean induced refractive astigmatism was 0.25 0.29 D (1 ring) and 0.47
0.53 D (two rings). The extent of refractive change in each group was correlated with
the amount of laser pulse energy using the following algorithms: for one-ring treatment,
change in spherical equivalent (diopters) 3.20 0.0171 pulse energy; for two-ring
treatment, change in spherical equivalent (diopters) 14.47 0.0685 pulse energy.
Corneal topographic changes confirm peripheral corneal flattening and central corneal
steepening, with a greater change in curvature being produced with two-ring treatment.(41)
Two-year follow-up of low hyperopic treatment with eight spots at a 6 mm diameter
revealed stable refractive effect, similar to the 1-year data (42). Eighteen-month follow
up of low hyperopia treatment with two octagonal staggered rings at 6- and 7-mm diameter
also confirmed stability of refractive results (43).
Two-ring treatments may be performed with radial or staggered rings of eight spots.
Vinciguerra et al. compared the effects of the two treatment patterns in the correction of
hyperopia with Ho:YAG LTK (44). The treatment consisted of 24 spots in three concentric
rings of eight spots each, with ring diameters of 6, 7, and 8 mm. Each spot received seven
pulses of laser energy. One eye of each patient received the radial ring pattern, while the
fellow eye was treated with the staggered ring pattern. The radial and staggered patterns
effectively corrected low hyperopia, and both were subject to regression. However, the
radial pattern produced faster postoperative recovery of spectacle-corrected visual acuity
and demonstrated greater refractive stability.
Histopathological studies of rabbit and human corneas have shown a direct correla-
tion between the amount of pulse radiant energy and resulting acute tissue injury (25,45).
These studies have shown that Ho:YAG laser irradiation produces acute epithelial and
stromal tissue changes, which stimulate a brisk wound-healing response. The wound heal-
ing response has been correlated to rapid early regression of refractive effect. In order to
determine whether regression correlates to initial pulse energy, a clinical trial was con-
ducted using five pulses of laser light (1.2 J of total energy compared to 2.35 J with 10
pulses) for treatment of low to moderate hyperopia (46). Thirty-nine eyes with preoperative
spherical equivalent of 2.95 0.97 D (1.50 to 4.75 D) were treated with two radial
rings of eight spots with diameters of 5 and 6 mm (Group A), 6 and 7 mm (Group B),
or 6.5 and 7.5 mm (Group C). Uncorrected distance visual acuity improved in all three
groups at 1-year follow-up. The mean change in spherical equivalent was 2.08 1.13
D for Group A, 1.83 0.88 D for Group B and 1.22 0.88 D for Group C. In
comparing the 10-pulse with the 5-pulse Ho:YAG treatment, there was less initial refractive
effect with the 5-pulse treatment. However, there was also less regression, with increased
stability of refractive effect. In addition, the duration of treatment for five pulses is reduced
to 1 s, which is more comfortable for patients and less likely to produce irregular effects
due to motion. Group C also showed reduced refractive effect when compared to groups
A and B because of reduction in areal energy density with peripheral treatment. The
induced refractive cylinder was greatest with group A, corresponding to the proximity of
treatment spots to the central visual axis.
Regression of initial refractive effect can be large with Ho:YAG LTK. Alio et al.
demonstrated a direct relationship between refractive regression, age, and measurements
of central corneal thickness (47). In this study, 57 eyes, with a mean preoperative spherical
equivalent of 3.80 0.22 D (1.50 to 5.00 D), were treated with Ho:YAG LTK, applying
90 Mian and Azar

two or three rings of eight spots, with 6-, 7-, and 8-mm-zone diameters. The mean spherical
equivalent at 15 months was reduced to 1.73 0.16 D. In all, 57.8% of the eyes were
1.00 D of intended correction, while 21% were 0.50 D of intended correction. Patients
with 75 to 100% regression were compared to those with 25% or less regression. Full
regression was more common in patients between 18 and 30 years of age, with an inverse
correlation with increasing age. Gezer et al. reported 18% regression in patients older than
20 years and 48% in patients less than 20 years of age (48). Corneal thickness correlated
directly with regression. Patients with central corneal thickness of 525 m or less experi-
enced the least amount of regression. Average keratometry did not influence regression.
Alio et al. hypothesize that the regression of effect might be due to the elasticity of
Bowmans membrane and stromal collagen in younger patients, or due to thicker corneas,
allowing the cornea to return to its original shape. In addition, the thermal effectiveness
of Ho:YAG LTK may depend on the water content of the corneal stroma, which may be
age-dependent. Alio et al. have developed a formula for preoperative evaluation of the
potential amount of postoperative regression: % of regression average keratometry x
pachymetry/15 x age.
Since regression is common after Ho:YAG LTK, retreatment may be necessary.
Nano and Muzzin conducted a study with 182 eyes with low hyperopia with mean preopera-
tive spherical equivalent of 2.50 0.87 D (0.75 to 4.75 D) (49). At 12 months, the
mean spherical equivalent was 1.25 0.96 D, with 45% regression in manifest refrac-
tion. Seventeen percent of the operated eyes were retreated (31 eyes). Eighteen (56%)
eyes were retreated with Ho:YAG LTK, which has been reported to have a success rate
between 50 and 70%. In the Sunrise LTK clinical trials, 85% of eyes were within 1.0
D of emmetropia after retreatment (50).
Excimer laser retreatment with laser-assisted in situ keratomileusis (LASIK) or pho-
torefractive keratectomy (PRK) may also be performed after LTK. Nano and Muzzin
treated 14 (45%) eyes with PRK (49). Portellinha et al. treated 12 eyes with hyperopic
LASIK for residual hyperopia after LTK (51). The mean preoperative cycloplegic spherical
equivalent refraction was 3.31 D (1.00 to 6.50 D). Postoperatively, all eyes achieved
reduction in hyperopia to a mean postoperative refraction of 0.88 D. No morphological
changes were observed in the radial thermal scars. Attia et al treated 50 eyes with hyperopic
LASIK for regression after LTK (52). The mean spherical equivalent refraction improved
from 2.92 1.60 D to 0.36 1.48 D; the predictability and efficacy were less than
with primary LASIK for hyperopia. This study reported confluent haze between previous
LTK spots in most eyes, as LASIK ablation took place at the sites of the LTK spots. The
haze was greater when the LASIK flap cut coincided with the LTK spots. However, the
corneal scarring did not seem to influence the visual results. Both studies conclude that
LASIK after LTK is a good alternative for management of hyperopic regression.

3. LTK for PRK-Induced Hyperopia


Myopic treatment with PRK may result in a significant overcorrection in 2 to 5% of
patients. Ho:YAG LTK has been evaluated for the correction of hyperopia induced by
PRK (5356). Alio et al. evaluated the use of noncontact Ho:YAG LTK in 14 eyes with
hyperopia induced by PRK with a mean spherical equivalent of 4.20 1.80 D (1.75
to 6.25 D) (54). The Ho:YAG laser spots were applied outside the previous ablation
zone to avoid confluence of haze. After 12-month follow-up, there was no difference
between the mean preoperative spectacle-corrected visual acuity and the mean postopera-
Laser Thermokeratoplasty 91

tive uncorrected visual acuity. There was a mean increase of 4.60 1.20 D in central
keratometric power. Contact Ho:YAG LTK was also evaluated for correction of hyperopia
and astigmatism after PRK. Eggink et al. reported limited efficacy and predictability in
16 eyes treated with contact Ho:YAG LTK (55). However, there were no sight-threatening
complications. Goggin and Lavery reported treatment of 11 eyes with mean preoperative
spherical equivalent of 2.06 1.02 D and postoperatively to 0.511 0.55 D after
1-year follow-up. (56) a total of 91% were 20/40 or better and 82% were within 1.00
D of the target spherical equivalent.

4. LTK for LASIK-Induced Hyperopia


LASIK is a safe and effective technique for correction of moderate to high myopia. How-
ever, 2 to 8% of patients may have significant overcorrection (57). The efficacy and safety
of noncontact Ho:YAG LTK for correction of hyperopia after LASIK was evaluated in
13 eyes (58). After 18 months of follow-up, the mean cycloplegic refraction changed from
4.6 1.4 D (2.50 to 7.25 D) to 0.76 0.11 D. All of the patients were within
1.50 D of emmetropia, and no patient lost lines of best-corrected visual acuity.

G. COMPLICATIONS
Mild pain, tearing, photophobia, and foreign-body sensation have been reported 1 to 3 days
after surgery.(21,39,42,46,50) These complications were related to laser-induced epithelial
injury, which resolved within 3 days in most patients. Opacities in each treatment spot
decreased over time, becoming undetectable in most patients in room light; however, the
opacities were observed with slit-lamp biomicroscopy even after 2 years (42). Astigmatism
has been shown to be induced by Ho:YAG LTK, especially with the smaller treatment
diameters (32,42,50). No significant changes in endothelial cell density occurred up to 12
months postoperatively (33,44). There was no significant loss of contrast sensitivity and
no change in glare test measurements (33,46,50).

H. CONTINUOUS-WAVE DIODE LTK


Compared to pulsed Ho:YAG lasers, diode lasers provide continuous heat to the target
tissue with more uniform stromal heating. This potentially allows for higher and more
stable refractive correction. Wavelength settings of 1.854, 1.870, 1.885, and 2.1 m have
been studied (5963). The shorter wavelengths achieve greater corneal depth, with a
wavelength of 1.854 m causing extensive local endothelial damage (0.8 to 1.2 mm in
diameter) (61,62). A wavelength of 1.885 m has a penetration depth of 380 m, compara-
ble to the absorption of the Ho:YAG laser emitting at 2.07-m wavelength. Continuous-
wave diode LTK has been tested in eight blind human eyes (63). A wavelength of 1.854
or 1.870 m with 100 to 150 mW power was applied for 10 s. The radiation was focused
into the corneal stroma between 400 and 600 m or 1000 m with one or two eight-spot
rings. The refractive change increased with higher laser power and smaller ring diameters.
Two rings provided higher and more stable refractive effect of up to 5.66 D. The
refractive effect stabilized between 3 and 6 months. Greater endothelial damage was noted
with a wavelength of 1.854 m.
Ho:YAG LTK offers an alternative treatment for the correction of hyperopia up to
2.50 D. There is an initial overcorrection followed by regression, dependent on age and
92 Mian and Azar

corneal thickness. Clinical studies have established the safety and efficacy of Ho:YAG
LTK up to 2 years after treatment. LTK may also be used to treat PRK and LASIK-
induced hyperopia. Diode lasers may help further improve stability of refractive effect
with LTK. Wavefront-guided LTK may further improve the predictability of this procedure
and allow for predictable outcomes even for retreatments of initial undercorrections.

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49. Nano HD, Muzzin S. Noncontact holmium:YAG laser thermal keratoplasty for hyperopia. J
Cataract Refract Surg 1998; 24:751757.
50. Aker AB, Brown DC. Hyperion laser thermokeratoplasty for hyperopia. Int Ophthalmol Clin
2000; 40(3):165181.
51. Portellinha W, Nakano K, Oliveira M, Simoceli R. Laser in situ keratomileusis for hyperopia
after thermal keratoplasty. J Refract Surg 1999; 15(2 suppl):S218S220.
52. Attia W, Perez-Santonja JJ, Alio JL. Laser in situ keratomileusis for recurrent hyperopia
following laser thermal keratoplasty. J Refract Surg 2000; 16:163169.
53. Pop M. Laser thermal keratoplasty for the treatment of photorefractive keratectomy overcorrec-
tions: a 1-year follow-up. Ophthalmology 1998; 105(5):926931.
54. Alio JL, Ismail MM, Artola A, Perez-Santonja JJ. Correction of hyperopia induced by photore-
fractive keratectomy using non-contact Ho:YAG laser thermal keratoplasty. J Refract Surg
1997; 13:1316.
55. Eggink CA, Meurs P, Bardak Y, Deutman AF. Holmium laser thermal keratoplasty for hyper-
opia and astigmatism after photorefractive keratectomy. J Refract Surg 2000; 16:317322.
56. Goggin M, Lavery F. Holmium laser thermokeratoplasty for the reversal of hyperopia after
myopic photorefractive keratectomy. Br J Ophthalmol 1997; 81:541543.
57. Perez-Santonja JJ, Bellot J, Claramonte P, Ismail MM, Alio JL. Laser-in-situ keratomileusis
to correct high myopia. J Cataract Refract Surg 1997; 23:372385.
58. Ismail MM, Alio JL, Perez-Santonja JJ. Noncontact thermokeratoplasty to correct hyperopia
induced by laser-in-situ keratomileusis. J Cataract Refract Surg 1998; 24:11911194.
59. Bende T, Jean B, Oltrup T. Laser thermal keratoplasty using a continuous wave diode laser.
J Refract Surg 1999; 15:154158.
60. Brinkmann R, Koop N, Geerling G, Kampmeier J, Borcherding S, Kamm K, Birngruber R.
Diode laser thermokeratoplasty: application strategy and dosimetry. J Cataract Refract Surg
1998; 24(9):11951207.
61. Koop N, Wirbelauer C, Tungler A, Geerling G, Bastian GO, Brinkmann R. Thermal damage
to the corneal endothelium in diode laser thermokeratoplasty. Ophthalmologe 1999; 96(6):
392397.
62. Wirbelauer C, Koop N, Tungler A, Geerling G, Birngruber R, Laqua H, Brinkmann R. Corneal
endothelial cell damage after experimental diode laser thermal keratoplasty. J Refract Surg
2000; 16:323329.
63. Geerling G, Koop N, Brinkmann R, Tungler A, Cand med.m, Wirbelauer C, Birngruber R,
Laqua H. Continuous-wave diode laser thermokeratoplasty: first clinical experience in blind
human eyes. J Cataract Refract Surg 1999; 25:3240.
9
Conductive Keratoplasty for the
Correction of Low to Moderate
Hyperopia

MARGUERITE B. McDONALD
Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A.
JONATHAN DAVIDORF
Davidorf Eye Group, West Hills, and Maloney Vision Institute, Los Angeles,
California, U.S.A.
ROBERT K. MALONEY
Maloney Vision Institute, Los Angeles, California, U.S.A.
EDWARD E. MANCHE
Stanford University School of Medicine, Palo Alto, California, U.S.A.
PETER HERSH
Cornea and Laser Vision Center, Teaneck, New Jersey, U.S.A.
GEORGE M. SALIB
Tulane University School of Medicine, New Orleans, Louisiana, U.S.A.

A. HYPEROPIA CORRECTION BY CONDUCTIVE KERATOPLASTY


1. Thermokeratoplasty Procedures
Surgical correction of hyperopia has been a greater challenge to ophthalmology than the
correction of myopia. Attempts to steepen the central cornea by non-ablative methods,
such as thermal keratoplasty, date back to the rabbit studies by Lans in the nineteenth
century. During the 1980s, hot-wire thermokeratoplasty, a technique developed in the
95
96 McDonald et al.

Soviet Union, was used to produce thermal burns (up to 600C) that penetrated to 95%
of corneal depth (1). Studies showed substantial overcorrection followed by marked regres-
sion (24). Evaluation of the procedure through well-designed clinical trials before adop-
tion and dissemination was recommended (5).
The failure of high-temperature probes to produce a stable, predictable, and safe
hyperopic correction led to the investigation of other modalities of thermal keratoplasty,
including contact holmium: YAG laser thermal keratoplasty (Holmium 25, Technomed,
Baesweiler, Germany) (68), pulsed, noncontact holmium:YAG laser keratoplasty (non-
contact LTK, Hyperion System, Sunrise Technologies, Fremont, CA) (918), continuous-
wave diode laser thermokeratoplasty (DTK, Rodenstock, ProLaser Medical Systems, Inc.,
Dusseldorf, Germany) (1920), and radiofrequency-based conductive keratoplasty (CK)
(Refractec, Inc., Irvine, CA) (21). These techniques have been more successful than the
original hot-needle technique, although regression and induction of astigmatism have con-
tinued to be concerns with some techniques.
In addition to thermokeratoplasty procedures, ablative methods, such as photorefrac-
tive keratectomy (PRK) (2227) and laser in situ keratomileusis (LASIK) (2834), have
been used to correct hyperopia. Generally, attempted hyperopia corrections with these
methods have been higher (3.00 D) than the range recommended for CK.

2. Conductive Keratoplasty: The Mechanism


The conductive keratoplasty procedure performed with the ViewPoint CK System (Fig.
1) is designed to treat spherical, previously untreated hyperopia of 0.75 to 3.00 D. Treat-
ment of astigmatism, presbyopia, and over- or undercorrections following LASIK or other
refractive procedures are other potential applications.
Conductive keratoplasty delivers low-energy, high-frequency (radiofrequency, 350
kHz) current directly into the corneal stroma by means of a Keratoplast tip inserted into
the peripheral cornea at eight or more treatment points (Fig. 2). Collagen within the targeted
treatment zone is heated in a gentle, controlled fashion as a result of the natural resistance
of stromal tissue to the flow of the current (35). Because resistance to the flow of the

Figure 1 The ViewPoint Conductive Keratoplasty (CK) System: console, probe, and specula.
Conductive Keratoplasty 97

Figure 2 The CK Keratoplast tip shown next to a 70 suture. (Courtesy of Refractec, Inc., Irvine,
CA.)

current increases with increasing dehydration of collagen, the process tends to be self-
limiting. A thermal model predicts a cylindrical footprint approximately 150 to 200 m
wide by 500 m deep that extends to approximately 80% of the depth of the mid-peripheral
cornea at each treated spot (36). Striae form between the treated spots, creating a band
of tightening that increases the curvature of the central cornea, thereby decreasing hyper-
opia. The Hyperion noncontact LTK technique, on the other hand, applies heat directly
to the surface of the cornea, heating tissue in a gradient, and generates a conical footprint
(10).

B. THE CONDUCTIVE KERATOPLASTY PROCEDURE


1. The Conductive Keratoplasty Device
The Viewpoint CK system consists of a radiofrequency energy-generating console, a hand-
held, reusable, pen-shaped handpiece attached by a removable cable and connector, a
speculum (choice of two, Lancaster or Barraquer) that provides a large surface for an
electrical return path, and a pedal that controls release of radiofrequency energy. Attached
to the handpiece is the Keratoplast tip, a single-use, disposable, stainless steel penetrating
tip, 90 m in diameter and 450 m long, that delivers the current directly to the corneal
stroma. At the very distal portion of the tip is a Teflon-coated stainless-steel stop that
assures correct depth of penetration.

2. Patient Selection
a. Suitable Patients
Patients suitable for treatment with the Viewpoint CK System should have 0.75 to 3.00
D of spherical hyperopia and 0.75 D of refractive astigmatism. Visual acuity should be
correctable to at least 20/40 in both eyes. Hard or rigid gas-permeable lenses should be
98 McDonald et al.

discontinued for at least 3 weeks and soft lenses for at least 2 weeks prior to the preoperative
evaluation. Wearers of hard contact lenses should have two central keratometry readings
and two manifest refractions taken at least 1 week apart. The manifest refraction measure-
ments must not differ from the earlier measurements by more than 0.50 D in either merid-
ian. Keratometry mires must be regular.
b. Unsuitable Patients
Patients with a peripheral pachymetry reading at the 6-mm optical zone of less than 560
m are not suitable for treatment with the Viewpoint CK System. Also unsuitable are
those who have had strabismus surgery; have anterior segment pathology; have residual,
recurrent, active ocular or uncontrolled eyelid disease or any corneal abnormality; or have
signs of progressive or unstable hyperopia. Other relative contraindications are a history
of herpes zoster keratitis, herpes simplex keratitis, glaucoma, a history of steroid-respon-
sive rise in intraocular pressure (IOP), a preoperative IOP 21 mmHg, or narrow angles.
Patients with diabetes, diagnosed autoimmune disease, connective tissue disease, an immu-
nocompromised state, current treatment with chronic systemic corticosteroid or other im-
munosuppressive therapy that may affect wound healing; a history of keloid formation;
intractable keratoconjunctivitis sicca; or pregnancy are also contraindicated to receive the
CK treatment.

3. Examinations
Preoperative examinations should include a manifest and cycloplegic refraction, an uncor-
rected and best spectacle-corrected visual acuity (distance and near), a slit-lamp and fun-
doscopic examination, applanation tonometry, central keratometry, ultrasonic pachymetry,
and computed corneal topography.

4. Performing the CK Procedure


Correct the patients full cycloplegic spectacle refraction. Administer one drop of topical
anesthetic three times at 5-min intervals and monitor the patient for degree of anesthesia.
Do not use pilocarpine. Insert the CK lid speculum to provide corneal exposure and act
as an electrical return path. Do not use a lid drape, for it may prevent direct contact of
the lid speculum and eyelid, which would disrupt the electrical current return path. Tape
the fellow eye closed. Position the operating microscope or slit-lamp biomicroscope over
or in front of the eye to be treated.
Mark the cornea with the CK marker, and remind the patient to fixate on the light
from the microscope. Dampen the CK marker with gentian violet or rose bengal stain.
Center the markers cross hairs over the center of the pupil and apply light pressure on
the marker to make a circular mark with eight intersections on the cornea. If using gentian
violet, irrigate with balanced salt solution to remove excess ink. Dry the surface of the
cornea thoroughly with a fiber-free sponge to avoid dissipation of applied energy by a
wet surface.
Set the appropriate treatment parameters on the console according to the nomogram
(Table 1). The default setting for treatment is 350 kHz, 60% power (0.6 W) for 0.6 s.
Inspect the Keratoplast tip under the microscope to ensure it is not damaged or bent prior
to application. When treating 0.75 to 0.875 D of hyperopia (eight spots), treat only at the
7-mm optical zone, beginning treatment at the 12 oclock position and continuing in the
sequence shown in Figure 3. When treating higher levels of hyperopia, follow the nomo-
Conductive Keratoplasty 99

Table 1 Conductive Keratoplasty Nomogram


Diopters to be Number of
corrected CK treatment spots

0.75 D to 0.875 D 8
1.00 D to 1.625 D 16
1.75 D to 2.25 D 24
2.375 D to 3.00 D 32
CKConductive Keratoplasty

gram and application sequence. For example, for treating 1.00 to 1.625 D of hyperopia,
apply a total of 16 spots: 8 spots at the 6-mm optical zone and 8 at the 7-mm optical
zone. Begin application at each of these optical zones at the 12 oclock position and
continue in sequence until the full circle of spots has been completed. For treating 1.75
to 2.25 D, apply treatment at the 6-, 7-, and 8-mm optical zones for a total of 24 spots.
For treating 2.375 D to 3.00 D, apply treatment to the 6-, 7-, and 8-mm optical zones and
then to each of the eight sectors between the previously treated spots at the 7-mm optical
zone for a total of 32 spots.
To treat each spot, place the tip of the delivery probe at the treatment mark on the
cornea, perpendicular to the corneal surface. Apply light pressure until the tip penetrates
the cornea down to the insulator stop. Depress the foot pedal to apply the radio frequency
energy. A tone will sound as the energy is applied. At each treatment spot, keep the tip
in place until the preprogrammed treatment time has been completed (the tone stops).
Clean the tip with a fiber-free sponge after each treatment spot to remove any tissue debris,

Figure 3 Number, location, and sequence of treatment spots. (Courtesy of Refractec, Inc., Irvine,
CA.)
100 McDonald et al.

taking care not to damage the tip. Perform intraoperative keratometry after completing
the full circle of treatments to check for any induced cylinder.

5. Postoperative Care
The surgeon may follow his or her usual refractive surgery postoperative care regimen.
Administration of one drop of a topical ophthalmic antibiotic solution and one drop of an
ophthalmic nonsteroidal anti-inflammatory drug, continued for up to 3 days, according to
product labeling, is recommended. Administration of topical corticosteroids is not recom-
mended. A bandage contact lens may be used for comfort for 24 to 48 h postoperatively
but is usually not necessary.

C. UNITED STATES MULTICENTER CLINICAL TRIAL


1. Patients and Methods

A 2-year, multicenter, prospective clinical trial is being conducted in the United States to
evaluate the safety, efficacy, and stability of conductive keratoplasty when performed on
eyes with 0.75 to 3.00 D of hyperopia and less than 0.75 D of cylinder. Each procedure
was performed by one of 14 surgeons at 20 centers according to methods described above.
All eyes were treated at the default setting of 350 kHz, 60% power for 0.6 s. No retreatments
were performed.
A total of 231 patients were treated; 361 eyes were treated with the current nomogram
for CK and an additional 29 were treated with an earlier nomogram that had a tendency
to undercorrect (Table 2). These 29 eyes were excluded from analysis of efficacy variables.
Thus, data from 361 eyes were evaluated for efficacy, stability, and safety, while data
from 390 eyes were evaluated for stability and safety only. At 12 months, a total of 96
eyes were available for stability and safety analyses and 127 were available for stability,
safety, and efficacy analyses. Uncorrected distance visual acuity (UCVA) preoperatively
was 20/40 or worse in 81% of the eyes, and uncorrected near visual acuity was J5 or
worse in 95%. Postoperative care and examinations followed the methods described above.

Table 2 Clinical Study Eyes


Eyes Attribute

Evaluated for safety and stability variables only N 390


Evaluated for all variables (Efficacy, safety, stability) N 361
Available at 12 months for stability and safety analyses N 96
Available at 12 months for safety, efficacy, and stability N 127
analyses
Age 55 5.4 years (40 to 74)
Mean Preoperative MRSE 1.82 0.60 D (0.75 to 3.00 D)
Mean Preoperative CRSE 1.76 0.60 D (0.75 to 3.25 D)

MRSEManifest refractive spherical equivalent


CRSECycloplegic refractive spherical equivalent
Conductive Keratoplasty 101

Figure 4 Postoperative UCVA over time.

2. Results
a. Efficacy
Twelve months postoperatively, UCVA was 20/20 or better in 53/96 (55%), 20/25 or
better in 73/96 (76%), and 20/40 or better in 87/96 (91%) of the eyes (Fig. 4). Near UCVA
increased an average of six Jaeger lines. Mean MRSE values showed 53/96 (55%) within
0.50 D of intended correction, 87/96 (91%) within 1.00 D, and 94/96 (98%) within
2.00 D (Fig. 5). A summary of the efficacy results with conductive keratoplasty is
shown in Table 3.

Table 3 Summary of Efficacy Results with Conductive Keratoplasty Compared with FDA
Guidelines for Refractive Procedures

FDA 6 Months 9 Months 12 Months


guideline (N348) (N276) (N96)

UCVA 20/20 50% 46% 48% 55%


UCVA 20/25 Not stipulated 65% 72% 76%
UCVA 20/40 85% 90% 92% 91%
MRSE 0.50 D 50% 60% 66% 55%
MRSE 1.00 D 75% 88% 88% 91%
MRSE 2.00 D Not stipulated 99% 99% 98%
FDA Food and Drug Administration
UCVA Uncorrected Visual Acuity
MRSE Manifest Refractive Spherical Equivalent
102 McDonald et al.

Figure 5 Accuracy of achieved MRSE.

b. Corneal Topography
Corneal topography of a typical eye with an MRSE of 3.25 D and UCVA of 20/125
preoperatively shows central steepening postoperatively surrounded by a midperipheral
flattening (Fig. 6). Twelve months postoperatively, this eye had an MRSE of 0.25 D
and UCVA of 20/20.

Figure 6 Conductive keratoplasty case study. Corneal topography of a typical eye with an MRSE
of 3.25 preoperatively D and UCVA of 20/125 preoperatively shows post-CK central steepening
surrounded by a midperipheral flattening. Twelve months postoperatively, this eye had an MRSE
of 0.25 D and UCVA of 20/20.
Conductive Keratoplasty 103

Table 4 Stability of Manifest Refraction through 12 Months (Cohort of Patients with All
Postoperative Visits, N 115)

Change in MRSE 36 Months 69 Months 912 Months

0.50 D 73% 85% 83%


0.75 D 90% 94% 97%
1.00 D 96% 97% 97%
Mean Change (SD) 0.27 D (0.43) 0.09 D (0.40) 0.15 D (0.39)
(paired differences)
95% Confidence Interval 0.19,0.35 0.01,0.17 D 0.07,0.23
MRSEManifest Refractive Spherical Equivalent

c. Stability
Refractive stability after the procedure was demonstrated by the mean change in residual
SE refraction for all treated eyes at three intervals during the study (Table 4). During the
last two intervals (6 to 9 months, 9 to 12 months), the mean MRSE changed 0.09 D
(confidence interval 0.01, 0.17) and 0.16 D (confidence intervals 0.07 and 0.22), respec-
tively. The mean change in MRSE between postoperative visits from 0.50 D or less in
73% of the eyes between the 3- and 6-month visits, in 85% of the eyes between the 6-
and 9-month visits, and in 83% of the eyes between the 9- and 12-month visits and in
83% of the eyes between the 9- and 12- month visits (Fig. 7). The refraction appeared to
stabilize at approximately 6 months.

Figure 7 Change in MRSE between postoperative visits. N 115 (patients present for all follow-
up visits).
104 McDonald et al.

Figure 8 Slit-lamp view of treatment spot 1 h after CK showing bands of striae between spots.
The surface leukomas are small because all of the energy is delivered within the stroma. (Courtesy
of Refractec, Inc., Irvine, CA.)

d. Slit Lamp
One hour after treatment, the opacities at each treatment spot were visible by slit lamp as
small surface leukomas, with a band of striae connecting the treatment spots (Fig. 8).
These leukomas are small because CK delivers energy deep into the stroma rather than
on the surface. The striae between treatment zones remain visible at 3, 6, and 12 months,
as reported by the United States CK clinical trial investigators, and suggest that the effect
of treatment on the stroma is long-lasting.
e. Safety
No eye had lost two or more lines of BSCVA and no eye had BSCVA worse than 20/40
at 12 months (Table 5). A total of 1/127 (1%) of eyes had an increase of 2.00 D of

Table 5 Summary of Safety Results with Conductive Keratoplasty


Postoperative visit

1 Month 3 Months 6 Months 9 Months 12 Months


(N390) (N390) (N384) (N218) (N79)

2 Lines loss of BSCVA 6% 5% 4% 2% 0%


2 Lines loss of BSCVA 2% 1% 1% 1% 0%
BSCVA Worse than 20/40 0% 0% 0% 0% 0%
Increase 2.00 D Cylinder 3% 2% 1% 0% 0%
Increase 2.00 D Cylinder 3% 2% 1% 1% 1%
BSCVA 20/25 if better 4% 2% 1% 1% 0%
than 20/20 Pre-op

BSCVABest Spectacle-Corrected Visual Acuity


Conductive Keratoplasty 105

cylinder at 12 months and 0/127 had an increase of 2.00 D. Seventy five percent had no
change (within 0.50 D) in cylinder. No eye with BSCVA of 20/20 or better preopera-
tively was worse than 20/25 postoperatively. No intraoperative complications or adverse
events occurred during the surgeries, and there were no treatment-related adverse events.

D. CONCLUSION
The 12-month results in the ongoing 2-year prospective clinical study of the CK technique
for correcting low to moderate spherical hyperopia are encouraging. Postoperative visual
acuity and predictability of refraction were excellent and are comparable to or better than
results obtained with PRK or LASIK for low hyperopia (1734). The CK refractive effect
appears to stabilize by 6 months, surpassing the early studies of refractive stability results
seen following the noncontact LTK method (1116). However, recent LTK postmarketing
approval data from phase 3 FDA clinical trials shows that LTK is stable after 3 months.
Availability of the 2-year results will confirm the efficacy, predictability, and safety
of results seen with CK at 1 year and provide validation of this nonlaser option for the
treatment of low to moderate hyperopia.

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10
Intracorneal Segments for Hyperopia

LAURA GOMEZ and ARTURO S. CHAYET


Codet Aris Vision Institute, Tijuana, B.C., Mexico

A. BACKGROUND
The intracorneal segments (ICS) for hyperopia reshape the anterior surface of the cornea
without permanently changing the structure or function of the natural eye and are intended
to be an alternative to eyeglasses, contact lenses, or irreversible refractive surgery proce-
dures for hyperopic patients. The radially placed segments create a flattening of the periph-
eral cornea by shortening the chord length tangential to the limbus. This peripheral flatten-
ing causes the central cornea to steepen and the corneal radius to decrease, thus correcting
for hyperopia (Fig. 1). Implantation of the segments does not involve the central cornea
and no tissue is removed. In addition, the cornea maintains its asphericity and normal
prolate shape when the segments are implantedan advantage also reported for the intra-
stromal corneal ring segments for myopia (Intacs) (1,2).
The ICS for hyperopia are designed to be permanent; however, they can be removed
if desired. The ICS were conceptualized and developed by Steven M.Verity and David
Schanzlin. They initiated these studies in cadaver eyes using wires as the implantable
intracorneal devices.
The ICS for hyperopia were manufactured by Kera Vision, a vision correction com-
pany, founded in 1986 with the purpose of giving people clear vision without using correc-
tive lenses or undergoing surgeries that cut or remove tissue from the central optical zone
of the cornea. The company filed for bankruptcy in 2001, and these segments are currently
not produced. However, the segments have been licensed to another entity, which may
produce them in the future.
The ICS are inserted radially between the layers of the corneal stroma through six
or eight small incisions made in the periphery of the cornea. When surgically placed at
approximately two-thirds depth into the corneal stroma, these segments reshape the anterior
corneal curvature, steepening the central cornea and thereby correcting for hyperopia (Fig.
107
108 Gomez and Chayet

Figure 1 Diagram showing how the intrecorneal segments (ICS) work. The six radially placed
segments create a flattening of the peripheral cornea by shortening the chord length between each
segment in the direction of the arrows. This peripheral flattening causes the central cornea to steepen,
correcting for hyperopia

2). The degree of corneal steepening achieved using the ICS is directly related to the
thickness of the ICS product implanted.
The segments are made of polymethylmethacrylate (PMMA) and vary in length
from 1.5 to 2.0 mm. Each segment has a hexagonal cross section and is tapered along the
internal side to facilitate implantation. The ICS thicknesses that we tested were 0.35, 0.40,
and 0.45 mm. The width of the segments was 0.5 or 0.8 mm. The 1.8 mm length with
0.8 mm width has been the most used.

Figure 2 A 42-year-old woman with six ICS in place 18 months postoperatively.


Intracorneal Segments for Hyperopia 109

Most of the initial ICS surgeries worldwide in human eyes were performed by the
authors (AC and LG) in Tijuana, Mexico. A small European trial was started. In the United
States, there is no experience with this technique in human eyes.

B. INDICATIONS/CONTRAINDICATIONS
The intracorneal segments for hyperopia are intended for the correction of low hyperopia
with a cylinder less than or equal to 0.75 D. Our experience included patients with a
cycloplegic spherical equivalent refraction between 1.00 to 5.00 D; however, we
found that this technique did not correct hyperopias greater than 2.0 D. Patients should
have a documented stability of their refraction as demonstrated by a change of less than
or equal to 0.50 D in spherical and cylindrical components of the manifest refraction for
the prior 6 months.
The ICS are contraindicated in
Pregnant or nursing women
Patients with signs of keratoconus
Patients with clinically significant corneal dystrophy or scarring in the 6- or 7-mm
central zone
Patients with a history of herpetic keratitis
Patients with an autoimmune disease, collagen vascular disease, clinically significant
atopic syndrome, insulin-dependent diabetes or an immunocompromised state

C. PREOPERATIVE PREPARATION
A complete ocular exam of both eyes should be performed. This includes visual acuity
testing with and without correction using standardized ETDRS (Early Treatment Diabetic
Retinopathy Study) visual acuity charts, slit-lamp examination, corneal topography, kera-
tometry, manifest and cycloplegic refractions, tonometry, and ultrasound pachymetry of
the central and peripheral cornea and funduscopy.

D. SURGICAL TECHNIQUE
The operative eye was prepared with povidone-iodine 10% solution and the eyelid margins
and cilia were draped to fully isolate the surgical field. Topical anesthesia was achieved
using two drops of 0.5% tetracaine hydrochloride. A Barraquer wire speculum was placed
to hold the lids apart. One eye was treated at a time.
The surgical procedure started with the identification of the geometric center of the
cornea using a blunt Sinskey hook. A preinked marker was centered on the cornea to
provide a visual guide for the placement of the six circumferential incisions and the
placement of each segment at a 6.0-mm optical zone. Corneal pachymetry (DHG Technol-
ogy, Exton, PA) was performed over the site of each incision. A 15-degree diamond knife
(KMI, Philadelphia, PA) was used to make a 1.0-mm incision at a depth of 67% of the
pachymetry reading along the peripheral corneal marks. A modified Suarez spreader was
used to begin a lamellar corneal dissection at the base of each incision. Specially designed
instruments (KeraVision, Fremont, CA) were used to create an intrastromal pocket toward
the previously marked 6-mm optical zone. It is very important to make sure that the tunnels
110 Gomez and Chayet

are made at approximately two-thirds of the corneal depth, otherwise the segments are
placed too superficially; this may lead to extrusion of the segments or undercorrection.
Each segment is then manually inserted into each tunnel with the use of specially
designed forceps (Kera Vision, Fremont, CA). All ICS were supplied sterile. The ICS
were sterilized with ethylene oxide (EtO) and subjected to aeration to remove residual
EtO. The segments should be introduced far enough that they are left at the 6.0-mm optical
zone. Leaving them too close to the limbus increases the possibility of neovascularization.
The 1.8-mm segments are easier to insert, as they are shorter. There is generally no need
to suture the incisions. In our hands the surgical procedure takes 15 to 17 min in all.

E. POSTOPERATIVE CARE
After the procedure is completed, topical gentamicin 0.3% eyedrops and topical diclofenac
0.1% are instilled into the eye before removal of the speculum. The patient is then dis-
charged wearing a protective eye shield. No patch is necessary. The postoperative manage-
ment for ICS placement is similar to that for Intacs (3).
Patients are instructed to apply 0.3% tobramycin and 0.1% dexamethasone four
times daily for 1 week. Artificial tears are used as needed. Patients should be examined
the day after the procedure for wound revision. The incision sites will show a linear
fluorescein staining for 3 to 5 days. By the first postoperative week most of the staining, is
resolved. Each subsequent postoperative visit should include a manifest and a cycloplegic
refraction with and without correction visual acuity testing, slit-lamp examination, tonome-
try, keratometry, and topography examination.
After 3 months of follow-up on the operative eye and if refractive stability is
achieved, the patients contralateral eye can be surgically corrected.

F. VISUAL OUTCOMES
We have performed over 50 ICS implantations in men and women under 58 years of age.
We have implanted all the types of segments manufactured to date: the 2.0-, 1.8- and 1.5-
mm segments and a variety of thinner segments. The hyperopias we have treated have
not exceeded the manifest refraction spherical equivalent (SE) of 2.75 and cycloplegic
refraction SE of 4.5 D.
Visual recovery after the ICS procedure was not as rapid as after Intacs (4). Patients
experienced blurry vision for distance but were able to read without glasses after a week.
Near (uncorrected visual acuity) (UCVA) was better than distance UCVA because there
was an initial overcorrection.
Improvement in UCVA occurred earlier with the 1.8-mm segments than with the
others. Some 71% of the patients achieved 20/20 or better UCVA 2 weeks after the surgery
compared with 27% in the 2.0-mm segment group. Ghost images and halos were a frequent
complaint in this first postoperative period. Visual acuities continued to improve over the
following weeks; by the first month, 76% of the patients were 20/20 or better in the 1.8-
mm segments and 64% in the 2.0-mm group. The visual acuity and visual recovery were
similar to those reported for other keratorefractive procedures, and the results remained
constant at 18 months (5,6).
The procedure has not been associated with loss of best spectacle-corrected visual
acuity (BSCVA), demonstrating the safety of the procedure. Moreover, no patient had a
BSCVA less than 20/20. This can be attributed to the fact that the central cornea is not
Intracorneal Segments for Hyperopia 111

Figure 3 Corneal topographies of the right and left corneas showing the central steepening of
the cornea produced by the ICS.

touched during the procedure. Some 25% of the patients in the 2.0-mm group and 35%
of the patients in the 1.8-mm group experienced a gain of one line of BSCVA at 18
months. This advantage is due to the preservation of the corneal positive asphericity with
this procedure.
Refractive stability was achieved later than in the Intacs for myopia (4). After the
initial overcorrection, stability is obtained by the third month postoperatively. Corneal
topographies showed the central steepening of the cornea with an optical zone between
5 and 6 mm in diameter (Fig. 3). Continuing follow-up however, has demonstrated that
there is no long-term stability of the correction and visual outcome achieved. We followed
these patients for over 3 years and found that there is progressive hyperopic drift with
time, which is observed after the second year. This finding is similar to that observed with
laser thermokeratoplasty, where one sees a good initial correction but loss of effect with
time (7). With the ICS, only 60% of the initial manifest refraction correction and 46% of the
cycloplegic refraction is maintained after 3 years. Eyes with higher corrections (hyperopias
greater than 2.0 D) show a greater tendency to lose correction with time. The average
amount of hyperopic drift is 0.9 D, ranging from 0.5 to 1.75 D. Although the amount of
loss of correction has been small, considering that the attempted correction was 2.0 D,
this change is significant for these patients. Similarly, by 3 years, only 9% of the patients
have an UCVA of 20/15 or better.

G. COMPLICATIONS
Most of the complications we encountered were related to the fact that the surgical tech-
nique is mostly manual. Among the single segment complications we encountered, the
presence of neovascularization was the most common. Segments placed too peripherally
and close to the limbus will predispose for growth of neovessels surrounding the segments.
These neovessels can grow deeply in the stromal tunnel and will eventually surround the
segment. We encountered this complication in 19% of the patients. In our experience,
112 Gomez and Chayet

topical steroids did not stop the growth of the vessel at any time during the active growth
stage. We recommend removal of the affected segment, especially if the patient is symp-
tomatic. Coagulation of the vessel with argon laser might stop the vessel growth. However,
typically such vessels recanalize; therefore we do not recommend intervention with laser.
A shallow placement of the segments will produce superficialization of the segments
with time, superficial punctate keratitis, and thinning of the overlaying cornea. Spontaneous
extrusion of a single segment is a rare complication that is related to shallow implantation
of the segment. Epithelial ingrowth can occur around the segment and is surgically induced.
We have found that by avoiding corneal de-epithelization during the procedure and by
dissecting each tunnel as tightly as possible, this complication is almost completely elimi-
nated. When these complications occur, the segments can be removed and subsequently
reinserted. In our experience, most single segments can be successfully reinserted without
complications or loss of preoperative BCVA. In the case of the shallow segments, a deeper
tunnel can be dissected and the segments reinserted more deeply at the same surgical
sitting as the explantation. In the presence of neovascularization, it is recommended to
wait until the vessels have regressed and then to proceed with reinsertion of the segment.
With experience, we have found that these types of complications are significantly reduced,
which tells us that there is a learning curve with this technique.
Some complications are related to the presence of the segments per se. These were
white, chalky crystalline lamellar deposits that developed only in the inner most third of
the segments (Fig. 4). The lamellar deposits present around the segments are similar to
those reported adjacent to hydrogel corneal inlays (8,9) and in some patients after Intacs
(10). These deposits are presumably caused by separation of the corneal lamellae. Lamellar
deposits were seen in 80% of the eyes. Half of them were fully confluent, and no iris
detail could be seen. They started to appear between 2 to 3 months after the procedure
and peaked at 9 months. Only rarely were they noticeable to the patient. However, in one
case, they were so severe and esthetically visible, that all the segments had to be explanted.
After explantation, the deposits tend to disappear. In our experience, if the segment is not
removed, the deposits do not recede, as it appears to be the case with Intacs (3). They
generally do not produce visual symptoms. Other causes for removal of all segments in

Figure 4 White, chalky lamellar deposits typically seen in the inner portion of the segments.
Intracorneal Segments for Hyperopia 113

one eye are varied. Undercorrection and patient dissatisfaction with the refractive result,
usually due to induced irregular astigmatism, are among the most common causes.
Removal of the intracorneal segments is performed under topical anesthesia (tetra-
caine 0.5%) after sterilization of the eye with topical povidone-iodine solution. The patient
is prepared and draped in the same fashion as in the original surgery. A speculum is
inserted to hold the eyelids apart. The incision is reopened with a diamond blade, as this
allows minimally traumatic reopening of the incision. In our experience, attempts at blunt
dissection with instruments like a Sinskey hook are more traumatic than reopening with
a sharp blade. After the incision is opened, the tunnel is approached with a corneal spreader
spatula designed for this purpose. The spatula is used to reopen the tunnel and loosen
each segment within the tunnel. Subsequently, two small hooks are used to slide the
segments into the corneal tunnel and bring them through the incision. There is no position-
ing hole at the tip of the segments to engage each segment and facilitate its removal. Care
is taken to do this in a minimally traumatic manner.
The explantation of the ICS for hyperopia is not an easy procedure, unlike the
explantation of the Intacs for myopia (4,11). The exceptions are when single segments
are explanted in the presence of neovascularization. These segments are usually loose,
close to the limbus, and easy to remove. When the segments are inserted close to the 6.0-
mm optical zone, they are harder to loosen, and no instruments are available to grasp the
segment and pull it out through the tunnel and out of the incision. Potential problems can
also be encountered when there have been difficulties with wound healing.
Postoperative care after total explantation of the ICS for hyperopia is moderately
painful; patients usually require systemic analgesia and topical anti-inflammatory drops.
Reversibility of the refractive effect, as demonstrated with the return of BSCVA and
manifest refraction to preoperative levels, is on average achieved at 3 months after the
explantation, rarely before. Removal of these segments can be followed, if desired, by a
safe and effective Lasik or PRK for low to moderate myopia.
This procedure is not intended to produce astigmatism; however, we induced 1D or
more of astigmatism in 23% of our cases. All segments should be placed symmetrically
and at the same depth in order to avoid this complication.
Rarely, patients have reported occasional pain without apparent cause or an unex-
plained photophobia. We have not seen cases of glare or halos 6 months after the surgery
and beyond.

H. SUMMARY
The ICS procedure reduces low hyperopic errors without astigmatism while sparing the
visual axis. They work better for patients with hyperopias of less than 2.0 D. As opposed
to laser thermokeratoplasty and conductive keratoplasty, the ICS procedure offers the
benefit of reversibility and preservation of the positive corneal asphericity. The procedure
is safe and there has been no loss of BSCVA in any treated patient so far. The effect of
ICS implantation appears to stabilize after the first 3 months and is maintained for 18 to
24 months after the procedure. However, after the second year there is a progressive
loss of correction, which leads us to question the benefit of performing this procedure.
Complications with ICS implantation are mostly related to the surgical technique, which
is manual.
In general, removal of these segments can be followed by a safe and effective
segment reinsertion or, if preferred, LASIK or PRK for low to moderate myopia.
114 Gomez and Chayet

REFERENCES
1. Nose W, Neves RA, Burris TE. The intrastromal corneal ring: 12-month sighted myopic eyes.
J Refract Surg 1996; 12:2028.
2. Holmes-Higgin DK, Baker PC, Burris TE, Silvestrini TA. Characterization of the aspheric
corneal surface with the intrastromal corneal ring segments. J Refract Surg 1999; 15:520528.
3. Asbell PA. Intrastromal corneal ring. In: Kaufman HE, Barron BA, McDonald M, eds. Cornea,
2nd ed. Boston: Butterworth-Heinemann, 1997: 10371044.
4. Gomez L, Chayet A. Laser in situ Keratomileusis results after intrastromal corneal ring seg-
ments (intacs). 2001; 108:17381743.
5. Anschutz T. Laser correction of hyperopia and presbyopia. Int Ophthalmol Clin 1994; 34:
107137.
6. Jackson WB, Casson E, Hodge WG, Mintsioulis G, Agapitos PJ. Laser vision correction for
low hyperopia. Ophthalmology 1998; 105:17271737.
7. Koch DD, Berry MJ, Vassiliadis A. Noncontact holmium: YAG laser thermal keratoplasty.
In: Salz JJ, ed. Corneal Laser Surgery. St Louis: Mosby, 1995:247254.
8. McCarey B, Andrews D. Refractive keratoplasty with intrastromal hydrogel lenticular implants.
Invest Ophthalmol Vis Sci 1981; 21:107115.
9. Gomez ML, Barraquer JI. Permalens hydrogel intracorneal lenses for spherical ametropia. J
Refract Surg 1997; 13:342348.
10. Reinstein DZ, Srivannaboon S, Holland SP. Epithelial and stromal changes induced by Intacs
examined by three-dimensional very high-frequency digital ultrasound. J Refract Surg 2001;
17(3):310318.
11. Asbell PA, Ucakgan O, Odrich M. Photorefractive keratectomy after intrastromal corneal ring
segment explantation. Am J Ophthalmol 1999; 128(suppl 6):755756.
12. Koch DD, Kohnen T, McDonnell PJ, Menefee R, Berry M. Hyperopia correction by noncontact
holmium: YAG laser thermal keratoplasty: US phase IIA clinical study with 2-year follow-
up. Ophthalmology 1997; 104(suppl 11):19381947.
13. Brinkmann R, Radt B, Flamm C, Kampmeier J, Koop N, Birngruber R. Influence of temperature
and time on thermally induced forces in corneal collagen and the effect on laser thermokera-
toplasty. J Cataract Refract Surg 1995; 26:744754.
14. Asbell PA, Maloney RK, Davidorf J, Hersh P., McDonald M, Manche E. Conductive Kera-
toplasty Study Group. Conductive keratoplasty for the correction of hyperopia. Trans Am
Ophthalmol Soc 2001; 99:7984, discussion 8487.
11
Anterior Chamber Phakic Intraocular
Lenses in Hyperopia

GEORGES BAIKOFF
Clinique Montecelli, Marseille, France

INTRODUCTION: BACKGROUND
Nowadays, several methods of surgery may be applied to treat myopia. These methods
may be combined to achieve the surgical goal. While photorefractive keratectomy (PRK),
laser assisted in situ keratomileusis (LASIK) and intracorneal rings (ICR), may be used
to treat low myopia, LASIK is the method of choice for up to 10 diopters. Higher levels
of myopia may require phakic intraocular lenses (IOLs) or even clear lens extraction.
However, treatment of the most common cause of ammetropia, presbyopia, is still under
investigation. Several techniques have been assessed including presbyopic LASIK, intra-
corneal inlays, clear lens extraction followed by multifocal IOL implantation, scleral rings
and recently phakic presbyopic IOLs. Among these techniques, additive surgeries benefit
adjustibility, adaptibility, and reversibility. This is why we have been investigating the
design of phakic multifocal IOLs for the past 18 months.

A. ANTERIOR CHAMBER PHAKIC IOLS


Phakic intraocular lenses may be divided in 3 main categories:
Posterior chamber IOLs
Anterior chamber IOLs with iris fixation
Anterior chamber IOLs with angle fixation
Since 1986 we have been designing anterior chamber lenses with angle fixation (ZB,
ZB5M, NUVITA, GBR, VIVARTE), we now aim to apply the multifocal concept to the
most recent generation lenses.
115
116 Bakoff

We decided on foldable anterior chamber lens that may be inserted using a 3.2 mm
incision. A 2 piece implant has been designed: the haptics with PMMA properties have
a 2 shape that ends with three footplates fixated in the angle. A very soft optic, in
hydrophilic acrylic, binds tangentially to the haptics. This design allows maintaining a
stable anterior chamber as well as a gentle fixation in the angle (with the hydrophilic
acrylic footplates).
The lens profile is equivalent to that of the NUVITA. Indeed, prospective and
retrospective studies demonstrated the short and long term safety of the ZB5M and the
NUVITA on the endothelium. The only problem detected with these lenses was cosmetic:
moderate pupil deformations (that may give a cats eye aspect) have been rarely reported
(less than 5% of the cases).
In order to reduce the risk of pupil ovalization, a special interest has been held on
a precise measurement of the anterior chamber. The measurement from sclera to sclera
using a caliper is indeed inaccurate. It is the reason we developed an objective technique
based on the retro-illumination of the anterior segment. This method allows precise and
accurate assessment of the angle-to-angle inner diameter of the anterior chamber and
therefore to exactly adjust the size of the implant. Additionally, a plastic stick has been
designed to confirm this measurement preoperatively.

B. FOLDING OF THE OPTIC


The optic was initially folded in two; the aperture was then either anterior (with a risk of
endothelial touch) or posterior (with a risk of iris contact). It was therefore necessary to
expand significantly the anterior chamber with healon. A special folding device is now
available to overcome this problem.
Indeed, an N shaped folding system has been designed to allow an aperture of
the implant parallel to the iris plan. The first model of presbyopic implant favors far vision
in the center of the optic, while the middle and the peripheral parts allow near and far vision
respectively. Many other possibilities may be evaluated throughout the future clinical trials.

C. INDICATIONS AND CONTRAINDICATIONS


The current indication includes presbyopic patients with emmetropia and without astigma-
tism. It is known that pseudophakic emmetropic patients without astigmatism implanted
with multifocal lenses have a success rate of 70%; which means that they do not wear
glasses for either near or far vision. If either an ametropia or an astigmatism exists, this
success rate falls down to 30%. Accordingly, in the first set of investigation, the implanta-
tion of presbyopic intraocular lenses is only proposed to emmetropic and stigmatic patients
in order to obtain optimal results. However, it may be possible in the near future to develop
implants with spherical power to treat low myopia or hyperopia. The only method currently
available to treat an associated astigmatism is to perform LASIK.

CONTRAINDICATIONS
Contraindications are those of anterior chamber implant surgery, including the need to
respect a 3 mm anterior chamber depth, an endothelial cell count over 2500 cells per
mm2, and the absence of other disorders of the anterior chamber (cataract, uveitis, corneal
dystrophy, glaucoma, etc.).
Anterior Chamber Phakic IOL in Hyperopia 117

D. PREOPERATIVE MANAGEMENT
Preoperative management is generally easy. The eye to be treated, obviously lacking any
signs of conjunctival or corneal infection, must be in therapeutic myosis.

E. SURGICAL TECHNIQUE
The first patients have been operated under general or loco-regional anesthesia. In the
future topical anesthesia may be used. A 3.2 mm surgical incision, using a pre-calibrated
phako knife is first performed.
The incision, performed in an auto-sealed fashion, may be placed at 12 oclock
while one or two lateral paracenthesis may be performed to help the manipulations. The
anterior chamber is then deepened using viscous material to:
1. Protect the endothelium
2. Enhance the volume of the anterior chamber to facilitate the lens aperture with-
out any danger for either endothelium or iris.
The implant removed from its container is then placed on the folder. Once folded in N,
the implant is held with a special forceps that will allow the anterior chamber followed
by the rest of the inferior handle. The haptic may be easily folded to pass through the 3.2
mm incision. Subsequently, the optic is introduced in the anterior chamber and the inferior
footplates are directed towards the opposite angle. Once the optic is entirely introduced,
the superior blocks the implant and the inserting forceps is removed. The optic gently
opens in the anterior chamber parallel to the iris. The last manipulation of the insertion
is to place the trailing haptic in the anterior segment using either a forceps or a Leister
hook. Gonioscopy is performed to check the correct location of the handles, then viscous
is removed.

F. VISUAL OUTCOMES/COMPARISON OF RESULTS


As of today, 6 eyes of 5 patients benefited the implantation with more than 1 year follow
up (thanks to professor Eva VOLKOVA in BRNO, Czech Republic). As the first implanted
lenses were prototypes, the correct sizes were not available for all the treated eyes. Two
have been removed due to an oversizing, the 4 remnants are still in place. No anatomical
complications have been detected on these eyes and visual outcome is excellent. Three
eyes recovered 20/20 and the other 20/25 without additional correction in the 1st day
postoperatively. No complications could be observed on this first series.

G. SUMMARY
Presbyopic phakic IOLs implantation is an emergent technique that will become more and
more important in the future due to its simplicity. The benefit of a foldable implant is to
be inserted with a small auto sealed incision without induced astigmatism. The technique
has been simplified since the beginning and it will soon be feasible under topical anesthesia.
The major interest of this technique is to adjust the power of the addition to the
patients presbyopia and to be reversible in case of unfavorable outcome. Multicentric
studies must be performed to better assess the quality of the optic.
12
Hyperopic Phakic Intraocular Lenses

THANH HOANG-XUAN
Fondation Ophthalomogique Adolphe de Rothschild and Paris University, Paris, France
FRANCOIS MALECAZE
Hopital Purpan, Toulouse, France

A. BACKGROUND
The use of phakic intraocular lenses (IOLs) in refractive surgery started in the 1950s and
was initially aimed only at correcting high myopia (1). It is now also indicated in moderate
myopia, particularly when photorefractive keratectomy (PRK) and laser-assisted in situ
keratomileusis (LASIK) are contraindicated. Surgical correction of hyperopia is more
recent. Hexagonal keratotomy (2), epikeratoplasty (3) and automated lamellar keratoplasty
(4) are no longer used, and holmium: YAG laser thermokeratoplasty (5), conductive kera-
toplasty (16), PRK, and LASIK are only effective in low hyperopia (4 D or less) (6,7).
The only surgical procedures to correct high hyperopia are phakic IOL implantation and
clear lens extraction associated with one- or two-(piggyback) posterior chamber (PC) IOL
implantation. Disadvantages of clear lens extraction associated with PC IOL implantation
include loss of accomodation, difficulties with IOL power calculation, and irreversibility
(8,9). Only the iris-fixed and PC phakic IOLs can be used to correct hyperopia. Angle-
supported phakic IOLs are contraindicated in hyperopic patients because they often have
or will have narrow angles. The literature on correction of hyperopia using phakic IOLs
is scant, since this surgical procedure is is relatively new for this indication. Only five
reports have been published: one on the Artisan iris-claw lens (10) and four on PC phakic
IOL (1114).

B. PHAKIC IOL TYPES


1. Iris-Fixed Phakic IOL (Artisan)
The Artisan hyperopia lens is a biconvex lens manufactured by Ophtec. It is fixed to the
iris at its midperiphery, which is immobile, by enclavation of a fold of anterior iridal
119
120 Hoang-Xuan and Malecaze

Figure 1 Hyperopic Artisan phakic intraocular lens. (Courtesy of Ophtec, Groningen, the Nether-
lands.)

tissue into the two diametrically opposed claws of the lens. It is a one-piece, UV-
absorbing, polymethylmethacrylate lens with an overall length 8.5 mm (IOLs 7.5 mm
long may also be available) and a diameter of the optical part of 5.0 mm. Its power range
is 1.0 to 12.0 D with a 0.5increment increase (Figs. 1 and 2).

2. Posterior Chamber Phakic IOL


The only marketed hyperopia PC phakic IOL is the STAAR Collamer intraocular lens,
also called an implantable contact lens (ICL) and manufactured by STAAR Surgical. It
is made of a flexible hydrophilic collagen copolymer, a compound combining HEMA and
porcine collagen (less than 0.1%). Its refractive index is 1.45 at 35C. It is available with
lengths of 11.0 to 13 mm. The diameter of the optical zone is 5.5 mm, and the dioptric
power ranges from 3 to 17 D (Fig. 3).

C. INDICATIONS/CONTRAINDICATIONS
The best indications are hyperopes of 4 D or more who do not tolerate contact lens, cannot
wear spectacle correction for occupational or psychological reasons, and cannot or do not
want to undergo alternative refractive procedures. Candidates are often middle-aged or
older patients whose visual discomfort is increased by presbyopia. Hyperopes also experi-
ence more difficulties in inserting their contact lenses.
Contraindications include
One-eyed patients
Unstable refraction
History of ocular disease, including glaucoma, cataract, uveitis, and progressive and/
or severe retinal/choroidal disease
Hyperopic Phakic Intraocular Lenses 121

Figure 2 Hyperopic Artisan phakic intraocular lens. (Courtesy of Ophtec, Groningen, the Nether-
lands.)

Figure 3 Hyperopic Artisan phakic intraocular lens.


122 Hoang-Xuan and Malecaze

History of connective tissue disease


Corneal endothelial disease and/or endothelial cellular density less than 2000 mm2
Central anterior chamber depth less than 3.0 mm for the Artisan iris-claw lens, and
2.8 mm for the ICL STAAR lens
Pupil larger than 6.0 mm in scotopic luminance
Patients who will obviously not be compliant for lifelong ophthalmological follow-
up

D. PREOPERATIVE PREPARATION
1. IOL Power Calculation
The Artisan iris-claw lens dioptric power is calculated on the basis of the curvature of
the cornea (K), the anterior chamber depth, and the spectacle correction by applying the
van der Heijde formula (15). It is approximatively the same as the power of the spectacles
at a vertex distance of 12 mm.
The STAAR Collamers IOL dioptric power is determined using Feingolds formula
(proprietary) that utilizes the refraction, keratometric power, corneal thickness, and anterior
chamber depth. The IOL length is the horizontal limbal white-to-white measurement 0.5
mm (not well defined).

2. Anesthesia
Most patients are operated on on an outpatient basis. The anesthesia methods are based
on patient and surgeon preferences: general anesthesia or peribulbar injection. Topical
anesthesia can be applied for STAAR Collamer lens implantation but not for Artisan iris-
claw lens surgery, for which full akinesia and analgesia are required.

3. Pupil Size
Artisan iris-claw lens implantation requires preoperative miosis to protect the natural lens
during the insertion and fixation of the IOL. A constricted pupil also facilitates proper
centration of the lens. For this purpose, two argon laser marks can be made on the iris at
diametrically opposite sites to facilitate proper centration of the IOL during the surgery,
contrary to STAAR Collamer phakic lens implantation, which requires full pupillary dila-
tion.

4. Prevention of Pupil Block


A perioperative peripheral surgical iridotomy is performed during the Artisan iris-claw
lens implantation procedure, rather than preoperative laser iridotomies. Two generous
peripheral laser iridotomies separated by 80 degrees are required before implantation of
the STAAR Collamer phakic lens.

E. SURGICAL TECHNIQUE
1. Artisan Iris-Claw Lens
Two side port incisions and a 5.2-mm (superior or temporal) clear corneal or (superior)
scleral tunnel incision are made. High-viscosity sodium hyaluronate is injected, and the
Hyperopic Phakic Intraocular Lenses 123

Figure 4 ICL hyperopic phakic intraocular lens.

phakic IOL is introduced with a specially designed fixation forceps into the anterior cham-
ber through its smaller diameter. It is then rotated 90 degrees, its long axis becoming
parallel to the incision.
Most surgeons use specially designed iris entrapment needles introduced through
the side port incisions to enclavate the iris folds into the lens claws (Figs. 4 and 5).
Intraocular acetylcholine chloride can be added if miosis is not sufficient. Accurate centra-

Figure 5 ICL phakic intraocular lens.


124 Hoang-Xuan and Malecaze

Figure 6 Trapping of an iris fold between the claws of a hyperopic Artisan phakic intraocular
lens using an enclavation needle.

tion and fixation of the IOL is crucial to prevent postoperative glare or halos. A 1-mm
fold of midperipheral iris tissue is created under the claw using the iris entrapment needle;
a gentle pressure of the claw over the fold entraps it. The peripheral iridotomy is then
performed, the viscoelastic substance removed, and the wound tightly closed with 100
nylon sutures.
Postoperative care consists of steroidal and antibiotic eyedrops for 2 weeks and a
regular follow-up, particularly long-term evaluation of the corneal endotheliums density
using specular microscopy. Patients also must be instructed not to rub their eyes after
surgery.

Figure 7 Introduction of an ICL hyperopic phakic intraocular lens into the eye using an injector.
Hyperopic Phakic Intraocular Lenses 125

Figure 8 Positioning of the haptic of the ICL phakic intraocular lens into the sulcus using a
tucker.

2. STAAR Collamer Phakic IOL


A side port incision is performed and viscoelastic material is injected. The foldable implant
is inserted through a 3.2-mm clear corneal beveled incision on the steepest axis, either
with an injector (Fig. 6) or MacPherson forceps. Care must be taken to orient the lens
properly while it unfolds and to avoid any central touch of IOL with the natural lens. The
optic disk is centered, and gentle downward pressure using a specially designed instrument
makes it possible to place each footplate one after the other behind the iris (Figs. 7 and
8). Then, the viscoelastic material is removed and acetylcholine chloride is injected into
the anterior chamber. Postoperative care consists of steroidal and antibiotic eyedrops for
1 to 2 weeks.

F. VISUAL OUTCOMES/COMPARISON OF RESULTS (Tables 1 and 2)


1. Artisan Iris-Claw Lens
Fechner et al. (10) published in 1998 the only study on hyperopic correction using the
iris-claw phakic lens. A total of 67 hyperopes were divided into three groups: 6.0 to
8.9 D (group 1), 9.0 to 11.9 D (group 2), and more than 12.0 D (group 3). In
all groups, the standard deviation between intended and final postoperative uncorrected
visual acuities was less than 2.80 D. The refractive results were stable at a follow-up of
4 months, and there was no loss of the mean best corrected postoperative best-corrected
visual acuity (BCVA). We implanted nine hyperopic patients, 4.4 to 8.1 D, with a
mean follow-up of 12 months (personal communication). Postoperative spherical equiva-
lent (SE) ranged from 0.75 to 0.75 D; 100% and 66.7% of eyes were within 1.00
and 0.50 D of emmetropia, respectively. Because of the loss of magnification, 78% of
patients demonstrated a loss in postoperative spectacle BCVA compared to the preopera-
tive spectacle BCVA.
126

Table 1 Visual and Refractive Outcomes


Refractive Refractive Uncorrected Uncorrected
outcome outcome VA postop VA postop
Phakic IOL No. of Follow-up ES (D) ES (D) (D) 0.50 (D) 1.00 20/40 orbetter 20/20 or better
type Authors eyes (months) preop postop (% eyes) (% eyes) (% eyes) (% eyes)

Artisan Fechner (10) 67 78.1 6 to 18 5 to 3.5


(1998) (12 to 120) (9.98 2.6) (0.07 2.03)
Artisan Hoang-Xuan and 9 12 4.40 to l8.12 0.75 to 0.75 66.7 100 67 11
Malecaze (2001)
(unpublished data) 6.61 0.35 0.08 0.71
STAAR Rosen (11) 9 3 2.25 to 5.62 0.12 to 0.50 88.8 89 44
(1998)
STAAR Davidorf (12) 24 8.4 3.75 to 10.50 3.88 to 1.25 58 79 63 8
(1999) (1 to 18) (6.51 2.08) (0.39 1.29)
STAAR Pesando (13) 15 12 4.75 to 11.75 1.00 to 1.50 69.25 92.3 46.15 0
(1999) (6 to 18) (7.77 2.08) ( 0.02 0.64)
STAAR Sanders (14) 10 6 2.50 to 10.88 0.50 to 1.50 80 90 100 70
(1999) ( 6.23) ( 0.20 0.61)
Hoang-Xuan and Malecaze
Hyperopic Phakic Intraocular Lenses 127

Table 2 Safety of Hyperopic Phakic Intraocular Lenses


Loss of Unchanged Gain of
Phakic IOL BSCVA BSCVA BSCVA
type Authors (% eyes) (% eyes) (% eyes) Complications

Artisan Fechner (10) (1998) One glaucoma and


corneal edema
(in two eyes of
same patient)
Artisan Hoang-Xuan and 22.2 (1 line) 0 22.2 (1 line) None
Malecaze (2001) 55.5 (2 lines)
(unpublished data)
STAAR Rosen (11) (1998) 44.4 22.2 (1 line)
22.2 (2 lines)
STAAR Davidorf (12) (1999) 25 (1 line) 33 29 (1 line) Three pupillary
block glaucomas
4 (2 lines) 4 (2 lines)
4 (2 lines)
STAAR Pesando (13) (1999) 7.69 76.92 15.38 Two pupillary
block glaucomas
One lens opacity
STAAR Sanders (14) (1999) 0 2 (3 lines) None

2. STAAR Collamer Phakic IOL


Four studies on hyperopic correction using the STAAR Collamer phakic lens have been
published (1114).
These studies included 9, 24, 15, and 10 hyperopes respectively, the latter study
(14) being a phase I clinical trial sponsored by the U.S. Food and Drug Administration.
In total, 58 patients underwent STAAR Collamer phakic IOL implantation.
Cumulative data show that preoperative SE ranged from 2.25 to 11.75 D. Mean
follow-up ranged from 3 to 12 months. Postoperative SE ranged from 3.88 to 1.50
D; 58 to 80% of eyes were within 0.50 D of emmetropia and 79 to 92.3% of eyes were
within 1.00 D of emmetropia. In Rosens study (11), the efficacy index was 0.98, which
was superior to the index for myopic patients implanted with the same type of phakic IOL
in series published by the same authors. Davidorf et al. (12) also compared their results
favorably to the predictability in their series of high myopic eyes.
Seven of 24 eyes (29%) (12) and one of 15 eyes (7.69%) (13) lost one or more lines
of postoperative BCVA. Conversely, only 8% of hyperopic eyes operated on by Davidorf et
al (12) demonstrated a gain in postoperative spectacle BCVA compared to the preoperative
spectacle BCVA. This is explained by the loss of magnification induced by the surgery.

G. COMPLICATIONS
In Fechners series of the artisan lens, one patient had glaucoma and corneal edema in
both eyes (10). In our study, no complications occurred and no change in endothelial cell
density was noted after a follow-up of 1 year (personal communication).
128 Hoang-Xuan and Malecaze

For the ICL, postoperative pupillary block glaucoma occurred in 3 of 24 eyes and
in 2 of the 15 eyes in the series of Davidorf et al. (12) and Pesando et al. (13), respectively.
This complication was due to iridotomies that were too small.

H. SUMMARY
Two types of phakic IOLs are available to correct hyperopia: the Artisan iris-claw lens
and the STAAR Collamer PC IOL. These represent the only surgical refractive procedures
capable of correcting hyperopia of 4 D or more. There have been very few publications,
but the results are encouraging. The predictibility, efficacy, stability, and safety of these
procedures are excellent, as well as the quality of the resultant vision. The time of recovery
is short and the surgeries are reversible. Long-term follow-up is, however, mandatory with
respect to delayed complication such as iris atrophy at the fixation sites and progressive
endothelial cell loss (iris-claw lens), and cataract and pigmentary dispersion (PC phakic
lens).

REFERENCES
1. Strampelli B. Sopportabilita di lenti acriliche in camera anteriore nella afachia o nei vizi di
refrazione. Ann Ottamol Clin Oculist Parma 1954; 80:7582.
2. Basuk WL, Zisman M, Waring III GO, Wilson LA, Binder PS, Thompson KP, Grossniklaus
HE, Stulting RD. Complications of hexagonal keratotomy. Am J Ophthalmol 1994; 117:3749.
3. Ehrlich MI, Nordan LT. Epikeratophakia for the treatment of hyperopia. J Cataract Refract
Surg 1989; 15:661666.
4. Lyle WA, Jin GJC. Hyperopic automated lamellar keratoplasty: complications and visual
results. Arch Ophthalmol 1998; 116:425428.
5. Koch DD, Kohnen T, McDonnell PJ, Menefee RF, Berry MJ. Hyperopia correction by noncon-
tact holmium:YAG laser thermal keratoplasty; United States phase IIA clinical study with a
1-year follow-up. Ophthalmology 1996; 103:15251536.
6. Jackson WB, Casson E, Hodge WG, Mintsioulis G, Agapitos PJ. Laser vision correction for
low hyperopia. An 18-month assessment of safety and efficacy. Ophthalmology 1998; 105:
17271738.
7. Arbelaez MC, Knorz MC. Laser in situ keratomileusis for hyperopia and hyperopic astigma-
tism. J Refract Surg 1999; 15:406414.
8. Kolahdouz-Isfahani AH, Rostamian K, Wallace D, Salz JJ. Clear lens extraction with intraocu-
lar lens implantation for hyperopia. J Refract Surg 1999; 15:316323.
9. Holladay JT, Gills JP, Leidlein J, Cherchio M. Achieving emmetropia in extremely short
eyes with two piggyback posterior chamber intraocular lenses. Ophthalmology 1996; 103:
11181123.
10. Fechner PU, Singh D, Wulff K. Iris-claw lens in phakic eyes to correct hyperopia: preliminary
study. J Cataract Refract Surg 1998; 24:4856.
11. Rosen E, Gore C. Staar Collamer posterior chamber intraocular lens to correct myopia and
hyperopia. J Cataract Refract Surg 1998; 24:596606.
12. Davidorf JM, Zaldivar R, Oscherow S. Posterior chamber phakic intraocular lens for hyperopia
of 4 to 11 diopters. J Refract Surg 1998; 14:306311.
13. Pesando PM, Ghiringhello MP, Tagliavacche P. Posterior chamber Collamer phakic intraocular
lens for myopia and hyperopia. J Refract Surg 1999; 15:415423.
14. Sanders DR, Martin RG, Brown DC, Shepherd J, Deitz MR, deLuca MC. Posterior chamber
phakic intraocular lens for hyperopia. J Refract Surg 1999; 15:309315.
15. van der Heijde GL, Fechner PU, Worst JGF. Optische Konsequenzen der Implantation einer
negativen Intraokularlinse bei myopen Patienten. Klin Mbl Augenheilk 1988; 193:99102.
16. McDonald MB, et al. Ophthalmology 2002; 109:19781989.
13
Hyperopia and Presbyopia
Topographical Changes

STEPHEN D. KLYCE, MICHAEL K. SMOLEK, MICHAEL J. ENDL, VASAVI


MALINENI, MICHAEL S. INSLER, and MARGUERITE B. McDONALD
Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A.

A. INTRODUCTION

Techniques for refractive surgery have made tremendous strides since the pioneering work
of Jose Barraquer and the introduction of radial keratotomy in the late 1970s (1). Traditional
outcome measures for the efficacy of specific refractive surgeries are primarily uncorrected
and best-corrected visual acuities and cycloplegic and manifest refractions. Corneal topog-
raphy analysis has not been considered a primary outcome measure for clinical trials in
the United Statesthis despite the fact that corneal topography is now the standard of
care for preoperative screening of refractive surgical candidates and analysis of postopera-
tive results and is a mainstay of anterior segment practice. Direct analysis by corneal
topography has clearly shown the causes of visual loss after eventful refractive surgery.
The best examples include the formation of central islands and peninsulas after surface
ablation with the excimer laser (2) and induced generalized irregular astigmatism after
automated lamellar keratectomy (3). In this chapter, the topographic characteristics of the
presbyope and the current modalities for the correction of hyperopia are reviewed.

B. KERATOFRACTIVE PROCEDURES FOR


HYPEROPIATOPOGRAPHICAL CORRELATES

Kohnen et al. (4) used computed videokeratography to demonstrate peripheral corneal


flattening and central corneal steepening following noncontact Ho:YAG laser thermal
keratoplasty (LTK) for the correction of hyperopia. Greater changes in corneal curva-
129
130 Klyce et al.

ture and smaller amounts of topographical regression were noted when a two-ring laser
treatment pattern was applied. When the topography was analyzed, several forms of in-
duced astigmatism were observed: bowtie (both symmetrical and asymmetrical), irregu-
larly irregular, and semicircular patterns. Only one eye in the entire study group was
observed to have a homogeneous pattern. At present, noncontact LTK appears to be most
promising for low hyperopia up to approximately 2 D. Regression of the effect appears
to limit the procedures usefulness for refractive errors higher than 2 D. Furthermore,
factors such as younger age (less than age 30) and increased preoperative corneal thickness
may also contribute to faster rates of regression (5).
Early hyperopic photorefractive keratoplasty (H-PRK) ablations consisted of small
optical zones (approximately 4.0 mm) with small transition zones, creating an overall
treatment zone diameter of 7 to 8 mm. Small optical zones increase the patients sensitivity
to small decentrations. Likewise, small transition zones produce abrupt topographical and
refractive changes between treated and untreated tissue. This lack of smoothness pro-
motes more aggressive stromal and epithelial regeneration and thus refractive regression
(6). It should also be noted that in myopic PRK, significant decrements in the character
and magnitude of corneal optical aberrations have been found with larger optical and
transition zones. Larger optical and transition zones result in a more natural physiological
pattern of measured aberrations in myopic PRK (6), and a similar result would be expected
in approaches to correct hyperopia. These considerations have led to larger optical zones
of 6.0 mm, with overall hyperopic ablations now reaching 9.0 mm.
With these considerations, induced aberrations after H-PRK have been carefully
evaluated (7). Corneal topography after H-PRK showed a change from positive to negative
spherical aberration on the order of 3 D. It is known that the positive spherical aberration
of the cornea and the spherical aberration of the crystalline lens act in concert to decrease
the overall aberrations of the eye. However, if hyperopic procedures over correct for
corneal spherical aberration, a negative impact on visual function is expected. This effect
can be seen in Figure 1.
Even with larger ablation sizes, difficulties remain. By the nature of the procedure,
the functional optical zone becomes smaller as the attempted correction increases in size.
This is undoubtedly one of the most significant factors contributing to the poor success
rate of both H-PRK and hyperopic laser assisted in situ keratomileusis (H-LASIK) for the
correction of 5.00 D or greater. Moreover, Choi et al. (8a) report an increased risk of
irregular astigmatism based on topographic analyses when corrections above this level
are attempted. The comfort level in this respect seems to be surgeon-related; therefore
some surgeons limit attempted corrections to 4.0 D or less.
In reference to H-LASIK, a 9.0-mm ablation size requires the creation of a 9.5-mm
flap. Although modern microkeratomes may provide for this flap size, some patients with
small eyes or thin corneas are unsuitable candidates for this treatment. Larger flap diame-
ters and larger amounts of correction increase the chances of striae formation, which can
translate to irregular astigmatism on corneal topography.
H-LASIK is gaining widespread use as a procedure to correct primary hyperopia as
well as to modify consecutive hyperopia after overcorrection from LASIK for myopia; it
is said to be safe and effective (8). Two typical case reports are given below to illustrate
the topography obtained. Each patient underwent hyperopic LASIK with the VISX, Inc.,
Star Excimer Laser System. The diameter of the optical zone was 5.00 mm, with a total
treatment zone of 9.00 mm OU.
Changes in Hyperopia and Presbyopia 131

Figure 1 H-LASIK effect on corneal topography and total eye aberration measured with NIDEK
OPD-Scan. (1) (top left panel) standard corneal topography showing off-center treatment; (2) skias-
copic (pointwise refraction) map: in the postoperative period, corneal aberrations for this eye account
for the bulk of the total ocular aberrations; (3) placido image; (4) wavefront map showing induction
of excess negative spherical aberration and coma.

Case 1. A 66-year-old woman with no prior history of ocular surgery underwent H-LASIK
for a refraction of 0.75 1.00 170 OD and 0.25 1.25 180 OS. Her best spectacle-
corrected visual acvity (BSCVA) was 20/20 (2) OU. The patient requested refractive surgery
for monovision. Her preoperative K-readings were 44.3/44.5 at 118 OD and 44.4/44.8 at 163
OS. The laser was programmed to correct OD for 1.00 1.25 170 and OS for 2.50
1.50 180. The total ablation depth was 20 m OD and 38 m OS. Optical zone diameter
was 5.00 mm. Her visual acuity without correction on postoperative day 1 was 20/200 OD
and 20/80 OS. Two weeks postoperatively, her visual acuity without correction was 20/70
(1) OD and 20/200 OS and her BSCVA was 20/25 OD and 20/40 OS. The manifest
refraction was 0.75 1.00 050 OD and 2.50 0.75 055 OS. At 4 weeks
postoperatively, her visual acuity without correction was 20/30 (2) OD and 20/25 (2)
OS. Her refraction at this time was 0.75 0.75 055 OD and 1.50 0.75 165
OS, with BSCVA being 20/25 OD and 20/25 (2) OS. Postoperative corneal topography
132 Klyce et al.

B
Figure 2 H-LASIK 1-month postoperative topography for 66-year-old requesting monovision.
(A) OD; attempted correction: 1.00 1.25 170. (B) OS; attempted correction: 2.50 1.50
180.
Changes in Hyperopia and Presbyopia 133

showed the extent of induced cylinder, revealed a steepening of the central 5 mm of the
cornea, and produced simulated keratometry readings (SimKs) of 46.13/44.17 at 96 with a
potential visual acuity (PVA) of 20/25 to 20/30 OD and 47.41/46.68 at 94 with a PVA of
20/20 to 20/30 OS (Figure 2).
Case 2. A 26-year-old woman presented for refractive surgery evaluation. She had a refractive
error of 4.75 0.50 083 OD and 5.25 0.75 095 OS. Her BSCVA was 20/25
OU. Her keratometry readings were 44.1/45.6 at 091 OD and 44.1/46.0 at 099 OS. The desired
correction for the right eye was 6.00 0.50 083 and for the left eye was 6.00
0.50 105. Total ablation depth was 65 m OU. Optical zone diameter was 5.00 mm. On
postoperative day 1 her uncorrected visual acuity was 20/30 OD and 20/40 OS. Six months
postoperatively, BSCVA was 20/25 (1) OD with no improvement with manifest refraction.
BSCVA OS was 20/25 (1) with a manifest refraction of 1.00 0.75 165. There was
some evidence of regression OS. Postoperative keratometry readings were 48.70/49.18 at 058
OD and 47.24/48.07 at 051 OS (Figure 3).
Hence, H-LASIK seems a good choice of procedures at least for the temporary
correction of hyperopia. Long-term stability will need to be demonstrated for this approach,
as for others discussed in this chapter.
Conductive keratoplasty (CK) is being developed as an alternative procedure for
treating hyperopia. It is argued that if the collagen is heated to a carefully controlled
critical temperature, the shrinkage and changes in corneal shape might be more permanent.

Figure 3 Six-month postoperative corneal topography of H-LASIK patient showing good centra-
tion OU. (Central green irregularities OS are temporary, from tear film breakup.)
134 Klyce et al.

Figure 4 Preoperative and postoperative topographies after CK. Note large uniform area of in-
creased power.

Conductive keratoplasty uses radiofrequency energy to generate heat in the corneal periph-
ery. As with LTK, the shrinkage of the collagen occurs from the production of a ring
pattern of treatment spots around the corneal periphery. This shrinkage creates a purse-
string effect to steepen the central cornea. One of the immediately appreciated benefits
of CK over H-LASIK is the larger functional optical zone (Figure 4).

C. MULTIFOCAL EFFECTS
As the number of patients undergoing refractive surgery expands, the curious phenomenon
of presbyopic patients presenting with functional near and far vision after refractive surgery
is being more frequently reported for both myopic and hyperopic corrections. Described
as a multifocal effect, this side effect of the surgery deserves scrutiny.
It was Benjamin Franklin who conceived the first bifocal spectacle in 1874, initiating
what is perceived to be a sequence of developments (Figure 5). Deliberate multifocality
was introduced to the contact lens field prior to 1967 (9) and to the intraocular lens
(IOL) arena before 1987 (10). While early models of IOLs and contact lenses exhibited
pronounced aberrations that reduced contrast sensitivity, current renditions have enjoyed
a measure of patient acceptance, at least with contact lenses. Unintentional iatrogenic
multifocality was first identified with corneal topography in 11 eyes after radial kerato-
Changes in Hyperopia and Presbyopia 135

Figure 5 Historical use of multifocality in vision correction: Ben Franklins bifocal spectacles,
bifocal contact lenses, bifocal IOLs, multifocality in radial keratotomy (11) and in photorefractive
keratectomy for myopia (13).

tomy, and although the possibility of complications from degradation of contrast sensitivity
as well as monocular diplopia was anticipated, no patient complaints of this type were in
fact reported (11). However, shortly after this report, additional analysis showed that
certain patients with the multifocal effect after radial keratotomy could experience visually
debilitating irregular astigmatism. This should be considered a complication of surgery
(12). Multifocal effects have also been found following PRK (13) for myopia and contrib-
ute to a form of artificial accommodation in pseudophakic eyes (14).
It is well known that patients with an extreme amount of irregular corneal astigma-
tism often refract over a large range of powers. This is the basis for the so-called multifocal
effect; in spectacles, distinctly separate areas of the lens are prepared with different specific
powers, whereas the power distributions of the multifocal cornea are more continuously
graded and are analogous to gradations of refractive powers of the Varilux contact lens
system. It might therefore be more accurate to describe the multifocal property as one of
varifocality.
A topographical multifocal effect can be assessed by direct examination of the distri-
bution of corneal powers over the entrance pupil. The standard statistical metric for measur-
ing the width of such distributions is the coefficient of variation; hence, an appropriate
topographic definition of corneal multifocality is the coefficient of variation of corneal
power (CVP) (15). The increase in the range or width of the distribution of central corneal
136 Klyce et al.

Figure 6 Corneal power distribution in the central 3 mm before and after conductive keratoplasty.
Note the broader distribution of corneal powers after surgery, which will enhance the multifocal
effect. This is an analysis of the topography shown in Figure 3.

powers is illustrated in Figure 6. It can be noted that the power distribution is broad and
without distinct peaks; hence the appellation varifocal. Conversely, Benjamin Franklins
bifocals would produce a bimodal distribution: two peaks whose widths directly relate to
the precision of manufacture.
Despite the promising aspects of artificially inducing accommodation with controlled
corneal multifocality, significant levels of uncontrolled multifocality can lead to a reduction

Figure 7 The effect of irregular astigmatism on vision can be simulated by placing the measured
surface into a model eye and doing ray tracing. CTView V3.12 (Sarver and Associates, Merritt
Island, FL) was used for this calculation.
Changes in Hyperopia and Presbyopia 137

Figure 8 After correction for distance vision with conductive keratoplasty for hyperopia, uncor-
rected near vision (UNVA N) also improves (p 0.001). (Data courtesy of Refractec, Inc., lrvine,
CA).

in contrast sensitivity and symptomatic vision. The effect of varifocality in corneal surgery
can be evaluated mathematically by fitting the surface with Zernike polynomials and
calculating from this the modulation transfer function. This will give the global optical
characteristics of the corneal surface and allow the simulation of multifocal effects on
vision, as shown in Figure 7.
With hyperopic keratorefractive surgery, there is another effect that comes into play
under the guise of multifocality. In one cohort of patients undergoing the conductive
keratoplasty procedure for the correction of low hyperopia, postoperative near vision either
remained constant or was enhanced at 1 month for every eye in the study (Figure 8). The
average improvement was statistically significant (p 0.001). This is a striking effect
that generally contrasts with myopic keratorefractive surgeries, where functional near
vision typically worsens in the presbyopic patient population (16). This effect can be
explained. Presbyopes who are mildly myopic often have excellent near vision without
correction. With keratorefractive surgery, near vision is sacrificed for improved distance
vision. On the other hand, presbyopic hyperopes have very poor uncorrected near vision,
and when keratorefractive surgery is used to correct their distance vision, this brings their
near focal point closer to the eye and improves vision at the near reading distances.
Multifocality and better than expected near vision after keratorefractive surgery for
the correction of hyperopia are due to a combination of factors. Focus over a range of
distances is made possible by the varifocal nature of some postoperative corneal topo-
graphies. Residual accommodation in younger patients can enable uncorrected near vision.
Use of the pinhole effect and bright illumination make a contribution as well. Finally,
improvements in uncorrected near vision can be expected after hyperopic corrections
because the near focal plane is brought closer to the eye, whereas with myopic corrections,
it is moved further away.

D. DIAGNOSTIC IMPLICATIONS
Several approaches have been developed to provide for the automatic interpretation of
corneal topography (17). Among these, neural networks appear to have the greatest poten-
138 Klyce et al.

tial for success (1820). A principal consideration in developing a strategy for the training
of such a network is data collection. Generally, 20 to 30 examples of each class of corneal
topography are collected to provide a broad range of experience for the neural network.
In this way the network can learn the hallmarks of each corneal condition and then be
able to classify new corneal maps accordingly. With the widespread success of refractive
surgery, there is concern that donor corneas for transplantation might be compromised by
previous surgery. As a result, a class of corneas was developed that are referred to as
having myopic refractive correction. There appear to be no consistent features among
the various myopic refractive corrections that persist to allow differentiation between the
various types. This even includes radial keratotomy, because the lower power over the
incision sites tends to be erased with time. Fortunately, no other corneal condition or
disorder is known that has the principal feature of uniform central corneal flattening. With
hyperopia, central corneal steepening is the principal characterizing feature, and again,
differentiation among the several corneal surgical approaches may not be possible. How-
ever, the central corneal steepening after hyperopic correction, unlike correction for my-
opia, outwardly mimics the characteristics of keratoconus, with a centralized cone (Figure
9). This may confound the clinician, as well as the automated classification algorithms
that detect keratoconus. Patient history and corneal pachymetry may be required for differ-
entiation between hyperopia-corrected corneas and keratoconus unless some distinguishing
topographical metric is found.

Figure 9 Postoperative topography of H-LASIK. Note the fairly typical appearance of keratoconus
as a consequence of the surgery. Corneal topography classification programs will need to be retrained
to determine whether it is possible to automatically differentiate H-LASIK from keratoconus.
Changes in Hyperopia and Presbyopia 139

E. SUMMARY
Corneal topographic analysis is helpful in elucidating the strengths and weaknesses of
refractive surgical procedures, and surgery for hyperopia is no exception. Centration is
critical, and a large treatment zone size is technically difficult to achieve. A hyperopic
procedures stability can be objectively and precisely measured with corneal topography.
However, the results of stability measurements may be confounded by the fact that people
in this age group (5065 years) are undergoing progressive hyperopia naturally; this must
be taken into account. Several factors, including varifocality of corneal topography, con-
tribute to better than expected near visual function after the surgery. With advancing age,
qualities of the tear film diminish, and this leads to fine surface irregularities, while the
induction of coma results from global asymmetrical changes in shape.

REFERENCES
1. Waring GO. Refractive Keratotomy for Myopia and Astigmatism, St Louis: Mosby, 1992.
2. Lin DT, Sutton HF, Berman M. Corneal topography following excimer photorefractive keratec-
tomy for myopia. J Cataract Refract Surg 1993; 19(suppl):149.
3. Klyce SD, Martinez CE. Corneal topography. In: Albert DM, Jakobiec F, eds. Principles and
Practice of Ophthalmology. Philadelphia: Saunders, 2000: 668694.
4. Kohnen T, Husain SE, Koch DD. Corneal topographical changes after noncontact holmium:
YAG laser thermal keratoplasty to correct hyperopia. J Cataract Refract Surg 1995; 22:
427435.
5. Alio JL, Ismail MM, Pego JLS. Correction of hyperopia with noncontact Ho:YAG laser thermal
keratoplasty. J Refract Surg 1997; 13:1722.
6. Endl MJ, Martnez CE, Klyce SD, McDonald MB, Coorpender SJ, Applegate RA, Howland
HC. Effect of larger ablation zone and transition zone on corneal optical aberrations after
PRK. Arch Ophthalmol 2001; 119:11591164.
7. Oliver EM, OBrart DPS, Stephenson CG, Applegate RA, Tomlinson A, Marshall J. Anterior
corneal optical aberrations induced by photorefractive keratectomy for hyperopia. J Refract
Surg 2001; 17:406413.
8. Ziff SL. Multifocal contact lenses. Am J Optom Arch Am Acad Optom 1967; 44:222225.
8a. Choi RY, Wilson SE. Hyperopic laser in situ keratomileusis: primary and secondary treatments
are safe and effective. Cornea 2001; 20:388393.
9. Keates RH, Pearce JL, Schneider RT. Clinical results of the multifocal lens. J Cataract Refract
Surg 1987; 13:557560.
10. Werblin TP, Klyce SD. Epikeratophakia: the surgical correction of aphakia: I. Lathing of
corneal tissue, Curr Eye Res 1981; 1:123129.
11. McDonnell PJ, Garbus J, Lopez PF. Topographic analysis and visual acuity after radial kerato-
tomy. Am J Ophthalmol 1988; 106:692695.
12. Maguire LJ, Bourne WM. A multifocal lens effect as a complication of radial keratotomy.
Refract Corneal Surg 1989; 5:394399.
13. Scher K, Hersh PS. Disparity between refractive error and visual acuity after photorefractive
keratectomy: multifocal corneal effects. J Cataract Refract Surg 1997; 23:10291033.
14. Fukuyama M, Oshika T, Amano S, Yoshitomi F. Relationship between apparent accommoda-
tion and corneal multifocality in pseudophakic eyes. Ophthalmology 1999; 106:11781181.
15. Martinez CE, Klyce SD, Waring III GO, El Maghraby A. The topography of LASIK. In:
Pallikaris IG, Siganos DS, eds. LASIK. Thorofare, NJ: Slack, 1997:339357.
16. Wright KW, Guemes A, Kapadia MS, Wilson SE. Binocular function and patient satisfaction
after monovision induced by myopic photorefractive keratectomy. J Cataract Refract Surg
1999; 25:177182.
140 Klyce et al.

17. Maeda N, Klyce SD, Smolek MK, Thompson HW. Automated keratoconus screening with
corneal topography analysis. Invest Ophthalmol Vis Sci 1994; 35:27492757.
18. Maeda N, Klyce SD, Smolek MK. Application of neural networks to the classification of
corneal topography: preliminary demonstration. Invest Ophthalmol Vis Sci 1995; 36:
13271335.
19. Maeda N, Klyce SD, Smolek MK. Comparison of methods for detecting keratoconus using
videokeratography. Arch Ophthalmol 1995; 113:870874.
20. Smolek MK, Klyce SD. Current keratoconus detection methods compared with a neural net-
work approach. Invest Ophthalmol Vis Sci 1997; 38:22902299.
14
Corneal Surface Profile After
Hyperopia Surgery

DAMIEN GATINEL
Fondation Ophthalomogique Adolphe de Rothschild and Bichat Claude Bernard
Hospital, Paris, France

The desired change in corneal curvature to correct for hyperopia with current excimer
laser systems is based on principles of geometric optics and the precise interaction of the
excimer radiation with the corneal tissue. In comparison to myopic correction in which
the goal is to flatten the central cornea, in hyperopia the central corneal area must be
steepened to increase its optical power. This central steepening makes the planned correc-
tion of the hyperopic eye more difficult because the steepened central corneal portion has
to join the peripheral unablated area of lower curvature via a transition area. These represent
the important special features of the correction of hyperopic errors, which are emphasized
in this chapter.

A. CORRECTION OF PURE SPHERICAL HYPEROPIC ERRORS


The profile of ablation to correct for spherical hyperopia is radially symmetrical and
predominates in the periphery in an annular fashion. A subtraction shape model based on
geometric optics allowed Munnerlyn et al., in 1988, to announce the principles of laser-
guided photoablation in the central corneal area (effective optical zone) (1). The modifica-
tions of the corneal profile are analyzed separately below for the optical zone and for the
transition zone.

1. Optical Zone Design


Conforming to the pioneering work of Munnerlyn et al., the change in paraxial corneal
power can be predicted by considering the initial unablated and the final ablated corneal
141
142 Gatinel

Figure 1 Schematic representation of the lenticule ablated for the correction of spherical hyper-
opia. The profile of ablation is outlined along two perpendicular meridians (green). The thickness
of the lenticule is maximal at its edges and null at its center.

surface as two spherical surfaces with a single but different radius of curvature. The
removal of tissue is equivalent to adding a thin lens of equal but opposite power. This
permits the calculation of the ablation profile over the optical zone for a spherical hyperopic
error (see Appendix 1).
To generate a three-dimensional graphic representation of the theoretical shapes of
the lenticules ablated during laser-assisted in situ keratomileusis (LASIK) of similar
amounts of spherical and cylindrical ablation, we used a digital modeling software that
allow to visualize the results of Boolean operation on orientated three-dimensional surfaces
(see Appendix 2).
The difference between each of the radii of curvature was exaggerated as compared
to the surgical range so as to facilitate the spatial visualization of the contour features of
the generated lenticules.
Spherical hyperopic ablation results in the ablation of a concave lenticule within
the optical zone, which is represented on Figure 1. Its thickness is null in the center and
increases progressively toward the periphery, where it reaches its maximum at the edge
of the optical zone. In first-order approximation, the maximum thickness of the edge of
the ablated lenticule over the optical zone is proportional to the magnitude of the hyperopic
treatment and to the square of the chosen optical zone diameter. The volume of tissue
ablation needed to steepen the cornea is thus delimited by the initial anterior surface and
the final postoperative steeper spherical surface over a circular optical zone.

2. Transition Zone Design


For necessary geometric feature, Any cornea that has had tissue removed centrally to
steepen its curvature (optical zone) while leaving the periphery untouched must undergo
an additional ablation to sculpt a smooth blending zone (transition zone).
This flatter area, commonly referred to as the transition zone, thus represents a
constant feature that ideally would have no undesirable optical effects and would ensure
the stability of the induced refractive changes in the optical zone by limiting unwanted
biological and biomechanical changes.
Corneal Surface After Hyperopia Surgery 143

When we address theoretical considerations on the different approaches to blend a


steepened optical zone to the untouched peripheral cornea, some constraints had be taken
into consideration (2). Should this be done by a noncontinuous constant curvature profile,
avoiding the induction of a continuous negative curvature, or by minimizing the slope of
the transition zone with a continuous change in its curvature but inducing negative curva-
ture (Fig. 2)? Because the patterns of ablation for the hyperopic transition zone are proprie-
tary, it is difficult to find confirmations of the use and interest of any of the transition
zone profile design characteristics. It seems, however, reasonable to postulate that any
profile of ablation should be smooth in a mathematical sensei.e., avoiding local dis-
continuities to prevent epithelial hyperplasia. A continuous profile of ablation with a very
gradual change in its curvature seems a better option to correct for hyperopia while limiting
regression. This pattern implies the need of two points of inflexion (inversion of the sign
of the local curvature) to prevent the occurrence of discontinuities (Fig. 2).
Some publications have emphasized on the need for a large transition zone outer
diameter in order to improve biological tolerance and minimize regression (35). Con-
versely, enlarging the optical zone diameter, although desirable to preserve the quality of
vision and reduce the risk of decentration, represents a limiting factor, since the depth per
diopter at the edge of the optical zone will increase with the square of the optical zone
diameter. This could account for the low success rate observed for corrections over 5 or
6 D of hyperopia. The determination of the diameter of the ablation zone should logically

Figure 2 Profile of ablation for the spherical hyperopic error. O, ablation center; OZ, optical
zone; TZ, transition zone; dotted black line, preoperative corneal profile; full black line, postoperative
corneal profile; blue line, postoperative profile over the transition zone with no local curvature
discontinuities but negative slope between the points of inflexion T and N; red line, postoperative
transitional profile having a constant positive slope, but with a noncontinuous junction with the
edge of the optical zone.
144 Gatinel

depend on the diameter of the optical zone. For example, a planned optical zone of 6.0
mm would require an ablation zone of 8.5 to 9.0 mm. Otherwise, effective optical zone
diameters might be diminished by epithelial filling of the peripheral ring of ablation in
case of high-magnitude of treatment. In LASIK, the corneal flap covering of the ablation
zone minimizes the epithelial healing response (6). This might account for the better
reported results of this technique over photorefractive keratectomy (PRK).
Because the total ablation zone diameter is equal to the outer diameter of the transi-
tion zone, it is mandatory to obtain large flap sizes for hyperopic LASIK procedures (7).

B. CORRECTION OF PURE CYLINDRICAL HYPEROPIC ERRORS


1. Optical Zone Design
The principles of the Munnerlyn pattern can be extended to the correction of astigmatism
by taking into consideration the meridional variations in corneal apical power. In the case
of pure hyperopic astigmatism, a cylindrical profile of ablation can be generated, which
aims to selectively steepen the initial flatter principal meridian. This pattern has no center
but there is axis symmetry along each of the principal meridians. A three-dimensional
representation of the etched corneal lenticule for such correction over a circular optical
zone is depicted in Figure 3. The depth of ablation is maximal at the edge of the optical
zone along the flat meridian, while the steep meridian is untreated by the laser.

2. Transition Zone Design


The shape of the transition zone is dictated by the features of the optical zone. As for the
optical zone, the central symmetry is broken. The step in tissue height is maximal at the
boundary of the optical zone along the flat meridian. This discontinuity then tapers slowly
and becomes null along the untreated steep meridian. To alleviate this variation, the diame-
ter of the transition zone should be longer along the flat meridian and minimal (equal to

Figure 3 Schematic representation of the lenticule corresponding to the correction of a pure


hyperopic astigmatism. Its thickness is null along the steep meridian (S) and maximal in the periphery
along the flat meridian (F). The profile of ablation along the flat meridian is underlined in green.
Corneal Surface After Hyperopia Surgery 145

B
Figure 4 (A) Schematic representation of the lenticule corresponding to the correction of a pure
hyperopic astigmatism with the transition zone. The ablation along the flat meridian is highlighted
in green. (B) Representation of the volume of the transition zone alone. Its outer perimeter is
elliptical, since the groove to blend reaches its maximum depth over the flat axis.

that of the optical zone) and minimal along the steep meridian while having a constant
slope over the optical zone. The shape of the outer limit of the transition zone is thus
elliptical (Fig. 4A and B). This might be clinically relevant in optimizing the position of
the hinge in LASIK procedures by placing it perpendicular to the flat meridian.

C. CORRECTION OF COMPOUND CYLINDRICAL HYPEROPIC


ERRORS
The refraction as commonly done clinically is an arc-based mathematical expression lim-
ited to the principal major and minor axes, and any compound hyperopic astigmatic refrac-
tive error can be expressed by different equivalent expressions. Thus, different sequential
treatment strategies for the correction of compound hyperopic astigmatism have been
proposed: they all consist in the combination of spherical and cylindrical treatments of
equal or opposite signs.
146 Gatinel

1. The positive-cylinder approach (ablating the cylinder along the flattest meridian
and then treating the residual spherical component)
2. The negative-cylinder approach (ablating the cylinder along the steepest merid-
ian and then treating the residual spherical component)
3. The cross-cylinder approach (ablating half of the power of the cylinder along
the steepest meridian and the remaining half along the flattest meridian before
the residual spherical equivalent is treated)

Even if the optical result may be the same, these strategies may result in different
amount and depths of tissue ablation. The increasing number of reports of corneal ectasia
following LASIK suggests that the strategies that remove less of the corneal tissue should
be preferred for the treatment of any compound astigmatism. Recently Azar et al. compared
the theoretical ablation profiles and depths of tissue removal in the treatment of compound
hyperopic astigmatism and of mixed astigmatism (8). They found that strategies combining
the use of hyperopic spherical and myopic cylindrical corrections incur the greatest amount
of corneal tissue ablation.
Three-dimensional drawings were generated to depict the theoretical shapes of the
volumes of corneal tissue ablated to treat similar amounts of compound astigmatic hyper-
opic errors (Fig. 5AC). These images can be interpreted more easily and quickly than
abstract mathematical functions. The shapes and volumes of the corresponding lenticules
can be analyzed for different strategies of ablation, and this makes if possible to estimate
the theoretical differences in the amount of ablated corneal volume.
In compound hyperopic astigmatism, all the corneal meridians have excessive flat-
tening. The negative cylinder and the cross cylinder approaches both imply an additional
flattening that will cause redundant ablation by necessary additional positive spherical
treatment.

Figure 5 Schematic representation of the lenticules ablated for the correction of compound hyper-
opic astigmatism for three different strategies to treat the same refraction: 3 (2 0 degrees).
The optical zone diameter is identical for each of the depicted strategies. (A) Positive-cylinder
approach. The positive cylinder (2 0 degrees) ablated lenticule is represented above, with its
section along the flat axis outlined in light green. The spherical ablated lenticule (3) is represented
below, with two meridian outlined in dark green.
Corneal Surface After Hyperopia Surgery 147

Figure 5 Continued. (B) Cross-cylinder approach. The astigmatic component is split in two parts:
(1 0 degrees) and (1 90 degrees). The corresponding lenticules are represented (the
profile of ablation along the principal meridians are outlined in red and light green for the negative
and positive cylinders, respectively). The remaining spherical equivalent (4) is then treated by
the ablation of a positive spherical lenticule (two perpendicular meridian outlined in dark green).
(C) Negative-cylinder approach. The refraction is treated as: (2 90 degrees)5. The lenticules
corresponding to the negative-cylindrical and the positive-spherical treatments are shown with their
meridian outlined in red and dark green, respectively. The positive-cylinder approach minimizes
the volume of ablation and induces no ablation at the center of the optical zone. The cross-cylinder
approach induces an additional volume of ablation compared to the positive-cylinder approach. The
negative-cylinder approach induces the maximum volume of ablated tissue.

D. CUSTOMIZED ABLATION
In the preceding text, we have studied the changes in corneal profile induced by the
correction of simple spherocylindrical errors. Customized ablations aim to correct both
the spherocylindrical error and the higher-order aberrations based on the collection of
wavefront or corneal topography data. This induces variations of the amount of tissue
removed at specific locations, and the ablation profile thus specified will have specific
features. For example, taking into account the corneal apical radius asphericity will induce
variations in the ablation depth. This might, however, not alter the global pattern of the
148 Gatinel

ablation profile for patients with hyperopic errors but rather induce radially asymmetrical
variations in the peripheral step at the edge of the optical zone. The transition zone
pattern will have to take this variability in account and its optimized slope will have to
be determined to ensure the stability of the induced changes over the optical zone.

E. CONCLUSION
For several reasons, the correction of hyperopia with PRK or LASIK is more difficult
than for myopia. The patterns of the profiles of ablation to steepen the cornea might
account for the limited success in excimer laser surgery for hyperopia. Refinements based
on simple geometrical considerations and the incorporation of customized data might
improve the results of such surgery.

APPENDIX 1
To correct for a spherical hyperopic error, Munnerlyn et al., by considering the initial
unablated and the final ablated corneal surface as two spherical surfaces with a single but
different radius of curvature (Fig. 6), proposed the following formula for the ablation
profile over the optical zone:
t(y) R2 R1 R 21 y2 R 22 y2
where t(y) expresses the depth of tissue removal as a function of the distance y from the
center of an optical zone diameter of S when R1 and R2 are the initial and final corneal
anterior radii of curvature, respectively. The power of the removed lenticule (D) corre-
sponds to the intended refractive change and is related to R1, R2, and the index of refraction
(n) as follows:

Figure 6 Schematic representation of the profile of ablation for spherical hyperopia along a
corneal meridian. Both initial and final surfaces are assumed to be spherical of radius R1 and R2
respectively. The gray portion corresponds to the material to be removed to steepen the anterior
part of the cornea over an optical zone diameter of S mm.
Corneal Surface After Hyperopia Surgery 149

D (n 1) R1 R1
2 1

where R2 R1 for hyperopic ablations


The maximal depth occurs at the edge of the optical zone of diameter S and is equal
to:
t(S/2) R2 R1 R 21 (S/2)2 R 222 (S/2)2

APPENDIX 2
To generate a conceptual graphic representation of theoretical shapes of the lenticules
ablated during LASIK treatments of similar amounts of spherical and cylindrical treatment,
we used a digital modeling software that makes it possible to visualize the results of
Boolean operation on orientated three-dimensional surfaces (Bryce 3D, Metacreation Corp.
Dublin, Ireland). Using these Boolean operations (subtraction of one object from another)
on geometrical primitives such as spheres, cylinders, or toroidal ellipsoids, three-dimen-
sional representations of the theoretical ablated volumes were generated (Fig. 7).
The optical zone was circular and the final corneal surface was spherical in all
cases. For spherical corrections, the initial and final corneal surfaces were modeled as two
spherical surfaces of different radii of curvature (the latter being flatter for myopic spherical
corrections and steeper for hyperopic correction). For pure cylindrical corrections, the
initial corneal surface was modeled as a spherocylinder with two major apical radii of
curvature along the principal meridians, the final surface being spherical. In cases of
myopic cylindrical correction, one of the principal radii of curvature of the initial surface
was shorter, the other being equal to that of the final corneal surface. In the case of
hyperopic cylindrical corrections, one of the principal radii of curvature of the initial
surface was longer, the other being equal to that of the final corneal surface. The three-

Figure 7 Model of the ablated lenticule for the correction of pure hyperopic astigmatism. This
volume is generated by boolean operation on primitive figures such as sphere, ellipsoid, cylinder,
in accordance with assumptions regarding subtraction shape models.
150 Gatinel

dimensional representation of a lenticule was obtained by first subtracting the volume of


the primitive modeling of the final theoretical corneal surface from the primitive volume
modeling of the initial corneal surface. These primitives were aligned and centered on the
Z axis. The ablated lenticule for the correction of pure cylindrical myopic astigmatism
was generated by adjusting the distance between the apex of each surface so that they
would intersect along the steep meridian within a predetermined circular optical zone.
The difference between each of the radii of curvature was exaggerated as compared to
the clinical and surgical range to facilitate the spatial visualization of the contour features
of the generated lenticules. However, in comparing different strategies, the initial and final
surfaces were identical and were rescaled to the same ratio for purposes of comparison.
This made it possible to estimate the theoretical differences in the amount of ablated
corneal volume by the different available strategies that combine the ablation of these
elementary lenticules to correct for a given compound hyperopic astigmatic refractive
error.
The transition zone was modeled as a spherical (constant positive curvature) surface
encompassing the circular inferior edge of the ablated lenticule and joining the peripheral
unablated cornea.
To facilitate the visualization and the distinction of the shapes of the ablated lenti-
cules, cross-sectional color outlines were added along the principal meridians.

REFERENCES
1. Munnerlyn C, Koons S, Marshall J. Photorefractive keratectomy: a technique for laser refractive
surgery. J Cataract Refract Surg 1988; 14:4652.
2. Dierick HG, Missoten L. Corneal ablation profiles for correction of hyperopia with the excimer
laser. J Refract Surg, 1996; 12:767773.
3. Chayet AS, Assil KK, Montes M, Castellanos A. Laser in situ keratomileusis for hyperopia:
new software. J Refract Surg 1997; 13(suppl):S434S435.
4. Arbelaez MC, Knorz MC. Laser in situ keratomileusis for hyperopia and hyperopic astigmatism.
J Refract Surg 1999; 15:406414.
5. Ditzen K, Huschka H, Pieger S. Laser in situ keratomileusis for hyperopia. J Cataract Refract
Surg 1998; 24:4247.
6. Pallikaris IG, Siganos DS. Excimer laser in situ keratomileusis and photorefractive keratectomy
for correction of high myopia. J Refract Corneal Surg 1994; 10:498510.
7. Rashad KM. Laser in situ keratomileusis for the correction of hyperopia from 1.25 to 5.00
diopters with the Technolas Keracor 117C laser. J Refract Surg 2001; 17:113122.
8. Azar DT, Primack JD. Theoretical analysis of ablation depths and profiles in laser in situ
keratomileusis for compound hyperopic and mixed astigmatism. J Cataract Refract Surg 2000;
26(8):11231136.
15
Wavefront Changes After Hyperopia
Surgery

MARIA REGINA CHALITA and RONALD R. KRUEGER


Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.

A. BASIS OF WAVEFRONT ANALYSIS


1. Definition of Wavefront and Aberrations
In physical optics, light is considered as a wave, and the light wave spreads in all directions
as a spherical wave. The wavefront is the shape of light waves that are all in phase (1). The
ideal eye, defined as an emmetropic eye without any aberrations, has a perfect wavefront,
described as a plane perpendicular to the line of sight (Fig. 1) (2). For real eyes, wavefronts
that converge toward the retina are not spherical, so perfect imaging never occurs.
Wavefront aberration is defined as the difference between the actual wavefront and
the ideal wavefront in the plane of the eyes exit pupil (Fig. 2) (3).
Ocular aberrations are not constant during life (4); they increase with age (5) and
may change during accommodation (6,7). In optics, aberrations are classified in two differ-
ent types: monochromatic and chromatic (8).

2. Monochromatic Aberrations
Monochromatic aberrations involve specific wavelengths of visible light and can be subdi-
vided into defocus (spherical refractive error), astigmatism (cylindrical refractive error),
coma, spherical aberration, and other terms of higher-order aberrations. Defocus and astig-
matism are considered low-order aberrations and can be corrected with glasses, contact
lenses, or refractive surgery (9). They correspond to approximately 85% of the average
wavefront error. Coma, spherical aberrations, and others are high-order aberrations (refrac-
tive distortions, that limit the vision of healthy eyes to less than the retinal limits) and
cannot be corrected with spherocylinder lens or with standard refractive surgery (10).
151
152 Chalita and Krueger

Figure 1 The Shack-Hartmann wavefront sensor forms a regular lattice of image points for a
perfect plane wave front of light.

They are responsible for approximately 15% of the average wavefront error. For coma,
the wavefront is asymmetrical about the perfectly spherical wavefront, producing a comet-
shaped pattern on the emmetropic plane. For spherical aberration, the converging wave-
front looks spherical near the center of the pupil but changes its curvature toward the edge
of the pupil. This aberration gives a continuum of foci and results in point images with
halos. Other terms of higher order aberrations are a group of all other deviations of the
converging wavefront from perfect sphericity.
3. Chromatic Aberrations
Chromatic aberrations are errors that result of dispersion in optical elements of the eye.
Refractive surgery techniques cannot correct chromatic aberration, since this error is inher-
ent to the properties of the ocular materials and not to the shape of the ocular components
(11).

Figure 2 The Shack-Hartmann wavefront sensor forms an irregular lattice of image points for
an aberrated wavefront of light.
Wavefront Changes After Hyperopia Surgery 153

Figure 3 Three-dimensional pictorial directory of Zernike modes 0 to 20.

Aberrations are also classified in terms of orders using Zernike polynomials (12).
The wavefront error (difference in shape between the aberrated wavefront and the ideal
wavefront) for myopia, hyperopia, and astigmatism is well represented by a polynomial
of second order. These aberrations are therefore called second-order aberrations. Following
the same principle, coma is a third-order aberration and spherical aberration a fourth-order
aberration (Fig. 3).
Laser surgery [photorefractive keratectomy (PRK) and laser-assisted in situ keratom-
ileusis (LASIK)] increases high-order optical aberrations in human eyes, especially spheri-
cal aberration and coma (13,14). This increase in high-order optical aberrations after cor-
neal laser surgery is correlated with a significant decrease in quality of vision, especially
under scotopic conditions (15).

4. Detection of Wave Aberration: History of Shack-Hartmann


Most of the methods of wave aberration detection and reconstruction have been based on
ray tracing. These methods were first described in1900 by Hartmann. About 5 years earlier,
Tscherning constructed an aberroscope: a grid superimposed on a 5-D spherical lens where
a subject could see a shadow image of the grid on the retina. From the distortions of the
grid, one could infer the aberrations of the eye. Over 70 years later, Howland invented
the crossed cylinder aberroscope. Instead of using a spherical lens, he used a crossed
cylinder lens of 5 D with the negative axis at 45 degrees (16,17).
In 1961, Smirnov developed another method where a grid is viewed by the entire
aperture of the eye minus a single central intersection, which is viewed through a small
154 Chalita and Krueger

aperture made to scan the entire pupil sequentially. In 1998, Webb and coauthors made
a modern implementation of Smirnovs method that computes the wave aberration and
reduces it to Zernike polynomials.
Last, the Shack-Hartmann sensor was developed in 1970 by Shack in order to im-
prove the images of satellites taken from earth. The first practical application was in 1984
by Wilson to test large telescopes. In 1989, Bille was the first to publish using the Shack-
Hartmann in ophthalmology to measure the profile of the cornea and in 1997 he became
the first to project a source onto the retina and use the Shack-Hartmann sensor to measure
aberrations of the eye. In the same year, Williams became the first to use the Shack-
Hartmann sensor with adaptative optics to measure and correct aberrations of the eye (18).

5. Principles of Shack-Hartmann
The Shack-Hartmann aberrometer has an objective lens that is actually an array of tiny
lenses. With this kind of lens the reflected light is broken into many individual beams,
thereby producing multiple images of the same retinal spot of light. For a perfect eye, the
reflected plane wave will be focused into a perfect lattice of point images, each image
falling on the optical axis of the corresponding lenslet. By contrast, the aberrated eye
reflects a distorted wavefront. By measuring the displacement of each spot from its corre-
sponding lenslet axis, we can deduce the slope of the aberrated wavefront when it entered
the corresponding lenslet. The wavefront should be analyzed as soon as it passes through
the eyes pupil (19,20).

B. WAVEFRONT OF HYPEROPIC TREATMENT


1. Profile of Hyperopic Correction
In 1988 Munnerlyn and coworkers described the equations that served as a starting point
for developing current ablation algorithms. For a hyperopic ablation, the preoperative
cornea is modeled as a sphere of lesser curvature than the desired postoperative cornea,
which is also modeled as a sphere. Tissue is removed from the peripheral area, flattening
this region and producing increased postoperative corneal curvature as a final result. This
concept is referred to as the shape-subtraction model of refractive surgery; it permeates
current thinking in refractive surgery and forms the basis for both topography and wave-
front-guided procedures (21).

2. Wavefront Measurements and Aberration Changes Before and


After Conventional Hyperopic LASIK
In our service, we use the Alcon LADARWave Device (Orlando, FL) to study visual
aberrations. The LADARWave Device makes detailed measurements of the aberrations
present using the Shack-Hartmann principles. We can measure defocus, astigmatism, and
higher-order aberration that can be decomposed into coma, spherical aberrations, and other
terms of higher order aberrations (Fig. 4).
If we imagine a normal cornea with its normal prolate shape without any kind of
surgery done, we will find higher-order aberrations but in low amounts. The pattern of
each higher-order aberration is well defined: coma has a comet-shaped pattern with an
elevated area (semicircle of hyperopia) just next to a depressed area (semicircle of myopia)
in the same meridian (Fig. 5). Spherical aberration has a central elevated area (focus of
Wavefront Changes After Hyperopia Surgery 155

Figure 4 LADARWave image showing the total wavefront pattern of a patient with hyperopic
LASIK to achieve monovision.

Figure 5 Coma pattern in a normal eye (LADARWave).


156 Chalita and Krueger

Figure 6 Spherical aberration pattern in a normal eye (LADARWave).

hyperopia) surrounded by a depressed circle (annulus of myopia) and with normalization


in the far periphery (resembling a flat sombrero) (Fig. 6).
Other terms such as trefoil, quadrafoil, and secondary astigmatism generally have
lower values (Fig. 7A and B).
Patients that underwent hyperopic treatments have an accentuated prolate corneal
pattern (Fig. 8) (22,23).
When we analyze the spherical aberration pattern of these eyes, we can notice a
decrease in the magnitude of spherical aberration and an inversion in the shape pattern.
This is because the waves that come from the peripheral ablated zone converge less, so
this area looks like a peripheral elevated red ring (annulus of relative hyperopia) and the
central rays converge more, giving a central depressed area (focus of relative myopia).
We call this pattern a flipped over sombrero hat, which is the opposite pattern of myopic
treated eyes (Fig. 9).

C. COMPARISON OF HYPEROPIC VERSUS MYOPIC TREATMENT


WAVEFRONT
1. Profile of Myopic Correction
As described by Munnerlyn in 1988, for a myopic ablation, the preoperative cornea is
modeled as a sphere of greater curvature than the desired postoperative cornea, which is
also modeled as a sphere within the treated zone. The apex of the desired postoperative
cornea is displaced from the preoperative cornea by the maximal ablation depth, which
is determined by the ablation zone size. The intervening tissue is simply removed or
subtracted to produce the final result.
Wavefront Changes After Hyperopia Surgery 157

B
Figure 7 (A) Trefoil pattern. (B) Quadrafoil pattern.
158 Chalita and Krueger

Figure 8 LADARWave image showing defocus, astigmatism, and higher-order aberrations of a


hyperopic patient.

Figure 9 Spherical aberration after hyperopic treatment showing negative asphericity, as repre-
sented by a flipped over sombrero.
Wavefront Changes After Hyperopia Surgery 159

Figure 10 LADARWave device showing defocus, astigmatism, and higher-order aberrations in


a myopic patient.

Patients who have undergone myopic treatments have an oblate corneal pattern (Fig.
10) (24). The wavefront pattern shows a flattening or concavity to the otherwise bowl-
shaped wavefront of myopia.
Analyzing the wavefront of these myopic treatments, we notice that the spherical
aberration increases in number and size, with the depressed and elevated areas being
accentuated. We describe this kind of pattern as a sombrero hat (Fig. 11).

2. Comparison of Aberration Changes in Hyperopia Versus Myopia

In a study of 113 candidates for LASIK surgery, analyzing all aberrations, defocus and
astigmatism were dominant. When analyzing only higher-order terms, coma and spherical
aberrations were the most significant.
Another study described the pre-and postwavefront measurements of patients sub-
mitted to LASIK for myopia or hyperopia and myopic PRK. It was found that, for LASIK,
postoperative total error was significantly smaller for myopes than hyperopes (p 0.05).
Both myopic and hyperopic LASIK patients exhibit modest regression in defocus. In
analyzing higher-order aberrations, it was noticed that spherical aberration decreased in
hyperopic treatments and increased in myopic corrections. All other higher-order terms
increased after either type of correction. In the postoperative interval, coma was the most
dynamic higher-order aberration, with an overall decrease over time until 6-months postop-
eratively.
160 Chalita and Krueger

Figure 11 Spherical aberration after myopic treatment showing increased positive asphericity,
as represented by a sombrero hat.

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RA, eds. Customized Corneal Ablation: The Quest for Supervision. Thorofare NJ: Slack, 2001:
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Wavefront Changes After Hyperopia Surgery 161

13. Oshika T, Klyce SD, Applegate RA, Howland HC, Danasoury MAE. Comparison of corneal
wavefront aberrations after photorefractive keratectomy and laser in situ keratomileusis. Am
J Ophthalmol 1999; 127:17.
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after laser refractive surgery. A problem of subclinical decentration. J Cataract Refract Surg
2001; 27:362369.
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16:S552S553.
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21. Roberts C, Dupps Jr WJ. Corneal biomechanics and their role in corneal ablative procedures.
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16
Contrast Sensitivity Changes After
Hyperopia Surgery

LAVINIA C. COBAN-STEFLEA
Bucharest University Hospital and Carol Davila University of Medicine and
Pharmacy, Bucharest, Romania
TOMMY S. KORN
University of CaliforniaSan Diego and Rees-Stealy Medical Group, San Diego,
California, U.S.A.
BRIAN S. BOXER WACHLER
Boxer Wachler Vision Institute, Beverly Hills, California, U.S.A.

A. INTRODUCTION
Understanding the importance of contrast sensitivity can be easier if we emphasize its
relationship to spatial vision, which is the core of the visual perception (1). Spatial fre-
quency theory of image processing is based on spatially extended patterns called sinusoidal
gratings, which are characterized by four parameters: spatial frequency, orientation, ampli-
tude, and phase. The contrast sensitivity function is a measure of the observers sensitivity
to gratings at different frequencies and is determined by the lowest contrast at which the
sinusoidal gratings can still be detected (2). Over 200 years ago, contrast sensitivity began
to be acknowledged as a clinical tool for doctors in studying visual disorders (3). In
1760 Bouguer defined and gave a value to the term light-difference threshold, the first
denomination of contrast threshold. Since then other researchers have made a great number
of contributions to this field: Bjerrum (1884) with letter charts, the first low-contrast letter
acuity tests, and Young (1918) with the ink spot test, an easy method to measure the light-
difference threshold. More recently Schade (1956) applied his knowledge of television
technology to contrast sensitivity testing. The work of Campbell and Green contributed
to a better understanding of the optical and neural mechanism of contrast sensitivity testing
and inspired further studies regarding alterations of contrast sensitivity in ocular diseases.
163
164 Coban-Steflea et al.

Correction of hyperopia has been a constant concern of ophthalmologists over the


past decades. Some of the surgical procedures that have been developedhexagonal
keratotomy (4,5), keratophakia, keratomileusis, and epikeratophakia (69)have been
abandoned because of limited applicability or side effects. Among current corrective proce-
dures undoubtedly laser-assisted in situ Keratomileusis (LASIK) and Ho:YAG laser ther-
mal keratoplasty (LTK) are the most widespread. Recently published clinical results em-
phasize the fact that LASIK is a procedure with good predictability, stability, efficacy,
and safety for the correction of low to moderate spherical hyperopia (10). Long-term
predictability with occurrence of undercorrection is influenced by the preoperative kerato-
metric values and ablation zone diameter (11). Other studies point out the importance of
corneal thickness and width of the flap for LASIK feasibility (12). The effectiveness of
LASIK for severe hyperopia and hyperopic astigmatism is reduced (13,14). For treatments
over 5.00 D, the incidence of loss of best-corrected visual acuity was increased. Current
nomograms require the cut of a larger flap in order to enlarge the ablation zone and to
decrease the risk of halos, glare, and night vision difficulties for patients with high hyper-
opia and astigmatism (15). A lower predictability for astigmatic corrections was also
reported after LASIK for myopia (16) in spite of in situ axis alignment (17,18). Encourag-
ing results have been reported with respect to the safety, predictability, and stability of
LASIK correction, for small degrees of hyperopia that were secondary to previous radial
keratotomy (RK), and for automated lamellar keratoplasty (ALK) (19). The degree of
regression after H-LASIK was reported to be higher relative to myopic corrections but
lower, even in high hyperopia, than with the PRK procedure (20). Flap irregularities,
epithelium, infection, or nonspecific inflammation at the flap interface have been reported
complications of the LASIK procedure (21). Loss of vision can occur in cases of button-
holes, free cap, or amputation of the flap (22).
Correction of hyperopia and astigmatism by thermal keratoplasty was reported more
than 100 years ago (2325). The actual mechanism by which this procedure alters the
anterior corneal curvature has been clarified with the discovery of shrinkage temperature
of corneal collagen by Stringer and Parr (26). In 1970s and 1980s, keratoconus was the
focus of theromokeratoplasty technology. A number of clinical studies done have evaluated
thermal keratoplasty potential to replace penetrating keratoplasty in keratoconus treatment
(2730). In spite of the fact that initial flattening of the cone followed the procedure,
regression occurred within a few weeks postoperatively. It was not uncommon for these
keratoconus treatments to be accompanied by complications such as corneal scarring,
vascularization, and bullous keratopathy. Additionally, poor predictability and stability
contributed to the withdrawing of the procedure from clinical use for keratoconus.
A more recent approach to thermal keratoplasty is credited to Fyodorov, who devel-
oped a technique, using controlled thermal burns of corneal stroma with a retractable probe
tip heated to 600C and applied in a radial pattern. The procedure was eventually abandoned
because of the high incidence of postoperative regression (31). In spite of repeated chal-
lenges to achieve predictable and stable refractive outcomes, researchers did not give up
on probe technology but took another avenue, which was the use of lasers to deliver
controllable amounts of energy to the stroma.
Lasers such as continuous CO2 and cobalt magnesium fluoride have been used in
experimental studies on rabbit corneas, with transient results (32,33). Reports of clinical
studies that used the erbium:glass laser (34) have shown good results for hyperopia higher
than 3.00 D. Over the past decade, ophthalmologists in the United States have directed
their work at evaluating two Ho:YAG laser systems: the noncontact system (Sunrise Tech-
Changes After Hyperopia Surgery 165

nologies, Fremont, CA) and the contact system (Summit Technologies, Waltham, MA).
The Sunrise Ho:YAG is a pulsed laser that emits laser light at a wavelength of 2.13 m.
Other technical characteristics include pulse repetition frequency of 5 Hz and pulse energy
in the range of 226 to 258 in correlation with the amount of refractive correction required.
The energy is applied to the cornea in a noncontact mode through a fiberoptic slit-lamp
system; the treatment pattern is represented by rings of spots concentric to the pupil (35).
Sand, who was granted a patent for performing infrared LTK, was an important contributor
to the development of this technology. Initial in vitro investigations have been made on
swine and human cadaver eyes (36,37) in an attempt to establish a treatment protocol.
Further studies done on human poorly sighted eyes showed a mean change in corneal
curvature of 1.10 D followed by some amounts of regression (38). Results of clinical trials
done outside the United States, which used the eight-spot treatment pattern applied at
different diameters (6, 7, or 8 mm), had shown that the procedure works best up to 3.00
D. They also proposed a treatment algorithm adjusted to variables such as age and central
corneal thickness (39). Other studies have demonstrated that the amount of refractive
change is increased when a two-ring treatment is applied at the 6- and 7-mm center line
in a radial instead of a staggered pattern (40,41). The U.S. phase III study protocol has
defined the efficacy criteria for the LTK procedure as improvement in distance UCVA
and reduction in hyperopia manifest refraction spherical equvalent (MRSE) 0.5 D.
Evaluation at 2 years showed that 69.4% of patients had more than two lines of improve-
ment in distance uncontrolled visual acuity (UCVA) and no eyes had lost more than two
lines of best spectacle corrected visual acuity (BSCDVA) (35).

B. CONTRAST SENSITIVITY IN LASIK AND LTK


In understanding the outcomes of contrast sensitivity, we conducted a study to evaluate
the quality of vision through its changes in LASIK and noncontact Ho:YAG LTK for the
correction of low to moderate spherical hyperopia. We analyzed the results of two groups
of patients who had LASIK and LTK, respectively, as primary procedures. There was no
history of ocular diseases or surgery. We compared best-corrected contrast sensitivity
values preoperatively and at 3 months postoperatively. Contrast sensitivity was measured
with the self-calibrated, internally luminated CSV-1000E Vector Vision (Dayton, OH) at
12 cycles per degree (cpd) spatial frequency. The patient was instructed to identify whether
the bars were in the top circle, bottom circle, or neither. The last correct identification
has been taken as the contrast sensitivity. On the contrast sensitivity chart the numbers
represent normalized ratios where values greater than 1.0 correspond to percent contrasts
sensitivity above the population average and values below 1.0 represent percent of the
average contrast sensitivity below the population average (42). Visual acuity was measured
with the Vector Vision acuity chart using a scoring method of the U.S. Food and Drug
Administration for refractive surgery clinical trials (43). All visual function tests were
done with best spectacle-corrected visual acuity.
Data were analyzed with the StatView (SAS Institute Inc., Cary, NC) statistical
package. Visual acuity data were analyzed in logMAR values. Normalized contrast sensi-
tivity values were converted to log values and used for statistical analysis.
The LASIK study group comprised 94 eyes of 49 patients, 21 men and 28 women.
Mean patient age was 59.67 years 7.95 SD, range 44 to 78 years. Preoperatively, mean
deviation from target manifest refraction was 2.4 D 1.2 D, SD, (range 0.37 to
5.60 D). LASIK procedures were performed by the same surgeon (B.B.W.) using the
166 Coban-Steflea et al.

Table 1 H-LASIK GroupPreoperative and Postoperative Log Contrast Sensitivity Values and
Best Spectacle-Corrected LogMAR Visual Acuity Values

Mean Standard deviation Minimum Maximum

Preop log CS 1.30 0.22 0.61 1.69


Postop log CS 1.23 0.27 0.61 1.54
Preop logMAR VA 0.01 0.08 0.20 0.20
Postop logMAR VA 0.02 0.10 0.20 0.50

Moria LSK (Doylestown, PA) microkeratome and the Summit Apex Plus Laser (Summit
Technology Inc., Waltham, MA); the treatment zone was centered on the pupil. Results
have shown a mean postoperative deviation from target manifest refraction of 0.09 D
0.88 D, SD, (range 2.25 to 2.00 D) at 3 months. Table 1 shows the mean preopera-
tive and postoperative log contrast sensitivity values, standard deviations, and maximum
and minimum values. At 3 months postoperatively the mean log contrast sensitivity value
was not statistically significantly different compared to preoperative levels (p 0.18). The
mean best spectacle-corrected logMAR visual acuity value at 3 months was statistically
significantly worse relative to preoperative value (p 0.008). However, the change was
not clinically significant, as the logMAR conversion was a loss of 1.5 letters on the acuity
chart. There was a statistically significant correlation between achieved refraction and
changes in log contrast sensitivity values (p 0.006) (Fig. 1) (r 0.29, p 0.006).
This indicated that higher amounts of hyperopic correction were associated with greater
loss of best-corrected contrast sensitivity. No statistically significant correlation was ob-

Figure 1 Correlation between changes in log contrast sensitivity values and achieved refraction
in the H-LASIK group.
Changes After Hyperopia Surgery 167

Figure 2 Correlation between changes in best spectacle-corrected logMAR visual acuity values
and achieved refraction in the H-LASIK group.

served between achieved refraction and changes in best spectacle-corrected logMAR visual
acuity (r 0.05, p 0.58)(Fig. 2).
The LTK study group comprised 55 eyes of 35 patients, 16 males and 19 females.
Mean patient age was 57.61 years 7.35, SD, with a range of 39 to 71 years; mean
deviation from target manifest refraction of treated eyes was 1.5 D 0.59 D, SD, range
0 to 3.00 D. Noncontact Ho:YAG LTK treatments were performed by the same surgeon
(B.B.W.) using the Sunrise Hyperion Holmium Laser Corneal Shaping System (Sunrise
Technologies Inc., Fremont, CA). The treatment was centered on the corneal purkinje
image of the patient fixation light. The light reflex closely approximates the visual axis.
Therefore, in cases of positive angle kappa, the treatment was not centered on the pupil.
Laser parameters included wavelength, 2.13 m; pulse duration, 250 s; pulse repetition
frequency, 5 Hz; pulse energy, adjustable from 226 to 258 mJ/pulse. In the current study
we used a two concentric radial 8-spot ring treatment pattern centered around the fixation
light reflex on the cornea. Postoperatively, results showed a mean deviation from target
manifest refraction of 0.36 D 0.84 D, SD, range 3.50 to 1.25 D. Mean log
contrast sensitivity value was not statistically significantly decreased (p 0.07) (Table
2) and mean best spectacle-corrected logMAR visual acuity value was statistically signifi-

Table 2 LTK GroupPreoperative and Postoperative Log Contrast Sensitivity Values and Best
Spectacle-Corrected LogMAR Visual Acuity Values

Mean Standard deviation Minimum Maximum

Preop log CS 1.28 0.24 0.61 1.69


Postop log CS 1.19 0.29 0 1.84
Preop logMAR VA 0.01 0.08 0.2 0.2
Postop logMAR VA 0.04 0.11 0.1 0.6
168 Coban-Steflea et al.

Figure 3 Correlation between changes in log contrast sensitivity values and achieved refraction
in the LTK group.

cantly worse (p 0.0067) relative to preoperative values. The change in acuity was not
clinically significant as the change represented approximately four letters on the acuity
chart. No statistically significant correlation (R 0.16, p 0.25) was found between
achieved refraction and changes in log contrast sensitivity values (Fig. 3). Figure 4 shows
the lack of correlation between achieved refraction and best-spectacle corrected logMAR
visual acuity values (r 0.15, p 0.26).

Figure 4 Correlation between changes in best spectacle-corrected logMAR visual acuity values
and achieved refraction in the LTK group.
Changes After Hyperopia Surgery 169

C. DISCUSSION
As new surgical procedures are added to the refractive surgery armamentarium, assessing
visual outcome becomes more difficult. Information regarding postoperative visual acuity
and refractive changes is no longer satisfactory to evaluate the quality of the image
projected on the retina (44). Contrast sensitivity, as a functional method, has been shown
to be directly affected by the distorted image following excimer laser surgery (45). Using
digitized retroillumination, Vinciguerra has shown that corneal distortion arising from
prominent flap striae may be overlooked by the customary slit-lamp examination (46).
Our results have shown a slight decrease in contrast sensitivity at 12 cpd spatial frequency
postoperatively after LASIK procedure. However the difference was not statistically signif-
icantly different (p 0.18). Previous literature data that have demonstrated that spatial
frequency of 12 cpd is mostly affected by degradation in optics, such as aberration or blur
(47). Other studies reported a loss of contrast sensitivity at 12 months after LASIK of up
to one line for low hyperopia and of more than two lines for high hyperopia with no
statistical significance (13). An interesting finding in the LASIK group was the significant
correlation between achieved refraction and change in contrast sensitivity, demonstrating
that larger amounts of correction are accompanied by larger loss of contrast sensitivity.
This indicates that with the Summit Apex Plus laser used for LASIK and centered on the
pupil, higher degrees of hyperopic treatment as associated with a higher risk of loss of
best-corrected contrast sensitivity.
Contrast sensitivity showed little change after the LTK procedure. The minimal
decrease observed was not statistically significant (p 0.07). Furthermore, contrast sensi-
tivity changes showed no correlation with the amount of spherical correction attempted.
Clinical trials at 1 and 2 years after LTK reported that mean contrast sensitivity increased
at all follow-up visits for the two-ring treatment group at Regan charts (40,48). Postopera-
tively visual acuity did not vary significantly (p 0.0067) and was not influenced by
the amount of correction, although the amount of hyperopia corrected in the LTK group
was less than that corrected in the LASIK group.
We conclude that measuring contrast sensitivity after refractive surgical procedures
should be encouraged and further developed in order to assess the limits of safety for
given procedures and devices used for such procedures. Studies should be directed at
identifying laser characteristics and treatment patterns that are able to optimize the optical
system of the eye, thus increasing safety.

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17
Wound Healing After Hyperopic
Corneal Surgery
Why There Is Greater Regression in the
Treatment of Hyperopia

RENATO AMBROSIO, JR.


University of Washington, Seattle, Washington, U.S.A., University of Sao Paolo,
Sao Paolo, and Clnica e Microcirurgia Oftalmologica Renato Ambrosio, Rio de
Janeiro, Brazil
STEVEN E. WILSON
University of Washington, Seattle, Washington, U.S.A.

A. INTRODUCTION
Biological diversity in the corneal wound-healing response is a major factor in the out-
comes of all keratorefractive surgical procedures (1,2). It is one of the most important
determinants for overcorrection, undercorrection, and other complications, such as haze
(3) and irregular astigmatism, which occur with laser-assisted in situ keratotomileusis
(LASIK) and photorefractive keratectomy (PRK) in the treatment of myopia (4,5), hyper-
opia (6,7), or astigmatism (8,9).
This response is very similar in different species, facilitating the creation of animal
models for better characterization of the wound-healing response. There are quantitative
and qualitative variations in specific processes that comprise the cascade. There is also
variability depending on the inciting injury within a species. For example, thermal, inci-
sional, lamellar, and surface scrape injuries are followed by wound-healing responses that
are similar in some respects but different in others.
Corneal wound healing following correction of hyperopia may be more complex
than that associated with corrections of myopia (10). Steepening of the central cornea is
required for hyperopic treatments. This leads to the creation of a corneal contour with a
steeper central area and a flatter paracentral area.
173
174 Ambrosio and Wilson

Refractive regression is defined as a gradual, partial, or total loss of the initial


correction. It limits the predictability of all refractive surgery procedures performed on
the cornea. It has been hypothesized that changes occurring as a result of corneal wound
healing lead to addition of new tissue. Epithelial hyperplasia and stromal remodeling are
the two mechanisms that are thought to underlie this phenomenon (3,11,12).

1. Keratocytes Disappear in Response to Epithelial


InjuryKeratocyte Apoptosis

One of the earliest observations that debunked the prior dogma regarding the quiescence
of keratocytes was detection of disappearance of superficial keratocytes following corneal
epithelial scrape injury. This observation was made first by Dohlman and coworkers in
1968 (16). Studies by later investigators confirmed that keratocytes in the anterior stroma
disappear following corneal epithelial scrape injury (1720) as well as thermokeratoplasty
(21). The mechanism of disappearance of the keratocytes was not elucidated in these
studies. The authors of these studies suggested that the disappearance of the keratocytes
was attributable to several factors, such as osmotic changes from the loss of epithelium,
exposure to the atmosphere, or even artifact.
In 1996, Wilson and coworkers (20) first demonstrated that the early disappearance
of keratocytes that follows epithelial injury is mediated by apoptosis (1315,2229). Cell
shrinkage, blebbing with formation of membrane bound bodies, condensation, fragmenta-
tion of the chromatin, and DNA fragmentation consistent with apoptosis were detected
in anterior stromal keratocytes after epithelial scrape wounds by transmission electron
microscopy. Nuclear DNA fragmentation was confirmed by the TUNEL assay for 3-
hydroxyl DNA ends.
Apoptosis is a programmed form of cell death that occurs without the release of
lysosomal enzymes or other intracellular components that could damage the surrounding
tissue or cells. Uncontrolled release of cellular contents is characteristic of necrotic cell
death (26). Studies have suggested that apoptosis is mediated by cytokines released from
the injured epithelium, such as interleukin 1 (IL-1) (22), the Fas/Fas ligand system (27),
bone morphogenic proteins (BMP) 2 and 4 (28), or tumor necrosis factor (TNF) alpha
(29).
Virtually any type of epithelial injury induces keratocyte apoptosis. These include
mechanical scrapes (2225), corneal surgical procedures like PRK and LASIK (24), herpes
simplex keratitis (14), incisions (25), and even a plastic ring pressed firmly against the
epithelial surface (24).
Keratocytes undergo apoptosis after epithelial injury to a depth of one-third to one-
half the stromal thickness, depending on the species and the type of injury. Cellular pro-
cesses, known as gap junctions, connect keratocytes in the unwounded cornea to form a
syncytium (31,32). It is possible that signals transmitted by cytokines to the most superficial
keratocytes are relayed to deeper keratocytes via these intercellular communication chan-
nels. Alternatively, the proapoptotic cytokines may penetrate into the stroma after injury.
The keratocyte apoptosis response in the stroma varies with the type of corneal
epithelial injury (25). Thus, injuries such as scraping of the epithelium (25) or viral infec-
tion of the epithelium (14) triggers keratocyte apoptosis in the superficial stroma. A lamel-
lar cut across the cornea produced by a microkeratome also induces keratocyte apoptosis.
This can be detected at the site of epithelial injury and along the lamellar interface (Figure
Wound Healing After Corneal Surgery 175

Figure 1 (A) Apoptosis detected along the lamellar interface by TUNEL assay in rabbit eye that
had LASIK and (B) on the surface in rabbit eye that had PRK.

1). Localization of keratocyte apoptosis in LASIK is thought to be attributable to tracking


of epithelial material, including proapoptotic cytokines, into the interface by the microkera-
tome blade (2225). Alternatively, cytokines from the injured peripheral epithelium could
diffuse along the lamellar interface and into the central stroma (2225).
Apoptosis has also been correlated with severe complications. Meitz et al. (33)
reported a severe case of acute corneal necrosis following PRK for hyperopia that required
penetrating keratoplasty. Histopathological studies of the excised tissue were negative for
micro-organisms. Utilizing light microscopy, an anterior zone of corneal necrosis was
found to be present, with a moderate amount of acute inflammation at the interface between
necrotic and viable corneal stroma; in addition, keratocytes with typical features of
apoptosis were detected by TUNEL assay and electron microscopy (Figure 2).

2. Keratocyte Proliferation and Migration: Myofibroblasts

After the loss of keratocytes caused by apoptosis within the first few hours of corneal
epithelial injury, there will be an area of stroma devoid of keratocytes. Zieske and cowork-
ers (34) demonstrated that remaining keratocytes in the posterior and peripheral cornea
begin to undergo mitosis about 12 to 24 hours after the injury (34). Keratocyte mitosis
can be detected using bromodeoxyuridine incorporation or immunocytochemical staining
for a mitosis-specific antigen called Ki-67 (34).
176 Ambrosio and Wilson

Figure 2 Transmission electron microscopy (TEM) of rabbit cornea, 24 hours after Hi PRK
(9.0D): Keratocyte apoptosis and a PMN.

The cell types derived from the keratocytes that undergo mitosis following corneal
epithelial injury remain to be completely characterized. Studies have suggested that myofi-
broblasts are an important cell type generated following injury (3841). These studies,
however, are primarily in vitro tissue culture-based investigations. Little information is
available regarding the fate of the cells that undergo mitosis following PRK (41). Nothing
has been reported about the status of these cells following LASIK.

3. Resolution of The Wound-Healing ResponseReturn to


Normalcy
In the months following injury to the cornea, the wound-healing response is completed
and there is a return to normal morphology and function. This process is associated with
elimination of some of the cells associated with wound healing and remodeling of disor-
dered collagen that was produced by myofibroblasts or keratocytes during the wound-
healing process (5455). This process begins within a few weeks after injury and can
continue for years following severe injury.
The corneal epithelium may undergo hyperplasia following corneal injury (1,56)
as well as refractive surgery (11,12,21,5759) as a part of the wound-healing response.
Hyperplasia may vary between individuals, the eyes of a single individual, and with differ-
ent types and levels of refractive correction. This is thought to be an important mechanism
for regression of many keratorefractive procedures (1,12,5659). There may be a return
to a normal epithelial thickness over a period of months to years, and this may result in
instability of the refractive effect of PRK or LASIK. The regulatory mechanisms that
modulate this return to normal corneal epithelial morphology have not been characterized.

B. CONSIDERATIONS ON HYPEROPIC CORRECTIONS: WHY ARE


THEY DIFFERENT FROM MYOPIC CORRECTIONS?
The surgical correction of hyperopia remains challenging, especially for corrections greater
than 4 to 5 D. While corneal surgery for myopia requires flattening the cornea with an
Wound Healing After Corneal Surgery 177

Table 1 Classification of Hyperopic Refractive Surgery


1. Excimer laser procedures
2. Collagen shrinkage procedures
3. Corneal implants and inlays
4. Phakic intraocular lens (IOL)
5. Clear lens extraction with IOL (also piggyback; multifocal IOL)

appropriate effective optical zone, hyperopic treatments require steepening of the central
cornea. This leads to the creation of more complex compound curves, which are steeper
in the center and flatter in the paracentral area.
Currently, options for refractive surgery to treat hyperopic patients can be separated
into five categories (Table 1). The present chapter discusses only the first two options.
The excimer laser allows reshaping of the corneal surface to a desired contour
with submicron precision and reproducibility (65). Several issues must be considered
in differentiating hyperopic and myopic corrections using the excimer laser. In myopic
corrections, the laser is applied in the center of the cornea. Hyperopic treatment with the
excimer laser consists of an annular zone of ablation to cause a relative flattening of the
corneal periphery and a concomitant relative steepening of the center (optical zone) to
achieve the desired refractive effect. Hyperopic corrections require more complex laser
delivery systems (66). Since the treatment is typically longer and performed in the periph-
ery, careful alignment of the laser beam is critical in order to prevent decentration. Thus,
a greater chance of decentration may be noted. Optical zone and ablation zone sizes are
fundamental to the efficacy of these procedures. A blend transitional zone must be created
to avoid abrupt steps on the corneal surface, which would be likely to lead to regression
via epithelial hyperplasia (67). The maximum ablation depth will be in an annulus between
the optical zone and the outer diameter of the ablation zone. Larger outer zones may
provide for less regression of the refractive effect (68,69) (Figure 3). However, Aron-
Rosa and Febbraro noted that when using an ablation zone of 5.5 8.25 mm with LASIK,

Figure 3 Diagram showing epithelial hyperplasia after hyperopic cornea surgery.


178 Ambrosio and Wilson

there was better predictability and stability than with an ablation zone of 5.5 9.0 mm
(70). One possible explanation for this observation is that the corneal flap size may have
been smaller than the periphery of the hyperopic treatment. In such settings, a smaller
ablation zone may be preferable.
Excimer laser surgery for hyperopia may induce more astigmatism than for myopia.
Significant change in the astigmatism power and axis was noted 3 months following
hyperopic spherical LASIK in a two-step approach for treating hyperopic or mixed astig-
matism (71). This could be related to centration issues in the treatment of hyperopia relative
to myopia.
Attempts to shrink the peripheral corneal collagen with thermal energy (thermokera-
toplasty) were first reported by Lans over a century ago (72). Central steepening of the
cornea is achieved by thermal shrinkage of the midperipheral corneal tissue. The use of
different types of lasers and radiofrequency energy in the corneal stroma to shrink the
collagen lamellae is an active topic of study and is discussed elsewhere in this book.
Recent reports have shown that these procedures may be effective in correcting low hyper-
opia, although corrections were subject to regression (73). Age-dependent corneal factors
were shown to influence the effectiveness of thermal energy on stromal collagen and
regression (74). Stability following thermokeratoplasty may be related to the type of lesion
produced. A perfect thermal lesion, delivered at the perfect depth, with a perfect geometry,
and for the perfect length of time would cause a permanent change in the collagen fibers
in the cornea, so that regression would be less likely to occur. It remains to be seen whether
such a perfect thermal lesion that is permanent can be created or whether ever-vigilant
keratocytes will eventually detect these anomalies in the collagen fibers and repair them.
Corneal iron pigmentation lines or rings can be observed after hyperopic corneal
surgery (7578). Corneal iron deposition has been seen in the normal cornea with aging
(Hudson-Stahli line) and in pathological corneal conditions such as keratoconus (Fleischer
ring), pterygia (Stocker-Busacca line), and filtering blebs (Ferrys line). Stellate iron lines
were also described after radial keratotomy (79) and in cases of central island (80). The
most likely explanation for the formation of such lines is that the iron is derived from the
tear film and deposited in the corneal epithelium in those areas where there is tear pooling.
Since keratorefractive procedure for hyperopia sculpts the cornea to resemble a convex
lens, a furrow-like ring zone in the corneal periphery is produced. This can be observed
when looking at the corneal elevation map after H-LASIK. (Figure 4). Tear pooling occurs
and subsequently triggers iron deposition. It may also prolong the exposure time to tear
film cytokines (81,82) causing epithelial hyperplasia in this midtransition zone (junction
of the optical and ablated zones) (11).

C. MECHANISMS OS REGRESSION
A complete understanding of the mechanisms underlying regression after keratorefractive
surgery in vivo require the study of the wound-healing response and factors related to
biomechanics. A thorough understanding of corneal microstructure can now be obtained
using new methods. High-frequency (50-MHz) ultrasound biomicroscopy (UBM and
VHF) (8386) (Figure 5) and optical coherence tomography (OCT) (8789) are two
promising technologies that have the capacity to measure the thickness of each layer within
the cornea. These measurements could help us to distinguish between epithelial hyperplasia
and stromal remodeling as the cause of the refractive regression in individual eyes. Confo-
cal microscopy allows for optical sectioning through intact living cornea, obtaining images
Wound Healing After Corneal Surgery 179

Figure 4 Elevation map before and after hyperopic LASIK.

of the cornea at its cellular level in four dimensions (x, y, z, and t-time) (3,10,90,91). It
has been difficult, however, to obtain reliable measurements of epithelial thickness using
this technology. Slit-based videokeratography instruments like the Orbscan (Bausch &
Lomb, Orbtek, Inc., Salt Lake City, UT) may be useful for assessing pachymetric values
through the entire cornea as well as for measuring posterior curvature (92,93). However,
uncertainty regarding the meaning of values derived from the posterior surface of the
cornea is a limiting factor. Studies have shown that corneal thickness measurements are
inaccurate with this instrument (94,95). At the present time, therefore, it appears that
high-frequency ultrasound or OCT provides the best opportunity for monitoring epithelial
thickness following refractive surgery procedures. Studies are in progress using these
methods.
Animal model studies have been performed to characterize corneal wound healing
following surgery for hyperopia (11,21,9699). It is important to recognize the possible
limitations of the rabbit model in assessing the nature of the wound-healing response in
humans. Wound healing is thought to be more vigorous in rabbits, and qualitative as well
as quantitative differences may exist. It is feasible to perform studies in patients who
180 Ambrosio and Wilson

Figure 5 Corneal image using ultrasound biomicroscopy.

undergo surgery for enucleation or exenteration, as well as before penetrating keratoplasty,


to clarify these potential differences between humans and animal models (21).
Our working hypothesis at the present time is that regression after LASIK or PRK
surgery for hyperopia is due to a combination of epithelial hyperplasia and stromal re-
growth in the ablation zone. Using confocal microscopy and histological examination in
a rabbit model, Hosoda at al. detected subepithelial proliferative changes in the ablated
zone that progressed for 1 month after surgery, then decreased by the third month (96).
In a similar study by Dierick et al. (11), mean stromal regrowth after 10-D hyperopic
PRK was 50% of ablated tissue. Deposition showed a lenticular pattern and could account
for up to 5.00 D of regression (11). In addition, the epithelium thickened 20% at the
midtransition zone (junction of the optical and ablated zones), contributing to more refrac-
tive regression (11).
A key question is whether the epithelial hyperplasia is attributable to an increased
wound healing response due to the size of the ablation zone, the altered surface topography
associated with steepening the central contour, or a combination of both these factors.
With smaller ablation zone diameters that have been tested in the past, rapid regression
may have been largely due to abrupt changes in corneal curvature in the midperiphery of
the ablation. With wider ablations that allow a more gradual transition than with smaller
ablation zones, there is less tendency for regression, suggesting that the influence of this
factor has been reduced. Differences in tear pooling and distribution on the corneal surface
between smaller and larger ablation zone diameters could play a role. Well-controlled
studies of varying ablations with careful measurements of epithelial hyperplasia and stro-
Wound Healing After Corneal Surgery 181

mal regrowth should help to increase our understanding of regression associated with the
laser correction of hyperopia.
Other sources of regression may be a greater than average wound-healing response
in individual patients or variations in surgery that promote increased healing. For example,
a thin flap may be associated with regression, since the stromal wound-healing response
and epithelium-modulating modulating growth factor production are more likely to be in
proximity to the epithelium (13). This is probably a major factor promoting epithelial
hyperplasia. Other factors such as epithelial defects produced by the microkeratome and
diffuse interface keratitis may also be associated with a stronger wound-healing response
and therefore regression. The rate of enhancement in a recent series was significantly
higher (53 versus 16%; p0.02) following DLK than for eyes that did not have DLK
(Wilson and Ambrosio, unpublished data, 2001). Since the treatment for hyperopia is
typically performed in the periphery of the cornea, closer to the limbus, it is likely that a
stronger inflammatory reaction will follow those surgeries. A study involving an animal
model comparing hyperopic and myopic PRK, using specific antibodies for inflammatory
cells as well as cytokines, might be helpful for elucidating this hypothesis.
The higher the level of correction attempted for hyperopia, the more likely regression
due to wound healing will occur. In our experience with hyperopic LASIK and PRK,
regression is most common in eyes where the attempted correction is over 4 to 5 D.
Intraocular pressure could be a factor in the regression of hyperopic LASIK in some
cases with high-pressure increases. A case of acute angle-closure glaucoma was reported
by Paciuc et al. 1 year after hyperopic LASIK (100). The glaucoma attack was treated
with laser peripheral iridotomy and a prophylactic iridotomy was performed in the fellow
eye. Corneal topography was performed 2, 5, and 18 weeks after the acute episode and
a myopic shift occurred in the eye that had angle closure. This resolved over 3 months.
It is important to consider that the eye blinks over 10,000 times per day (101) at lid
velocities up to 30 cm/s (102). Each blink has enough force to raise intraocular pressure
10 to 70 mmHg (103).
Koch and coworkers (21) studied Ho:YAG LTK on three human corneas 1 day
before their removal at penetrating keratoplasty in patients with corneal edema secondary
to Fuchs endothelial dystrophy (without bullous epithelial changes) and on six New
Zealand white rabbit corneas followed for up to 3 months. The pulse radiant energy level
was noted to be proportional to the acute tissue injury. In human corneas, changes in the
irradiated zones included epithelial cell injury and death, loss of fine filamentous structure
in Bowmans layer, disruption of stromal lamellae, and keratocyte injury and death. A
cone-shaped zone of increased stromal hematoxylin uptake extending posteriorly for 90%
of stromal thickness was noted in the treatment areas. Special immunohistochemical stains
to detect apoptosis were not used, although transmission electron microscopy findings
suggested that they might play a role. In the rabbit corneas, similar acute changes were
noted. By 3 weeks, epithelial hyperplasia and stromal contraction were present. Wound
healing in the rabbits included repair of the epithelial attachment complex, keratocyte
activation, synthesis of type I collagen, and partial restoration of stromal keratin sulfate
and type VI collagen. There was also a marked endothelial proliferative response in the
rabbit corneas. Attempted corrections with LTK of greater than 2 D are associated with
significant regression. This is likely related to stromal remodeling, with the keratocytes
functioning to repair the altered collagen over time.
182 Ambrosio and Wilson

D. FUTURE DIRECTIONS AND CONCLUSIONS


The ability to modulate corneal wound healing to achieve better clinical outcomes would
be beneficial to extend the efficacy and safety of keratorefractive corrections of hyperopia.
Apoptosis is the first detected event in the complex cascade of the corneal wound healing.
Differences in this initiator and subsequent events in healing between eyes likely is a
major determinant of variation between eyes following laser correction for hyperopia.
Development of methods to control this first event may be useful for normalizing the
response between patients.
A better understanding of the mechanisms associated with regression, especially
differentiating between the key determinants epithelial hyperplasia and stromal remodel-
ing, would provide specific strategies to improve stability.
Corneal implants and inlays may become an option for hyperopic treatment in the
future. New alloplastic materials with acceptable permeability for corneal tissue, with
refractive indices and clarity equal to those of the cornea, may provide a reversible refrac-
tive procedure for hyperopia. Intracorneal lenses with higher refractive indexes than the
cornea and therefore intrinsic refractive power would not rely on changing the corneas
shape. They could attenuate epithelial hyperplasia as a factor in regression.
Corneal surgery for hyperopia has lagged behind that of myopia primarily due to
issues related to efficacy, stability, and safety. Several procedures were abandoned during
the past decade. Understanding and respecting the limits of the available procedures is
key for achieving success with hyperopic patients. Intraocular procedures for hyperopia,
such as phakic intraocular lenses and clear lens extraction, may have an important role
in treating this group of patients if safety can be improved.

ACKNOWLEDGMENTS
Supported in part by an unrestricted grant from Research to Prevent Blindness, New York,
N.Y., and U.S. Public Health Service grant EY 10056 and EYO1730 from the National
Eye Institute, National Institutes of Health, Bethesda, Maryland.

PROPRIETARY INTEREST STATEMENT


The authors have no proprietary or financial interest in relation to this manuscript.

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18
Monovision Refractive Surgery for
Presbyopia

DIMITRI T. AZAR, MARGARET CHANG, CAROLYN E. KLOEK,


SAMIAH ZAFAR, KIMBERLY SIPPEL, and SANDEEP JAIN
Corneal and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary,
Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A

A. INTRODUCTION

Many refractive surgery patients are in the presbyopic or prepresbyopic age group and
often experience difficulties with near vision after their myopia is corrected. Preopera-
tively, many of these patients are able to read by taking off their glasses; postoperatively,
they may find they are no longer able to do so. Most patients choose to undergo refractive
surgery in order to decrease their dependence on spectacles and are therefore not happy
with the prospect of needing reading glasses (13). One means of addressing the problem
of presbyopia is monovision refractive surgery, in which one eye is surgically corrected
for distance vision and the other eye for near vision (17). The near vision eye may be
placed in focus at a reading distance (33 cm) or at an intermediate distance (for example,
at 50 cm for computer use). The monovision approach has been successfully applied to
laser-assisted in situ Keretomileusis (LASIK) and to presbyopic contact lens wearers.
Monovision can be used to circumvent the presbyopia problem in refractive surgery
patients. The procedure entails using photorefractive keratotomy (PRK) or LASIK to
correct one eye for distance and undercorrecting the other eye by 1 to 2 D. For those
refractive surgery patients able to adapt, monovision represents a means of markedly
decreasing dependence on spectacles for both near and distance work. However, not every
patient is a good candidate for monovision. The monovision option may be associated
with compromises of binocular visual function, and some people are not able or willing
to accept these compromises (3).
189
190 Azar et al.

B. THE IDEAL MONOVISION RESULT

Ideally, the monovision patient should be able to see clearly at all distances. The depth
of focus under binocular viewing conditions should be continuous and equal to the sum
of the monocular depths of focus (4). Inherent in the monovision concept is the fact that
at any given distance, the image in one eye will be blurred and the image in the other eye
in focus. Ideally, at any given distance, a patient should be able to suppress the blurred
image from one eye so that it does not interfere with the image from the other eye (known
as interocular blur suppression) (5).
Any compromises in binocular visual function (such as in visual acuity, contrast
sensitivity, or stereopsis) as a result of monovision should not interfere with the patients
ability to function comfortably at home, while driving, or at work. Monovision patients
may require spectacle correction in order to obtain optimal visual functioning for certain
tasks such as night driving or fine near vision tasks. Monovision is considered successful
in a given individual if it is satisfactory 85% of the time and spectacles over monovision
are needed only 15% of the time (3).

C. MONOVISION SUCCESS RATES AFTER CONTACT LENSES

Many published reports address monovision success rates in contact lens wearers. The
reported monovision success rates vary considerably and in large part because differing
definitions of monovision success are applied and study designs vary. Jain and associates
reviewed 19 articles that met their definition of monovision success, which was the ade-
quate adaptation to 1.00 to 2.00 D of monocular blur after 3 or more weeks of acclimatiza-
tion (2). In an attempt to predict success rates after refractive surgery, these authors in-
cluded only reports that studied contact lens patients above 40 years of age with
astigmatism of less than 1.00 D, no previous monovision experience, and no previous
contact lens intolerance. The mean monovision success rate was found to be 76%. When
failures related to contact lens intolerance were excluded, the success rate increased to
81%. The latter figure is important because of its applicability to monovision success rates
after refractive surgery (3).

D. MONOVISION REFRACTIVE SURGICAL OUTCOMES

We have evaluated a group of 97 patients over 45 years of age who satisfied the criteria
for strict monovision (n 60) and minimonovision (n 37) after LASIK surgery (Table
1). Best-corrected visual acuity (BCVA) before LASIK ranged from 20/15 to 20/30. The
average SE before LASIK was 3.71 2.73 D OD and 3.77 2.93 D OS. The
lasers used were both the VISX and the Summit (7).
After LASIK, the average SE for eyes corrected for distance was 0.12 0.29
D and 1.32 0.54 D for near vision. The mean anisometropia was 1.20 0.06 D.
BCVA after LASIK ranged from 20/15 to 20/30. The mean Snellen uncorrected visual
acuity (UCVA) after LASIK in the distance eye was 20/23 (range: 20/15 to 20/60); and
in the near eye, it was 20/53 (range: 20/20 to 20/400). Satisfied and dissatisfied patients
had similar distance and near UCVA. The average follow-up time was 6.1 4.7 months
(7).
Monovision Refractive Surgery for Presbyopia 191

Table 1 Monovision Subdivision Criteria


A. Based on near spherical equivalent (SE)
Strict monovision
Distance SE: 0.5 to 0.5 D
Near SE: 1.0 D to 3.75 D
Anisometropia 0.75 D
Minimonovision
Distance SE: 0.5 D to 0.5 D
Near SE: 0.5 D to 1.0 D
B. Based on ocular dominance
Uncrossed monovision
Dominant eye corrected for distance
Nondominant eye corrected for near
Crossed monovision
Nondominant eye corrected for distance
Dominant eye corrected for near
C. Based on near Spherical Equivalent and ocular dominance
Conventional monovision
Strict monovision
Uncrossed monovision
Crossed minimonovision
Minimonovision
Crossed monovision

E. SATISFACTION WITH MONOVISION AFTER REFRACTIVE


SURGERY
Of our 97 LASIK patients, 78 (80.4%) reported satisfaction with visual outcome after
LASIK; 19 (19.6%) were not satisfied; 37 (47.4%) of the satisfied patients were happy
with visual outcome, and 41 (52.6%) expressed no complaints. Of those who were not
satisfied with their outcome, 4 (21.1%) were unhappy with the quality of distance vision,
3 (15.8%) were unhappy with near vision, 2 (10.5%) were unhappy with both distance
and near vision, and 6 (31.6%) complained of imbalance. Four patients (21.1%) were
unhappy for reasons unrelated to monovision; three complained of dry-eye symptoms and
one of floaters. Satisfaction was unrelated to age, gender, dominance, myopia, type of
laser, and type of microkeratome (2 NS). Of the 78 satisfied patients, 29 (37.2%)
fulfilled criteria for minimonovision; of these, 10 (34.5%) had crossed monovision. Of
the 78 satisfied patients, 49 (62.8%) fulfilled criteria for strict monovision; 12 of the
49 (24.5%) had crossed monovision. There was no statistically significant difference in
satisfaction between strict and minimonovision groups or between uncrossed and crossed
monovision groups. The average anisometropia of the unsatisfied patients was 1.05 D and
of the satisfied patients 1.23 D; the difference was not significant. There was also no
statistically significant relationship between lines of BCVA lost after LASIK and satisfac-
tion with visual outcome.
Patients who were treated with strict monovision versus minimonovision were simi-
lar with regard to distribution of age, gender, dominance, myopia, type of laser used, and
type of microkeratome used. Minimonovision patients had an average anisometropia of
192 Azar et al.

0.68 D; strict monovision patients, 1.52 D (P .001). Twenty-nine (78.4%) minimonovi-


sion patients and 49 (81.7%) strict monovision patients were satisfied with visual outcome
after LASIK. The difference in satisfaction between the two groups was not statistically
significant. Only three patients in our entire study were monovision failures requiring
retreatment; all had strict monovision before retreatment. One was dissatisfied with dis-
tance vision, and two complained of imbalance.
Other studies have examined monovision success rates after refractive surgery. In
42 presbyopic myopic patients with monovision induced by refractive surgery, Jain and
associates found a monovision success rate of 88% (1). One case report examined an
aircraft pilot who underwent PRK with intentional undercorrection of the dominant eye.
Postoperatively, the patient noted no deleterious visual effects and was still able to pilot
an aircraft (8).
Wright and colleagues studied binocular function and patient satisfaction in 21 pres-
byopic myopic patients between the ages of 37 and 53 in whom monovision induced
by refractive surgery (9). Sixteen emmetropic patients served as a control group. In the
monovision group, 20 patients (95.2%) had binocular visual acuity of 20/25 or better. No
patient in the monovision group used reading glasses postoperatively, whereas 4 of 16
patients (25%) in the control group used such glasses. Stereoacuity was slightly lower in
the monovision group but not statistically significantly so. Patient satisfaction was very
high in the monovision group.
Anecdotal evidence indicates that refractive surgery patients are often able to read
better than their refractive error would suggest; for example, a 50-year-old myope corrected
to plano in one eye and 0.75 D in the other may still able read fine print. This phenome-
non has been attributed to the creation of a multifocal corneal topography after refractive
surgery (10,11). Therefore, a smaller degree of anisometropia may be required to obtain
adequate visual function for near and distance for refractive surgery monovision patients.
This would serve to preserve binocular visual function and increase monovision success
rates compared to monovision contact lens users.

F. PREOPERATIVE COUNSELING
All patients who opt for monovision should be informed of the adverse effect monovision
may have on some visual function parameters (2,3). Specifically, they need to be informed
of the risks of reduced binocular visual acuity, stereoacuity, and contrast sensitivity. In
addition, they need to be made aware of the risk of distance and near ghosting as a result
of incomplete blur suppression. Blur suppression appears to be particularly problematic
under night driving conditions because, as mentioned earlier, interocular blur suppression
becomes less effective under dim illumination conditions (2,3). Therefore, patients must
be advised of the need for distance glasses when driving. Liability is an important consider-
ation when selecting a refractive patient for monovision (3,12). Therefore, discussions of
the risks and benefits associated with monovision need to be carefully documented in a
patients chart.
It is important to ascertain the personal preference of the patient. Some patients
(particularly those who are active in sports) wish to have the most optimal distance vision
possible and are willing to tolerate difficulties with near vision and associated need for
reading glasses in order to achieve this. These patients should be fully corrected for distance
vision in both eyes. Other patients (particularly those who do a lot of reading or other
fine near work) may be willing to tolerate mildly decreased binocular distance vision in
Monovision Refractive Surgery for Presbyopia 193

order to be able to perform near tasks comfortably without glasses. These patients may
wish to be undercorrected in both eyes (3).

G. MONOVISION TRIAL
Although the best way to demonstrate the effects of monovision preoperatively is with a
monovision trial with contact lenses (13,14), this is often impractical. A monovision trial
can also be performed with spectacles. However, spectacles may induce magnification
and minimization effects and, therefore, a monovision trial is more accurately conducted
with contact lenses. If a patient has a refractive error of approximately 1.00 to 2.00
D, a monovision surgical trial can be performed (12). Instead of a bilateral procedure,
surgery is initially performed on only one eye, which is targeted for distance. If the patient
is unable to adapt to the monovision situation, the other eye is treated and targeted for
plano.
It is important to allow for at least a 3-week acclimatization period before concluding
whether or not monovision is appropriate for a given individual. If a patient experiences
difficulties with a monovision contact lens trial, two problems must be ruled out before
one declares that monovision has failed in that patient. First, accurate contact lens fitting
must be ascertained. Second, the clinician must ensure that all residual astigmatism has
been corrected by performing a spherocylindrical overrefraction. As mentioned previously,
even small amounts of uncorrected astigmatism can have a substantial negative effect on
binocular distance visual acuity (3).
A major benefit of a contact lens trial is that adjustments to the monovision arrange-
ment can be made before refractive surgery is performed. For example, switching the
distance and near eyes can serve to relieve undesirable visual symptoms (16). One common
complaint with monovision is blur at an intermediate distance. Slightly reducing the add
in the near eye can relieve this symptom, although this change may compromise near
vision. Plus power may also be added to the distance eye, although this change may reduce
distance vision. Even small (0.25-D) changes can make a large difference in creating an
acceptable monovision situation for a patient (3,17).
An unsuccessful contact lens trial does not necessarily mean that surgically induced
monovision will be unsucessful (17). A patient may respond to refractive surgery with a
gradual transition into monovision as a result of regression of the refractive result, in
contrast to a contact lens trial. For example, a patient may initially be 0.75 D in the
distance eye and 0.25 D in the near eye but, after several weeks, may have regressed
to plano in the distance eye and 1.00 D in the near eye. This gradual transition may
allow for an easier adaptation to monovision.

H. DETERMINING THE EYE FOR DISTANCE


Different approaches have been used for selecting the distance-vision eye. Among these
are (1) correcting the left eye for distance for increased driving safety (18); (2) using
handedness to determine which eye is corrected for distance, (i.e., matching the selected
eye to the patients handedness) (19); (3) designating as the near-vision eye the eye with
the closer near point of convergence; and (4) using the swinging-plus test to select the
near eye. In the latter test, the patient walks around the examination room with a 1.50
lens first over one eye, then over the other eye, and the eye that is most comfortable with
the plus lens then is designated as the near-vision eye (3,4).
194 Azar et al.

The most commonly used approach, however, is determining which eye is the domi-
nant eye and correcting that eye for the most commonly used viewing distance (11), which
is generally considered to be the far distance. The dominant eye has been shown to be
superior for spatial-locomotor tasks such as walking, running, or driving a car (2,20). Blur
suppression appears to be greater when the dominant eye is corrected for the most com-
monly used distance (i.e., far) (3). Correcting the dominant eye for distance also produces
less esophoric shifts (21).
The dominant eye is generally identified by use of sighting dominance tests (22).
One of the more common tests is the hole test (8), for which the patient is asked to frame
an object that lies at an intermediate distance from him or her with a triangle created by
his or her outstretched arms while keeping both eyes open. The eye that is in alignment
with the object and the hole is considered the dominant eye.

I. CROSSED MONOVISION
Crossed monovision occurs when the nondominant eye is corrected for distance and the
dominant eye for near. This can happen either accidentally or intentionally (1). Crossed
monovision may be the intended goal when, for example, a contact lens monovision trial
demonstrates better visual function if the nondominant eye is corrected for distance. A
patient may also change his or her mind regarding monovision versus full distance correc-
tion for both eyes after the nondominant eye has already been treated for distance and the
dominant eye has not yet been treated. Patients who wish to have only one eye treated
and who are markedly more myopic in the nondominant eye may elect to have the nondomi-
nant eye corrected for distance (1,3).
Unintentional crossed monovision can occur when correction in the dominant eye
is less than expected in patients requesting full distance correction for both eyes. Con-
versely, in patients desire equivalent undercorrection in both eyes, an overcorrection in
the nondominant eye can produce crossed monovision. Unintentional crossed monovision
is a result of the fact that refractive surgery is not a completely predictable procedure (1).

J. UNCROSSED MONOVISION VERSUS CROSSED MONOVISION


Of our 97 LASIK patients, 69 (71.1%) had uncrossed monovision, and 28 (28.9%) had
crossed monovision. The average age was 51.7 0.5 years for patients with uncrossed
monovision and 49.7 0.7 years for patients with crossed monovision (p0.04). The
two groups were similar with regard to distribution of gender, dominance, myopia, type
of laser used, and type of microkeratome used (2NS). The average anisometropia of
uncrossed monovision patients was 1.28 D, and of crossed monovision patients 0.98 D
(p0.03).
Of the 69 uncrossed monovision patients 56 (81.2%) were satisfied after LASIK,
as were 22 (78.6%) of the 28 crossed monovision patients. Two (33.3%) of the 6 patients
dissatisfied with crossed monovision and 2 (15.4%) of the 13 patients dissatisfied with
uncrossed monovision were unhappy for reasons unrelated to monovision, such as dry-
eye symptoms and floaters. One patient each (16.7%) complained of poor distance vision,
poor near vision, imbalance, and poor overall quality of vision in the crossed monovision
group. Of the 13 dissatisfied uncrossed monovision patients, 3 (23.1%) complained of
poor distance vision, 2 (15.4%) were unhappy with near vision, 5 (38.5%) felt imbalanced,
and 1 (7.7%) was unhappy with overall quality of vision.
Monovision Refractive Surgery for Presbyopia 195

Among minimonovision patients, 19 of the 24 (79.2%) patients with uncrossed


monovision were satisfied, as were 10 of the 13 (76.9%) with crossed monovision. Of
the monovision patients, 37 of the 45 (82.2%) patients with uncrossed monovision were
satisfied, as were 12 of the 15 (80.0%) crossed monovision patients. Of the 3 patients
who were monovision failures, 2 had crossed monovision. One patient with crossed monov-
ision was retreated to uncrossed monovision, while the other two patients did not have a
change in crossed monovision status. The patient with uncrossed monovision before and
after retreatment remained dissatisfied.

K. VISUAL PERFORMANCE IN MONOVISION


1. Monovision Failures
All 13 patients dissatisfied with monovision outcome were offered retreatment, but only
3 (23.1%) elected to undergo a second procedure. Most patients chose to defer retreatment
for one of three reasons (1) the patient was unwilling to sacrifice near and intermediate
vision for sharper distance vision, (2) symptoms were not bothersome enough to merit
risks of additional surgery, and (3) the patient was willing to give additional time to
adjust to monovision. Patients were then prescribed glasses for distance vision or reading,
depending on the complaint, or were to be re-evaluated for retreatment following some
period of adjustment. Many patients were then lost to follow-up. This suggests that the
degree of dissatisfaction was relatively mild and that many patients eventually adjust to
monovision or wear glasses on occasion for specific activities.
Overall patient satisfaction with monovision after LASIK was 80.4%, compared to
80.6% in contact lens wearers after exclusion of contact lens intolerance. Furthermore,
the satisfaction among strict monovision, minimonovision, uncrossed monovision, and
crossed monovision groups did not differ significantly from satisfaction in contact lens
wearers.
Due to the retrospective nature of most monovision refractive surgical studies, there
was no standardized instrument to measure patient satisfaction. Rather, patient dissatisfac-
tion was noted if the patient had any complaints or negative comments about vision at
the last follow-up visit. In addition, near vision was not documented in many charts and
could not be analyzed as an outcome. It was also difficult to determine from charts whether
monovision was intended or whether regression of one or both eyes led to a monovision
result. These factors may be better analyzed through a prospective study.

2. Interocular Blur Suppression


Two tests used to measure the ability to suppress interocular blur are the anisometropic
blur-suppression test and the American Optical vectographic test. The anisometropic blur-
suppression test indicates that the interocular suppression of blur is greater for smaller
degrees of anisometropia (2). Both testing modalities indicate that blur suppression is
greater when the dominant eye is corrected for distance.
Monovision success is dependent on interocular blur suppression. In successful wear-
ers of monovision lenses, the interocular suppression of blur was found to be approximately
two orders of magnitude greater than in unsuccessful wearers of monovision lenses (2).
Of note, interocular blur suppression becomes less effective under dim illumination condi-
tions (2), which accounts for the well-known poorer visual performance of monovision
patients under night driving circumstances.
196 Azar et al.

3. Binocular Visual Acuity


Jain and colleagues (1,2) reviewed six articles addressing the effect of monovision on
binocular visual acuity and found the effect to be mild. High-contrast and low-contrast
visual acuities at standard room illumination were found to be reduced by 0.04 to 0.08
logMAR unit and 0.04 to 0.09 logMAR unit, respectively. This reduction was slightly
higher (0.10 logMAR unit) under low illumination conditions. The effect on visual acuity
was particularly pronounced when the dominant, distance-corrected eye had a residual
astigmatic error at an oblique axis (23).

4. Stereoacuity
Reduced stereoacuity is considered to be the major disadvantage associated with monovi-
sion (24). Jain and coworkers reviewed twelve articles that examined the effect of monovi-
sion on stereoacuity (1,2). When near stereoacuity under monovision conditions was com-
pared to stereoacuity under binocular viewing conditions, a mean decrease of 37 arc
seconds (from 87 to 124 arc seconds) was found. The average normal value for stereopsis
is 20 arc seconds and, for persons over 40 years of age, 58 arc seconds (13,25). A more
recent paper by Kirschen and coworkers found that near stereoacuity decreased from a
median of 50 arc seconds with bifocal contact lenses to 200 arc seconds with monovision
(26).
Patients in whom monovision is successful exhibit a lower reduction in stereoacuity
than do unsuccessful monovision patients. Patients in whom monovision was unsuccessful
were found to have a 50 to 62 arc seconds greater reduction in stereoacuity as compared
to successful monovision patients (1).

5. Contrast Sensitivity
When two eyes are used instead of one, visual performance, and especially contrast sensi-
tivity, greatly improves (binocular summation). Contrast sensitivity increases by a factor
of 2 when the stimulus is viewed binocularly; therefore, binocular contrast sensitivity
is 42% greater than monocular contrast sensitivity. With increasing monocular defocus,
the binocular contrast sensitivity decreases steadily until it is actually worse than monocular
contrast sensitivity (binocular inhibition) (27). If the defocus is increased beyond 2.50
D the binocular contrast sensitivity reverts back to the monocular level, indicating suppres-
sion of the defocused eye. Because monovision results in loss of binocular summation,
or may even result in binocular inhibition, monovision results in a significant reduction
in contrast sensitivity, especially at higher spatial frequencies (greater than 4 cycles per
degree).

L. PERIPHERAL VISION AND VISUAL FIELDS


Monovision appears to have no significant effect on peripheral visual acuity and only a
minimal effect on binocular visual field width (14).

1. Binocular Depth of Focus


The binocular depth of focus is the range in which an image may move without noticeable
blur under binocular viewing conditions (without changing accommodation). In patients
in whom neither eye is clearly dominant (i.e., in whom there is no sighting preference),
Monovision Refractive Surgery for Presbyopia 197

the binocular depth of focus is approximately equal to the sum of the monocular depths
of focus. However, in patients with a strong sighting preference, the image becomes blurred
as the object moves from the monocular clear range of the dominant eye to the monocular
clear range of the nondominant eye. Therefore, in patients with a strong sighting preference,
the depth of focus under monovision conditions is considerably less than the sum of the
monocular depths of focus (3).

2. Phorias
Patients using monovision tend to exhibit a small-angle esophoric shift. At distance, this
manifests as an esophoria. At near, the effect is offset by the fact that presbyopes generally
exhibit a moderate to large exophoria at near. The magnitude of the esophoric shift is
believed to correlate with the degree of binocular stress created by monovision. The eso-
phoric shift at distance in successful monovision contact lens (0 to 0.6 prism diopters)
was found to be less than the shift in unsuccessful monovision wearers (2.1 to 2.2 prism
diopters) (7,28). Interestingly, the magnitude of esophoric shift is less when the dominant
eye is corrected for distance, thus lending support to the generally accepted custom of
correcting the dominant eye for distance (21).

3. Task Performance
Monovision appears to be associated with adverse effects on, in particular, stereoacuity
and contrast sensitivity in particular. The question is whether these effects have clinical
significance. The effect of monovision on the performance of various visually oriented
near tasks can be assessed by comparing an individuals performance of these tasks under
monovision conditions, under monocular viewing conditions (i.e., with one eye covered),
and under binocular viewing conditions (i.e., with full near correction for both eyes). Use
of this method revealed that monovision reduced performance of the tasks by 2 to 6%
when compared to performance of the tasks under binocular viewing conditions. However,
this reduction was quite minimal when compared with the 30% reduction seen under
monocular viewing conditions with near tasks requiring high stereopsis (29).

M. FACTORS INFLUENCING MONOVISION SUCCESS


On the basis of the above-mentioned findings, poor candidates for monovision are patients
who exhibit minimal interocular suppression of blur, patients with large esophoric shifts
with monovision, and patients with a significant reduction in stereoacuity with monovision.
Certain psychological and personality factors also appear to play a role in determining
the success of monovision (30).
An additional consideration is sighting preference. The inputs from the two eyes
are not identical in their relative influence on cortical cells: the dominant eye produces a
greater response to a given stimulus than does the input from the other eye. Those individu-
als who do not have a strong sighting preference (i.e., who have alternating dominance)
appear to have constant interocular blur suppression and therefore tend to be more success-
ful with monovision. Furthermore, the choice of eye that is corrected for distance, whether
the dominant or the nondominant eye, appears to have an effect on monovision success.
In 16 articles reviewed by Jain and coworkers, the average age of successful monovi-
sion users ranged from 48 to 55 years (1,2). No articles were found that compared the
success rate in younger versus older presbyopes. Two articles examined the difference
198 Azar et al.

between the average age of successful versus unsuccessful monovision patients but failed
to find any statistically significant difference in age between the two groups (5,31).

N. CONCLUSIONS
Monovision has been evaluated extensively in contact lens users, but few studies comment
on its success in refractive surgery. Furthermore, the impact of the magnitude of anisome-
tropia created in monovision patients has not been fully characterized. We have introduced
a new term, minimonovision, to characterize monovision patients with a lesser degree of
near vision correction than full monovision (7). The inclusion criteria for strict monovision
and minimonovision are mutually exclusive. We found that strict monovision and minimo-
novision groups had comparable satisfaction rates. We also found that crossed monovision
patients overall were as satisfied as uncrossed monovision patients, and that within the
minimonovision and monovision subgroups, crossed monovision did not affect satisfac-
tion. The rate of satisfaction for monovision after LASIK was similar to the rate in contact
lens wearers.
Monovision is associated with some compromises of visual function, the extent of
which depend on the particular individual and the requirements imposed by different
viewing conditions. However, for those refractive surgery patients willing and able to
adapt, these compromises constitute reasonable a trade-off for reducing dependence on
near-vision correction.
Refractive surgery may be used to take advantage of the monovision option in
presbyopic refractive surgery patients. However, this option should be pursued only after
careful preoperative screening and counseling of the patient. Creating a monovision situa-
tion with refractive surgery constitutes a practical alternative to other surgical treatment
modalities for presbyopia, such as scleral expansion/relaxation and multifocal corneal
treatment.

REFERENCES
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3. Sippel KC, Jain S, Azar DT. Monovision achieved with excimer laser refractive surgery. Int
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Am J Optom Physiol Opt 1988; 65:853861.
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6. Fonda G. Presbyopia corrected with single vision spectacles or corneal lenses in preference
to bifocal corneal lenses. Trans Ophthalmol Soc Aust 1966; 25:7880.
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monovision LASIK surgery in presbyopes. Arch Ophthalmol 2002. Submitted.
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19
Multifocal Corneal Approach to Treat
Presbyopia

JANIE HO
University of California at San Francisco, San Francisco, California, U.S.A.
DIMITRI T. AZAR
Corneal and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary,
Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

A. INTRODUCTION

Refractive surgery to correct presbyopia continues to be at an experimental stage despite


a decade of investigation. The dilemma in presbyopia is the need for differing refractive
powers of the optical media for near versus distance vision. In this chapter, we review
several studies using a multifocal corneal approach to treating presbyopia. The techniques
and results of the studies are presented, as well as a discussion of comparative conclusions
and areas in need of further investigation.

B. HISTORICAL/EXPERIMENTAL

For several decades, refractive surgery has been successfully employed in treating patients
with myopia and, later, hyperopia. Nevertheless, the presbyope continues to pose a chal-
lenge to refractive surgeons, owing to the need for differing optical powers for near and
distance vision. In the late 1980s, investigators observed a phenomenon wherein radial
keratotomy patients achieved excellent uncorrected visual acuity at near and distance;
however, this was inconsistent with the measured change in spherical equivalent (1,2).
Further topographical analysis demonstrated an unintended multifocal lens effect of the
201
202 Ho and Azar

cornea, enabling optimization of both near and distance vision through a range of optical
zones. These studies offered the theoretical basis for refractive surgery to treat presbyopia
using a multifocal corneal approach. The multifocal approach espouses the concept of
pseudoaccomodation, or the ability to process multiple simultaneous images at the retina
(3).
Anschutz performed studies with photorefractive keratectomy (PRK) on polymethyl
methacrylate (PMMA) lenses and porcine eyes to intentionally create multifocal corneal
surfaces. A sectoral near zone as part of a concentric zone for distance was favored. He
subsequently applied the models in clinical trials testing the effectiveness of PRK in
treating myopia-presbyopia and hyperopia-presbyopia, described below (4). In addition,
Moreira et al. investigated several modalities for achieving a multifocal surface (5). Four
configurations of ablation were compared: monofocal ablation, two concentric ablations,
two ablations with the smaller diameter ablation decentered inferiorly, and a single progres-
sive ablation. The group concluded that a corneal surface with multiple refractive powers
could be achieved in PMMA hemispheres and blocks, as well as, in rabbit corneas. They
believed that the single progressive ablation would be the most effective, created with an
iris diaphragm initially fully open to 6 mm and progressively closing until 3 mm, leaving a
central zone with the preoperative refractive power (5). This technique would theoretically
function in concert with pupillary miosis during near accommodation to decrease the
percentage of light rays traversing the flattened zone of the cornea. Thus, degradation of
the retinal image as a result of the multifocal lens effect may be reduced.

C. TECHNIQUES

In March 1999, Anschutz began human clinical trials of multifocal PRK to treat myopia-
presbyopia. A 193-nm Aesculap-Meditec laser was used with an iris diaphragm to bifocally
sculpt the cornea (4). The investigation involved two techniques for creating zones for
near and distance vision: (1) an inferior pie-shaped sectoral near zone within a concentric
distance zone and (2) a central near zone within a concentric distance zone. Both techniques
involved an initial circular ablation of 2 or 3 D less than the myopic baseline refraction.
For technique 1, this was followed by a second ablation to the full myopic correction
using a sectoral template. Technique 2 used a central nonrotating template in a similar
fashion. Figure 1 demonstrates the two techniques.
In treating hyperopia-myopia, Anschutz investigated the technique of an inferior
sectoral steepening of the cornea, to create active myopization for near vision (4). For the
initial hyperopic PRK ablation, a spiral eye mask (or double-heart mask) was used along
with a rotating spiral template to correct for the complete hyperopic refraction. Next, a
nonrotating presbyopic template with an oval aperture was inserted for the second ablation,
to create an inferior sectoral zone of an additional 2.0 to 3.0 D presbyopic correction (Fig.
2).
The hyperopia-myopia study also included a subgroup of emmetropic presbyopes.
Their ablations were performed with the hyperopic spiral mask and an oval template, to
create an inferior zone of steepening (3.0 D) within a transition zone of 0.5 D (4). The
configuration is similar to the inferior sectoral ablation for near vision shown in Figure
1.
Multifocal Corneal Ablations 203

Figure 1 Multifocal myopia-presbyopia PRK. Left, central near zone; right, sectoral near zone.
(Adapted from Ref. 4.)

In 1998, Vinciguerra et al. published their study involving zonal PRK for treating
presbyopia. The group used a 193-nm Aesculap-Meditec Mel 60 excimer laser with a
mask consisting of a mobile diaphragm formed by a blunt concave blade and a blunt
convex blade (6). An inferior semilunar region was ablated for a presbyopic correction
of 3.00 D. Within this region, the depth of cut was progressively reduced from the corneal
center to periphery as the blades of the diaphragm progressively closed upon each other.

Figure 2 Multifocal hyperopic-presbyopic PRK. (Adapted from Ref. 4.)


204 Ho and Azar

Figure 3 PRK for presbyopia; inferior semilunar zone of ablation. (Adapted from Ref. 6.)

Thus, the superior pole of the ablated area served as the optical zone for near vision.
Figure 3 shows the ablation zone.
Multifocal laser-assisted in situ keratomileusis (LASIK) has also been employed to
treat hyperopia-presbyopia. Bauerberg used a 193-nm Coherent/Schwind Keratom 2 exci-
mer laser with an 8.2-mm-diameter, 160-m-thickness corneal flap (7). Ablation depth
was calculated by adding 10% to the preoperative spherical equivalent. A centrally located
ablation was tested as well as an inferiorly decentered ablation (by 1 mm).

D. RESULTS
The myopia-presbyopia PRK study by Anschutz involved 46 eyes of 23 patients with
follow-up of 2 12 to 3 years (4). The preoperative refractions ranged from 2.0 to 12.0
D; patients were divided into three groups: group 1 (2.0 to 6.0 D), group 2 (6.25
to 10.0 D), and group 3 (10.25 to 15.0 D). The goal was a presbyopic correction
of 2.0 to 4.0 D. At 30 months, group 1 had a mean regression of 0.75 D, with an
uncorrected near visual acuity (VA) of 20/22, which was three lines better than for the
monofocally treated eyes. Group 2 had a mean regression of 1.5 D and an uncorrected
near VA of 20/25. Group 3 had a mean regression of 4.0 D, with uncorrected near VA
only 1 12 lines better than with monofocal ablation. Overall, greater regression occurred
with greater preoperative myopic refraction, and multifocal PRK results were identical to
those of monofocal PRK in patients with preoperative refraction greater than 6.0 D. In
terms of postoperative complications, the investigators found 2 cases of loss of best cor-
rected VA due to decentration; 1 case of wound-healing difficulties; and 2 cases of dimin-
ished near VA due to pupil sizes less than 2 mm. Glare and halo effects were also present
in patients for only the first 6 months postoperatively. In addition, 20% of patients experi-
enced ghost pictures and double contours for the initial 3 to 4 months postoperatively.
Frequent complaints of monocular diplopia occurred in patients who received a central
near zone ablation.
A total of 18 eyes with follow-up of 16 to 20 months were studied by Anschutz
for PRK treatment of hyperopia-presbyopia. At 18 months, patients with preoperative
refractions of 1.0 to 4.75 D showed a mean regression of 1.5 D and a mean near
Multifocal Corneal Ablations 205

VA of 20/30 (4). Mean regression was 3.5 D for patients with preoperative refractions
of 5.0 to 8.0 D, with a postoperative mean near VA of 20/50. The investigators found
a small loss of contrast sensitivity over 7 months. In addition, haze was greater in patients
with higher degrees of hyperopia. Some 30% of patients complained of ghost images and
10% complained of double contours; with all complaints resolved by 6 months postopera-
tively. Two cases of decentration occurred during the study. Last, the improvement in VA
occurred very slowly in the higher-diopter group secondary to a small optical zone (4
mm).
Four emmetropic eyes were also treated for presbyopia during the same study. Uncor-
rected near VA at 18 months follow-up was 20/30, with postoperative spherical equivalent
change of 0.25 to 0.75 D (4).
The Vinciguerra et al. study of PRK for presbyopia treated three patients with a
follow-up period of 24 months. A regression of 1.00 D occurred, followed by stabilization
of the presbyopic correction (6). The patients read Jaeger 3 at 35 cm without near correction
and were also able to read with their preoperative presbyopic correction using the 85%
of the pupillary area that was not treated by PRK. A mild haze was reported in the first
two postoperative months. Loss of contrast sensitivity only occurred with the 11% Regan
chart. Videokeratography of a treated eye is shown in Figure 4.

Figure 4 Videokeratography of eye treated with multifocal PRK for presbyopia. Upper left,
preoperative; upper right, 3 days postoperative; lower left, 1 month postoperative; lower right, 1
year postoperative. Immediate postoperative corneal steepening was almost 6.00 D. By 1 month,
the presbyopic correction was within 0.25 D of the planned 3.0-D correction, remaining stable at
1 year. At 1 year, there is also a slight nasal decentration of 0.63 mm. (From Ref. 6).
206

Table 1 Summary of Study Results


Number of Refractive error Follow-up Post-op Significant
Author patients (eyes) (pre-op) Technique time regression Post-op near VA complications
Anschutz (4) 26 (46) 1. 2.0 to 6.0 D PRK: concentric 3 years 1. 0.75 D 1. 20/22 Decentration, wound
2. 6.25 to 10.0 D distance zone with 2. 1.5 D 2. 20/25 healing, loss of near
3. 10.25 to 15.0 D central or inferior 3. 4.0 D 3. 11/2 lines better VA, transient glare,
sectoral near zone than monofocal halo, ghosting,
tmt monocular diplopia
Anschutz (4) 9 (18) 1. 1.0 to 4.75 D PRK: concentric 20 months 1. 1.5 D 1. 20/30 Loss of contrast
2. 5.0 to 8.0 D distance zone with 2. 3.5 D 2. 20/50 sensitivity, haze,
inferior semilunar decentration,
near zone transient ghosting,
decentration
Anschutz (4) 2 (4) 0 to 0.5 D PRK: inferior 19 months 0.25 to 20/30
sectoral near zone 0.75 D
Vinciguerra (6) 3 (3) 0.5 to 1.5 D PRK: inferior 24 months 1.0 D Jaeger 3 at 35 cm Loss of contrast
semilunar near sensitivity with 11%
zone Regan, transient
haze
Bauerberg (7) 8 (16) 2.0 to 6.0 D LASIK: 1. central 22 months 1. 20/40 or better, Induced astigmatism
near zone or Jaeger 02
2. inferior off-center 2. 20/30 or better,
near zone Jaeger 12
Ho and Azar
Multifocal Corneal Ablations 207

The Bauerberg LASIK study for hyperopia-presbyopia involved 16 eyes of 8 patients


(8 eyes with centered ablation and 8 eyes with off-center ablation) with maximum follow-
up of 22 months (7). Preoperative refractions ranged from 2.0 to 6.0 D. At 12 months,
the off-centered ablation eyes achieved uncorrected near VA of 20/30 or better with no
loss of Snellen lines. The centered ablation eyes had uncorrected near VA of 20/40 or
better with two eyes experiencing loss of 1 Snellen line. No glare was reported; however,
2 eyes had induced astigmatism. Subjectively, 6 patients preferred the eccentric inferior
ablation for near vision, while 2 noticed no difference.
A summary of results is presented in Table 1.

E. CONCLUSIONS
The multifocal corneal approach to treating presbyopia remains experimental, although
the technology and techniques of multifocal corneal sculpting have been well investigated.
The four studies reviewed had the drawback of low patient numbers; however, follow-up
time was considerably meaningful. A most important reason for studies of greater magni-
tude is the need to delineate the incidence of postoperative side effects such as glare,
halos, ghost images, and monocular diplopia. The reviewed studies reported that symptoms
such as halos, glare, and ghost images were present for a short period of time in the limited
patient groups. The presence of these symptoms was perhaps due to a temporary transition
period during which wound healing and adjustment to multifocal images occurred. Stability
of the presbyopic corrections and their relationship with the natural progression of presby-
opia should also be followed long-term.
Each of the studies revealed certain limitations for presbyopic multifocal refractive
surgery as well as benefits for particular techniques. For myopia-presbyopia, Anschutz
concluded that their inferior sectoral near zone is appropriate for patients with pupils
greater than 2 mm diameter (4). Additionally, for patients with pupils larger than 3 mm,
the central near zone may be advantageous in the case of dominant near vision, particularly
in the presence of high myopia (10.0 D). The investigators also concluded that current
multifocal hyperopia-presbyopia PRK is effective only for patients with a baseline refrac-
tion of less than 5.0 D due to the high degree of regression and the small optical zone
for those with refractions greater than 5.0 D (4). Anschutz cites a need for improvement
of the transition zone and aspherical reprofiling of the cornea in addition to simplifying
the technique to require only one template.
Vinciguerra et al. found that the zonal presbyopic correction was effective for pupils
up to 6 mm (6). Advantages of their technique include a pupillary center with intact
epithelium acting as a protective shield against decentration during photoablation and the
need for a very superficial (10 to 15 m) and small ablation zone. Because only 15% of
the light entering a 3 mm pupil traverses the treated zone, contrast sensitivity was not
significantly reduced. Nevertheless, Vinciguerra notes that the technique requires extreme
precision to avoid erroneously aligned ablation and suboptimal presbyopic correction. In
addition, for pupils greater than 6 mm, the technique may lead to an inadequate presbyopic
correction.
LASIK for presbyopia was shown to have stable postoperative results with minimal
recovery time and complications in a small study by Bauerberg (7). However, he notes
that longer follow-up is needed. He concluded that the preferred orientation of the presby-
opic ablation should be inferior off-center. It may be worth considering the implications
that an asymmetrical corneal contour has for flap orientation and healing. To our knowl-
208 Ho and Azar

edge, no studies have been undertaken to compare multifocal PRK and LASIK in the
treatment of presbyopia.
Last, pupillary size appears to play a significant role in the effectiveness of multifocal
refractive surgery, as shown by the aforementioned studies. Another aspect that may re-
quire investigation is the positioning of a individuals upper and lower lid margins with
respect to the treated zone during distance and near vision. Could a raised lower lid position
cover up a zone of inferior corneal steepening such that the presbyopic correction has no
benefit? Conversely, could the same positioning protect the patients vision from visual
distortion by covering up a rough transition zone?

REFERENCES
1. McDonnell PJ, Garbus J, Lopez PF. Topographical analysis and visual acuity after radial kerato-
tomy. Am J Ophthalmol 1988; 106:692695.
2. Maguire LJ, Bourne WM. A multifocal lens effect as a complication of radial keratotomy.
Refract Corneal Surg 1989; 6:394399.
3. Talamo J, Krueger R eds. The Excimer Manual. Boston: Little, Brown, 1997:106.
4. Anschutz T. Laser correction of hyperopia and presbyopia. Int Ophthalmol Clin 1994; 34(4):
107137.
5. Moreira H, Garbus JJ, Fasano A, Lee M, Clapham TN, McDonnell PJ. Multifocal corneal
topographic changes with excimer laser photorefractive keratectomy. Arch Ophthalmol 1992;
110(7):994999.
6. Vinciguerra P, Nizzola GM, Bailo G, Nizzola F, Ascari A, Epstein D. Excimer laser photorefrac-
tive keratectomy for presbyopia: 24-month follow-up in three eyes. J Refract Surg 1998; 14(1):
3137.
7. Bauerberg JM. Centered vs. inferior off-center ablation to correct hyperopia and presbyopia. J
Refract Surg 1999; 15(1):6669.
20
Scleral Relaxation to Treat Presbyopia

HIDEHARU FUKASAKU
Fukasaku Eye Centre, Yokohama, Japan

A. INTRODUCTION

Accommodation has until recently been explained by the Helmholtz hypothesis. This
hypothesis holds that passive anteroposterior thickening of the lens and relative curvature
changes in the anterior and posterior lens surfaces result from zonular relaxation with
ciliary muscle contraction (Fig. 1). Presbyopia is likewise described as the loss of accom-
modation due to decreasing elasticity of the lens fibers and capsule (1,2). Recent work
(3,4) suggests a very different model of accommodation. Morphological changes in the
lens with accommodative effort are seen as the result of active rather than passive interac-
tions. The three components of the ciliary bodythe longitudinal, radial and circular
fibersact in concert to increase tension in the equatorial zonules while decreasing tension
in the anterior and posterior zonules. The result is an active elongation of the lens diameter
with peripheral thinning and central thickening due to dynamic internal volume changes
(Fig. 2). The net result is increased plus refracting power of the eye.
The important difference between the Helmholtz model and the Schachar model is
that the latter suggests a more active interaction between the ciliary muscle and the lens/
zonule complex, positing an interaction in which active effort by the ciliary muscle leads
not only to passive relaxation of the lens/zonule complex but also a more complicated
active differential response of different zonular types resulting in morphological changes
in the lens.
If this recent model of accommodation is correct, then presbyopia may not be ex-
plained by simple sclerosis of the lens fibers and capsule as previously understood. Rather,
the decline in accommodative power of the eye may be due to the inability of the lens
equator to expand into the posterior chamber. Thornton (5) has described this as a crowd-
ing of the lens in the posterior chamber as the lens grows.
209
210 Fukasaku

Figure 1 Helmholtzs model of accommodation.

The lens is ectodermal in origin and grows throughout life, increasing in size in all
dimensions. The sclera, on the other hand, is mesodermal in origin and ceases growth in
and around puberty. There is a discontinuity in growth between the ectodermal lens and
mesodermal scleral shell that begins around puberty. The result is an increase in the
diameter of the lens and a gradual, progressive narrowing of the space between the lens

Figure 2 A new model of accommodation.


Scleral Relaxation to Treat Presbyopia 211

Figure 3 Lens crowding.

equator and the ciliary body/sclera or crowding of the lens in the posterior chamber (Fig.
3).
The strength of any muscle is dependent on the effective length of pull of that
muscle. Decreasing the distance between the equator of the lens and the ciliary body with
lens growth decreases the effective length of pull of the ciliary muscle. We visualize this
as a loss of ciliary muscle/zonular apparatus tone (Fig. 4). With the loss of ciliary
muscle/zonular apparatus tone, any given accommodative effort results in less pulling on
the equatorial zonules and less relaxation of the anterior/posterior zonules, which results
in less change in lens morphology and less accommodative response or presbyopia. Thus,
it is not truly mechanical crowding of the lens in the posterior chamber but a progressive
loss of ciliary muscle/zonular apparatus tone that causes presbyopia.
This very appealing model of accommodation/presbyopia suggests a possible surgi-
cal correction for presbyopia. If the space between the lens equator and the ciliary body
can be expanded, then the length of pull of the ciliary muscle/zonule apparatus should
increase and accommodative tone will be restored. Thornton (5) has suggested anterior
ciliary sclerotomy (ACS) as a method to safely and effectively expand the globe over the
ciliary body and uncrowd the lens (Fig. 5).

Figure 4 Accommodative tone.


212 Fukasaku

Figure 5 Anterior ciliary sclerotomy (ACS).

B. ANTERIOR CILIARY SCLEROTOMY: EVOLUTION OF A


PROCEDURE

As first described (6), ACS involved eight equally spaced radial incisions of the conjunctiva
and sclera overlying the ciliary body in each of the oblique quadrants. Our initial technique
(7) modified this to include limbal peritomies overlying the oblique quadrants. This
avoided excessive conjunctival bleeding and, more importantly, allowed accurate measure-
ment of the length and depth of the incision. Incisions through the conjunctiva are always
difficult to measure due to its elasticity and compressibility. In addition, we placed two
parallel or tandem incisions in each quadrant for a total of eight incisions.
We also introduced the use of ultrasonic biomicroscopy (UBM) to accurately mea-
sure the depth of the incision. As with radial keratotomy, an incision of insufficient depth
will probably be ineffective, and since one is incising sclera overlying the highly vascular
ciliary body and choroid, incisions of excessive depth might prove disastrous. UBM gives
us the first accurate method of measuring scleral thickness and is absolutely essential in
determining the setting for blade depth prior to incision of the sclera. Scleral/uveal border
with UBM. This allows easy measurement of scleral thickness. We have found scleral
thickness to be a consistent 670 m, with very little variation. However, due to the possibil-
ity of scleral ectasias or staphylomas overlying the ciliary body/choroid, we continue to
perform UBM scleral thickness measurements on all ACS cases.
Our objective was initially to obtain 95% scleral thickness incisions. Experience
with donor sclera indicated that using the Thornton Triple Edge diamond knife (Mastel-
KOI, T2241), the blade needed to be set at 600 m. We further determined that the
incision length would be 3.0 mm carried posteriorly, starting 1 mm posterior to the surgical
limbus to adequately include the sclera overlying the ciliary body and posterior chamber
without unnecessarily incising sclera overlying uvea and retina. UBM was used to deter-
mine the anteroposterior dimension of the ciliary body.
Initial results were encouraging but limited. After initial postoperative increases of
several diopters of accommodation, there was regression: within several months, only an
average of 0.8 D increase in accommodation was achieved (simple ACS) (Fig. 6). Distance
refraction remained stable and there were no postoperative complications such as infection
or uveitis. Although the results were limited, all the patients remained enthusiastic about
the improvement in their everyday near vision.
Scleral Relaxation to Treat Presbyopia 213

Figure 6 Accommodative amplitude.

To enhance the surgical effect and decrease regression, we increased the sclerotomy
depth to full thickness by a spreading dissection technique (Fig. 7). Following incision,
we carefully spread scleral tissue using specially designed Fukasaku ACS forceps (Katena)
down to the uveal plane. We termed this enhanced ACS. At first, we were quite concerned
about our ability to identify this surgical plane, since entry into the uvea would surely
cause hemorrhage. We found that in approaching the uveal plane, there is a distinct bluish
blush from the vascular uvea, which is easily recognizable. In addition, the subscleral space,
usually a potential space, opens easily to become an actual space. We have experienced no
hemorrhages in this spreading dissection.
The use of spreading dissection did enhance our results (Fig. 6). We now noted an
initial increase in accommodative amplitude of 2.2 D. However, Within several months

Figure 7 Enhanced ACS, technique.


214 Fukasaku

of surgery, the effect rapidly regressed to near preoperative levels. Obviously, as the
sclerotomy healed, any increase in globe diameter was lost.

C. ANTERIOR CILIARY SCLEROTOMY WITH IMPLANTATION OF


SCLERAL EXPANSION PLUGS (ACS-SEP)
The marked regression in effect due to wound contraction and loss of globe expansion
found with both simple and enhanced ACS suggested the addition of a material to keep
the incision open. The choice of silicone for the scleral expansion plug was dictated by
the need to use a stable, inert material that could be fashioned in the dimensions needed
and manipulated surgically. The silicone chosen came from scleral buckle material and
was shaped by hand in the operating room. The dimensions chosen, 2.5 mm length and
0.6 mm height, were determined by the estimated incision length of 3 mm and depth of 670
m. The width of 0.6 mm was calculated based on the desired circumferential expansion of
sclera. Given that the lens diameter change from age 20 to 90 years is 2.5 mm (6.5 to 9.0
mm lens diameter measured on post mortem specimens), there is an average increase of
0.036 mm per year in lens diameter. Hence, a 60-year-old will need to increase his or her
globe diameter by 0.72 mm over that of a 40-year-old. This equates to a circumferential
expansion of 2.45 mm.
Pi diameter or 2 3.41 0.36 2.45 mm
With four silicone plugs to be implanted, the width of each plug will have to be approxi-
mately 0.6 mm.
The silicone expansion plugs fashioned to the above dimensions were implanted in
the depth of the sclerotomy. They were then sutured in place through both sclera and plug
in a criss-cross fashion using 100 nylon (Fig. 8). Unlike the original simple ACS tech-
nique or our enhanced technique using spreading dissection, we used only single incisions
in each oblique quadrant, not tandem incisions.
The fact that there was rapid marked regression in the gained accommodative ampli-
tude following simple ACS and enhanced ACS only with spreading dissection is not

Figure 8 ACS with SEP, technique.


Scleral Relaxation to Treat Presbyopia 215

surprising. The effect depends on expansion of the scleral circumference overlying the
ciliary body. As the incisions heal, there is wound closure and a reduction in scleral
circumference back to near preoperative levels. The addition of silicone plugs in ACS-SEP
effectively blocked this wound closure and maintained the gained scleral circumferential
expansion and hence the gain in accommodative amplitude. The fact that the initial gain
in accommodative amplitude with ACS-SEP was actually slightly less than either our initial
ACS technique or our enhanced ACS technique using spreading dissection is probably due
the effect of the sutures holding the SEP in place tending to close the wound initially.
We are now careful not to place any unnecessary tension on these sutures. In addition,
we are now using 110 Merceline, which should induce less tension and last longer than
nylon.

D. ANTERIOR CILIARY SCLEROTOMY AND INTRAOCULAR


PRESSURE
We noted also that in addition to increasing the amplitude of accommodation, ACS-SEP
was also associated with a dramatic drop in intraocular pressure (IOP) (Fig. 9). Simple
ACS and ACS enhanced by spreading dissection, in contrast, caused only a minimal drop
in IOP that was lost fairly rapidly. The explanation probably lies in the depth and perma-
nence of the radial incisions. Simple ACS is a shallower incision. No attempt is made to
complete a full-thickness sclerotomy. ACS enhanced by spreading dissection, on the other
hand, ensures a full-thickness sclerotomy by use of the Fukasaku forceps to dissect down

Figure 9 Intraocular pressure.


216 Fukasaku

to the uveal plane. This exposes the subscleral space, which is normally an anatomical
potential space due to the differential embryological development of the scleral and uveal
coats. With dissection, it is possible to create a limited, localized ciliochoroidal detachment
that increases the uveoscleral outflow of aqueous. Traumatic cyclodialysis and surgical
ciliochoroidal detachments are known to dramatically increase uveoscleral outflow and
can cause hypotony (7,8). There is no evidence of wound leakage per se, as there is no
filtering bleb or Seidels sign when fluorescein is applied to the conjunctiva overlying the
wound.
The loss of IOP-lowering effect with ACS enhanced by scleral spreading over a
matter of several months probably reflects closure of the incision and hence closure of
the ciliochoroidal detachment with a decrease in uveoscleral outflow. ACS-SEP, on the
other hand, shows negligible loss in IOP-lowering effect over many months. This probably
represents continued maintenance of the incision separation with the silicone plug and
continued ciliochoroidal detachment with ongoing increased uveoscleral outflow.
We have been very satisfied with ACS-SEP and its ability to provide a stable increase
in accommodative amplitude. Patients likewise have been extremely pleased with the
results. They report that they are now able to attend to the activities of daily living much
better, such as reading newspapers and product labels. This despite the modest measured
increase in accommodative amplitude of only 1.5 D. We expect that patient satisfaction
will increase further with correction of the fellow eye.

E. FUTURE DIRECTIONS
Future planned improvements include replacing the criss-cross 100 nylon suture with a
110 Merceline horizontal mattress suture. We expect that we will be better able to lover
the profile of the suture knot to avoid potential conjunctival irritation or erosion and
achieve longer suture life. We have also redesigned the expansion plug to be broader at
the base (more trapezoidal on end view) to limit forces that might extrude the plug. We
are also creating preformed holes in the plug to avoid the time-consuming and difficult
task of driving the small cutting needle of 100 or 110 suture.
The dramatic and sustained drop in IOP with ACS-SEP suggests a possible role for
this procedure in the treatment of glaucoma. The advantage of ACS-SEP in this role is
that it seems to affect uveoscleral outflow. Uveoscleral outflow can account for up to 40%
of total aqueous outflow (9,10). Thus, unlike beta blockers, which have little effect on
IOP during sleep, stimulation of uveoscleral outflow should help to protect the patient
both day and night. Thus far, IOP reduction has been a serendipitous finding in ACS-SEP
in which we implant expansion plugs in each of the four oblique quadrants. The next
logical step will be to attempt to titrate IOP reduction by varying the number of plugs or
perhaps the size of the plugs. Again, this study is under way at our facility.
We believe that ACS-SEP is a valuable procedure in the treatment of presbyopiaa
procedure that is safe, effective, and well accepted by patients. Likewise, ACS-SEP prom-
ises to become another treatment modality for glaucoma, and we are working on improving
its predictability.

REFERENCES
1. von Helmholtz HL. Physiological Optics. New York: Dover Press, 1962: 143172,375415.
2. Fincham EF. The mechanism of accommodation. Br J Ophthalmol 1937; 8(suppl):580.
Scleral Relaxation to Treat Presbyopia 217

3. Schachar RA. Histology of the ciliary muscle-zonular connection. Ann Ophthalmol 1996;
28(2):7079.
4. Neider MW, Crawford K, Kaufman PL. In vivo videography of the rhesus monkey accommoda-
tive apparatus. Arch Ophthalmol 1990; 69:108.
5. Thornton SP, Shear NA. Surgery for Hyperopia and Presbyopia. Baltimore: Williams & Wil-
kins, 1997:3336.
6. Fukasaku H. Surgical Reversal of Presbyopia. Highlights of the 98 ASCRS meeting. CD
ROM, Ophthalmology Interactive, 1998.
7. Pederson JE, Gaasterland DE, MacLellan HM. Experimental ciliochoroidal detachment. Effect
on intraocular pressure and aqueous humour flow. Arch Ophthalmol 1979; 97:536541.
8. Toris CB, Pederson JE. Effect of intraocular pressure on uveoscleral outflow following cyclodi-
alysis in the monkey eye. Invest Ophthalmol Vis Sci 1985; 26:17451749.
9. Brubaker RF. Flow of aqueous humor in humans. Invest Ophthmol Vis Sci 1991; 32:
31453166.
10. Reiss GR, Lee DA, Topper J, Brubaker RF. Aqueous humor flow during sleep. Invest Ophthal-
mol Vis Sci 1984; 25:776778.
21
The Scleral Expansion Procedure

CHRIS B. PHILLIPS and RICHARD W. YEE


Hermann Eye Center and University of Texas Health Science Center at Houston
Medical School, Houston, Texas, U.S.A.

A. INTRODUCTION
Presbyopia, or age-related loss of accommodation, becomes noticeable between 40 and
45 years (1). It is one of the first signs of aging and results from the age-related decline
in the amplitude of accommodation. Some feel that presbyopia becomes apparent when
the near point is greater than 22 cm (2). Since the middle 1800s, Helmholtzs theory of
accommodation (3) and its modifications (48) have attributed accommodation to a de-
crease in zonular tension and presbyopia to lens sclerosis and/or ciliary muscle atrophy.
A recent theory proposed by Ronald Schachar (916), however, states that during accom-
modation the lens equatorial zonules are under increased rather than decreased tension,
as postulated by Helmholtz (Fig. 1). Furthermore, Schachar attributes presbyopia to a
continuous age-related increase in the equatorial diameter of the lens, with a subsequent
decrease in the effective working distance of the ciliary muscle. As a direct deduction
from his theory, Schachar proposed scleral expansion for the treatment of presbyopia (16).
The goal of this paper is to describe the technique of scleral expansion. The descriptions
of the theories of accommodation and presbyopia are presented in Chapter 4, on Schachars
theory of the mechanisms of accommodation.

2. Early Procedures for Scleral Expansion


The earliest attempts to expand the sclera in humans were made in the mid-1980s (16);
they consisted of simple radial incisions in the sclera, similar to radial keratotomy (RK)

The authors were supported in part by NEI core grant EY10608 and an unrestricted grant from Research to
Prevent Blindness.

219
220 Phillips and Yee

A B

C
Figure 1 (A) The human lens when not accommodating. (B) Accommodation according to Helm-
holtzs theory. (C) Accommodation according to Schachars theory.

of the cornea. This technique, however, was primarily applicable to young presbyopes,
as the average increase in the amplitude of accommodation was only about 1.50 D (16).
Additionally, as the incisions healed, the effect regressed.
The first scleral expansion procedures using an encircling band were performed in
1992 (16). In these procedures, a plastic polymethylmethacrylate (PMMA) band (Fig. 2)
was sutured to the sclera and covered with conjunctiva. The results were dramatic; how-
ever, the procedure was plagued with variable results, conjunctival erosion, and increased
intraocular pressure. Various modifications were attempted to circumvent these problems.
One such method involved passing portions of the bands through the sclera, forming scleral
belt loops (17). This method did not include the use of scleral sutures in an effort to
The Scleral Expansion Procedure 221

Figure 2 A complete encircling band.

simplify the surgical technique, reduce the complications, and decrease the variability of
the results.
In 1997 we reported six consecutive nonmyopic patients who underwent scleral
expansion using a complete encircling band (17). The band was passed through four
separate scleral belt loops located at the 12, 3, 6, and 9 oclock cardinal positions (Fig.
3) (17). The bands were then ultrasonically fused together at the 1:30, 4:30, 7:30, and
10:30 oclock positions (Fig. 4). All six patients demonstrated a marked improvement in
near vision (Table 1). Surprisingly, in our study, there was a lesser but definite increase
in the amplitude and near point of accommodation in the unoperated eyes of all patients.
The mechanism of this finding is not clear but was postulated to be related to an increased
central neurostimulation of the ciliary muscle of the unoperated eye as a result of the
increased function of the ciliary muscle of the operated eye.

Figure 3 Passage of a scleral expansion band into a scleral belt loop.


222

Table 1 Summary of Primary Outcome Variables at Each Follow-up Period (Mean SD)
Operated eye Nonoperated eye

Variable Preop (n6) 1 month (n6) 3 months (n6) 6 months (n3) Preop (n6) 1 month (n6) 3 months (n6) 6 months (n3)
a a a
NPA (cm) 691.67 20.835.19 20.836.31 24.675.69 691.26 40.1728.58 27.56.12 322.65a
SEb (diopters) 1.21.33 0.811.13 1.131.2 0.750.5 1.081.15 1.171.18 1.061.10 0.50.22
Cylinder 0.420.52 0.630.44 0.580.5 00 0.50.52 0.580.56 0.630.52 0.50.25
Distance VAc 0.330.5 0.110.16 0.140.19 0.060.1 0.330.5 0.110.22 0.120.24 0.030.06
20/43 20/26 20/28 20/23 20/43 20/26 20/26 20/21
Near VA 0.850.16 0.030.07a 0.060.07a 0.030.06a 0.850.16 0.470.45 0.120.21a 0.060.10a
20/142 20/21 20/23 20/21 20/142 20/59 20/26 20/23
Blur point 0.630.14 1.951.05 2.672.63 0.671.66 0.540.25 1.650.49a 1.540.37a 0.331.61
IOP 17.22.7 16.20.84 13.61.14 141.73 17.32.0 16.41.5 17.11.8 15.80.76
a
Significant difference between the preop and the follow-up measurements using paired t-test (p 0.05).
b
SEspherical equivalent.
c
Both distance and near vision are computed based on log10 scale. The numbers below these numbers indicate the equivalent snellen refraction.
Phillips and Yee
The Scleral Expansion Procedure 223

Figure 4 Ultrasonic fusion of portions of a scleral expansion band.

Unfortunately, five of the six patients required removal of their scleral expansion
bands 3 to 6 months later due to conjunctival erosion from the roughened areas where
the PMMA bands were ultrasonically welded together. After removal of the scleral expan-
sion bands, the accommodative amplitude of these five patients returned to preoperative
values.
An additional three consecutive patients subsequently underwent the same proce-
dure. In an effort to provide a better cosmetic result with more accommodation, the scleral
belt loops were made much deeper. These three patients subsequently developed anterior

Table 2 Scleral Expansion Patient Selection


Ideal surgical candidate Relative contraindications Contraindications

40 to 70 years old Severe keratoconjunctivitis Previous cataract extraction


sicca
No refractive error at distance Insulin-dependent diabetes or Scleromalacia
poorly controlled diabetes
Binocular vision Monocular patienta Previous trabeculectomy
Less than 1.00 of hyperopia Patients beyond 70 years of Coagulopathies
ageb
Patients with hyperopia Collagen vascular diseases
greater than 1.00c
a
Important because of the investigational status of scleral expansion.
b
These patients should be informed of the possibility of ciliary muscle atrophy and thus the possibility of a smaller
range of accommodation.
c
These patients should have surgical correction prior to scleral expansion, as they will use a significant amount of
their accommodative amplitude for distance vision, leaving less for near vision. Additionally, without prior
surgical correction of hyperopia, these patients are more likely to require bilateral procedures.
Source: Ref. 20.
224 Phillips and Yee

Figure 5 The scleral expansion procedure. The conjunctiva is opened at the limbus from 2:30
to 10:30 oclock and from 4:30 to 7:30 oclock with vertical relaxing incisions at 12:00 and 6:00
oclock. Scleral belt loops, 3.5 mm posterior to the posterior limbus, 4 mm long, 1.5 mm wide, and
300 to 400 m deep are made in each of the four oblique quadrants.

ischemic syndrome (AIS) and had their bands removed 24 to 96 h after surgery. Given
previous reports of treatment of AIS with hyperbaric oxygen (18,19), we opted to treat
these patients with hyperbaric oxygen. All patients responded well to hyperbaric oxygen
therapy and none lost vision as a result of the procedure. This was the first known occur-
rence of AIS as a result of scleral expansion. Despite the posterior insertions of the rectus
muscles, these deeper tunnels likely resulted in a significant reduction of blood flow
through the anterior ciliary arteries that perforate the sclera at the insertions of the rectus
muscles. In order to avoid compression of the anterior ciliary arteries and AIS, surgeons
began placing the scleral belt loops along the 45-degree meridians at 1:30, 4:30, 7:30, and
10:30 oclock.
Further modifications to the scleral expansion band followed. Unfortunately, con-
junctival erosion continued to be a problem. In 1998, however, a new prototype was
developed consisting of four individual PMMA segments that were not connected to each
other, resulting in decreased rates of conjunctival erosion, a simplified procedure, and a
significant decrease in instrumentation cost (120). To decrease the risk of AIS, these
segments were also placed in scleral belt loops along the 45-degree meridians, away from
the ciliary artery insertions (Fig. 5).
Not everyone, however, is a candidate for scleral expansion. See Table 2 for patient
selection.

C. CURRENT METHOD OF SCLERAL EXPANSION


1. Preop Medications
If the patient has no contraindications, it has been recommended that oral nonsteroidal
anti-inflammatory drugs (NSAIDs) be started 1 to 2 days preop. Nonsteroidals decrease
surgical pain and swelling and produce a smoother postoperative course. Additionally,
there is some thought that NSAIDs may help to preserve anterior segment circulation (70).
The Scleral Expansion Procedure 225

Figure 6 Marking the limbus with the quadrant marker.

Mark the 12 oclock position at the slit lamp. This is an important reference mark
to be used later for proper segment placement away from the area of ciliary arteries. If
this reference mark is not made, cyclotorsion of the eye can occur when the patient lies
down for the procedure. This will increase the risk of anterior ischemic syndrome from
malpositioned segments. After the patient is taken to the operating room, the 12 oclock
meridian is used to align the quadrant marker in order to mark the location of the scleral
expansion segments (Fig. 6.).

D. ANESTHESIA
A small amount of subconjunctival anesthesia is injected at the 12:00 and 6:00 oclock
meridians to elevate the conjunctiva and produce a surgical plane for dissection. Retrobul-
bar and peribulbar anesthesia is generally avoided because the pupil dilates and the eye
may become soft, making it more difficult to construct the scleral belt loops. Additionally,
a dilated pupil precludes evaluation of iris sphincter function, which is necessary to assess
anterior segment circulation.

E. CONJUNCTIVAL DISSECTION
A 4 to 5-mm vertical incision is placed perpendicular to the limbus at the 12 and 6 oclock
meridians. These incisions are extended circumferentially at the limbus approximately 1
mm past the oblique quadrant marks. The conjunctiva from 7:30 to 10:30 oclock and
from 2:30 to 4:30 oclock is left intact to avoid postoperative redness in the palpebral
opening. The flap is dissected approximately 5 mm posterior to the limbus, leaving no
Tenons capsule in the area where the scleral expansion segments will be placed. As little
cautery as possible should be used so as to preserve the structural integrity of the sclera.
226 Phillips and Yee

Figure 7 Limbus marker.

It is particularly important to avoid cauterizing the sclera between the area of the implant
bed and the limbus.

F. MARK THE SCLERAL BELT LOOPS


The limbus and the previous oblique quadrant marks are identified. Using a specially
designed marker (Fig. 7), the parallel entrance and exit ends of the scleral belt loop incisions
are marked so that the anterior aspect of the exit and entrance incisions of the scleral belt
loop will be 3.5 mm from the limbus (Fig. 8).

Figure 8 Marks (see arrows) are 3.5 mm posterior to the limbus.


The Scleral Expansion Procedure 227

A B
Figure 9 (A and B) The 300-m guarded diamond blade has a width of 1500 m and makes
an incision 300 m deep.

G. DISSECT THE SCLERAL BELT LOOPS


A specially designed scleral fixator is used to grasp the sclera. The scleral fixator should
be firmly inserted approximately 1.5 to 2 mm distal to the exit side of the future scleral
tunnel. Avoid setting the scleral fixator either too far forward or back to avoid significant
torque and tension when making the loop and inserting the segment.
A 300-m guarded square diamond blade (Fig. 9A and B) is used to make parallel
incisions at the previously marked locations (Fig. 10A and B). The incisions should be

Figure 10 (A and B) A calibrated marker is used to check the measurements and the diamond
blade is used to make the parallel incisions while stabilizing the eye with the scleral fixator.
228 Phillips and Yee

Figure 11 The 5-mm lamella diamond blade.

parallel to each other, not radial to the limbus. If the incisions are not parallel, the segment
may rotate within the incision losing most of its lift. Care should be taken to remove all
of Tenons capsule near the incision so as to avoid a shallow incision.
Without losing scleral fixation, a 5-mm-long 1.5-mm-wide lamella diamond blade
(Fig. 11) is placed in the incision located furthest from the scleral fixator. The diamond
blade is slowly advanced through the sclera toward the other incision near the scleral
fixator (Fig. 12). By observing the relative visibility of the lamella diamond blade through
the sclera, one controls the depth of the blade. The very tip of the diamond lamella blade
should not be visible as the blade is passed through the sclera. Only a slight elevation or
bulge of the sclera at the lateral edges of the blade should be seen. If the blade is easily

Figure 12 The lamella diamond blade being used to make a scleral belt loop.
The Scleral Expansion Procedure 229

Figure 13 The thickness of the scleral belt loops and the exit wound are checked with the 1.4-
mm-wide spatula.

seen through the sclera, then the loop is too shallow and the effect of the surgery will be
greatly reduced. In making the scleral belt loop, care should be taken not to retract and
advance the blade unnecessarily to avoid making blind pockets that will increase the
difficulty of passing the scleral expansion segment.
On nearing the exit incision with the diamond blade, the sclera is depressed with
the scleral fixator to help open the exit incision. It is usually necessary to aim the lamella
blade upward just before exiting to prevent a blind pocket under the exit incision. The
entire lamella diamond blade is 5 mm long. The front curve of the blade is 1 mm long.
Therefore, by seeing the complete front curve of the blade, the surgeon is assured that
the scleral belt loop is no longer than 4 mm.
In removing the lamella diamond blade, the surgeon must maintain fixation with
the scleral fixator and remove the lamella blade slowly and in a controlled manner. In
doing so, the surgeon avoids cutting the edges of the entrance incision, avoids perforating
the belt loop, and ensures that the blade is not passed into the suprachoroidal space. If
there is any doubt that the lamella blade is completely passed through the exit incision,
test the incision using a 1.4-mm-wide spatula (Fig. 13). It should be possible to readily
pass the spatula through the incision in the same direction that the scleral expansion
segment will be passed.

H. PLACE THE SCLERAL EXPANSION SEGMENTS


The four scleral expansion segments (Fig. 14A and B) come packaged in much the same
way as an intraocular lens (IOL). Prior to grasping the segments, place one or two drops
of sterile saline into the well holding the segments. This prevents loss of the segments
due to static electricity. Either a specifically designed scleral expansion segment holder
or the injector can be used to pass the segment through the scleral belt loop (Fig. 15).
Load the segment into the injector or segment holder curved side up. Without moving the
scleral fixator, the segment is passed into the scleral belt loop. In difficult cases it is
230 Phillips and Yee

Figure 14 (A and B) The dimensions of the segment.

sometimes necessary to pass the segment upside down and then rotate the segment into
place using the injector and heavy needle holder. Rotation of the segment will stretch the
belt loop, but a slightly stretched belt loop will produce a greater effect than a thin belt
loop. If it is still not possible to pass the segment, the segment may be getting caught in
a blind pocket. Reapply the scleral fixator at the opposite end of the tunnel and try passing
the segment in reverse by beginning at the exit side of the scleral belt loop.
If the patient suddenly moves or complains of eye pain, immediately stop advancing
the segment. This may indicate that the vitreous, subchoroidal space, or ciliary body has
been entered. This can be confirmed by the presence of vitreous or fluid containing black
pigment exiting one or both ends of the scleral belt loop. At this point, the segment should
be removed and the eye examined. If the surgeon feels it is safe, it may still be possible
to pass the segment upside down from the other direction.
If the scleral belt loop is torn or severed, remove the segment and close the sclera.
The operation may be completed after the sclera is healed in 2 or 3 months.

Figure 15 Placement of the segment.


The Scleral Expansion Procedure 231

I. CONJUNCTIVAL CLOSURE
Sutures are placed at the 12:00 and 6:00 oclock meridians by passing the suture through
the conjunctiva and back out through the sclera and burying the knot. The corners of the
conjunctival incision should be overlapped. Finally, administer 20% mannitol (1 g/kg)
intravenously over 30 min to avoid malignant glaucoma.

J. CHECK THE PUPILS THE NEXT POSTOPERATIVE DAY


The pupils should be checked for reactivity and pupil size. An irregular or dilated pupil
may suggest AIS or sector AIS. If a pupillary abnormality is noted, place one drop of
0.5% pilocarpine in each eye. Pupillary constriction provides evidence that adequate ante-
rior segment blood flow is present. The sine qua non for AIS is a dilated nonreactive pupil
or a nonreactive pupillary sector. Other signs of AIS are nausea, an intraocular pressure
(IOP) less than 10 mmHg, corneal edema and folds, and anterior chamber cell and flair
(Fig. 16). At this point some recommend that the segment or segments causing AIS be
immediately removed. Others recommend giving the patient an additional dose of intrave-
nous manitol and 2 to 4% pilocarpine every 5 min for a total of six times in addition to
oral or intravenous steroids and aspirin if not contraindicated (21). If the pupil does not
respond in 2 h, repeat the manitol and six doses of pilocarpine (21). If there is still no
response after another 2 h, the segments should be removed.
Artificial tears, topical antibiotics, and topical anti-inflammatory or nonsteroidal
agents should be administered postoperatively. It is recommended that topical antibiotics
and anti-inflammatory eye drops be used for 2 weeks. Any remaining sutures should be
removed after 10 to 14 days. Artificial tears should be used frequently and a bland ointment
administered at night for at least 3 months.
Some patients complain of a mild to severe brow ache beginning about 30 min after
surgery and lasting 2 to 6 h. It may be necessary to treat these patients with analgesics.

K. EYE EXERCISES
Following the procedure, it is important that patients perform accommodation eye exercises
for rehabilitation of the ciliary muscle (22). Patients are asked to exercise from near to

Figure 16 Characteristic photograph of a dilated pupil and corneal folds consistent with anterior
ischemic syndrome.
232 Phillips and Yee

far rather than far to near. Patients should hold an eye chart 4 in. (10 cm) from their eye
and look at the smallest line they can see. Patients are then asked to concentrate until they
can see any letter on the next smaller line. Next they should hold fixation on the letter
on the smaller line and slowly move it away from the eye until it is at full arms length.
The eye chart can then be brought slowly back toward the eye while continuously holding
fixation on the smaller line until the eye chart is back at 10 cm from the eye. Once they
can read all the letters on that smaller line, have them move to the next smaller line and
again move the eye chart to arms length while maintaining fixation on the smaller line,
and so on. Patients should repeat this exercise as frequently as possible, but for at least
10 repetitions, four times a day, each time trying to fixate on a smaller line beginning at
the close distance of 10 cm from the eye. It is much better to do frequent exercise sessions
throughout the day than one long session. Following the exercises, patients will notice
that they can read better. Patients will usually experience ciliary pain during the exercises
for the first 2 weeks after surgery. The patients can be told that this pain is a good sign
and that the exercise is strengthening their ciliary muscles. Patients should avoid the use
of a near vision optical aid during their daily reading tasks. Additionally, patients should
squint as little as possible during the eye exercise; if they initially have difficulty perform-
ing their daily reading tasks, encourage them to use a bright light or, only if absolutely
necessary, to squint in order to avoid the use of a near optical aid. As they continue the
eye exercise, the requirement to squint or use a bright light during their daily reading
tasks will decrease.

L. COMPLICATIONS

Only one case of AIS has been reported using the latest 5.5-mm scleral expansion segments
(23). This complication may have resulted from improper positioning of the segments
(23). One case of endophthalmitis has also been reported (23). This case was thought to
result from a break in sterile technique (23). Additionally, one case of scleral thinning
similar to that observed with scleral buckles has been reported and may have been a result
of scleral expansion (24). To date, no cases of malignant glaucoma have been reported
using the new scleral expansion segments. Theoretically, this is a possibility, as the seg-
ments may increase posterior pressure, blocking outflow and resulting in aqueous misdirec-
tion. Intravenous manitol is given to dehydrate the vitreous decreasing the likelihood of this
complication. Other minor complications include conjunctival hyperemia, subconjunctival
hemorrhage, transient ptosis, rotation or subluxation, of the scleral expansion segments,
photophobia due to tear film instability, conjunctival erosion, accommodative fatigue,
temporary keratoconjunctivitis, swollen or irregular conjunctiva, and astigmatism, which
may last for 2 to 3 months and but subsides with intense treatment with artificial tears.

M. CLINICAL RESULTS

Increases in accommodation after this technique have ranged from 1.00 to 10.00 D (13).
Two different studies (20) of 29 and 7 patients have reported an increased range of accom-
modation in all patients, with an average of 3.02 and 3.13 D respectively. Similar to our
findings, an increased range of near vision was also noted in the unoperated eye. This
increase approached 20 to 50% of the increase measured in the operated eye.
The Scleral Expansion Procedure 233

N. SCLERAL EXPANSION AND OTHER REFRACTIVE PROCEDURES


Scleral expansion has been successfully performed after LASIK, PRK, and RK. With
regard to LASIK, however, it is easier to perform LASIK before scleral expansion due
to difficulties that may be encountered while applying the suction ring. Scleral expansion
has been performed as early as 6 weeks post-LASIK. Obviously, PRK and laser epithelial
keratomileusis (LASEK) are good alternatives for patients who have had previous scleral
expansion procedures.

O. OTHER SCLERAL EXPANSION PROCEDURES


Several other methods have been used to expand the sclera. Some surgeons have made
simple scleral incisions with a diamond knife to expand the sclera. The scleral incisions
are limited to an accommodative range of only about 1.50 D, and, as the incisions heal,
the effect declines (R. Schachar, personal communication, 2001). In order to prevent the
incisions from healing, Fukasaku has inserted silicone plugs into the scleral incisions (24a).
The infrared laser has also been used to make deep scleral incisions (25). The average
correction is also limited to an accommodative range of about 1.50 D and will likely
regress with time (R. Schachar, personal communication, 2001). In contrast to the above,
Lin has described no regression after scleral expansion using infrared laser (J. Lin, personal
communication, 2001). A major concern with the infrared laser is that it can coagulate
blood vessels and lead to anterior segment ischemia. There have been two phthisical eyes
as a result of making scleral incisions with the infrared laser for the treatment of presbyopia
(R. Schachar, personal communication, 2001). Last, as a result of the deeper tissue ablation,
the potential for rupture after blunt trauma is also a concern.

P. SCLERAL EXPANSION AND GLAUCOMA


While chronic open-angle glaucoma is a genetic disease, predisposed patients may benefit
from scleral expansion due to anatomical modifications produced by the procedures in
the ciliary muscle and trabecular meshwork (26,27). International clinical trials evaluating
scleral expansion for the treatment of ocular hypertension and primary open-angle glau-
coma in Canada and Mexico have demonstrated excellent preliminary results (27,28). The
median decrease in IOP after scleral expansion was 7 mmHg, and the postoperative de-
crease in IOP appears to be equivalent to the IOP-lowering effect of the preop, physician-
prescribed topical glaucoma medications (27).

Q. SUMMARY
Scleral expansion is a new procedure designed to treat presbyopia surgically. While the
theory on which it is based continues to be a subject of intense debate, it must be noted
that patients report an improved ability to read at near after scleral expansion. Given the
immense impact of presbyopia, surgical reversal of presbyopia will likely continue to be
an area of significant interest. In addition, scleral expansion may offer a new modality
for the treatment and prevention of ocular hypertension and primary open-angle glaucoma.
If scleral expansion is found to effectively decrease IOP, the adverse reactions and systemic
side effects commonly observed with glaucoma medications could be avoided and potential
surgical filtering and shunt procedures could be delayed or eliminated.
234 Phillips and Yee

ACKNOWLEDGMENT
The authors would like to thank Presby Corp for their assistance in writing this chapter
and the illustrations they provided. Additionally, we would like to thank Dr. Adrian Glasser
and Dr. Ronald Schachar for their comments.

REFERENCES
1. Donders FC. On the Anomalies of Accommodation and Refraction of the Eye. London: The
New Sydenham Society, 1864:204214.
2. May CH, Perera CA. Manual of the Diseases of the Eye for Students and General Practitioners,
17th ed. Baltimore: William Wood and Company, 1941:365366.
3. von Helmholtz H. Uber die Akkommodation des Auges. Graefes Arch Klin Exp Ophthalmol
1855; 1:189.
4. Rohen JW. Scanning electron microscopic studies of the zonular apparatus in human and
monkey eyes. Invest Ophthalmol Vis Sci 1979; 18:133144.
5. Fisher RF. Presbyopia and the changes with age in the human crystalline lens. J Physiol (Br)
1973; 228:765779.
6. Coleman DJ. Unified model for accommodative mechanism. Am J Ophthalmol 1970; 69:
10631079.
7. Fincham EF. The mechanism of accommodation. Br J Ophthalmol 1937; 8(suppl):580.
8. Stuhlman O. An Introduction to Biophysics. New York: Wiley, 1948:106107.
9. Schachar RA. The mechanism of accommodation. Int Ophthalmol Clin 2001; 41:1732.
10. Schachar RA. Histology of the ciliary muscle-zonular connections. Ann Ophthalmol 1996;
28:7079.
11. Schachar RA, Tello C, Cudmore DP, Liebmann JM, Black TD, Ritch R. In vivo increase of
the human lens equator diameter during accommodation. Am J Physiol (Regul Integr Comp
Physiol 40) 1996; 271:R670R676.
12. Schachar RA, Anderson DA. The mechanism of ciliary muscle function. Ann Ophthalmol
1995; 27:126132.
13. Schachar RA, Black TD, Kash RL, Cudmore DP, Schanzlin DJ. The mechanism of accommo-
dation and presbyopia in the primate. Ann Ophthalmol 1995; 27:5867.
14. Schachar RA. Zonular function: a new hypothesis with clinical implications. Ann Ophthalmol
1994; 26:3638.
15. Schachar RA, Cudmore DP, Black TD. Experimental support for Schachars hypothesis of
accommodation. Ann Ophthalmol 1993; 25:404409.
16. Schachar RA. Cause and treatment of presbyopia with a method for increasing the amplitude
of accommodation. Ann Ophthalmol 1992; 24:445452.
17. Yang GS, Yee RW, Cross WD, Chuang AZ, Ruiz RS. Scleral expansion: a new surgical
technique to correct presbyopia. Invest Ophthalmol Vis Sci 1997; 38(suppl):S497.
18. De Smet MD, Carruthers J, Lepawsky M. Anterior segment ischemia treated with hyperbaric
oxygen. Can J Ophthalmol 1987; 22:381383.
19. Jampol LM. Oxygen therapy and intraocular oxygenation. Trans Am Ophthalmol Soc 1987;
85:407437.
20. Cross WD, Zdenek GW. Surgical reversal of presbyopia. In: Agarwal S et al, eds. Refractive
Surgery. New Delhi: Jaypee Brothers Medical Publishers, 2000:592608.
21. Cross WD. Scleral expansion band technique treats presbyopia. Ocul Surg News 2001; 19:
2834.
22. Ruelas V. Optometric postoperative care. In: Schachar RA, Roy FH, eds. Presbyopia: Cause
and Treatment. The Hague, The Netherlands: Kugler, 2000: 105107.
23. Zdenek G. Complications in surgical reversal of presbyopia can be avoided, managed. Ocul
Surg News 2001; 19:3944.
The Scleral Expansion Procedure 235

24. Singh G, Chalfin S. A complication of scleral expansion surgery for treatment of presbyopia.
Am J Ophthalmol 2000; 130:521523.
24a. Fukasaku H, Marron JA. Anterior ciliary sclerotomy with silicone expansion plug implantation:
effect on presbyopia and intraocular pressure. Int Ophthalmol Clin 2001; 41:133141.
25. Johannes L. Is the end of reading glasses in sight? The Wall Street Journal. March 28, 2001,
P B1.
26. Schachar RA. The scleral expansion band procedure: Therapy for ocular hypertension and
primary open angle glaucoma. Ann Ophthalmol 2000; 32:8789.
27. Rifkind AW, Yablonski ME, Shuster JJ. Effect of scleral expansion band (SEB) on ocular
hypertension Canada phase 1 study. Compr Ther 2001; 27:333340.
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band (SEB) procedure on ocular hypertension. Submitted.
22
Multifocal IOLs for Presbyopia

HIROKO BISSEN-MIYAJIMA
Tokyo Dental College, Suidobash Hospital, Tokyo, Japan

A. BACKGROUND
With recent advancements in refractive surgery, we can achieve sufficient results in the
treatment of myopia, hyperopia, and astigmatism. Patients are able to appreciate good
uncorrected visual acuity (VA), and their quality of life can also be improved. The next
interest goes to how we can treat presbyopia. Several methods have been introduced.
Implantation of multifocal intraocular lenses (IOLs) instead of original crystalline lenses
is familiar to the ophthalmic surgeon, since we are performing this technique for cataract
patients for many years. We could learn most results of multifocal IOLs from our cataract
patients.

1. Cataract Surgery as Refractive Surgery


When the IOL was introduced, both patients and the surgeons were impressed by the
resulting relatively good vision without spectacles or contact lenses. Recently, cataract
surgery has been accepted as refractive surgery, since we can correct preoperative myopia
or hyperopia at the time of surgery. Even clear lens extraction following IOL implantation
is accepted for the treatment of extreme myopia or hyperopia. An ideal IOL would be
one that would replace the original crystalline lens at younger age. We can correct not
only preoperative refractive error but also age-related presbyopia.

2. Impression of the Multifocal IOL


When the multifocal IOL was first introduced, we expected it to act like bifocal spectacles,
so that the patient would have clear vision at far and near. The results with first-generation
multifocal IOLs were somewhat disappointing, however, since the distance visual acuity
237
238 Bissen-Miyajima

was dependent on pupil size and sometimes inferior to that with monofocal IOLs. Another
concern is the loss of contrast sensitivity. Because of these unpleasant drawbacks, many
surgeons went back to implanting conventional monofocal IOLs. The results of recent
multifocal IOLs are more promising and the interest in this type of IOL has increased
again.

B. THEORETICAL BENEFITS AND CAVEATS


Before describing theoretical benefits and caveats, one should understand the different
designs of IOL.

1. Different Types of Multifocal IOLs


a. Refractive Type
The initial refractive type was two zones with a central 2-mm button for near, and this
IOL was called bulls eye (Fig. 1A). The center part had additional 4 D, which would
be equivalent to 2.5 D in spectacles. If the pupil size was too small, the patient had
insufficient visual acuity and this lens was abandoned. Then other types of refractive IOLs
were introduced (Fig. 1B and C). Some are far-dominant and others are near-dominant.
Recently, the zonal progressive type of AMO ARRAY (Fig. 1D) became a standard
multifocal IOL in several countries. The center part is for far vision and patients usually
get good distance visual acuity (VA).
b. Diffractive Type
Another type is the diffractive type, which is not affected by pupil size. This IOL has a
0.6-mm central zone and some 30 annular diffracting zones on its posterior surface (Fig.
1E). The light can be diffracted toward two foci; 41% for near and 41% for distance.
Thus, 18% of the light would be lost, and the loss of contrast sensitivity became the
biggest concern.

2. Theoretical Benefit
a. Less Dependence on Spectacles
Theoretical benefits of multifocal IOLs are based on their depth of focus. Figure 2 shows
the results of distance visual acuity with defocus of the patient from emmetropia following
AMO ARRAY. There are two spikes, which means that the patient can focus both far
and near. Another interesting thing about this particular IOL is that the valley between
two spikes is not deep and patients have a chance to see things at middle distance. Thus,
the potential of not depending on spectacles is high.

3. Theoretical Caveat
a. Decreased Contrast Sensitivity
The caveat of multifocal IOLs in general is the loss of contrast sensitivity due to their
design. By in a randomized study of multifocal IOLs, a significant decrease of visual
acuity was reported at 11% contrast with multifocal IOLs compared to the monofocal
IOLs (1). Although this problem can be detected by examination of contrast visual acuity,
most patients do not have the problem in daily life.
Multifocal IOLs for Presbyopia 239

Figure 1 (A) IOLAB two-zone refractive type with a central 2-mm button for near. (B) IOPTEX.
(C) Pharmacia. (D) AMO ARRAY. (E) Diffractive IOL (3M). This IOL has a 0.6-mm central zone
and some 30 annular diffracting zones on its back surface.
240 Bissen-Miyajima

Figure 2 Defocus curve. Two spikes for far and near can be observed.

b. Glare and Halo


Another caveat would be glare and halo, especially at night. When the pupil is dilated in
dim light, some patients recognize halo due to its annular design.
c. Incorrect Power
The correct biometry is very important for this particular IOL. Especially when clear lens
extraction is planned, this is critical. Patients expect better uncorrected vision at far and
near. Even with perfect surgery, the results can be miserable if the IOL power calculation
fails.

C. INDICATIONS/CONTRAINDICATIONS
Some indications and contraindications depend on the type of multifocal IOL. Recent
refractive-type IOLs are indicated for most patients if they are not included in exclusion
criteria (Table 1).

1. Cataract
In case of cataract surgery for a younger patient, this IOL can avoid the loss of accommoda-
tion, an undesirable complication. The results in this age group may represent the possibil-
ity of treating presbyopia.
Multifocal IOLs for Presbyopia 241

Table 1 Exclusion Criteria


Patient with multifocal IOL in the fellow eye
Uncontrolled glaucoma
Progressive diabetic retinopathy
Corneal lesions that may affect visual acuity
Other complications that may affect visual acuity
Preoperative astigmatism greater than 1.5 D
Frequent driving or operation of dangerous machinery at night

2. Expectation of the Patient


The patient who is highly motivated is often a good candidate. The increased number of
refractive surgeries has proved that many patients long for life without spectacles and
contact lenses. Younger patients underage 45 are also candidates, since the most undesira-
ble complication following cataract surgery at this age is the loss of accommodation.
Despite their perfect vision at far, they may suffer from the new experience of not being
able to read without spectacles.

3. Occupation
Individuals with occupations that require good far and near vision in which the use of
spectacles or contact lenses might be dangerous represent another good candidate group.

D. PREFERRED SURGICAL TECHNIQUES


The preferred surgical techniques should provide predictability of postoperative refraction
and stability of IOL position. For this purpose, small incision and continuous curvilinear
capsulorhexis (CCC) are recommended.

1. Incision
It is well known that surgically induced astigmatism has recently been diminished by the
use of small-incision cataract surgery. For this purpose, a foldable multifocal IOL is
preferable. Also, a self-sealing incision should be made so as to avoid suture-induced
astigmatisms.

2. IOL Position
Capsular bag implantation of IOLs provides a stable position. IOL tilt or decentration
causes severe complications with multifocal IOLs due to their design. Thus, CCC should
be completed. If the IOL haptics position is unclear, which may cause unpleasant phenom-
ena such as glare and halo, one should try to implant the IOL symmetrically, either both
haptics in the capsular bag or in the sulcus.

3. Posterior CCC
Near vision can easily be decreased by the posterior capsular opacity with multifocal IOLs.
In other words, the rate of neodymium:YAG capsulotomy is higher than that of monofocal
242 Bissen-Miyajima

Table 2 Visual Acuities with Different Multifocal IOLs


Lindstrom Usui and Negishi and
(1993) associates (1992) associates (1997)
IOL 3M Ioptex AMO Array
Type of IOL Diffractive Refractive Refractive
Uncorrected distance 20/40 or better 53.1% Not described 20/40 or better 90.3%
VA
Corrected distance VA 20/25 or better 84.9% 20/40 or better 20/25 or better 100%
94.9%
Uncorrected near VA 82% 45.6% 62.1%
J1-J3
Distance-corrected near 92% 60.4% 62.1%
VA J1-J3
Best-corrected near VA 97% 94.1% 97%
J1-J3

IOLs. If the opacity or the fibrosis of the posterior capsule is obvious and cannot be
polished during surgery, one may perform posterior CCC. Especially when we implant
multifocal IOLs in younger patients, we should consider performing posterior CCC, since
a neodymium:YAG capsulotomy may be necessary earlier.
a. Clinical Results
There have been many reports on the results of multifocal IOLs following cataract extrac-
tion. The reports on multifocal IOL with clear lensectomy are limited. The desirable results
with cataract patients persuade clear lensectomy for the patient who would like to have
refractive surgery, including the correction of presbyopia.
b. Visual Acuity (VA)
Table 2 shows the reported results of several multifocal IOLs (2). The time-lapse changes
of the mean postoperative VA in a Japanese clinical study are shown in Table 3. The
average distance uncorrected VA was 20/25, best corrected VA was better than 20/20.
For near, uncorrected VA was 0.39, with distance correction, it was 0.43; and best corrected

Table 3 Time Lapse Changes of the Average VA


Observation

Pre-op 1 day 1 week 1 month 3 months 6 months 1 year

Uncorrected distance VA 0.13 0.63 0.73 0.74 0.69 0.73 0.78


Corrected distance VA 0.23 0.90 1.06 1.08 1.07 1.05 1.12
Uncorrected near VA 0.13 0.29 0.34 0.36 0.40 0.41 0.39
Distance-corrected near VA 0.13 0.30 0.36 0.38 0.39 0.40 0.43
Best corrected near VA 0.20 0.56 0.74 0.73 0.72 0.72 0.77
Multifocal IOLs for Presbyopia 243

VA was 0.77. The VA at the 1 week postoperative visit was as good as the one at 1 year.
We can expect early visual recovery with this type of IOL.
c. Contrast Sensitivity
The loss of contrast sensitivity with multifocal IOLs is accepted as a drawback of this
design. Despite previous reports, our results are encouraging. The mean contrast sensitivity
at 1 year after the operation was above the lowest of normal range (Fig. 3). Contrast VA
with variable-contrast charts (VCVAC) showed that the contrast VA of the eye with a
multifocal IOL in 15 and 2.5% contrast was comparable to that with a monofocal IOL
(Fig. 4).
d. Halo and Glare
Halo and glare are also of concern following multifocal IOL surgery. One year after the
operation, patients were asked about halo and confirmed its intensity. At each final follow-
up observation, 22.4% complained mild or moderate halo, which was only a transient
symptom in every case against sun in daytime and/or light sources at night. This was not
experienced to the extent of causing problems in daily life. Glare values were measured
by Miller-Nadler Glaretester and percent glare was 5.6. No percent glare decrease was
observed, potentially generating clinical problems.
e. Spectacle Usage
It is not easy to analyze spectacle usage, since some patients use spectacles most of the
time and the others use them only when necessary. Approximately 60% were able to
function comfortably without spectacles. Figure 5 shows the changes of using spectacles
by the follow-up time. Until 1 month after operation, most patients were not using specta-

Figure 3 Contrast sensitivity. The mean contrast sensitivity after the operation was above the
lowest of normal range.
244 Bissen-Miyajima

Figure 4 Contrast visual acuity. Contrast VA of the eye with multifocal IOL (array) in 15 and
2.5% contrast was comparable to that with monofocal IOL.

Figure 5 Changes of using spectacles.

Figure 6 Patients satisfaction.


Multifocal IOLs for Presbyopia 245

Figure 7 Vision simulation system.

cles. Once they get used to read with reading glasses, some prefer the clear letters using
the zone for far with additional correction with spectacles. That is why the rate for spectacle
usage increases after 3 months or 1 year.
e. Patients Satisfaction (Questionnaire)
It is important that patients be satisfied with the results (Fig. 6). Especially if clear lens
extraction has been performed, patients expect better reading ability.
f. Patients View with Model Eye
a. Vision Simulation System
The concern of implanting multifocal IOL is that the surgeon or patient cannot estimate
the view after the surgery. Because of this, it takes a long time to explain to the patient
about the results of multifocal IOL. The image through multifocal implantation was
recorded using the vision simulation system developed by Ohnuma (Fig. 7) (3).
b. Patients View
Using photos taken by the vision simulation system, the view of the patient was examined.
First, the view was seen by each eye while the fellow eye was covered. Then the view
was compared with each eye. The photo which was most similar to the view with multifocal
IOL was chosen.
The results are shown in Figure 8. During the day, the vision is clearer than that
with a multifocal IOL and closer to the view with a monofocal IOL. However, for near
vision, the photo taken by the model eye was similar to the real view with a multifocal
IOL.

E. COMPLICATIONS AND MANAGEMENT


1. IOL Power Miscalculation
When the biometry was not perfect and the patient ends up with myopia or hyperopia, he
or she may not receive the advantage of multifocal IOL. It is known that this type of
multifocal IOL should be emmetropic to slightly hyperopic (Fig. 9A). If the postoperative
refraction is more than 0.5 D, the blur circles become larger at distance and near compared
to emmetropia (Fig. 9B)). This will cause potential halos at night. If the postoperative
246 Bissen-Miyajima

Figure 8 Patients view. (A) Clinic at day. (B) Clinic at night. (C) Clock.

refraction is hyperopic, halo at night should be minimal (Fig. 9C). Thus, postoperative
refraction is an important factor. IOL exchange or piggyback implantation should be
considered if the patient suffers halo at night or strongly wishes better distance and near
vision.

2. IOL Decentration
With the introduction of CCC, clinically obvious decentration of IOL became rare. How-
ever, when it occurs, it may cause visual disturbance. Mostly, these are caused by asymmet-
Multifocal IOLs for Presbyopia 247

Figure 9 Refractive error and blur circles. (A) Emmetropic to slightly hyperopic (plano to 0.5
D). (B) Myopic refraction ( 0.5). (C) Hyperopic refraction ( 0.5 D).

rical fixation of the IOL. Surgical replacement of the IOL should be considered. If the
replacement is not possible due to the defect of posterior capsule, one may consider
exchanging the IOL to monofocal IOL.
3. Halo and Glare Vision
Complications are mainly related to IOL design. Most common complaints are halo and
glare at night. These are usually relieved by time. From our questionnaire, some patients
248 Bissen-Miyajima

have reported being bothered with halo and glare while they were driving at night. How-
ever, the readability of traffic signs is about the same as with monofocal IOLs.

4. Insufficient Near Vision


This is caused by incorrect IOL power calculation, small pupil diameter, or opacity in the
path from cornea to retina. The former two reasons are most common. If the incorrect
IOL power is the main reason, one may consider IOL exchange or piggyback implantation.
If the pupil diameter is smaller than the near zone, the patient will not get the advantage
of near addition.

F. CONCLUSIONS
Treating presbyopia is still a challenge. However, we already have clinical data of im-
planting multifocal IOLs for cataract patients. At this time, if the patient will need cataract
surgery sooner or later, multifocal IOL is a rather safe way to treat presbyopia. On the
other hand, for the patient with a clear lens, this may be a decision to be made by the
surgeon. The surgeon must be confident in his or her biometry and surgical technique. If
the patient understands the risk of removing the lens and implanting an IOL, a multifocal
IOL should always be considered as the best choice for the treatment of presbyopia.

REFERENCES
1. Steinert RF, Post CT Jr, Brint SF, Fritch CD, Hall DL, Wilder LW, Fine IH, Lichtenstein SB,
Masket S, Casebeer C. A prospective, randomized, double-masked comparison of a zonal-
progressive multifocal intraocular lens and a monofocal intraocular lens. Ophthalmology 1992;
99:853860.
2. Negishi K, Bissen-Miyajima H, Kato K, Kurosaka D, Nagamoto T. Evaluation of a zonal-
progressive multifocal intraocular lens. Am J Ophthalmol 1997; 124:321330.
3. Ohnuma K. Image focused by a multi-focal intraocular lens and its estimation. J Eye 2001; 18:
395400.
23
Refractive Lens Exchange with a
Multifocal Intraocular Lens

I. HOWARD FINE, RICHARD S. HOFFMAN, and MARK PACKER


Casey Eye Institute, Oregon Health and Science University,
Portland, Oregon, U.S.A.

A. INTRODUCTION
The options for treating the refractive surgery patient are greater now than at any time in
ophthalmic history. Excimer laser refractive surgery is growing in popularity throughout
the world, but it has its limitations. Patients with extreme degrees of myopia and hyperopia
are poor candidates for corneal refractive surgery, and presbyopic patients must rely on
reading glasses or monovision in order to obtain the full range of visual function. These
limitations in laser refractive surgery have led to a resurgence of intraocular modalities
for the correction of refractive errors.

B. MULTIFOCAL LENSES
Perhaps the greatest catalyst for the resurgence of refractive lens exchange has been the
development of multifocal lens technology. High hyperopes, presbyopes, and patients with
borderline cataracts who have presented for refractive surgery have been ideal candidates
for this new technology.
Multifocal intraocular lens (IOL) technology offers patients substantial benefits. The
elimination of a presbyopic condition and restoration of normal vision by simulating
accommodation greatly enhances the quality of life for most patients. The only multifocal
IOL available for general use in the U.S. is the Array (Advanced Medical Optics; Irvine,
CA). The advantages of astigmatically neutral clear corneal incisions have allowed for
increased utilization of multifocal technology in both cataract and refractive lens exchange
surgery.
249
250 Fine et al.

Figure 1 The AMO Array foldable silicone multifocal intraocular lens.

C. LENS DESIGN
The principle of any multifocal design is to create multiple image points behind the lens.
The goal of these lenses is to enable less reduction in visual acuity for a given amount
of defocus by improving the depth of field. The Array is a zonal progressive intraocular
lens with five concentric zones on the anterior surface (Fig. 1). Zones 1, 3, and 5 are
distance dominant zones while zones 2 and 4 are near dominant. The lens has an aspherical
component and thus each zone repeats the entire refractive sequence corresponding to
distance, intermediate, and near foci. This results in vision over a range of distances. The
lens uses 100% of the incoming available light and is weighted for optimum light distribu-
tion. With typical pupil sizes, approximately half of the light is distributed for distance,
one-third for near vision, and the remainder for intermediate vision. The lens utilizes
continuous surface construction and consequently there is no loss of light through defrac-
tion and no degradation of image quality as a result of surface discontinuities. The lens
has a foldable silicone optic that is 6.0 mm in diameter, with haptics made of polymethyl-
methacrylate and a haptic diameter of 13 mm. The lens can be inserted through a clear
corneal or scleral tunnel incision that is 2.8 mm wide, utilizing the Unfolder injector
system (Advanced Medical Optics; Irvine, CA).

D. CLINICAL RESULTS
The efficacy of multifocal technology has been documented in many clinical studies. Early
studies of the one-piece Array documented a larger percentage of patients who were able
to read J2 print after undergoing multifocal lens implantation compared to patients with
monofocal implants (1315). Similar results have been documented for the foldable Array
(16). Clinical trials comparing multifocal to monofocal lens implantation in the same
patient also revealed improved intermediate and near vision in the multifocal eye versus
the monofocal eye (17,18).
Refractive Lens Exchange 251

Many studies have evaluated both the objective and subjective qualities of contrast
sensitivity, stereoacuity, glare disability, and photic phenomena following implantation of
multifocal IOLs. Refractive multifocal IOLs, such as the Array, were found to be superior
to diffractive multifocal IOLs by demonstrating better contrast sensitivity and less glare
disability (19). The Array does produce a small amount of contrast sensitivity loss equiva-
lent to the loss of one line of visual acuity at the 11% contrast level using Regan contrast
sensitivity charts (14). This loss of contrast sensitivity at low levels is only present when
the Array is placed monocularly; it has not been demonstrated with bilateral placement
and binocular testing (20). In addition to relatively normal contrast sensitivity, good ran-
dom-dot stereopsis and less distance and near aniseikonia were present in bilateral versus
unilateral implants (21).
One of the potential drawbacks of the Array lens has been the potential for an
appreciation of halos around point sources of light at night in the early weeks and months
following surgery (22). Most patients will learn to disregard these halos with time, and
bilateral implantation appears to improve these subjective symptoms. Concerns about the
visual function of patients at night have been allayed by a driving simulation study in
which bilateral Array multifocal patients performed only slightly worse than patients with
bilateral monofocal IOLs. The results indicated no consistent difference in driving perfor-
mance and safety between the two groups (23). In a study by Javitt et al., 41% percent
of bilateral Array subjects were found never to require spectacles, compared to 11.7% of
monofocal controls. Overall, subjects with bilateral Array IOLs reported better overall
vision, less limitation in visual function, and less use of spectacles than monofocal controls
(24).
A small recent study reviewed the clinical results of bilaterally implanted Array
multifocal lens implants in refractive lens exchange patients (25). A total of 68 eyes
were evaluated, comprising 32 bilateral and 4 unilateral Array implantations. Of patients
undergoing bilateral refractive lens exchange, 100% achieved binocular visual acuity of
20/40 and J5 or better measured 1 to 3 months postoperatively. Over 90% achieved uncor-
rected binocular visual acuity of 20/30 and J4 or better, and nearly 60% achieved uncor-
rected binocular visual acuity of 20/25 and J3 or better (Fig. 2). This study included patients

Figure 2 Clinical results of bilateral Array implantation following refractive lens exchange.
252 Fine et al.

Figure 3 Scattergram demonstrating reduction of spherical equivalent in refractive lens exchange


eyes.

with preoperative spherical equivalents between 7 D of myopia and 7 D of hyperopia,


with the majority of patients having preoperative spherical equivalents between plano and
2.50. Excellent lens power determinations and refractive results were achieved (Fig. 3).

E. PATIENT SELECTION
Specific guidelines with respect to the selection of candidates and surgical strategies that
enhance outcomes with this IOL have been developed. AMO recommends using the Array
multifocal IOL for bilateral cataract patients whose surgery is uncomplicated and whose
personality is such that they are not likely to fixate on the presence of minor visual
aberrations such as halos around lights. There is obviously a broad range of patients who
would be acceptable candidates. Relative or absolute contraindications include the presence
of ocular pathologies other than cataracts that may degrade image formation or may be
associated with less than adequate visual function postoperatively despite visual improve-
ment following surgery. Pre-existing ocular pathologies that are frequently looked upon
as contraindications include age-related macular degeneration, uncontrolled diabetes or
diabetic retinopathy, uncontrolled glaucoma, recurrent inflammatory eye disease, retinal
detachment risk, and corneal disease or previous refractive surgery in the form of radial
keratotomy, photorefractive keratectomy, or laser-assisted in situ keratomileusis (LASIK).
However, a recent study has revealed comparable distance acuity outcomes in Array and
Refractive Lens Exchange 253

monofocal patients with concurrent eye disease such as macular degeneration, glaucoma,
and diabetic retinopathy (26).
Utilization of these lenses in patients who complain excessively, are highly introspec-
tive and fussy, or obsess over body image and symptoms should be avoided. In addition,
conservative use of this lens is recommended in evaluating patients whose occupations
involve frequent night driving or that place high demands on vision and near work, such
as engineering and architecture. Such patients must demonstrate a strong desire for relative
spectacle independence in order to be considered for a refractive lens exchange with Array
implantation.
In our practice, patient selection has been reduced to a very rapid process. Once
someone has been determined to be a candidate for refractive lens exchange, he or she is
asked two questions: the first is If an implant could be placed in your eye that would
allow you to see both distance and near without glasses under most circumstances, would
that be an advantage? Patients are then asked: If the lens is associated with halos around
lights at night, would it still be an advantage? If they do not think they would be bothered
by these symptoms, they receive a multifocal IOL. If concern over halos or night driving
is strong, these patients may receive monofocal lenses with appropriate informed consent
regarding loss of accommodation and the need for reading glasses or consideration of a
different refractive surgical procedure.
Prior to receiving an Array, all candidates should be informed of the lens statistics
to ensure that they understand that spectacle independence is not guaranteed. Approxi-
mately 41% of the patients who are implanted with bilateral Array IOLs will never need
to wear glasses, 50% wear glasses on a limited basis as for driving at night or during
prolonged reading, 12% will always need to wear glasses for near work, and approximately
8% will need to wear spectacles on a full-time basis for distance and near correction (23).
In addition, 15% of patients were found to have difficulty with halos at night and 11%
had difficulty with glare, compared to 6% and 1% respectively of monofocal patients.

F. PREOPERATIVE MEASUREMENTS

The most important assessment of successful multifocal lens use other then patient selec-
tion involves precise preoperative measurements of axial length in addition to accurate
lens power calculations. There are some practitioners who feel that immersion biometry
is necessary for accurate axial length determination. However, applanation techniques in
combination with the Holladay 2 formula yield accurate and consistent results with greater
patient convenience and less technician time. A newer device now available, the Zeiss
IOLMaster, is a combined biometry instrument for noncontact optical measurements of
axial length, corneal curvature, and anterior chamber depth that yields extremely accurate
and efficient measurements with minimal patient inconvenience. The axial length measure-
ment is based on an interference-optical method termed partial coherence interferometry
and measurements are claimed to be compatible with acoustic immersion measurements
and accurate to within 30 m. The Quantel Axis II immersion biometry unit is also a
convenient and accurate device for axial length measurements. The device yields quick
and precise axial length measurements using immersion biometry without requiring the
patient to be placed in the supine position. Regardless of the technique being used to
measure axial length, it is important that the surgeon use biometry that he or she feels
yields the most consistent and accurate results.
254 Fine et al.

When determining lens power calculations, the Holladay 2 formula takes into ac-
count disparities in anterior segment and axial lengths by adding the white-to-white corneal
diameter and lens thickness into the formula. Addition of these variables helps predict the
exact position of the IOL in the eye and has improved refractive predictability. The SRK
T and the SRK II formulas can be used as a final check in the lens power assessment;
for eyes with less than 22 mm in axial length, the Hoffer Q formula should be utilized
for comparative purposes.

G. SURGICAL TECHNIQUE
The multifocal Array works best when the final postop refraction has less than 1 D of
astigmatism. It is thus very important that incision construction be appropriate with respect
to size and location. A clear corneal incision at the temporal periphery that is 3 mm or
less in width and 2 mm long is highly recommended (29). Each surgeon should be aware
of his or her usual amount of surgically induced astigmatism by vector analysis.
In preparation for phacoemulsification, the capsulorhexis must be round in shape
and sized so that there is a small margin of anterior capsule overlapping the optic circumfer-
entially (Fig. 4). This is important in order to guarantee in-the-bag placement of the IOL
and prevent anterior/posterior alterations in location that would affect the final refractive
status.
Minimally invasive surgery is very important. Techniques that produce effective
phacoemulsification times of less than 20 s and average phacoemulsification powers of
10% or less are highly advantageous and can best be achieved with power modulations
(burst mode or two pulses per second) rather than continuous phacoemulsification modes
(33,34). The Array is inserted most easily by means of the Unfolder injector system.
Complete removal of all viscoelastic from the anterior chamber and behind the lens will
reduce the incidence of postoperative pressure spikes and myopic shift from capsular block
syndrome.

Figure 4 The Array multifocal intraocular lens in situ. Note the capsulorhexis overlapping the
edge of the lens optic.
Refractive Lens Exchange 255

H. COMPLICATIONS MANAGEMENT
When intraoperative complications develop, they must be handled precisely and appropri-
ately. In situations in which the first eye has already had an Array implanted, management
of complications must be directed toward finding any possible way of implanting an
Array in the second eye. Under most circumstances, capsular rupture will still allow for
implantation of an Array as long as there is an intact capsulorhexis. Under these circum-
stances, the lens haptics are implanted in the sulcus and the optic is prolapsed posteriorly
through the anterior capsulorhexis.
It is important to avoid trauma to the iris since pupillary size and shape may affect
the visual function of a multifocal IOL postoperatively. If the pupil is less than 2.5 mm,
there may be an impairment of near visual acuity due to the location of the rings serving
near visual acuity. For patients with small postoperative pupil diameters affecting near
vision, a mydriatic pupilloplasty can be performed successfully with the Argon laser (35).
Enlargement of the pupil will expose the near dominant rings of the multifocal IOL and
restore near vision in most patients.

I. TARGETING EMMETROPIA
The most important skill to master in the refractive lens exchange patient is the ultimate
achievement of emmetropia. Emmetropia can be achieved successfully with accurate intra-
ocular lens power calculations and adjunctive modalities for eliminating astigmatism. With
the trend toward smaller astigmatically neutral clear corneal incisions, it is now possible
to address pre-existing astigmatism more accurately at the time of lens surgery. The popu-
larization of limbal relaxing incisions by Gills and Nichamin has added a useful means
of reducing up to 3.50 diopters of pre-existing astigmatism by placing paired 600-m-
deep incisions at the limbus in the steep meridian. When against-the-rule astigmatism is
present, the temporal groove of the paired limbal relaxing incisions can be utilized as the
site of entry for the clear corneal incision. This is a simple and practical approach for
reducing pre-existing astigmatism at the time of surgery, and since the coupling of these
incisions is one to one, no alteration in the calculated lens power is needed.

J. REFRACTIVE SURPRISE
On occasion, surgeons may be presented with an unexpected refractive surprise following
surgery. These miscalculations in lens power can be disappointing to both the surgeon
and patient, but happily the means for correcting these refractive errors are increasing.
When there is a gross error in the lens inserted, the best approach is to perform a lens
exchange as soon as possible. When smaller errors are encountered or lens exchange is
felt to be unsafe, various adjunctive procedures are available to address these refractive
surprises.
One of the simplest techniques to address residual myopia following surgery is a
two-, three-, or four-cut radial keratotomy (RK) with a large optical zone. RK is still a
relatively safe procedure with little likelihood for significant hyperopic shift with conserva-
tive incision and optical zone placement. When residual hyperopia is present following
cataract surgery, conductive keratoplasty (Refractec) is an option for reducing hyperopia
and appears to work best in older patients and in patients with 1 to 2 D of refractive error.
Another option for reducing 0.5 to 1.0 D of hyperopia involves rotating the IOL out of
256 Fine et al.

the capsular bag and placing it in the ciliary sulcus to increase the functional power of
the lens. LASIK can also be performed to eliminate myopia, hyperopia, or astigmatism
following surgery complicated by unexpected refractive results.
An interesting and simple intraocular approach to the postoperative refractive sur-
prise involves the use of intraocular lenses placed in the sulcus over the primary IOL in
a piggyback fashion. Staar Surgical now produces the AQ5010V foldable silicone IOL
that is useful for sulcus placement as a secondary piggyback lens. The Staar AQ5010V
has an overall length of 14.0 mm and is available in powers between 4.0 to 4.0 D
in whole-diopter powers. Useful for smaller eyes with larger hyperopic postoperative errors
is the Staar AQ2010V, which is 13.5 mm in overall length and is available in powers
between 5.0 to 9.0 diopters in whole-diopter steps. This approach is especially useful
when expensive refractive lasers are not available or when corneal surgery is not feasible.

K. POSTOPERATIVE COURSE
If glasses are required after surgery in a patient implanted with a multifocal IOL, the
spherical correction should be determined by overplusing the patient to a slight blur and
gradually reducing the power until the best acuity is reached. Patients are able to focus
through the near portions of their IOL; thus it is possible to overminus a patient if care
is not taken to push the plus power. When using this defocusing technique, it is critical
to stop as soon as distance acuity is maximized to avoid overminusing the patient. The
cylinder power should be the smallest amount that provides the best acuity. If add power
is necessary, the full add power for the required working distance should be prescribed.
If patients are unduly bothered by photic phenomena such as halos and glare, these
symptoms can be alleviated by various techniques. Weak pilocarpine at a concentration
of 1/8% or weaker will constrict the pupil to a diameter that will usually lessen the severity
of halos without significantly affecting near visual acuity. Similarly, brimonidine tartrate
ophthalmic solution 0.2% (Alphagan) has been shown to reduce pupil size under scotopic
conditions (36) and can also be administered in an attempt to reduce halo and glare
symptoms. Another approach involves the use of overminused spectacles in order to push
the secondary focal point behind the retina and thus lessen the effect of image blur from
multiple images in front of the retina. Polarized lenses have also been found to be helpful
in reducing photic phenomena. Perhaps the most important technique is the implantation
of bilateral Array lenses as close in time as possible in order to give patients the ability
to use the lenses together, which appears to allow for improved binocular distance and
near vision compared to monocular acuity. Finally, most patients report that halos improve
or disappear with the passage of several weeks to months.

L. FINAL COMMENTS
As this procedure becomes more popular, it will create a win-win situation for all involved.
First, patients can enjoy a predictable refractive procedure with rapid recovery that can
address all types and severities of refractive errors in addition to addressing presbyopia with
multifocal or accommodative lens technology. Second, surgeons can offer these procedures
without the intrusion of private or government insurance and establish a less disruptive
relationship with their patients. Finally, government can enjoy the decreased financial
burden from the expenses of cataract surgery for the ever-increasing ranks of aging baby
Refractive Lens Exchange 257

boomers as more and more of these patients opt for lens exchanges to address their refrac-
tive surgery goals, ultimately reaching Medicare coverage as pseudophakes.
Successful integration of refractive lens exchanges into the general ophthalmolo-
gists practice is fairly straightforward, since most surgeons are currently performing small-
incision cataract surgery for their cataract patients. Essentially, the same procedure is
performed for a refractive lens exchange, differing only in removal of a relatively clear
crystalline lens and simple adjunctive techniques for reducing corneal astigmatism. Al-
though any style of foldable IOL can be used for lens exchanges, multifocal IOLs currently
offer the best option for addressing both the elimination of refractive errors and presbyopia.
Refractive lens exchange with multifocal lens technology is not for every patient consider-
ing refractive surgery but does offer substantial benefits, especially in high hyperopes,
presbyopes, and patients with borderline or soon to be clinically significant cataracts who
are requesting refractive surgery. Appropriate patient screening, accurate biometry and
lens power calculations, and meticulous surgical technique will allow surgeons to maxi-
mize their success with this procedure.

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24
The Limits of Simultaneous Ametropia
Correction in Phaco-Ersatz

ARTHUR HO and PAUL ERICKSON


The Cooperative Research Centre for Eye Research and Technology, The University
of New South Wales, Sydney New South Wales, Australia
FABRICE MANNS
Bascom Palmer Eye Institute, University of Miami Medical School, Miami, and
University of Miami College of Engineering, Coral Gables, Florida, U.S.A.
VIVIANA FERNANDEZ
Bascom Palmer Eye Institute, University of Miami Medical School, Miami, Florida,
U.S.A.
JEAN-MARIE PAREL
Bascom Palmer Eye Institute, University of Miami Medical School, Miami,
University of Miami College of Engineering, Coral Gables, Florida, U.S.A., and
University of Liege, CHU Sart-Tilman Liege, Belgium

A. INTRODUCTION
To the eye-care practitioner, the importance of presbyopia as a major concern need not
be emphasized. Currently, in the United States alone, 35% of the population of 278 million
(1) is presbyopic and therefore requires some form of optical aid for near vision. Further,
the number of presbyopes is increasing. Statistics from the U.S. Census Bureau predict
that over the next decade, the number of people over 45 years of age will increase by
approximately 21 million, but the population under 45 years will remain relatively un-
changed.* This trend for an increasing representation of the over-45 age group in the popula-

* U.S. Census Bureau, International Database, May, 2000. The projected population of the United States in the
year 2010 is 300 million, on increase of 22 million from the figure for year 2001. Of this increase, the (presbyopic)
age group above 45 years age will account for approximately 21 million (1).
259
260 Ho et al.

tion is occurring throughout the developed countries. Therefore, increasing emphasis will
be placed on the provision of near vision aids to this sector of the worlds population.
1. Background to Presbyopia Restoration
Unfortunately, currently available devices for near vision assistancewhich we may call
the conventional presbyopia optionssuffer from a number of optical and practical
disadvantages. Devices such as bifocal spectacles, diffractive intraocular lenses (IOLs),
and monovision compromise the position of gaze, field of view, image contrast, or stereop-
sis because of the method by which they provide near focusing power. More critically,
these conventional options do not recreate the continuous focusing ability of the natural
young eye. Of the conventional options available, the progressive aspheric spectacle lens
(PAL) most closely approaches the ideal of providing continuous near focal distance.
However, the continuous focus facility of PALs compromises the position of gaze and
field of view within which the required power may be used and introduces often significant
optical distortions due to the need to employ sophisticated aspheric surfaces in the design
(2,3).
Clearly, none of the conventional options can provide a continuous near focus, full
aperture, and field optical system for the presbyope.
Given the deficiencies of the conventional options, many workers have been engaged
in the development of strategies seeking to truly restore accommodative function to the
presbyopic eye (48).
2. Phaco-Ersatz
The strategy of Phaco-Ersatz (4,7,911) is to restore accommodation to the presbyopic
eye. In this method (Fig. 1), the contents of the presbyopic crystalline lens is extracted

Figure 1 The procedure of Phaco-Ersatz for restoring accommodation. (A) A corneal incision is
made followed by a very small diameter (1 mm) capsulorhexis. The lens nucleus, cortex, and
epithelial cells are extracted through the minicapsulorhexis, leaving an intact lens capsule (B). Using
a fine cannula, a polymer gel with the appropriate properties is injected into the lens capsule (C),
reproducing a soft, flexible de novo lens (D). The two controllable variables in this approach, which
forms the basis of the strategies discussed in this chapter, are the refractive index of the polymer
gel and the refilled volume of the de novo lens.
Phaco-Ersatz 261

through a small (around 1 mm in diameter) capsulorhexis and is replaced with a soft


polymer gel that is injected into the intact lens capsule. Accommodation is restored by
replacing the hardened lens with a polymer gel that recreates the flexibility of the young
lens.
Phaco-Ersatz can restore up to 4 D of accommodation in the senile nonhuman primate
when a silicone gel is used as the lens refillant (9,10). The most recent developments have
refined Phaco-Ersatz by using more sophisticated polymer gels that do not leak out of the
capsule and by improving the delivery of the surgery (1114).
Modern Phaco-Ersatz has reached a sufficiently advanced stage that our attention
may now be extended to address other patient-related issues. Certainly with the Phaco-
Ersatz method, it is possible for the patient to employ any of the conventional options for
correcting static refractive error such as spectacles and contact lenses. However, patients
strongly prefer to avoid any form of ophthalmic appliance. This is evident by the increasing
development in and popularity of refractive surgery. Hence, an ability to simultaneously
correct refractive error while restoring accommodation would significantly enhance the
attractiveness and acceptability of any such procedure for presbyopia correction.

3. Simultaneous Correction of Ametropia


Surgical vision correction options such as radial keratotomy (RK), photo-refractive kera-
tectomy (PRK), laser-assisted in situ keratomileusis (LASIK), keratoprostheses (e.g., cor-
neal inlays) and phakic IOLs may also be used with Phaco-Ersatz. Together, these would
restore accommodation as well as correct the ametropic patient.
However, there are advantages in providing a Phaco-Ersatz procedure that can, by
itself, simultaneously correct ametropia. For example, there would be reduced risk because
only one instead of two surgical procedures is required. Further, the disadvantages [e.g.,
postsurgical corneal haze and discomfort in PRK and LASIK (15,16)] of some of the
aforementioned vision correction options may be obviated.
The purpose of this chapter is to investigate the feasibility of strategies intrinsic to
the Phaco-Ersatz procedure that could simultaneously correct ametropia while restoring
accommodation.

4. Two Intrinsic Approaches


As the Phaco-Ersatz procedure can principally modify the crystalline lens physical param-
eters, we are limited to two intrinsic strategies by which ametropia may be corrected
simultaneously:
1. controlling the refractive index of the refillant
2. controlling the refilled volume of the de novo lens
The first strategy relies on controlling the power of the de novo lens by increasing
or decreasing the refractive index of the polymer gel used for refilling. Assuming that the
other properties such as curvature and thickness are not altered, this strategy is conceptually
relatively straightforward. Using a polymer gel with a lower refractive index would reduce
the power of the crystalline lens, thereby reducing the power of the total eye. This could
be used to correct myopia. Conversely, polymer gel with a higher refractive index would
increase the power of the eye and be useful for correcting hypermetropia.
The implementation of this first strategy requires polymer gels with a range of
refractive indices to be synthesised and made available for Phaco-Ersatz. During the opera-
262 Ho et al.

tion, the surgeon would choose a polymer gel with an appropriate refractive index for the
correction of the patients particular amount of ametropia.
The second strategy involves altering the volume of the de novo lens with a view
to altering the anterior and posterior curvatures and thickness. By doing so, the power of
the crystalline lens and hence the total power of the eye can also be altered.
This second strategy can be implemented in two ways. Firstly the refractive error
of the patient could be measured prior to operation and the appropriate volume for refilling
calculated and used. Alternatively, an in-line refractometer could be used to monitor the
refractive state of the eye during refilling to provide an endpoint indication to the surgeon
when the correct volume has been reached.
Given the simplicity of these strategies, their applicability and feasibility is worthy
of evaluation.
While the concepts relating to these two strategies are relatively simple, there are
numerous difficulties that render the evaluation of the feasibility of these strategies imprac-
tical by physical in-surgery means. For instance, in order to evaluate the feasibility of
controlling refractive index of the refillant, a range of polymers would need to be synthe-
sized first. Even then, extraneous factors, such as the mechanical properties of the range
of polymer gels, would need to be controlled in order to return valid results.
With these constraints, analyses by theoretical modeling provide a good, workable,
first approximation as an alternative to evaluation of the feasibility of these strategies. In
the remainder of this chapter, we endeavor to evaluate, by computer-assisted modeling,
the feasibility of controlling refractive index and controlling refilled volume as strategies
for the simultaneous correction of ametropia with Phaco-Ersatz.

5. Controlling Refractive Index

As mentioned, this strategy involves the management of the refractive status (or error)
of the eye through controlling the power of the de novo lens by controlling its refractive
index. A hint as to the feasibility of this strategy came from early studies in lens refilling
that coincidentally made use of materials of a low refractive index. In those studies, the
eye with de novo lenses with low refractive index were found to be hypermetropic (17).
However, altering the refractive index of the lens has an accompanying effect on
the amplitude of accommodation. Hence, while ametropia may be correctable by control-
ling the refractive index of the refillant, it is equally important to ensure that the resultant
amplitude of accommodation is sufficient for near work. Therefore, any analysis of the
feasibility of this strategy must take into account the range of ametropia that is correctable
as well as the impact on the amplitude of accommodation.
We reported on such a study (18) in which the feasibility of simultaneous correction
of ametropia with Phaco-Ersatz through controlling the refractive index of the polymer
gel was analyzed by theoretical modeling (Fig. 3).
We analyzed a paraxial [Gullstrand no 1 Schematic Eye (19)] and a finite aspheric
eye [Navarro aspheric model eye (20)] using paraxial optical equations and computer-
assisted optical ray tracing (Zemax version 9, Focus Software Incorporated, AZ) respec-
tively. Both refractive and axial refractive ametropia were analyzed. In each case, the
refractive index of the gel varied between 1.34 and 1.49. A backward ray trace (from
retina to air) was conducted to find the corresponding far point of the eye. The accommoda-
tion state of the model eye was then set to a nominal value of 10 D and the backward ray
Phaco-Ersatz 263

trace repeated to find the near point. The amount of correctable ametropia was obtained
from the first ray trace. The difference in results between the second and first ray trace
yields the associated amplitude of accommodation.

B. RESULTS

1. Refractive Error Correction

Using the Gullstrand model eye and a refractive index range of 1.34 to 1.49 for the refillant,
the range of correctable refractive ametropia is between 11.0 D and 14.6 D, and
12.6 D and 12.4 D for refractive and axial ametropia, respectively (Fig. 2). For the
Navarro eye, this range is between 12.4 D and 12.2 D, and 14.6 D and 10.9 D
for refractive and axial ametropia, respectively.

2. Amplitude of Accommodation

When the refractive index of the refillant ranges from 1.34 to 1.49, the amplitude of
accommodation ranges from near zero to 14.6 D and 13.4 D for refractive and axial

Figure 2 Refractive and axial ametropia correctable by varying the refractive index of the polymer
gel in Phaco-Ersatz for two model eyes. Interpolation of the Gullstrand results indicates that the
lens cortex and nucleus may be replaced by an equivalent single uniform refractive index of 1.409
to achieve emmetropia. (From Ref. 18.)
264 Ho et al.

hypermetropia, respectively, with the Gullstrand eye model, and to 9.7 D and 8.9 D for
refractive and axial hypermetropia, respectively, with the Navarro model. The nominal
state of accommodation was equivalent to 10 D in all cases.

3. Discussion

It should be noted that the reported theoretical analysis (18) is based on a key assumption
that the shape of the refilled lens does not differ significantly from the original natural
lens. This assumption is probably reasonable given that the shape of the young lens is
determined largely by the properties of the capsule (21,22). Thus, provided the mechanical
properties of the polymer gel refillant closely mimic those of the young natural lens, large
departures from the natural shape are presumed to be unlikely (Fig. 3).
The implications of controlling the refractive index of the refillant on correction of
ametropia and amplitude of accommodation is shown by combining the data from Figs.
2 and 3 (Fig. 4). The amplitude of accommodation progressively decreases as we attempt
to correct higher amounts of myopia. In the limiting case, the correction of a 12 D
myope would result in virtually no accommodation being available. At this point, the
refractive index of the refillant is almost identical to that of the surrounding ocular media
and hence, the de novo lens has near zero power and consequently is also incapable of
providing accommodative power.

Figure 3 Amplitude of accommodation resulting from varying the refractive index of the polymer
gel in Phaco-Ersatz for two model eyes and ametropia types. (From Ref. 18.)
Phaco-Ersatz 265

Figure 4 Relationship between the amplitude of accommodation and the amount of ametropia
that was correctable for two model eyes and ametropia types. (From Ref. 40.)

A practical limit to the range of ametropia that is correctable may be derived by


assuming a required minimum amplitude for accommodation. For example, if a standard
near work distance of 40 cm is adopted and assuming that an additional 50% of accommo-
dative amplitude is required in reserve at all times for comfortable, prolonged reading
(23), we set the acceptable minimum amplitude of accommodation at around 5 D. With
this value, Figure 4 indicates that, for the Gullstrand model eye, myopia greater than 2.5
D should not be corrected by reducing the refractive index of the refillant. According to the
Navarro model, no corrections for myopia are acceptable with the assumed requirements.
In addition to the limitation on myopic corrections, the following practical issues may
also impact the feasibility of this strategy. These issues are as follows:

The need for a series of polymer gels with a large range of refractive indexes to be
available for Phaco-Ersatz. The synthesis of such a range of polymers with similar
mechanical properties and biocompatibility factors poses a daunting technical
challenge to polymer developers.
The accuracy required for correction of ametropia to an accuracy of 0.125 D
would require the refractive index to be controlled to an accuracy of 0.0008.
This accuracy needs to be maintained over its working life despite potential
changes in hydration and fouling.
Correction of ametropia with this strategy is limited to spherical refractive errors.
Astigmatic correction is not feasible.
266 Ho et al.

Figure 5 Geometrical definitions of the two models for under- and overfilling of the crystalline
lens. (A) Model 1 describes the spherization model. The normal lens is defined by an ellipsoid
of revolution with major and minor axes a and b (see Table 1). When the lens is under- or overfilled,
its major and minor axes are defined by a and b. A scaling factor is used to determine a and b
from a and b [Eq. (2a) and (2b)]. With this set of equations for defining a and b, the effect is that
as the lens volume changes, there is a more rapid accompanying change in the curvature of the
anterior than the posterior lens surface. (B) Model 2 describes the proportional expansion model.
In this model, a and b are set by a scaling factor according to Eqs. (3a) to (3c). This model provides
for a more rapid accompanying change in the posterior curvature of the lens surface as lens volume
changes. Note that the scaling factor [s in Eqs. (2a), (2b), (3b), and (3c)] is used only as a parameter
for computation. The relationship between this scaling factor and lens volume is different for the
two models.
Phaco-Ersatz 267

Figure 6 The relationship between the equivalent power of the crystalline lens and its thickness,
with lens volume according to Models 1 and 2.

Correction of anisometropia is also not feasible, as such an attempt would result in


anisoaccommodation. Further, the result at near is an induced anisometropia of
the opposite sign to the original state of anisometropia.
A further issue relates to ocular aberrations. There is evidence (2426) that the
spherical aberration of the eye changes over the range of accommodation (Figure 5). It
has been postulated that this change in spherical aberration with accommodation is an
effect of the refractive index gradient of the crystalline lens (27) (Fig. 6). When this
gradient is replaced by a uniform refractive index, ocular aberration during near work
with the de novo lens would differ from the natural lens and may affect near visual
performance (Fig. 7). Conversely, the greater positive aberration might increase depth of
focus and reduce the accommodative demand and, more significantly, permit greater toler-
ance in the accuracy of ametropia correction.
While a number of limitations have been presented above with respect to the strategy
under discussion, it should be noted that a few of these (e.g., requirement of accuracy of
refractive index) apply not just to controlling refractive index within Phaco-Ersatz but
also to any nonaccommodating polymer-based intracapsular ametropia correction devices
(e.g., injectable IOLs) as well (Fig. 8).

4. Summary
While conceptually attractive, it is clear from the foregoing findings and the number of
potential implementation difficulties that significant challenges will face any attempt to
introduce this strategy as a method for correcting ametropia within Phaco-Ersatz.
268 Ho et al.

Figure 7 Refractive and axial ametropia correctable by controlling the refilled volumed of the
crystalline lens in Phaco-Ersatz according to models 1 and 2 using the modified Navarro eye.

Figure 8 Axial positions of the anterior cornea, anterior and posterior crystalline lens surfaces
and the lens equator and retina as a function of lens volume for refractive and axial ametropia within
models 1 and 2. The anterior cornea is located at the x0 axial position. Note the extreme shallowness
of the anterior chamber and great lens thickness associated with the correction of high amounts of
hypermetropia.
Phaco-Ersatz 269

3. Controlling Refilled Volume


In this section, we evaluate the feasibility of the second strategy for simultaneous correction
of ametropia within Phaco-Ersatz. With this strategy, the interaction of the mechanical
and geometrical properties of the lens and capsule, as well as the influence of the vitreous
on lens position and potentially the shape of the lens, creates a more complex system. A
number of these parameters are unknown, as they have not been measured to any acceptable
level of accuracy in the living eye. For example, it is not known how the vitreous influences
lens position and shape. Even more basic parameters, such as the shape of the crystalline
lens at various levels of accommodation, have not been measured in a systematic manner.*
Due to the lack of detailed, quantitative knowledge about many of the influencing
parameters, any theoretical model of this strategy must necessarily require imposition of
a number of assumptions. To facilitate our modeling analysis, we adopted the following
assumptions:
1. The position and shape of the lens is not affected by the iris or vitreous regardless
of the volume of refilling.
2. The position of the lens is set by its equatorial plane at all volumes of refilling
and the position of the equatorial plane is fixed with respect to the eye.

4. Eye Models
a. Requirements
A suitable model eye for analyzing the optical effect of altering lens volume must possess
the following features:
1. Accurate rendering of lens volume
2. Reasonable anatomical approximation
3. Faithful rendering of the optics of the eye
The first requirement is absolute for the purpose of this study. The consequence of
the second requirement is that the model lens must not only possess similar radii of
curvature and thickness as the crystalline lens but that it must also have a continuous
surface at the equator.
Unfortunately, we have found no eye model in the literature that satisfies all of the
above requirements. We therefore set out to develop an eye model for the purpose of this
study by combining suitable elements from established eye and lens models.
b. Modified Navarro Eye
The current model is based on a modification of the Navarro aspheric eye model (20),
which represents a de facto standard in finite eye models in terms of its employment and
citation.
The crystalline lens component of the Navarro model was replaced by a model lens,
which accurately portrayed the lens volume as well as providing a reasonable approxima-

* Good data exist on the thickness, curvatures and optical power of a crystalline lens in the relaxed state (28,29).
However, no quantitative data exist relating changes in all of these parameters with accommodation. We note
that efforts are being made currently to develop measurement systems for quantifying the topography of the
anterior and posterior crystalline lens surfaces at various levels of accommodation (30,31). We look forward
to the availability of these data for improving the precision of our model.
270 Ho et al.

Table 1 The Prescription of the Modified Navarro Eye for Modeling the Relationship Between
Refilled Lens Volume and Ametropia Correction

Surface Radius Thickness Index Diameter Q

Cornea anterior 7.72 0.55 1.376 0.26


Cornea posterior 6.50 3.05 1.3374 0.00
Lens anterior 10.20 1.898 1.42 4.3740
Lens equator 3.227 1.42 8.8
Lens posterior 6.00 15.672 1.336 0.8595

tion to the anatomical and geometrical parameters of the crystalline lens. This lens model
was based on combining two half-ellipsoids of revolution, as employed by past workers
(27,32). The anterior and posterior radii of curvature of the lens were the same as those
of the Navarro eye. By setting the length of the major axes (perpendicular to the optical
axis) of the half-ellipsoids to be identical, the continuity of the lens surface at the equator
was ensured. We chose 200 L as a reasonable nominal initial volume of the model lens
to simulate the natural human lens (33).
Given the assumed curvatures, equatorial diameter, and lens volume, the asphericity
and half-thickness of each half-ellipsoid were calculated employing equations relating to
the apical radius of curvature and shape factors of conic sections (34).
Finally, the model eye was emmetropized by adjusting the vitreous chamber depth
(distance between posterior lens surface and retina).
The resultant prescription of the modified Navarro model eye for analysis of control-
ling refilled lens volume is given in Table 1. The volume of this lens model is 208 L.
The equatorial diameter of 8.8 mm is slightly less while the thickness of 5.12 mm
is slightly greater than the respective parameters for the typical adult lens (28). However,
this was necessitated by a compromise in providing reasonable optical and geometrical
properties to the model.

c. Refilling Model

No information is available in the literature about the quantitative relationship between


lens curvatures and lens volume. Hence, a validated model of the change in lens curvature
with refilling is not possible at this stage. In view of this paucity of information, we
developed two simple but plausible mathematical models for lens refilling. These were:

1. Model 1: spherization
2. Model 2: proportional expansion

These two models (Fig. 5) provide contrasting relationships between lens thickness
and curvature with increasing lens volume during refill. In general, Model 1 predicts that
the anterior curvature and half-thickness of the lens will change more quickly than the
posterior curvature and half-thickness as the lens refills during Phaco-Ersatz, while Model
2 predicts the converse. The intention of testing two such disparate models is to provide
a bracketing of the results, such that the actual life situation might lie somewhere in
between.
Phaco-Ersatz 271

Model 1: Spherization.
This model assumes that as the lens is filled and then overfilled; it converges toward a
sphere (i.e., the length of the major and minor axes at the endpoint of filling is the same).
Hence, the posterior and anterior curvatures would converge with overfilling. Given that
the anterior radius of curvature is greater at the normal volume, this model predicts that
with overfilling, the anterior curvature would change more rapidly than the posterior
curvature. We assumed that the lens equator expands slightly with overfilling.
Model 1 is represented mathematically as follows (Fig. 5). The anterior and posterior
half-lenses are represented by half-ellipsoids of revolution such that their two-dimensional
cross sections may be described by
x2 y2
2 2 1 (1)
a b
where x is the distance along the optical axis
y is the distance across the optical axis
a is the half-length of the minor axis representing the half-thickness of the lens-half
at normal volume
b is the half-length of the major axis representing the half-diameter of the lens at
its equator at normal volume
Lens refilling according to Model 1 follows the relationship of
a s (be a) a (2a)
b s (be b) b (2b)
where a is the half-thickness of the over-or underfilled half-lens.
b is the half-diameter of the over-or underfilled lens.
be is the radius of the endpoint sphere towards which the shape of an overfilled lens
will converge.
s is a scaling factor defining the amount of over-or underfilling (s 0 is normal
volume of filling, s 0 is overfilling, and s 0 is underfilling).
Model 2: Proportional Expansion.
Model 2 assumes that as the lens is filled and then overfilled, the posterior and anterior
half-ellipsoids increase in axial dimensions (i.e., the length of the minor axis) in the same
ratio. In contrast to Model 1, the posterior curvature in Model 2 would increase more
rapidly than the anterior curvature as the lens overfills. As in Model 1, we assumed that
the lens equator expands slightly with overfilling.
Model 2 is represented mathematically as follows (Fig. 5):
The anterior and posterior half-lenses are again represented by half-ellipsoids of
revolution according to Eq (1). During lens refilling, Model 2 defines the following changes
in lens shape:
aa (ap aa)/ap (3a)
ap s (be ap) ap (3b)
b s (be b) b (3c)
where nomenclatures are as for the previous equations and subscript a values pertaining
272 Ho et al.

to the anterior half-lens; subscript p values for the posterior half-lens. For both models,
we assumed be to be 4.9 mm.

5. COMPUTATION AND ANALYSES


a. Calculation of Volume of Over-Underfilling
For a lens constructed of two half-ellipsoids of revolution, the volume V can be calculated
as
2
V b2 (aa ap) (4)
3
From Eqs. (1) through (4) and assigning various values for scaling factor s, we can calculate
the volume of the de novo lens at various amounts of filling.
b. Calculation of Lens Power
The central radius of curvature r of an ellipse is given by (34)
a
r (5a)
b2
and its thickness (34) d by:
d a a ap (5b)
From Eqs. (1) through (3) and (5a) and (5b), the assigned refractive indices, and assigning
various values for the scaling factor s, the power of the de novo lens can be calculated
at various amounts of filling.
c. Modeling Correctable Ametropia
Armed with the calculated lens curvatures and thicknesses at different levels of lens refill-
ing, it is now possible to calculate the associated amount of ametropia that is correctable
within the two models using the modified Navarro eye model.
One final variable had to be fixedthat of the position of the lens at different
levels of filling. Because of the enormous complexity of the interactions between capsular
tension, lens volume, vitreous influence, zonular tension and iris influence as well as the
lack of precise, quantitative information in many of these factors, we assumed a simplified
model in which the equatorial plane of the lens remains fixed in the axial (x) direction at
all levels of filling. Under this assumption, the anterior and posterior lens surfaces would
bulge forward and backward, respectively, by an amount equal to the change in the length
of the minor axes of the respective half-ellipsoids.
The amount of ametropia correctable was computed in two waysassuming refrac-
tive ametropia and assuming axial ametropia.
Paraxial optical equations were used in all calculations. Dioptric values of ametropia
were referred to the plane of the cornea on the model eye.

6. Results
Figure 6 shows the relationship between the volume of lens refilled (expressed as a percent-
age of a lens with normal volume) and equivalent refractive power and thickness of the
resultant lens. The resultant lens thicknesses are not greatly different for Models 1 and 2.
Phaco-Ersatz 273

The refractive power of the refilled lens varied slightly more with change in refilled volume
for Model 1 than for Model 2. This suggests that should lens refilling follow the shape
and thickness changes predicted by Model 1, a greater amount of ametropia may be
correctable.
From the results shown in Fig. 6, the overall power of the eye with a refilled lens,
and hence the amount of ametropia correctable, was computed. This is shown in Fig. 7,
which plots the amount of ametropia that is correctable under Models 1 and 2 for both
axial and refractive ametropia. The maximum ametropia that is correctable occurs using
Model 1 with axial ametropia (approximately 4 D). The minimum ametropia that is
correctable occurs using Model 2 with axial ametropia.

7. Discussion
a. Eye Model
As noted, the geometrical dimensions of the lens model deviated from typical adult human
lenses in that the equatorial diameter was slightly less and the thickness slightly higher.
This compromise was necessary to enable simple ellipsoids of revolutions to be used to
construct a model lens while maintaining reasonable values for the optics and geometrical
parameters. A more mathematically sophisticated approach (35) has been developed to
provide an anatomically precise representation of the adult human lens. However, that
model employed a pair of parametric functions within a system of polar coordinates to
describe the lens. Given the parametric nature of the model description, there is no direct
method by which changes in volume and curvature may be modeled without a high level
of mathematical complexity. Hence for convenience, we adopted the half-ellipsoids of
revolution (27,32).
The assumed endpoint diameter of the lens was 8.9 mm, which represents a 0.1-
mm increase in the diameter of a lens when overfilled to 200% (double the volume).
Should this prove to be an overestimation, there would be an increase in the amount of
ametropia that is correctable with controlled lens refilling due to the expected increase in
curvatures.
This model is able to estimate only the amount of ametropia that is correctable by
controlling the refilled volume of a lens with Phaco-Ersatz. Due to a number of limitations
relating to quantitative understanding of the influence of lens volume on lens shape during
accommodation, it is not yet possible to study the effect of over- or underfilling on the
amplitude of accommodation, as has been done for the refractive index strategy.
Hence, there may be detrimental effects on the amplitude of accommodation in the
application of this strategy, which are yet to be determined.
The critical assumption in our lens model is that the lens capsule has a negligible
effect on the change in curvature and thickness during refilling. Intuitively, this would
not be the case, given that there is a difference in thickness between the anterior and
posterior capsules (21,36,37), which would influence lens shape and thickness during
refilling. However, we have introduced two contrasting models for refilling with the inten-
tion that the actual lens response would lie somewhere within this bracketing. We be-
lieve, therefore, that the robustness of the predictions within our model should be reasona-
ble, especially considering that the two contrasting refilling models returned similar
predictions.
Finally, there are effects on aberrations that have not been considered. First, the
gradient index of the natural lens has been eliminated by Phaco-Ersatz. This would alter
274 Ho et al.

the aberration state of the eye at both distance and, as discussed, more critically at near.
Further, as the lens shape changes, it is highly likely that its surface asphericity would also
change, thereby altering the aberrations at different refill volumes. These considerations are
beyond the scope of the current model but merit further investigation.

b. Correction of Ametropia

If we accept the above assumptions and exceptions discussed, then our theoretical analysis
with the eye model predicts the following:

Even at the highest estimate predicted, the amount of ametropia that is correctable
is too low to be practical (Model 1 and axial ametropia). Therefore controlling
the refilled volume alone during Phaco-Ersatz for correcting ametropia is insuffi-
cient to correct any other than low degrees of ametropia.
The reciprocal of the average slope of the four curves in Fig. 7 indicates that in
order to correct ametropia with an accuracy of 0.125 D, percentage refilling
would have to be controlled to an accuracy of 2.3%. This equates to an approxi-
mate accuracy in volume of 5 L. This may pose a technical and surgical
challenge.

c. Issues of Implementation

There are also issues of implementation relating to this strategy.


Figure 8 shows the predicted positions of the lens surfaces and retina with changes
in refilled lens volume assuming a fixed position for the equatorial plane. Over the range
of under-to overfilling analyzed (50 to 150%), the lens thickness changes from approxi-
mately 3.5 mm to approximately 8 mm. Even ignoring the effect of the iris and vitreous,
it is certain that such a range would impose impractical values to the resultant anterior
chamber depth. In particular, correction of medium to high hypermetropia would result
in dangerously shallow anterior chambers.
In addition to considerations of anterior chamber depth, there are other practical
limits to the amount of over-and underfilling that can be achieved. The minimum amount
of underfilling is set by the lowest volume that can still produce an undistorted, optically
useful de novo lens. Below this limit, prism due to sagging, and distortions due to rippling,
warping, or waviness as a result of a lack of sufficient capsule tension may degrade vision
below acceptable limits.
There is also an upper limit on the amount of overfilling. Beyond this limit, given
the finite breaking strain of the capsule (38,39), rupture of the capsule would occur.
While reliable data on the limits of optical imperfection with excessive underfilling
and capsule rupture with excessive overfilling do not exist, a reasonable estimation may
be assumed on these lower and upper limits. Experience in our laboratories, which has
been conducting surgical trials of Phaco-Ersatz, suggests that a safe limit for over- and
underfilling may be 20% of the normal volume. Referring back to Fig. 7, introduction
of this limit to the volume of refilling predicts that the range of ametropia that is correctable
is significantly reduced to approximately 2 D. This is probably not a viable range for
useful correction of ametropia.
In addition to the above, other implementation issues relevant to the first strategy
as listed in the previous section also apply. These include a limitation in the range of
correction to spherical (nonastigmatic) refractive errors.
Phaco-Ersatz 275

8. Summary
Due to the complexity of the interplay between physiology, mechanics, and optics, we
have been able to test only a simplified model of controlled refilling. However, even this
first approximation suggests that the range of corrections achievable within this strategy
would be small because of the limitations of lens thickness as well as implementation
difficulties.

9. Conclusions
In this chapter, we have analyzed, using theoretical modeling, the feasibility of two strate-
gies that are intrinsic to Phaco-Ersatz for simultaneous correction of ametropia. It appears
from the results and consideration of implementation issues that neither strategy on its
own is sufficient or feasible for simultaneous correction of ametropia within Phaco-Ersatz.
We have not investigated the feasibility of a combination of the two strategies.
However, in view of the above discussions, it may be expected that those combinations
would also lack sufficient range and accuracy for applicability.
We therefore conclude, even in the absence of physical experimental results, that
simultaneous correction using these two intrinsic strategies would be unattractive and
probably not feasible.
However, predictions from models are only as reliable as the assumptions made and
the values for parameters assumed. We recognize that there are potential shortcomings in
our theoretical analyses, which warrant further research. In particular, the lack of reliable,
quantitative knowledge of relationships such as lens shape and thickness with different
level of refillingas well as the effect of the capsule thickness, vitreous, and iris on lens
shape and positionmerits study as well in order to refine our models. A number of
studies are under way in our laboratories seeking to address such issues (13,30,31). We
believe that researchers in this area should persist in their efforts to understand those
relationships.

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7. Parel JM. Phaco-Ersatz 2001: cataract surgery designed to preserve and restore accommodation.
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an accommodative IOL. Ophthalmologe 1996; 93:7375.
276 Ho et al.

9. Haefliger E, Parel J-M, Fantes F, Norton E, Anderson D, Forster R, Hernandez E, Feuer WJ.
Accommodation of an endocapsular silicone lens (Phaco-Ersatz) in the nonhuman primate.
Ophthalmology 1987; 94(4):471477.
10. Haefliger E, Parel J-M. Accommodation of an endocapsular silicone lens (Phaco-Ersatz) in
the aging rhesus monkey. J Refract Corneal Surg 1994; 10(5):550555.
11. Parel J-M, Holden B. Accommodating intraocular lenses and lens refilling to restore accommo-
dation (restoring accommodation). In: Azar D, ed. Intraocular Lenses in Cataract and Refractive
Surgery. Philadelphia: Saunders, 2001.
12. Parel JM, Simon G. Phaco-Ersatz 2001: update. Ann Inst Barraquer 1995; 25:143151.
13. Tahi H, Fantes F, Hamaoui M, Parel J-M. Small peripheral anterior continuous curvilinear
capsulorhexis. J Cataract Refract Surg 1999; 25:744747.
14. Tahi H, Chapon P, Parel JM, inventors; CRCERT, assignee. Mini capsulorhexis valve (MCV)
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United States patent US60/121,179 (US Patent Appl, 2000). PCT/US00/04339 (International
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15. Wilson S. LASIK: management of common complications. Laser in situ keratomileusis. Cornea
1999; 17(5):459467.
16. Price F, Jr, Belin M, Nordan L, McDonnell P, Pop M. Epithelial haze, punctate keratopathy
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17. Kessler J. Refilling the rabbit lens. Further experiments. Arch Ophthalmol 1966; 76(4):
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18. Ho A, Erickson P, Manns F, Pham T, Parel J-M. Theoretical analysis of accommodation
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25
Accommodating and Adjustable IOLs

SANDEEP JAIN, DIMITRI T. AZAR, and RASIK B. VAJPAYEE


Corneal and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary,
Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

A. INTRODUCTION
This chapter focuses on recent developments of accommodating and adjustable intraocular
lenses (IOLs). The former group of lenses is aimed at compensating for the loss of lens
accommodation after cataract surgery, whereas the latter group aims to minimize and
compensate for the unpredictability of refractive outcomes after cataract surgery (1).

B. ACCOMMODATING IOLs
Following cataract surgery, some accommodative functions of the ciliary muscle are re-
tained. Several ophthalmic research groups have developed aphakic IOLs that can to
provide some accommodation based on the maintenance of the accommodative function
of the ciliary muscle. The AT45 (C&C Vision, Aliso Viejo, CA) IOL was designed by
Stuart Cumming, M.D., of Aliso Viejo (1). Khalil Hanna designed the Human Optics
accommodating IOL; these lenses are placed in the capsular bag and are designed to
change position once the accommodative stimulus induces ciliary muscle contraction. The
success of these lenses depends on their ability to achieve high fidelity in transmitting the
accommodative stimulus to the lens capsule after cataract surgery. Clinical studies with
these lenses are under way, and preliminary studies are encouraging (2).

1. Description of Accommodating IOLs


The accommodating AT45 lens is a conventional posterior chamber silicone lens. Its optic
measures 4.5 mm in diameter. It does not have conventional plate or loop haptics but has
279
280 Azar et al.

Figure 1 New intraocular lenses from C&C are designed to move forward into the anterior
chamber to accommodate much like the natural lens. (Courtesy of C&C Vision).

two flexible arms located 180 degrees apart (Fig. 1). These flexible arms allow the lens
to move forward and backward in the posterior chamber on constriction and relaxation
of the ciliary muscle. At the end of each arm is a T-shaped polyamide haptic that follows
the curve of the capsular bag after implantation and maintains centration and stability by
resting in the capsular bag. The HumanOptics designs had a modified steering wheel
appearance which has been modified to allow greater accomodation.

C. MULTICOMPONENT IOLs
Since the advent of refractive surgery, we have been able to correct ametropia to what is
achievable with spectacle and contact lens corrections. This has been especially applicable
to the calculation of intraocular lens power if cataracts occur after refractive surgery.
Several formulas have been used to improve the predictability of IOL calculations after

Figure 2 Intraocular lens from HumanOptics designed to move forward into the anterior chamber
to accommodate, much like the natural lens. (Courtesy of HumanOptics).
Accommodating and Adjustable IOLs 281

refractive surgery, but surprises are occasionally encountered. Patients who have had re-
fractive surgery and subsequent cataract surgery demonstrate surprising hyperopic errors
in IOL power determination. The ability to correct hyperopic surprises after cataract sur-
gery in patients who have undergone previous refractive surgery would be desirable in
the group of patients who are accustomed to spectacle-free vision (4). The use of adjustable
or multicomponent intraocular lenses is a new concept that allows fine tuning of an already
fairly accurate refractive procedure (Fig. 2).

1. Description of Multicomponent IOLs


The multicomponent intraocular lens is a three-component lens consisting of a base lens
and two additional refractive attachments. The base lens has a planoconvex optical, and
the overall mechanical design of the lens is similar to that of currently used posterior
chamber lenses. The lens is made of polymethylmethacrylate (PMMA) and consists of
one piece, with a diameter of 6.0 mm and an optical aperture of 5.5 mm. The basic lens
looks much like a conventional posterior chamber IOL (PCIOL). The base lens has two
machined slots whose thickness is approximately 1.2 mm. These slots accept the cap lens
and hold the assembly together. The base lens is placed into the posterior capsular bag
permanently heals there (Fig. 3). After its implantation, it acts as a platform for the other
two detachable refractive elements (3).
Attached to the base lens are two additional refractive elements. The middle lens,
or sandwich lens, carries the astigmatic (4.00-D sphere and 0.00 to 4.00-D diopter cylinder

Figure 3 Multicomponent IOL. (From Werblin TP. Multicomponent intraocular lens. J Refract
Surg. 1996S:187189, with permission).
282 Azar et al.

in 0.25-D increments) correction. This PMMA or silicone lens has an optical aperture of
5.5 mm. The other refractive attachment is a cap lens that has additional refractive power.
This lens may be either monofocal or multifocal. This PMMA planoconvex lens has an
optical clear aperture of 5.5 mm. It has a tab and two small haptics that, during the
assembly, are set into slots in the base lens using a specially modified forceps.
The total central thickness of a multicomponent intraocular lens is 1.88 mm for a
28.00-D lens. This is only slightly thicker than a standard silicone IOL of 20.00 D.

D. LIGHT-ADJUSTED IOL
This lens is also designed to help patients with cataracts who have previously undergone
corneal refractive procedures, in which it is difficult to measure corneal curvature accu-
rately for appropriate IOL calculations.
Calhoun Vision has developed this lens, which may allow for noninvasive adjustment
and correction of residual postimplantation refractive errors following cataract surgery by
applying near-ultraviolet light to the IOL (4). The refractive power of an IOLcomposed
of a cross-linked silicone polymer matrix, a guest macromer, and a photoinitiatorcan
be adjusted. The application of the appropriate wavelength of light onto the central optical
portion of the light-adjusted lens (LAL) polymerizes the macromer in the exposed region,
thereby producing a difference in the chemical potential between the irradiated and nonirra-
diated regions. To re-establish thermodynamic equilibrium, unreacted macromer and pho-
toinitiator diffuse into the irradiated region. As a consequence of the diffusion process and
material properties of the host silicone matrix, the LAL will swell, producing a concomitant
decrease in the radius of curvature of the lens and a corresponding hyperopic shift in the
refractive power of the lens (Fig. 4).
The process may be repeated if the surgeon wants further refractive change in the
lens. The surgeon may then irradiate the entire lens, consuming the remaining, unreacted

Figure 4 Cartoon schematic illustrating the proposed mechanism of swelling. (a) Selective irradia-
tion of the central zone of IOL polymerizes macromer, creating a chemical potential between the
irradiated and nonirradiated regions; (b) to reestablish equilibrium, excess macromer diffuses into
the irradiated region causing swelling; and (c) irradiation of the entire IOL locks the macromer
and the shape change.
Accommodating and Adjustable IOLs 283

macromer and photoinitiator. This action effectively locks in the refractive power of the
lens (4).
The surgeon may induce a myopic change by irradiating the edges of the LAL to
effectively drive macromer and photoinitiator out of the lens central region, thereby in-
creasing the radius of curvature and decreasing the power.
One concern with the LAL is that after irradiation, the lens may not necessarily
maintain a resolution efficiency acceptable to the patient. However, preliminary data show
that this light-adjustable silicone IOL materials may provide a means to precisely and
noninvasively adjust IOL power postop, after the refractive status of the eye has stabilized.

E. RESULTS OF ACCOMMODATING AND MULTIFOCAL IOL


IMPLANTATION
Calhouns adjustable silicone formulations may become a platform technology useful
in both pseudophakic and phakic IOLs. As additional IOLs are developed, such as the
accommodating IOLs of C&C Vision and Human Optics (Erlangen, Germany), the ability
to overcome imprecision in IOL power calculation by postoperative light adjustment has
the potential to add value to these and other novel IOL designs (14).
The accommodating IOL is implanted after conventional phacoemulsification sur-
gery through a 3- or 5-mm incision. The AT45 lens is maximally positioned against the
vitreous face and sealed in place with 3 weeks of atropine treatment posoperatively. At
the base of the arms of lens are hinges that allow the lens to move forward, based on
ciliary contraction and pressure from vitreous. Any forward movement of the lens allows
for near vision, simulating natural accommodation (1,2).
The early results of a phase 1 clinical trial show the lens to be safe, complication-
free, and well tolerated. The lens appeared to provide some accommodation. The lens is
still in the evaluation stage and further clinical trials are in progress (2).
The multicomponent lens is still in the process of development, and results of clinical
trials are awaited. The multicomponent lens has been used in a cat model; at 6-month
follow-up, it was well tolerated.
Werblin has developed a hypothetical human surgical procedure that is analogous
to routine phacoemulsification surgery with implantation of a PCIOL through a 7.00-
mm incision (Fig. 3) (3). Once the base lens is implanted, the cap-and-lens assembly is
intraoperatively affixed by the surgeon to the base lens. The sandwich lens is oriented
at the appropriate astigmatic axis, based on the preoperative assessment of anticipated
postoperative astigmatism.
Once refractive stability is achieved, the patients refractive status is evaluated and
the refractive attachments can be removed or changed, depending on the amplitude and
type of residual refractive error or, in case of a multifocal attachment, if the patient is not
satisfied with the quality of vision. Such change or removal involves a second operative
procedure consisting of opening the original wound, detaching the cap-and-sandwich lens
component, and replacing it with new attachments (1,3).
In contrast to accommodating and adjustable IOLs, several clinical studies have
evaluated the feasibility and efficacy of multifocal IOLs (1,515).
In a prospective study, Vaquero et al. compared the results of implanting the AMO
array multifocal lenses with implanting a monofocal lens (5). Although distance acuity
and contrast sensitivity were similar in both groups, patients with the multifocal lens had
significantly better near acuity. In a prospective, double-masked, comparative clinical trial,
284 Azar et al.

Steinert et al. reported that significantly less correction was required in the multifocal
group than the monofocal group. However, patients in the multifocal group sustained a
small loss of contrast sensitivity (6).
Holladay et al. have evaluated the optical performances of several multifocal lenses
using laboratory and photographic studies (7). They found a two- to threefold increase in
depth of field for all multifocals but also showed a 50% reduction in contrast in retinal
image and a one-line drop in best corrected acuity. Percival and Setty conducted several
clinical trials of multifocal lenses and found them to provide better simultaneous distance
and near acuities in a significantly higher number of patients (8). Bleckman and coauthors
found multifocal progressive IOLs to provide adequate visual performance at various
distances but only in optimal light conditions (9).
In a small-sample retrospective study, Negishi et al. demonstrated that eyes im-
planted with the five-zone refractive multifocal lenses showed better near visual acuity
than control eyes and that the results compared favorably in other aspects of visual function
(10). In a clinical trial, Wille reported a better performance of monofocal lenses for distance
vision when compared to multifocal lenses (11). The mean postoperative acuity was 0.5
line higher in the monofocal than in the multifocal group.
After testing contrast sensitivity and glare in patients implanted with diffractive
multifocal IOLs, Winther-Nielsen and coworkers concluded that the most significant loss
of contrast sensitivity is found with central glare under twilight conditions (12).
In a comparative study of monofocal versus multifocal lenses, Vaqero-Ruano, et al.
reported a wider depth of focus and significantly better near vision without addition in
patients with multifocal lenses (13). The contrast sensitivity results at 96 and 50% were
similar. Walkow et al. prospectively evaluated a diffractive versus a refractive multifocal
IOL and found similar and satisfactory functional results with both except that near uncor-
rected vision was significantly better with the diffractive lens (14).
In a case control study, Javitt et al. measured functional status and quality of life
after bilateral implantation of multifocal versus a monofocal IOLs (15). The subjects with
bilateral multifocal IOLs reported better overall vision, less limitation in visual function,
and less spectacle usage than the control subjects with monofocal lenses. The difference
was most significant in ratings of near vision without spectacles.

H. CONCLUSIONS

Based on the relatively high success rate of multifocal IOLs, it is likely that several design
adjustments may need to be incorporated into accommodating and adjustable IOLs before
their use becomes commonplace. It is also likely that several of these technological ad-
vances may have to be combined in order to provide increased predictability for distance
acuity without correction after cataract surgery as well as excellent near visual acuity. The
multifocal IOLs ability to provide good distance and near visual acuity is not without
visually disturbing loss of contrast sensitivity. Similarly, the success of monovision refrac-
tive surgery does not exceed the 80% mark in most studies (1619). Accordingly there
will be ample room for innovation in technology and surgical technique to provide excellent
uncorrected distance and near acuities without optical aberrations. The successful prelimi-
nary results of accommodating and adjustable IOLs will provide the incentive for continued
efforts and developments in this exciting field of research.
Accommodating and Adjustable IOLs 285

REFERENCES
1. Vajpayee RB, Jain S, Azar DT. Astigmatic intraocular lenses, multifocal intraocular lenses,
and other specialized intraocular lenses. In: Azar DT, ed. Intraocular Lenses in Cataract and
Refractive Surgery. Philadelphia: Saunders, 2001: 299306.
2. New IOL restored some accommodation in trial. Ocul Surg News. 1999.
3. Werblin TP. Multicomponent intraocualar lens. J Refract Surg 1996; 12:187189.
4. Schwiegerling JT, Schwartz DM, Sandstedt CA, Jethmalani J. Light-adjustable intraocular
lenses: finessing the outcome. Rev Refract Surg 2002: 2325.
5. Vaquero M, Encinas JL, Jimenez F. Visual function with monofocal versus multifocal IOLs.
J Cataract Refract Surg 1996; 22:12221225.
6. Steinert RF, Post CT Jr, Brint SF, Fritch CD, Hall DL, Wilder LW, Fine IH, Lichtenstein SB,
Masket S, Casebeer C. A prospective, randomized, double-masked comparison of a
zonalprogressive multifocal intraocular lens and a monofocal intraocular lens. Ophthalmol-
ogy 1992; 99:853861.
7. Holladay JT, van Dijk H, Lang A, Portney V, Willis TR, Sun R, Oksman HC. Optical perfor-
mance of multifocal intraocular lenses. J Cataract Refract Surg 1990; 16:413422.
8. Percival SPB, Setty SS. Prospectively randomized trial comparing the pseudoaccommodation
of the AMO ARRAY multifocal lens and a monofocal lens. J Cataract Refract Surg 1993; 19:
2631.
9. Bleckmann H, Schmidt O, Sunde T, Kaluzny J. Visual results of progressive multifocal poste-
rior chamber intraocular lens implantation. J Cataract Refract Surg 1996; 22:11021107.
10. Negishi K, Nagamoto T, Hara E, Kurosaka D, Bissen-Miyajima H. Clinical evaluation of a
five-zone refractive multifocal intraocular lens. J Cataract Refract Surg 1996; 22:110115.
11. Wille H. Distance visual acuity with diffractive multifocal and monofocal intraocular lenses.
J Cataract Refract Surg 1993; 19:251253.
12. Winther-Nielsen A, Corydon L, Olsen T. Contrast sensitivity and glare in patients with a
diffractive multifocal intraocular lens. J Cataract Refract Surg 1993; 19:254257.
13. Vaquero-Ruano M, Encinas JL, Millan I, Hijos M, Cajigal C. AMO Array multifocal versus
monofocal intraocular lenses: long-term follow-up. J Cataract Refract Surg 1998; 24:118123.
14. Walkow T, Liekfeld A, Anders N, Pham DT, Hartmann C, Wollensak J. A Prospective evalua-
tion of a diffractive versus a refractive designed multifocal intraocular lens. Ophthalmology
1997; 104:13801386.
15. Javitt JC, Wang F, Trentacost DJ, Rowe M, Tarantino N. Outcomes of cataract extraction with
multifocal intraocular lens implantation. Functional status and quality of life. Ophthalmology
1997; 104:589599.
16. Jain S, Azar DT. Eye infections after refractive keratotomy. J Refract Surg 1996; 12(1):
148155.
17. Jain S, Arora I, Azar DT. Success of monovision presbyopes: review of the literature and
potential applications to refractive surgery. Surv Ophthalmol 1996; 40(6):491499.
18. Sippel KC, Jain S, Azar DT. Monovision achieved with excimer laser refractive surgery. Int
Ophthalmol Clin 2001; 41(2):91101.
19. Chang MA, Kloek CE, Zafar S, Jain S, Azar DT. Analysis of strict monovision and minimonovi-
sion LASIK surgery in presbyopes. Arch Ophthalmol. Submitted.
26
Accommodative Amplitude
Measurements After Surgery for
Presbyopia

DAVID L. GUYTON
The Wilmer Institute, The Johns Hopkins University School of Medicine, Baltimore,
Maryland, U.S.A.

A. INTRODUCTION
Several years ago in Houston, Texas, through the courtesy of Dr. Richard Yee, I had the
opportunity to examine and refract two patients after surgery for presbyopia. My observa-
tions were not only surprising but also instructive. The surgery had been successful, but
by a different mechanism from that proposed. The answer was in the retinoscopic reflex.
Both patients had undergone Schachars scleral band procedures for presbyopia 2
to 3 months before. Both had experienced a beneficial optical effect, and both showed
similar retinoscopic reflexes. The one with the more complete effect had the more
striking reflexes. This patient was 56 years old. She had previously been essentially em-
metropic bilaterally and had depended on reading glasses for near vision. She now went
without glasses entirely, with 20/20 uncorrected visual acuity at both distance and near.
She was ecstatic with the result. She had been invited to the clinic for me to examine just
prior to having the scleral bands removed because of erosion through the conjunctiva.
After confirming the distance and near 20/20 uncorrected visual acuity in each
eye, I proceeded with the distance refraction. The retinoscopic reflex was confusing, but
subjective refraction showed only small astigmatic corrections. With these minor correc-
tions in place, I placed a small visual acuity chart beneath the peephole of my retinoscope
and asked her to look from distance to near as I observed the retinoscopic reflexes.

B. DYNAMIC RETINOSCOPY
The technique I was using is a form of dynamic retinoscopy first described by Edward
Jackson in 1895 (1). It is a marvelous method to assess the speed and completeness of
287
288 Guyton

Figure 1 Dynamic retinoscopy without lenses. The patient (A), wearing refractive correction if
any, looks alternately between a distant target and a near accommodative target that the examiner
holds just beneath the retinoscope peephole (B). Accommodation is observed objectively by neutrali-
zation of the with retinoscopic reflex when the patient accommodates to the plane of the near
target.

accommodation, a method well described in the literature (24) (see Fig. 1) but not familiar
to most ophthalmologists. The typical appearance is strong with movement with the
patient looking past the edge of the retinoscope at the distance fixation target. As attention
is shifted to the accommodative target just beneath the peephole of the retinoscope and
as the eyes accommodate to this distance, the retinoscopic reflex broadens to neutralization
over about 1/2 s. In other words, the pupil fills with light, and neither with nor against
movement is visible. This striking change in the retinoscopic reflex can be observed
repeatedly as the patient is instructed to look back and forth between distance and near.
The speed, completeness, and stability of accommodation can thus be observed objectively.
Residual astigmatism is easily detected, and when the procedure is performed under binoc-
ular conditions, anisometropia is evident by unequal neutralization of the two reflexes.
To my surprise, my rejuvenated presbyope showed absolutely no perceptible
change in the retinoscopic reflexes when looking from distance to near, and yet she could
easily read the smallest letters on the near acuity chart. The clue to this total lack of
objective accommodation, even though subjective accommodation appeared restored, was
the shape of the retinoscopic reflexes.

C. RETINOSCOPIC REFLEXES

The streak retinoscope gives a linear reflex in eyes with regular spherical or astigmatic
refractive error. In other words, the streak is the same width everywhere along its length.
Accommodative Amplitude Measurements 289

Figure 2 The retinoscopic reflex seen with (A) the eye focused well beyond the retinoscope; (B)
the eye focused just beyond the retinoscope; (C) a multifocal crystalline lens focused for distance
in the center of the pupil and for near in the periphery of the pupil.

Typical reflexes are illustrated in Figure 2A, which shows the eye focused well beyond
the retinoscope. Figure 2B shows the eye focused just beyond the retinoscope. If the eye
were focused exactly in the plane of the retinoscope peephole, the red retinoscopic reflex
would totally fill the pupil.

D. MULTIFOCAL CRYSTALLINE LENS


My patients reflexes correlated with neither Figure 2A nor Figure 2B but rather with
Figure 2C. The streak was narrow in the center and broad at the top and bottom, in an
hourglass shape. This shape persisted as the streak was rotated from one meridian to the
next. Clearly the eye was focused for distance in the center of the pupil and for near in
its periphery. A multifocal crystalline lens appeared to have been created by the procedure.
(This appearance changed little as the retinoscope was moved off axis, indicating that the
multifocal effect was in the crystalline lens, not in the cornea.)

E. INCREASED DEPTH OF FOCUS


It now became clear how this presbyopic patient was able to see clearly at both distances.
She had been given multifocal crystalline lenses by the surgery. Because the retinoscopic
reflex had not changed from distance fixation to near fixation, no true accommodation
was occurring. The new multifocal effect simply created a huge depth of focus that enabled
both distance and near vision without any active accommodation.
By adding plus lenses to neutralize the center of the retinoscopic reflex, I observed the
peripheral portion of the reflex to move strongly against, confirming that the periphery of
the pupil was myopic with respect to the center. This type of refractive aberration is called
positive spherical aberration, most commonly occurring naturally in young children.
When it occurs naturally, however, the zones in the center and periphery are more clearly
defined, with linear streak reflexes in each zone. In my rejuvenated presbyope, the
transition from the emmetropic central zone to the myopic peripheral zone appeared more
continuous, resulting in the hourglass-shaped reflex.

F. TRADITIONAL TECHNIQUES FOR MEASURING


ACCOMMODATION
I have not yet had the opportunity to confirm this retinoscopic appearance in other patients
after surgery for presbyopia. If indeed this finding is routinely present, then traditional
methods for measuring accommodation are not applicable to these patients.
290 Guyton

Donderss push-up method of measuring accommodative amplitude becomes instead


a method of measuring the effective depth of focus of the eye, with any contribution due
to true accommodation being impossible to distinguish. Similarly, adding minus lenses
until blur occurs is simply a measure of depth of focus, not of accommodation.
Infrared objective optometers have been used in attempts to measure accommodation
after surgery for presbyopia, but without success (5). Caution must be observed in using
these instruments, however, because some of them use only small portions of the pupil
for the refractive measurement, and small changes in alignment can yield variable results
in the presence of irregular or multifocal optics.

G. WAVEFRONT ANALYSIS
Wavefront analysis methods of measuring the refractive state across the pupil will be able
to determine the refractive state of the multifocal zones in the altered crystalline lenses
observed by retinoscopy. These new methods will also be able to detect whether or not
any true optical changes occur with attempted accommodation (6). To my knowledge,
these instruments have not yet been used to measure accommodation after surgery for
presbyopia. I look forward to the results.

H. CONCLUSION
Whatever the mechanism of refractive change produced by surgical procedures for presby-
opia, there is no question that a close focus can be created under certain conditions.
Whether these beneficial effects will prove to be reproducible and stable and whether they
will provide acceptable visual acuity and contrast remains to be seen.

REFERENCES
1. Jackson E. Skiascopy and Its Practical Application to the Study of Refraction. Philadelphia:
Edwards and Docker Co., 1895:8688.
2. Guyton DL, OConnor GM. Dynamic retinoscopy. Curr Opin Ophthalmol 1991; 2:7880.
3. Rutstein RP, Fuhr PD, Swiatocha J. Comparing the amplitude of accommodation determined
objectively and subjectively. Optom Vis Sci 1993; 70:496500.
4. Rosenfield M, Portello JK, Blustein GH, Jang C. Comparison of clinical techniques to assess
the near accommodative response. Optom Vis Sci 1996; 73:382388.
5. Mathews S. Scleral expansion surgery does not restore accommodation in human presbyopia.
Ophthalmology 1999; 106:873877.
6. Gray GP, Campin JA, Pettit GH, Liedel KK. Use of wavefront technology for measuring
accommodation and corresponding changes in higher order aberrations (abstr). Invest Ophthal-
mol Vis Sci 2001; 42:S26.
27
Complications of Hyperopia and
Presbyopia Surgery

LIANE CLAMEN GLAZER and DIMITRI T. AZAR


Corneal and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary,
Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

A. BACKGROUND

Planning refractive surgery for a myope is like being an experienced golfer with many
clubs to choose from and a good understanding of the potentials and the limitations of
each club. Choosing a procedure for hyperopic refractive surgery, on the other hand, is
more like being a novice golfer, still not quite sure which clubs are useful and which are
optimal under different circumstances. Indeed, there is still no consensus as to the best
methods for the surgical treatment of hyperopia. As one compares the treatment options
that are currently available, a solid understanding of the potential complications of each
refractive procedure will help one choose the most appropriate procedure for each patient.
There are a number of reasons why refractive surgery for hyperopia has not been
as popular as surgery to correct myopia. First, while hyperopia affects approximately
40% of the adult population, it is less visually significant than myopia (1). For example,
approximately 80% of adult hyperopes require corrections of only 3.0 D or less (2).
Accommodation may produce enough additional plus power to focus parallel rays of
light on the retina. Thus, young hyperopes can often compensate and see well until their
accommodative power weakens and they start experiencing manifest hyperopia in their
mid-to late 30s. It follows that the average age of people seeking hyperopic correction is
approximately 48 years, much higher than those seeking myopic correction (35). These
older patients are more likely to suffer from presbyopia, dry eyes, glaucoma, and cataracts.
Finally, hyperopic refractive surgery is more challenging than myopic surgery because it
is more difficult to permanently steepen the central cornea than to flatten it.
291
292 Glazer and Azar

Complications plagued early attempts at hyperopic refractive surgery. The first at-
tempts at hyperopic correction using hexagonal keratotomy, automated lamellar kera-
toplasty, contact laser thermal keratoplasty (LTK), epikeratophakia, and keratophakia often
created more problems than they solved: irregular astigmatism, corneal ectasia, unpredicta-
ble results, or regression frequently occurred. Therefore, these methods of correcting hyper-
opia have been abandoned. In the evolution of hyperopic refractive surgery, the fittest
procedures have proven to be PRK, LASIK, noncontact LTK, phakic intraocular lens
(IOL) implantation, and clear lens extraction with IOL implantation. Of course, even these
procedures can occasionally cause complications.

B. COMPLICATIONS OF PRK AND LASIK


Excimer lasers are used for both photorefractive keratectomy (PRK) and laser-assisted in
situ keratomileusis (LASIK). When using a laser to achieve correction of hyperopia, the
surgeon creates peripheral annular ablation around the central optical zone to produce
central steepening. This requires excimer lasers with larger ablation diameters than those
used to correct for myopia. In addition, more tissue must be removed per diopter of
correction for hyperopic versus myopic LASIK or PRK.

1. Hyperopic-Photorefractive Keratectomy (H-PRK)


PRK was introduced as a method for correcting refractive errors in 1983 (67). However,
PRK for hyperopia (H-PRK) is still fairly uncommon and certainly much less common
than PRK for myopia. A hyperopic ablation takes approximately three times longer to
perform than a myopic ablation of similar magnitude. It simply takes longer to create a
peripheral ablation zone that will steepen the central cornea than it does to create a central
ablation area that flattens the central cornea (Fig. 1). The time involved increases the
likelihood of dehydration and decentration (8). Decentration may cause irregular astigma-
tism and loss of best corrected visual acuity (BCVA). In addition, regression of effect is
more likely to occur after H-PRK than after a PRK procedure for myopia. Finally, while
the U.S. Food and Drug Administration (FDA) has approved PRK for the correction of
hyperopia of up to 6.00 D with less than 1.00 D of astigmatism, steepening a cornea
above 4.00 D becomes increasingly difficult: smaller optical zones and greater sensitivity

Figure 1. Hyperopic ablation profile of the VISX STAR Laser. This example of a hyperopic
ablation profile demonstrates the large peripheral ablation zone necessary for H-PRK. (From Ref.
4.)
Complications of Refractive Surgery 293

to decentration are evident in higher hyperopic corrections. There are other potential com-
plications of H-PRK (Table 1). For example, PRK produces large (9.5-mm) epithelial
defects, leading to prolonged healing time, and an increased risk of infection while the
cornea is healing. Recurrent corneal erosions are a bothersome potential complication of
PRK. Haze and scar formation may also occur. Postoperative glare may be a nuisance,
particularly for patients with larger pupils.

Table 1 Complications of PRK for Correction of Spherical Primary Hyperopia


Mean Loss of best
No. of follow-up Technique and corrected visual
Study Year eyes (months) microkeratome used Complications acuity (BCVA)

OBrart (12) 1997 43 6 Summit Apex Plus 21% subepithelial 23% lost 1 line
Laser, combining haze 5% lost 2 lines
an erodible mask 2.3% recurrent
and an Axicon corneal erosions
system 5% irregular
9.5-mm peripheral epithelial healing
zone/6.5-mm 2.3% astigmatic
optical zone change
Daya (3) 1997 25 6 Chiron Keracor 116 4.4% halos 6.7% lost 2
Excimer Laser 6.7% glare lines
8.5-mm peripheral (Note: Complication
zone/5.0-mm rates combine PRK
optical zone patients with PARK
patients.)
Jackson (4) 1998 65 14 VISX Star Excimer 15.4% filaments in 31% lost 1 line
Laser the eyes at 6 months
9.0-mm peripheral 21.5% epithelial 2% lost 2 lines
zone/ 5.0-mm erosions at 6 months
optical zone 23% epithelial ridge 29% lost 1 line
at the site of at 18 months
epithelial closure
Williams (5) 2000 41 12 VISX Star Excimer 21% haze No long-term
Laser (Note: Complication loss of BCVA
9.0-mm peripheral rates combine
zone/ 5.0-mm primary PRK and
optical zone secondary PRK
patients.)
El-Agha (9) 2000 22 12 VISX Star S2 4.5% transient 13.6% lost 1
Excimer Laser peripheral haze in line
8.8- to 9.0-mm the ablation zone 9.0% lost 2
ablation lines
diameter/5.0-mm
optical zone
Haw (10) 2000 18 24 Summit Apex Plus 78% midperipheral 5.5% lost 2 or
Excimer Laser, stromal haze, sparing more lines
Combining an the optical zone under glare
Erodible mask and conditions
an Axicon system
9.4-mm peripheral
zone/6.5-mm
optical zone
294 Glazer and Azar

a. Ablation Zone Decentration


A hyperopic correction, which produces a steepening of the central cornea, is less forgiving
of decentration. And yet centration is more difficult during hyperopic corrective surgery
because hyperopic eyes tend to be smaller, with smaller corneas, and because the ablation
zone must be large. In addition, H-PRK takes up to three times longer than a comparable
myopic PRK procedure; thus the risk of decentration is higher. Decentration is the H-
PRK complication that is most likely to cause loss of BCVA or irregular astigmatism.
Decentration, with either H-PRK or H-LASIK, may occur either due to a decentered
treatment throughout the ablation (shift) or due to intraoperative drift. Shift can be second-
ary to poor patient fixation or to the surgeons error. Drift occurs secondary to involuntary
intraoperative eye movement or to a surgeons attempt to correct apparent decentration
during treatment.
Decentration is difficult to treat. Theoretically, one can lift the flap and retreat the
patient with decentration of the treatment in the opposite direction to the previous ablation.
An alternative solution is to use miotics to constrict the pupillary axis and to minimize
optical aberrations. Finally, a hard contact lens may neutralize optical aberrations resulting
from irregular astigmatism (13).
Techniques to avoid decentration include (1) the creation of larger optical (5-mm)
and ablation (9.09.5 mm) zones, (2) the use of faster laser pulses to decrease the ablation
time, and (3) more sophisticated eye-tracking devices. Finally, performing the ablation
under the lowest illumination possible can improve patient fixation.
b. Regression
Regression of effect after H-PRK remains one of the limitations of this procedure. It has
been observed that aggressive healers, patients with severe corneal haze and marked
scarring in the region of ablation, had significant regression of their refractive correction.
This observation supports the theory that the mechanisms associated with regression are
the subepithelial deposition of collagen and glycosaminoglycans which occurs during
wound healing and produces a filling in of the ablation and loss of effect (12,1415).
Some ophthalmologists have given topical corticosteroids after PRK in an attempt to inhibit
regression. Studies consistently show that while topical corticosteroids (fluorometholone or
dexamethasone) inhibit some regression when used during the first 3 to 6 postoperative
months, this effect is negated approximately 3 months after cessation of steroids (4,1417).
The development of new strategies to reduce aggressive wound healing and haze after
PRK may prevent post-PRK regression.
c. Haze
One potential post-PRK complication is the development of haze. Fortunately, haze is
less of an issue with H-PRK than it is for myopic PRK. This is because the stromal haze
is most dense at the border of the ablated zone, which is in the peripheral (rather than
central) cornea of eyes treated for hyperopia (Fig. 2). Nevertheless, haze can contribute
to regression of effect, as mentioned above. Therefore, it is best to try to prevent haze
formation. Risk factors for haze include small ablation diameters with steep transition
zones, UV exposure, acute systemic viral illness, and ocular surface disorders such as dry
eyes (1820).
Haze may be prevented by maintaining a good tear film layer with nonpreserved
tears or punctal plugs if necessary. One can encourage patients to decrease exposure to
Complications of Refractive Surgery 295

Figure 2 Midperipheral ring of corneal haze, characteristic of the haze seen after PRK for hyper-
opia. (From Ref. 10.)

UV radiation by using sunglasses and a hat for 1 year after PRK is performed. Some
authors suggest preventing formation of the corneal haze with a single intraoperative
treatment of mitomycin C to suppress proliferation of keratocytes. Studies in rabbits have
proven this to be very effective (21). A less aggressive approach is to wait and see if haze
occurs and then to apply mitomycin C to treat corneal haze and reduce the regression that
often accompanies the haze (22). One can treat stromal haze that persists beyond 6 months
with excimer laser retreatment or a transepithelial PRK followed by PRK retreatment.

2. Hyperopic-Laser in situ Keratomileusis (H-LASIK)

Although early trials of hyperopic LASIK (H-LASIK) reported unsatisfactory results with
a high rate of BCVA loss and significant regression, H-LASIK is now supplanting H-
PRK as the refractive procedure of choice for hyperopia (23,24). H-LASIK is associated
with a faster recovery time with less postoperative pain than H-PRK. Initially, H-LASIK
was limited by small outer-zone ablations: microkeratomes that could create only small
flaps as well as unrefined excimer laser algorithms contributed to the poor results of early
H-LASIK. With the development of keratomes that are able to create 9.5-mm rather than
the older 8.5-mm flaps, H-LASIK has become safer. In addition, better algorithms and
nomograms are being developed as we accrue more experience with H-LASIK.
Limitations of LASIK for the treatment of hyperopia include problems with predicta-
bility, regression, and difficulty treating hyperopia greater than 4 D. Complications of
H-LASIK can be divided into three groups. First are the complications specific to the
surgical correction of hyperopia itself. As discussed above, these include the older age of
the patients and the length of time of the procedure. Second, there may be intraoperative
complications, including flap complications and ablation-related complications. Finally,
postoperative complications include infection, flap complications, striae, diffuse lamellar
keratitis, epithelial ingrowth, decentration, corneal ectasia, and, rarely, retinal complica-
tions (Table 2).
296 Glazer and Azar

Table 2 Complications of LASIK for Correction of Spherical Primary Hyperopia


Mean Loss of best
No. of follow-up Technique and corrected visual
Study Year eyes (months) microkeratome used Complications acuity (BCVA)

Suarez (25) 1996 154 3 Coherent/Schwind 1.3% corneal ectasia 2% lost 1 line
Keratom II Epithelial invasion of 1.3% lost 2
Excimer Laser the interface lines
Automated Corneal Traumatic flap
Shaper displacement
8.5-mm flap diameter Bilateral haze
Ditzen (26) 1998 43 12 MEL 60 Excimer 15% epithelial 9% lost 1 line
Laser ingrowth 4.7% lost 3
Automated Corneal 2.3% haze lines
Shaper 7.5% scars
8.5-mm flap diameter 4.7% vertical
decentration
2.3% central island
4.7% free cap
11.6% flap
dislocation
11.6% flap folds
Goker (27) 1998 54 19 Keracor 116 Excimer 31.4% epithelial 5.6% lost 2
Laser ingrowth lines
Automated Corneal 13%
Shaper regressed/under-
8.5-mm flap diameter corrected
9.3% glare at 9
months
3.7% transient
diplopia that resolved
entirely
1.8% irregular flap
cut
1.8% decentration
3.7% irregular
astigmatism
Knorz (28) 1998 23 12 Keracor 117 Excimer No significant 63% of low
Laser complications noted hyperopes lost
Automated Corneal 1 line
Shaper 50% of high
8.5-mm flap diameter hyperopes lost
1 line
Esqucnazi (29) 1999 100 12 Keracor 117CT 6% epithelial 6% lost 1 line
Excimer Laser ingrowth into the at 1 year
Automated Corneal interface follow-up
Shaper 4% scars on nasal 6% lost 2 lines
8.5-mm flap diameter side at 1 year
2% ablation follow-up
decentration 5% lost 2 lines
2% transient diplopia at 2 year
5% flap folds follow-up
Lindstrom (30) 1999 46 6 VISX STAR S2 6.5% transient 11% lost 1 line
Excimer Laser epithelial defect 2.2% lost 2
Hansatome 4.3% diffuse lamellar lines
9.5-mm flap diameter keratitis
(continued)
Complications of Refractive Surgery 297

Table 2 Continued
No. Mean Technique and Loss of best
of follow-up microkeratome corrected visual
Study Year eyes (months) used Complications acuity (BCVA)

4.3% epithelial cells


in the interface
2.2% haze
2.2% mild irreg astig
Arbelaez (31) 1999 192 12 Keracor 177C 0.6% had a free cap
Excimer Laser 0.6% sterile keratitis, 13% of high
Automated Corneal (Note: Complication hyperopes lost
Shaper rates combine the 2 lines or more
9.0-mm flap diameter 192 spherical
hyperopes with the
164 toric hyperopes.)
Zadok (32) 2000 72 6 Nidek EC-5000 No significant
Excimer Laser complications noted 1.4% lost 2
Automated Corneal lines or more
Shaper
8.5-mm flap diameter
Reviglio (33) 2000 50 6 Lasersight 200 2% epithelial
Excimer Laser ingrowth in the No eyes lost
with 9.0 software would edges BCVA
Automated Corneal associated with free
Shaper caps, not requiring
9.0- to 9.5-mm flap surgical removal
diameter
Argento (34) 2000 147 12 Keracor 117C 8.2% transient
Excimer Laser epithelial ulcer Less than 5.8%
Hansatome 4.5% stromal lost 1 line
5.9-mm optical zone infiltrates
diameter, flap
diameter not
reported
El-Agha (9) 2000 26 12 VISX STAR S2 No significant
Excimer Laser complications noted 19% lost 1 line
Hansatome 7.7% lost 2
9.5-mm flap diameter lines
Choi (35) 2001 32 6 VISX S2 Smoothscan No significant
Excimer Laser complications noted 25% lost 1 line
Hansatome 9% lost 2 lines
9.5-mm flap diameter

a. Flap Complications
Intraoperative complications include free flaps, incomplete flaps, buttonholes, small flaps,
and thin flaps. Free flaps, thin flaps, or incomplete flaps are more likely to occur in patients
with flat (41.00-D) and large (11.5-mm) corneas. Unusually steep (48.00-D) and
small (11.5-mm) corneas are more conducive to buttonholes or large flaps.
The larger ablation areas necessary for H-LASIK require larger flaps. Extra care
must be taken with the larger flaps because a large flap may be more prone to wrinkles
298 Glazer and Azar

or misalignment, which may lead to irregular astigmatism. When pannus exists, a large
flap may cause bleeding, which must be cleared from the bed prior to ablation.
Appropriate preoperative examinations can help one identify and discourage patients
at greater risk for flap complications. Preplaced surgical landmarks that straddle the flap
edge will help with accurate repositioning of the flap in the operative and postoperative
period. In addition, the newer microkeratomes and suction rings create fewer flap complica-
tions.
b. Epithelial Ingrowth
To achieve successful H-LASIK results, the diameter of the corneal flap must be large
enough. Epithelial ingrowth can result from laser energy to the periphery of the flap, or
it may occur secondary to wound edge instability with migration of epithelial cells under
the flap (Fig. 3). Epithelial ingrowth can progress to involve the visual axis, creating
irregular astigmatism and even melting of the overlying flap (13,36).
If epithelial cells under the flap progress toward the visual axis or induce stromal
melting, the flap should be lifted, the stromal bed and flap undersurface should be thor-
oughly irrigated and scraped, and the flap should then be repositioned (37).
With larger flaps of 9 to 10 mm, the risk of epithelial ingrowth is greatly reduced,
most likely because this avoids ablation of epithelium beyond the edge of the flap (38).
Other measures one may take to prevent epithelial ingrowth include using dedicated instru-
ments exclusively for interface manipulation, so that these instruments do not come in
contact with the surrounding epithelium. Also, one should be careful to avoid flap folds,
as these may provide a conduit for cell infiltration (13).
c. Decentration
Decentration or small optical zones may lead to irregular astigmatism, causing loss of
BCVA, glare, monocular diplopia or halos, and halo effects. The same principles of de-
centration described above for PRK apply here. For example, whether with PRK or LASIK,
a larger optical zone is more forgiving of a slight decentration. More sophisticated LASIK
ablation profiles may also diminish the risk of decentration: a more gradual transition
zone between ablated and unablated tissue helps minimize epithelial and stromal regenera-
tion, with its subsequent regression.

Figure 3 Epithelial ingrowth after LASIK. (A) Stable epithelial ingrowth at the LASIK interface.
(B) Retroillumination used to view the same area of epithelial ingrowth. (From Ref. 13.)
Complications of Refractive Surgery 299

Figure 4 Diffuse lamellar keratitis following LASIK. (A) Diffuse lamellar keratitis 2 days after
LASIK. (B) Diffuse lamellar keratitis, 5 days after LASIK, with central coalescence, scarring, and
stromal melt. (From Ref. 13.)

d. Diffuse Lamellar Keratitis


Although diffuse lamellar keratitis (DLK) is a recently described syndrome, not yet docu-
mented after H-LASIK, it has been reported in approximately 0.2 to 3.2% of cases of
myopic LASIK (13,3942). DLK is characterized by a proliferation of inflammatory cells
at the LASIK interface (Fig. 4). It can lead to loss of BCVA due to irregular astigmatism
and may also cause stromal corneal melting with induced hyperopia or hyperopic astigma-
tism.
The cause of DLK is still unclear; thus, prevention remains a challenge. When
present, however, DLK must be treated immediately with hourly topical prednisolone
actate 1% and broad-spectrum topical antibiotic coverage. It has been observed that if the
DLK is not resolved by the fifth postoperative day, there is typically central coalescence
of the inflammatory cells, which may lead to central stromal melting and scarring. Thus,
if inflammation progresses despite the steroid/antibiotic treatment, the flap should be lifted,
scraped, and irrigated by the fourth postoperative day at the latest (13). The use of topical
intrastromal steroid during LASIK has been proposed as a way of reducing the incidence
and severity of DLK (43).
e. Late Flap Dislocation
One rare, potential H-LASIK complication is traumatic flap dislocation, occasionally seen
months or years after LASIK (44,45). One might expect a slightly greater risk of flap
dislocation in H-LASIK because the flap tends to be wider than that created for myopic
LASIK. For this reason, it would be wise to avoid performing H-LASIK on high-risk
patients, such as boxers. One should also encourage patients to wear safety glasses when
engaging in high-risk sports activities after H-LASIK.
f. Corneal Ectasia
Corneal ectasia is a rare complication. For example, in one of the largest studies of H-
LASIK, Suarez et al. performed LASIK on 154 eyes of patients with simple hyperopia
of between 1.00 and 8.50 D with astigmatism of less than 0.75 D. Suarez et al. had
only two cases of postoperative corneal ectasia, both occurring in patients with high levels
of hyperopia. Keratectasia is most likely due to the mechanical uncoupling of the posterior
300 Glazer and Azar

from the anterior stroma, with subsequent weakness of the cornea. Denervation of the flap
or subclinical epithelial ingrowth may exacerbate this mechanical uncoupling. Other fac-
tors that may predispose to corneal ectasia include excessive ablation with less than 250
m of residual stromal bed, a thicker than normal flap with consequent ablation at a deeper
than planned level, and irregular corneal thickness (46). One can attempt to prevent corneal
ectasia with preoperative pachymetry maps to detect borderline cases. One must also
identify patients with keratoconus and prevent them from undergoing H-LASIK because
they, of course, would be at great risk for postoperative corneal ectasia.
g. Loss of Best Corrected Visual Acuity
Loss of BCVA is more likely to occur after H-LASIK performed on high hyperopes. Choi
notes that 50% of eyes with attempted corrections greater than 5 D lost two lines of BCVA.
These high rates of loss of BCVA in eyes with high hyperopia may be due to induced
irregular astigmatism (2728,3031,35). Irregular astigmatism can result from poor cen-
tration of the ablation. Even small levels of decentration can cause irregular astigmatism,
leading to degraded vision quality or monocular diplopia.
Knorz performed a pilot study on eyes with hyperopia and hyperopic astigmatism.
In eyes with 5.1 D to 10 D of hyperopia (15 eyes), 53% had lost one line at 1 month,
and 20% had lost two or more lines of BCVA at 1 month. For 12-month follow-up, 6
eyes were available, and 50% of these had lost one line while none had lost two or more
lines of BCVA. No significant intraoperative or postoperative complications were noted.
However, it was felt that the loss of acuity was due to image degradation by significant
optical aberrations caused by the new corneal surface. Knorz concluded his study by
suggesting that LASIK should not be used for hyperopia 5 D.(28) Studies of myopic
LASIK procedures have identified other causes of loss of BCVA to include flap folds,
epithelial defects, lamellar keratitis, and epithelial ingrowth (30).

3. Conclusion
As we gather more experience with hyperopic PRK and LASIK, we can achieve higher
rates of predictability and accuracy by creating nomograms adjusted for preoperative re-
fraction, keratometry, and age. Also, more sophisticated equipment can decrease complica-
tion rates for both PRK and LASIK: more sophisticated ablation profiles and better eye-
tracking systems can reduce decentrations. For LASIK, newer, larger microkeratomes that
produce flap diameters of at least 9.0 mm should be used.

C. COMPLICATIONS OF NONCONTACT LASER THERMAL


KERATOPLASTY
1. Background
Thermal keratoplasty (TK) was first performed in 1898 by the Dutch ophthalmologist
Lendert Jan Lans in an attempt to treat astigmatism (47). Lans demonstrated that thermal
energy, applied with a cautery, altered the structure of the corneal stromal collagen and
changed the anterior corneal curvature. Unfortunately, using simple cauteries and probes,
it was difficult to control the amount of energy applied, and TK resulted in unpredictable
results and regression (48,49). Interest in TK was rekindled with the development of lasers
that could heat the cornea in a more controlled manner.
Complications of Refractive Surgery 301

Figure 5 Slit-lamp photograph of a cornea immediately after treatment with noncontact holmium:
YAG laser thermal keratoplasty. (From Ref. 55.)

In 1990, Seiler first described laser thermal keratoplasty (LTK), which utilizes the
holmium:yttrium aluminum garnet (Ho:YAG) laser to correct hyperopia (50). Ho:YAG
LTK avoids damage to the corneal epithelium by delivering infrared radiation to the mid-
stroma. LTK changes the anterior corneal curvature because corneal collagen shrinks by
30 to 45% of its original length at temperatures of 55 to 60C (51). Local, peripheral
flattening causes central steepening, which corrects for hyperopia. Initially, both contact
and noncontact LTK were performed. However, contact LTK, performed by directly appla-
nating the cornea with a probe, tended to cause irregular astigmatism, regression and
undercorrection; this form of LTK was withdrawn from U.S. Food and Drug Administra-
tion (FDA) trials (5254).
Noncontact LTK, on the other hand, has been approved by the FDA. It is traditionally
performed by projecting one to three concentric rings of eight laser spots each onto the
cornea through a slit lampmounted, fiberoptic delivery system (Fig. 5). FDA phase IIA
clinical trials with 2 years of follow-up showed the uncorrected visual acuity (UCVA)
was improved by one or more lines in 19 (73%) of 26 treated eyes (55).

2. Complications
While a variety of complications may occur following LTK, the most common is regression
of effect (Table 3). Short-term complications include discomfort immediately after LTK
treatment or for 1 to 3 days post-LTK; some patients complain of mild pain (1820%),
tearing (4143%), mild photophobia (3341%), mild foreign-body sensation (4154%),
and other mild discomfort (29%). These side effects of laser-induced epithelial injury
typically resolve within 3 days of treatment (56,58). Corneal opacities and epithelial haze
and staining are common in the first week post-LTK treatment. However, by 2 years after
treatment, corneal opacities at the treated sites and golden-brown intraepithelial deposits
(presumably iron deposits) in or adjacent to inferior treatment spots are typically the only
evidence of change to the cornea (56). Long-term damage to the central cornea has not
been reported as a complication.
Clearly, the principal limitation of noncontact LTK is regression. Reported rates of
regression vary from 27 to 45% (5558). In one study, 70.1% had an UCVA of 20/20 at
302 Glazer and Azar

Table 3 Complications of Noncontact LTK for Correction of Spherical, Primary Hyperopia


Mean Loss of best
No. of follow-up Technique corrected visual
Study Year eyes (months) used Complications acuity (BCVA)

Koch (56) 1996 17 24 Sunrise 27% had 0.5 to 1.0 6% lost 2 lines
Technologies D of induced of BCVA
delivery system astigmatism
1 ring of 8 spots 27% regression
per ring
Koch (55) 1997 28 24 Sunrise 29% regression in 7% lost 1 line
Technologies the 1-ring group of spectacle-
delivery system corrected near
12 rings of 8 visual acuity
spots per ring
Alio (57) 1997 57 15 Sunrise 31.5% had total No loss of
Technologies regression BCVA
delivery system
23 rings of 8
spots per ring
Nano (58) 1998 182 12 Sunrise 45% regression No loss of
Technologies 0.55% decentered BCVA
delivery system treatment ring
13 rings of 8 0.55% with 1 D of
spots per ring induced astigmatism
Vinciguerra (59) 1998 16 12 Sunrise 25% complained of No loss of
Technologies halos or ghost BCVA
delivery system images at 12-month
3 rings of 8 spots follow-up
per ring

3 months, but only 50.8% maintained this level at 15 months. In fact, by 15 months, only
57.8% were within 1.00 D of the intended refraction (57). In addition to regression of
effect, astigmatism may occur as a result of noncontact LTK.

3. Etiology of Regression
Some researchers feel that regression is inherent to the current technique for LTK. The
Ho:YAG LTK technique delivers pulses of energy to the cornea. The pulses themselves
may trigger a mixed shrinkage/relaxation pattern. For example, if the energy pulses are
too low, an insufficient amount of collagen shrinkage is achieved, and the initial refractive
change may gradually be lost. On the other hand, if the laser heats the collagen fibrils to
65 to 70C, collagen relaxation occurs.
Regression after noncontact LTK is more common in younger patients and patients
with thicker central corneas (57). Regression may be due to the elasticity of Bowmans
membrane and stromal collagen in younger patients, which causes the cornea to return to
its previous shape. Similarly, thicker corneas may be more likely to resume their previous
configuration. At least in rabbit models, noncontact LTK provokes procollagen synthesis
by fibroblastic keratocytes, causing stromal remodeling which can produce irregularities
in the anterior corneal surface leading to epithelial hyperplasia. This in turn, results in an
Complications of Refractive Surgery 303

altered corneal curvature (60). While the precise wound healing response to noncontact
LTK in humans is not known, it is possible that both regression and astigmatism may
result from a similar response.

4. Prevention

Investigators are speaking optimistically about a new continuous-wave diode laser that
can change the shape of the cornea without the peaks and troughs of the pulsed Ho:YAG
laser (61,62). The continuous-wave diode laser is expected to avoid tissue overheating,
thereby improving long-term refractive stability. In addition, FDA trials are under way
on a device that uses radiofrequency energy to the peripheral cornea; this may produce
more controlled shrinkage of collagen lamellae (63).

5. Conclusion

One point to remember is that while regression and, less frequently, astigmatism may
result from noncontact LTK, it is rare for patients to lose even one line of BCVA. No
eyes have been reported to have lost two or more lines of BCVA from noncontact LTK
(5558). For risk-averse low hyperopes (0.75 to 2.50 D), noncontact LTK is a proce-
dure to consider because it causes very few BCVA-threatening complications.

D. COMPLICATIONS OF PHAKIC INTRAOCULAR LENSES AND


CLEAR LENS EXTRACTIONS WITH INTRAOCULAR LENS
IMPLANTS

1. Background

While most types of refractive surgeries alter the cornea, the refractive power of the eye
can also be changed by implanting an intraocular lens (IOL) with or without extraction
of the crystalline lens. Barraquer implanted the first phakic intraocular lens in the 1950s
(64). Unfortunately, many of these anterior chamber lenses were poorly finished and had
sharp edges. After Barraquer had implanted almost 500 lenses, significant complications
such as corneal edema occurred, and over 300 of the lenses had to be removed (65). After
this experience, interest in phakic IOLs waned until labs were better able to guarantee the
quality of IOLs.
Intraocular lenses being made today are of much better quality than those used in
the 1950s. A recent study used a scanning electron microscope to analyze the surface
quality of new-generation phakic IOLs; the study showed that these lenses did not have
any defects that would contraindicate their use as phakic IOLs (66). This study examined
the three major types of lenses currently used as phakic IOLs: anterior chamber lenses
(currently used only in myopic eyes), iris-fixated anterior chamber lenses, and posterior
chamber lenses.

2. Complications

Even when perfectly constructed IOLs with smooth surfaces are placed, there is still a
risk of progressive corneal endothelial cell loss secondary to phakic IOLs (6771). Other
304 Glazer and Azar

Table 4 Complications of Phakic Intraocular Lens Implantation for Correction of Hyperopia


Mean Loss of best
No. of follow-up IOL corrected visual
Study Year eyes (months) Implanted Complications acuity (BCVA)

Davidorf (76) 1998 24 18 Staar ICL 12.5% pupillary 4% lost 3


block glaucoma lines
8% IOL
decentration of
more than 1 mm
12.5% underwent
removal of their
IOL
Rosen (77) 1998 9 6 Staar ICL 11% pupillary block 22% lost 1
glaucoma, requiring line
surgical iridectomy
and removal of IOL
Fechner (78) 1998 69 120 Iris-Claw IOL 1.4% lens No loss of
dislocation BCVA
secondary to
postoperative
trauma
3% uveitis, corneal
edema, and
glaucoma
Pesando (79) 1999 15 18 Staar ICL 13% pupillary block 6.7% lost
glaucoma 2 lines
6.7% anterior
Sanders (80) 1999 10 6 Staar ICL No complications No loss of
BCVA
Pershin (81) 2000 33 12 Storz Phacoprofile 6% anterior No loss of
IOL subcapsular cataract BCVA
3% lens
replacement was
required due to
calculation error
9% pigment
dispersion without
IOP elevation

potential complications of IOL implantation include cataract formation, pupillary-block


glaucoma, endophthalmitis, and retinal detachments (Table 4) (7275).
Currently the most popular phakic IOL for the treatment of hyperopia is the Collamer
Staar Posterior Chamber IOL, also called the implantable contact lens (ICL) (Fig. 6). A
recent phase I trial of silicone plate posterior chamber lenses, implanted in hyperopes,
reported that 100% of patients had 20/40 or better UCVA, and 70% had 20/20 or better
UCVA (80).
In one study of hyperopes with phakic IOLs 1 year after implantation, opacities in
the area of lens contact with the capsule developed in two eyes (6%). Pigment dispersion
occurred in three eyes (9%), but without intraocular pressure elevation. One eye (3%)
required a lens replacement because of a calculation error (81). Another study reported
Complications of Refractive Surgery 305

Figure 6 The STAAR Collamer posterior chamber phakic intraocular lens implant. (From Ref.
79.)

an anterior subcapsular cataract developing immediately after surgery in one eye (6.7%),
causing a loss of two lines of BCVA (79).
Because hyperopic eyes tend to be shorter, they are more prone to pupillary block
after implantation of posterior chamber lenses. One study using the Staar Collamer Im-
plantable Contact Lens (ICL) reported 2 of 15 eyes (13%) developing a severe pupillary
block despite two iridotomies that had been performed 2 weeks prior to surgery. The
increased intraocular pressures due to the pupillary block necessitated removal of the
implants (79). Another study of the Staar ICL reported a 12.5% incidence of postoperative
pupillary block. In addition, IOL decentration of more than 1 mm occurred in 2 of the 24
eyes (76).
Sight-threatening complications such as endophthalmitis have been reported to occur
in phakic IOL procedures for myopia and could theoretically occur for hyperopic phakic
IOL implantation procedures as well (75). Occasionally, silicone plate phakic intraocular
lenses need to be removed due to incorrect sizing of the lens and poor fixation within the
sulcus (82). Retinal detachments after phakic IOL implantation have been reported in
4.8% of myopic eyes (74). This complication has not yet been reported in hyperopic eyes.
Iris-fixated phakic IOLs for the correction of high hyperopia can be associated with
serious complications such as corneal decompensation and glaucoma (Fig. 7) (78). Other
risks include cataract formation and glaucoma (pupillary block glaucoma, pigmentary
glaucoma, narrow-angle glaucoma, and malignant glaucoma) (76). Peripheral iridotomies
can treat or prevent pupillary-block glaucoma. Shallow anterior chambers should be a
contraindication to performing an ICL because of the risk of narrow-angle glaucoma. Lens
decentration may also occur.

3. Clear Lens Extraction with IOL Implantation


Clear lens extraction (CLE) with IOL placement has been studied as a surgical correction
of hyperopia. Some of the disadvantages associated with this procedure as a treatment for
myopia are not as a relevant when it is considered as a hyperopic treatment. For example,
306 Glazer and Azar

Figure 7 The Fechner iris-claw intraocular lens implant. (From Ref. 78.)

myopes are more prone to retinal detachments (RDs). But the increased risk of an RD
after clear lens extraction surgery is less relevant in hyperopes. In addition, the loss of
accomodation that accompanies removal of the crystalline lens is a moot point in the high
hyperope, who can see neither at distance nor at near without correction. One problem of
CLE with IOL placement encountered with hyperopes, which is not relevant in myopes, is
the potential need to implant more than one IOL (piggyback IOLs) to correct for hyperopia.
Several recent studies on clear lens extraction for hyperopia demonstrate that this
is a safe and effective procedure. Kolahdouz-Isfahani performed clear lens extraction on
18 eyes. Two eyes lost two lines of BCVA, but no reason for the loss of BCVA was
found after a complete ocular examination was performed. Complications included one
case of postcapsular opacification requiring one YAG capsulotomy, one case of a lens
dislocation requiring an IOL exchange, and one case of malignant glaucoma (83). Another
study of 35 eyes reported that no eyes lost BCVA postoperatively. Additional procedures
consisted of one IOL exchange and one PRK for overcorrection, both due to IOL miscalcu-
lations. Posterior capsular opacification developed in 19 eyes (54.2%), requiring 19 YAG
capsulotomies (84). One study of 20 eyes that underwent clear lens extraction and IOL
implantation reported no complications; there was no loss of BCVA and no need for
further procedures. The authors did find, however, that the procedure was less accurate
and less predictable for less than 3.00 D of hyperopia (85).
Pop et al. performed CLE with IOLs followed by PRK or LASIK. The only post-
CLE complication in this study was interlenticular opacification (ILO), which occurred
in 14 eyes that had piggyback polyacrylic lenses. Of the initial 65 eyes in the study, 40
eyes received two IOLs (piggyback IOLs) because the lens power needed was higher than
30 D. Thus, 35% of all the piggybacks developed interlenticular opacification. There were
no other reported complications from the CLE surgery (86).
Complications of Refractive Surgery 307

Other potential risks of clear lens extraction surgery with IOL implants include the
risks associated with any cataract surgery, such as hemorrhage, retinal detachment, cystoid
macular edema, and endophthalmitis. Approximately 10% of high hyperopes have axial
lengths of less than 21 mm, predisposing them to choroidal effusions.
4. Prevention
As with any type of surgery, many surgical complications of phakic IOL surgery or CLE/
IOL surgery decrease with surgeon experience. Visual complications such as halo and
glare are significantly reduced with increased optic size from 5.0 to 6.0 mm.
When iris-claw lenses are used, the risk of corneal decompensation can be decreased
by using adequate viscoelastic during surgery, so that the IOL does not touch the cornea;
ensuring sufficient anterior chamber depth; and providing long-term monitoring of the
corneal endothelium (78).
Glaucoma is always a potential problem associated with IOL implantation in small,
hyperopic eyes. During clear lens extraction with IOL implantation, peripheral iridectomies
should be performed in eyes with corneal diameters of 11.0 mm or less or axial lengths
of 20 mm or less. Peripheral iridotomies should be performed prior to the implantation
of phakic IOLs.
5. Conclusion
While many daunting complications may occur secondary to phakic IOL implantation or
CLE/IOL implantation, there are certainly many advantages to treatment of hyperopia
with either of these techniques. First, IOL implantation is the only refractive procedure
that can correct higher degrees of hyperopia. Second, it uses skills that physicians who
perform cataract surgery have honed and polished. Finally, it does not require expensive
equipment, such as lasers. Hopefully, more long-term data will be available in the future
to help decrease the rate of potential complications associated with phakic IOL surgery.

E. COMPLICATIONS OF INTRACORNEAL SEGMENTS AND LENSES


1. Background
Intacs, the intrastromal corneal ring segment (ICRS), consists of two 160-degree poly-
methyl methacrylate (PMMA) segments placed in two pockets of the peripheral stroma
(Fig. 8). The procedure is unique in that it retains the potential to be adjusted or reversed.

Figure 8 The Intrastromal corneal ring. (From Ref. 91.)


308 Glazer and Azar

In April 1999, the FDA approved Intacs for myopic correction of 1.00 to 3.00
D with 1.00 D or less of astigmatism. Intacs can also be used to create central corneal
steepening to correct for hyperopia. Studies are currently investigating the use of small
linear segments placed in the peripheral cornea to create shortening of the peripheral length
of the corneal arc, with subsequent central corneal steepening. By altering the thickness
of the insert, one can titrate the refractive effect.
Although there have been no published studies on Intacs for hyperopia, clinical trials
are currently under way in Germany and Spain. These trials have produced promising
preliminary results: study 1 enrolled 19 patients, and at 1 year 95% (18 of 19) achieved
an UCVA of 20/40 or better. Of note, an induced astigmatism of 1.00 D or greater was
seen in 32% (6 of 19) of the cases. Eleven patients were enrolled in study 2, with 6
months of follow-up. Ten of the 11 eyes (91%) were 20/40 or better, and 4 eyes (36%)
experienced an induced astigmatism of 1.00 D or more. Finally, study 3 enrolled 9
patients with 6 months follow up. All patients had an UCVA of 20/40 or better; only 1
patient had an induced astigmatism equal to or greater than 1.00 D (87).

2. Complications
Published studies of Intacs today are for the correction of myopia. However, the complica-
tions of Intacs would be similar whether the segments were placed for the correction of
myopia or for hyperopia. In the FDA phase II and III studies, the incidence of adverse
events was 2% of the 452 eyes enrolled. Complications of the ICRS procedure include
accidental perforation into the anterior chamber (2 eyes), surface perforation of the epithe-
lium anteriorly (3 eyes), significant decentration of the rings requiring removal or reposi-
tioning (5 eyes), and infectious keratitis (1 eye). All eyes in the group of patients with
complications returned to preoperative BCVA by their 6-month follow-up appointment
(88).
Schanzlin reported no serious complications in the 125 eyes that received ICRS in
his study. Minor postoperative problems included one case of transient conjunctivitis,
three cases of filamentary keratitis, and one case of transient iritis. One patient, whose
incision had gone into a region of superior pannus, developed deep stromal blood vessels.
At 12 months follow-up, four patients had a two-line loss of BCVA, from 20/12.5 to 20/
20. All four of these patients had a substantial improvement in their UCVA (89).
Postoperative astigmatism is clearly a significant potential problem, with 20 of 102
patients in one group experiencing post-ICR astigmatism of 1.0 D or more at 3 months
follow-up. Various theories exist as to the cause of the astigmatism; it may be related to
suture tightness (90). Induced astigmatism may also result from postoperative movement
of the intracorneal ring segments. Finally, Intacs-induced astigmatism can result from
irregular stromal and epithelial thickening between the Intacs rings (91).
Reports describe one patient with persistent focal edema due to a small Descemets
tear from a lamellar dissection that was too deep. Although the edema necessitated ICR
removal, the patients BCVA was 20/20 at exit from the study. One of 102 patients incurred
an intraoperative perforation of Descemets membrane, requiring an ICRS explantation
(90). Channel deposits associated with Intacs are occasionally seen but are not associated
with impaired visual acuity (88,89).

3. Prevention
One can attempt to prevent postimplant complications through meticulous attention to
positioning, proper incision depth and pocketing, and sterile technique. In addition, proper
Complications of Refractive Surgery 309

attention to wound architecture along with adequate closure and tissue approximation with
suturing can minimize the frequency of wound-related complications such as wound gape
and epithelial cysts. One can prevent corneal neovascularization status post-ICRS by avoid-
ing incisions that make contact with pannus or a limbal blood vessel and by warning
against eye rubbing so as to prevent wound dehiscence.

4. Conclusion
Intacs may prove to be a valuable tool for the correction of hyperopia. Advantages over
procedures such as LASIK and PRK include the fact that the Intacs insert is placed in the
peripheral cornea and the central cornea is never violated during the surgical procedure.
In addition, the Intacs devices can easily be removed if necessary. Finally, the refractive
effect can be adjusted by replacement of any of the implanted radial segments. The compli-
cation of induced astigmatism may become less of an issue as more Intacs devices are
implanted: the cause of induced astigmatism may become better understood and thus better
prevented. In addition, surgical technique will be improved as more of these surgeries are
performed.

F. CONCLUSION
Clearly, since hyperopic refractive surgery is entirely elective, the surgeon must have a
thorough understanding of any potential complications of each type of procedure. The
risk/benefit balance is tipping in favor of H-PRK, H-LASIK, or noncontact LTK for low
to moderate hyperopes and toward intraocular lens implantation with or without clear lens
extraction for moderate to high hyperopes. The use of ICRS for hyperopia may be useful
for low to moderate hyperopes; however, long-term results of current studies have yet to
be reported.
Thorough preoperative evaluations and preventive techniques such as those de-
scribed above can help to avoid complications. However, even with the most prepared
surgeon and in the best of hands, complications may occur. Thus, it is essential to provide
patients with a clear understanding of the potential risks of a procedure before proceeding.

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28
Future Developments

BRIAN S. BOXER WACHLER


Boxer Wachler Vision Institute, Beverly Hills, California, U.S.A.

Presently, there are several viable treatments for the correction of hyperopia and presby-
opia. In order to broaden the scope of patient acceptance, current and investigative tech-
niques will continue to develop in the future as the clinicians and researchers strive for
greater efficacy, safety, and visual quality. Each area within refractive surgery will bring
improvements specific unto itself.

A. HYPEROPIA
1. LASIK and PRK
Hyperopic laser-assisted in situ keratomileusis (LASIK) and photorefractive keratectomy
(PRK) have the advantage of directly reshaping the cornea with high safety in low to
moderate degrees of correction. There is growing interest in where hyperopic ablations
should be centered on the eye. Conventional teaching is to center treatments on the pupil-
lary center. This paradigm has developed from a 1987 article by Uozoto and Guyton(1)
that demonstrated, through mathematical analysis, the rationale for pupil centration of
refractive procedures. An opposing article by Pande and Hillman(2) used another set of
analyses to show that the corneal sighted light reflex (which best approximates the visual
axis of the eye) is the best location for centering refractive procedures. Positive angle
kappa (corneal sighted light reflex located nasal to pupilary center) is not nearly as common
in myopes as it is in hyperopes(3). Therefore, since the excimer was used initially for
myopia, the potential for decentered ablations due to pupilary centration was low. I believe
that the combination of delayed hyperopic excimer capability and the lower number of
such patients undergoing treatments has obscured the issue that hyperopic ablations and
perhaps myopic ablations as well may be better centered on the corneal sighted light reflex.
Over 2 years ago, I began to question the recommendation of the Uozoto and Guyton
315
316 Boxer Wachler

Figure 1 Decentration of the treatment zone is seen in the right eye compared to the left eye in
the hyperopic patient will bilateral angle kappa. The laser ablation was centered on the pupil in the
right eye and on the coaxially sighted corneal light reflex in the left eye.

article after noting the decentrations of hyperopic LASIK was not uncommon in my
practice. In one hyperopic patient with angle kappa, I centered the hyperopic treatment
on the pupil on the first eye; on the second eye, the treatment was centered on the corneal
sighted light reflex(4). The postoperative topographies demonstrate decentration of the
treatment in the eye where the laser was centered on the pupil, while the fellow eye showed
a centered ablation (Fig. 1). This area will undergo further study, evaluating not only
topography but also visual acuity, contrast sensitivity, and higher-order aberrations.
The dioptric limits of hyperopic excimer correction are not entirely clear. Therefore,
there will be better definitions of the limitations of hyperopic ablations, which may be
defined by acceptable degrees of induced higher-order aberrations. The pupil is the guard-
ian of the aberrations of the eye. Based on individual pupil-dependent aberrations, future
studies will likely determine the limits of hyperopic treatments.
In myopic LASIK, the flap itself has been shown to be a source of higher-order
aberrations, specifically spherical aberrations(5). In hyperopic LASIK, it is unknown what
role flap-induced aberrations play. We can expect to see such evaluations in the future
for hyperopic LASIK compared to hyperopic PRK.

2. Thermokeratoplasty
Laser thermokeratoplasty (LTK)has the advantage of being very safe due to its noncontact
modality, which also avoids surgery in the central cornea. As an indirectly acting proce-
dure, one of its limitation is that the variable corneal steepening may occur with the same
Future Developments 317

degree of treatment, also that some eyes have more instability of the effect than others.
The future of LTK lies in the ability to perform intraoperative, real-time refractive monitor-
ing using wavefront analysis during the treatment. This may allow the surgeon to stop
the treatment when the desired refractive effect is achieved, making the treatment indepen-
dent of corneal physiology, dehydration, stiffness, and surgeon technique. Preliminary
results of lower-energy treatments hold promise for more stable postoperative effects.
Like LTK, conductive keratoplasty (CK) offer the advantage of avoiding the central
cornea. CK will be evaluated for additional uses, as for astigmatism, by steepening the
flat axis (opposite to astigmatic keratotomy, whereby the steep axis is flattened). The
ability of the probe to be used selectively may make this device useful for treating irregular
astigmatism, as in keratoconus. Focal heat treatments of keratoconus have been evaluated
in the past, but the controlled temperature gradient of CK may lead to more stability than
previous probe technologies.

3. Intraocular Lenses

Phakic intraocular lenses offer the advantage of high-quality of vision in higher corrections
as well as being removable. Phakic lenses will continue to undergo safety evaluation with
longer-term follow-up. Such lenses have the ability to treat higher degrees of hyperopia
than excimer lasers. Wavefront analysis will help determine the optical advantages of
phakic implants compared to excimer laser treatments. Adjustability of lens power may
be achieved in the future through exchangeable optic with a haptic carrier or thoroughly
laser adjustments of the optic postimplantation.

B. PRESBYOPIA

1. Scleral Expanding Bands

Scleral expansion surgery, although not without controversy, has been slowly gaining
credibility. The data from international and preliminary U.S. Food and Drug Administra-
tion clinical trial results demonstrate improved reading ability postoperatively. As a result,
there will be greater attention paid to refining this technique and improving accommodative
predictability. Ultrasound will be used to elucidate the relationship to segment positioning
relative to zonules and lens capsule and how this affects postoperative accommodative
amplitudes. Surgical intrumentation will improve, thus decreasing the duration of what is
now an approximately 45-min procedure. The new device, called the Focal One, is an
automated blade that creates the belt loops and has already improved efficiency in perform-
ing the procedure.

2. Multifocal LASIK and Intraocular Lenses

Presbyopic LASIK has the advantage of improving near vision in carefully selected pa-
tients. Wavefront analysis will be an important adjunct to help elucidate the acceptable
induced aberrations that maximize near vision without compromising quality of vision.
Some monofocal intraocular lenses made with wavefront optic profiles have been reported
to improve near vision with distance as well. Accomodating endocapsular intraocular
lenses will continue to be evaluated for longer-term safety and efficacy.
318 Boxer Wachler

C. Conclusions
We are beginning a new era as refractive surgery now embraces the challenge of correcting
presbyopia. Through the creativity and determination of many ophthalmic care providers
and investigators, greater numbers of patients are experiencing the increased freedom that
comes with treating hyperopia and presbyopia. The future is very bright for the surgical
correction of hyperopia and presbyopia.

References
1. Uuzoto H, Guyton DL. Centering corneal surgical procedures. Am J Ophthalmol 1987; 103:
264275.
2. Pande M, Hillman JS. Optical zone centration in keratorefractive surgery. Entrance pupil center,
visual axis, coaxially sighted corneal reflex, or geometric corneal center? Ophthalmology 1993;
100:12301237.
3. Burian HM. The sensorial retinal relationships in comitant strabismus. Arch Ophthalmol 1947;
37:336340.
4. Korn T, Chandra N, Boxer Wachler BS. Visual outcomes of hyperopic LASIK: centration based
on pupil center versus visual axis. American Society of Cataract and Refractive Surgery Annual
Meeting, April 2001.
5. Roberts C. Flap-induced spherical aberrations. Videorefractiva Italy Ophthalmology Congress.
February 2001.
Index

Aberrations Accommodative mechanism, debate, 34


defined, 151 Accommodative tone, 211
hyperopia vs. myopia, 159 Accommodative triad, 31
Ablation zone decentration, 294 ACS (See Anterior ciliary sclerotomy (ACS))
Accommodating and adjustable intraocular ACS-SEP, 214
lens (IOL), 279285 Age-related cataract (ARC), 58
results, 283284 Aging
Accommodation crystalline lens, 5563
defined, 3031 size and shape, 5657
Fincham, 4042 oxidative stress, 5859
Gullstrand, 3940 presbyopia, 5758
Helmholtz description, 3233 refractive error, 57
measurement, 3638 zonule, 60
near vision, 1920 AIS, 223224, 232
optical changes, 3032 ALK, 5, 164
scleral expansion surgery, 44 Alternating-vision bifocal contact lenses, 68
Accommodative amplitude, 20, 213 American Optical vectographic test, 195
after surgery for presbyopia, 287290 Ametropia
dynamic retinoscopy, 287288 correctable modeling, 272
increased depth of focus, 289 correction, 261
measuring accommodation, 289290 simultaneous within Phaco-Ersatz, 269
multifocal crystalline lens, 289 AMO ARRAY, 238, 239
retinoscopic reflexes, 288289 foldable silicone multifocal intraocular
wavefront analysis, 290 lens, 250
Accommodative apparatus, anatomy, 2728 Amplitude of accommodation, 19
Accommodative intraocular lens (IOL) simultaneous ametropia correction
finite-element computer simulation, 10 Phaco-Ersatz, 263264
319
320 Index

Anesthesia, hyperopic phakic intraocular Bifocal spectacle, first, 134


lenses, 122 Binocular depth of focus, 196197
Anisometropic blur-suppression test, 195 Binocular inhibition, 196
Anterior chamber phakic intraocular lens Binocular summation, 196
hyperopia, 115117 Binocular visual acuity, 196
contraindications, 116 Blur circles, 247
indications, 116 BMP, 174
optic folding, 116 Bone morphogenic proteins (BMP), 174
preoperative management, 117 Bruckes muscle, 28
visual outcomes, 117 BSCVA, 110
Anterior ciliary sclerotomy (ACS), 910,
211, 212214 Calibrated marker, 227
enhanced, 213 Capsulorhexis, 254
future directions, 216 Carbon dioxide laser, 84
interocular pressure, 215216 Cataracts
Anterior ciliary sclerotomy with implantation age-related, 58
of scleral expansion plugs (ACS- oxidative stress, 5859
SEP), 214 presbyopia multifocal IOLs, 240241
Anterior ischemic syndrome (AIS), 223224, refractive surgery, 237
232 Central corneal power, 136137
Antibiotics, hyperopic phakic intraocular Chromatic aberrations, 152153
lenses, 124 Ciliary muscle, 2829, 35
Aphakic epikaratophakia, 130 magnetic resonance imaging, 51
Apoptosis, keratocytes, 174176 CK (See Conductive keratoplasty (CK))
ARC, 58 CK Keratoplast tip, 96
Array implantation, 251 Clear lens extraction (CLE), with IOL
Array lens, 251 placement, 305307
Array multifocal intraocular lens in situ, 254 Cobalt magnesium fluoride laser, 164
Artisan hyperopia, 6 Coma pattern, 155
Artisan hyperopia lens, 119120, 121 Compound cylindrical hyperopic errors,
Artisan iris-claw lens, 125 correction, 145146
hyperopic phakic intraocular lenses, Computed videokeratography (CVK), 129
122125 Conductive keratoplasty (CK), 133134
Artisan phakic intraocular lens (IOL) device, 97
hyperopia, 124 examinations, 98
Astigmatism, 67, 159, 178 hyperopia, 7, 95105
hyperopic, 8082 thermokeratoplasty procedures, 9596
cross-cylinder technique, 8082 mechanism, 9697
treatment, 82 patient selection, 9798
irregular, 136 performing, 98100
rigid gas permeable lens, 67 postoperative care, 100
thermal keratoplasty, 164 procedure, 9798
Automated lamellar keratoplasty (ALK), 5, radiofrequency-based, 96
164 for reducing hyperopia, 255
Axis variation, 82 United States multicenter clinical trial,
100105
Badal optical system, 52 corneal topography, 102
Baikoff foldable contact lenses, 6 efficacy, 101
Barraquer cryolathe, 4 patients and methods, 100
Beaver Dam Eye Study, 23 results, 101105
Best spectacle-corrected visual acuity safety, 104105
(BSCVA), 110 slit lamp, 104
Bifocal contact lens, presbyopia, 9, 68 stability, 103
Index 321

Conjunctival closure, scleral expansion [Cornea]


procedures, 231 thermal keratoplasty, slit-lamp photograph,
Contact holmium:yttrium-aluminum-garnet 301
laser (Ho:YAG) laser thermal topography, 77, 137
keratoplasty (LTK), safety, 8687 conductive keratoplasty, 102
Contact laser thermal keratoplasty (LTK), 85, H-LASIK, 131
86 wound healing
visual outcome, 8687 animal studies, 179180
Contact lens future directions, 182
Baikoff foldable, 6 Corneal collagen, peripheral
bifocal, presbyopia, 9, 68 thermokeratoplasty, 178
history, 63 Corneal surgery, hyperopia wound healing,
living, 4 173183
market information, 6364 Correction profile, hyperopia, 154
multifocal, 38, 68 Criss-cross nylon suture, 216
vs. refractive surgery, 6364 Cross-cylinder technique, hyperopic
rigid gas permeable, 6667 astigmatism, 8082
advantages, 66 Crossed monovision, 194
disadvantages, 66 Crystalline lens
selection, 6667 aging, 5563
soft, 6465 anatomy, 29
advantages, 65 magnetic resonance imaging, 51
astigmatism, 67 optics, 25
disadvantages, 65 size and shape, aging, 5657
selection, 6566 CSV1000E Vector Vision, 165
Staar Collamer implantable, 6 Customized ablation, 147148
Varilux, 135 CVK, 129
Continuous carbon dioxide laser, 164
Continuous-wave diode LTK, 9192
Decentration, 82, 298, 316
Contrast sensitivity, 196
ablation zone, 294
LTK, 165168
corneal curvature, 78
Contrast sensitivity changes after
Defocus, 159
hyperopia surgery, 163169
Defocus curve, 240
Conventional hyperopic LASIK
Deformable lens, equatorial stretch, 48
wavefront measurements and aberration
Diamond blade, 227
changes, 154156
Diffractive multifocal intraocular lens (IOL),
Cornea
238
cautery, 83
Diffuse lamellar keratitis, 299
collagen stability, laser thermal
Dilated pupil, 231
keratoplasty, 85
Diode laser treatment, hyperopia, 7
curvature, decentration, 78
curvature gradient, 73, 7980
eccentricity, 7273 Early hyperopic-photorefractive keratectomy
ectasia, 299300 (H-PRK) ablation, 130
folds, 231 Eccentricity, 73
haze, 295 Edinger-Westphal stimulated
image, ultrasound biomicroscopy, 180 accommodation, 37
implants, 7 Elevation map, hyperopic LASIK, 179
pachymetry, 109 Emmetrope, 18
pigmentation lines, 178 Encircling band, 220, 221
surface profile, after hyperopia surgery, Enhanced anterior ciliary sclerotomy (ACS),
141150 213
322 Index

Epikeratophakia, 4, 5 H-LASIK, 295300


Epithelium case study, 131135
hyperplasia, 177, 180 corneal topography, 131
ingrowth, 298 elevation map, 179
measurement, 178179 log contrast sensitivity values, 166
Equatorial stretch, deformable lens, 48 postoperative topography, 132, 133, 138
Erbium:glass laser, 164 refraction, 166, 167
Erbium:yttrium-aluminum-garnet (YAG) regression, 181
laser, 10 Holmium:yttrium-aluminum-garnet laser (Ho:
sclera incision, slit-lamp, 12 YAG) laser, 85
Excimer laser surgery, hyperopia, 178 pulsed, 84
Expansion band, 221, 223 Holmium:yttrium-aluminum-garnet laser (Ho:
Eye YAG) laser thermal keratoplasty
aberrations, 3132 (LTK), 96, 129, 164
exercises, scleral expansion procedures, H-PRK, 292294
231232 regression, 181
increase optical power, 3031 Hudson-Stahli line, 178
models, 269275 HumanOptics, 280
implementation issues, 274 Humphrey Instruments biomicroscope, 49,
predictions using, 274 50
pros and cons, 273274 Hyperbaric oxygen, 59
requirements, 269 Hyperion noncontact laser thermal
keratoplasty, 97
Far point, 1718 Hyperopia, 2, 6368
Fechner iris-claw intraocular lens implant, ablation, 6980
306 keratorefractive indexes, 7277
Fenestrated intracorneal polysulfone lenses, 7 anterior chamber phakic intraocular lens,
Ferrys line, 178 115117
Field depth, 31 Artisan phakic IOL, 124
Fincham, accommodation, 4042 astigmatism, 8082
Finite aspheric eye, 262 cross-cylinder technique, 8082
Finite-element computer simulation treatment complications, 82
accommodative intraocular lens, 10 conductive keratoplasty, 7, 95105
Flap complications, 297298 thermokeratoplasty procedures, 9596
Fleischer ring, 178 corneal surgery wound healing, 173183
Fogging, 20 correction
history, 45
vs. myopic corrections, 176179
Glass lens, 7 profile, 154
Glaucoma, scleral expansion, 233 excimer laser surgery, 178
Glutathione (GSH), 58 future developments, 315317
Goldman lens, 42 intracorneal lens, 8
Goniovideography intracorneal segments, 107113
iridectomized eyes, 50 keratofractive procedures, topographical
GSH, 58 correlates, 129135
Gullstrand, accommodation, 3940 manifest vs. latent, 20
vs. myopia, aberration, 159
Haze, 294295 optics, 1726
Helmholtz mechanism of accommodation, phakic intraocular lenses, 119128
2744, 220 refractive surgery, 71
Helmholtz model, 209, 210 classification, 177
Hexagonal keratotomy, 4 spherical aberration, 158
Index 323

[Hyperopia] [Intraocular lens]


surgery, 3, 6970 hyperopia anterior chamber phakic,
complications, 291309 115117
contrast sensitivity changes after, contraindications, 116
163169 indications, 116
corneal surface profile, 141150 optic folding, 116
wavefront changes, 151159 preoperative management, 117
thermal keratoplasty, 164 visual outcomes, 117
treatment complications, 7880 hyperopic Artisan phakic, 124
treatment wavefront, 154156 iris-fixed phakic, 119120
vs. myopic, 156159 light-adjusted, 282283
Hyperopic-laser in situ keratomileusis. see multicomponent, 280282
H-LASIK multifocal
Hyperopic LASIK. (See H-LASIK) decreased contrast sensitivity, 238
Hyperopic-photorefractive keratectomy (H- glare and halo, 240
PRK), 292294 impression, 237238
regression, 181 incorrect power, 240
types, 238
ICL (See Iris-claw lens (ICL)) phakic (See Phakic intraocular lens)
ICR myopia, 7 posterior chamber phakic, 6
ICS (See Intracorneal segments (ICS)) power calculation, hyperopic phakic
Ideal monovision result, 190 intraocular lenses, 122
IL1, 174 refractive multifocal, 238
STAAR Collamer phakic, hyperopic
Infrared videophotography, 51
phakic intraocular lenses, 125, 127
Injector, 124
Intraocular pressure, 215
Interleukin 1 (IL1), 174
Intrastromal corneal ring, 307
Interocular blur suppression, 195
IOL (See Intraocular lens (IOL))
Interocular pressure, ciliary sclerotomy,
Iridectomized eyes, goniovideography, 50
215216
Iridotomy, laser peripheral, 181
Interval of Strum, 3132
Iris-claw lens (ICL)
Intracorneal lens, hyperopia, 8
Artisan, 122125, 125
Intracorneal ring (ICR), myopia, 7 Fechner implant, 306
Intracorneal segments (ICS) hyperopic phakic intraocular lens,
central steepening, 111 122125
complications, 307309 Iris-fixed phakic intraocular lens, 119120
hyperopia, 107113 Irregular astigmatism, 136137
complications, 111113
contraindications, 109 Keratoconus, 178
indications, 109 Keratocytes
postoperative care, 110 apoptosis, 174176
preoperative preparation, 109 laser thermal keratoplasty, 85
surgical technique, 109 proliferation and migration, 175176
visual outcomes, 110111 Keratophakia, 4
postoperative, 108 Keratoplasty
Intraocular lens (IOL) automated lamellar, 5, 164
accommodating and adjustable results, thermal (See Thermal keratoplasty)
283284 Keratorefractive indexes, hyperopic ablation,
accommodative finite-element computer 7277
simulation, 10 Keratoscopy, 76
diffractive multifocal, 238 Kera Vision, 107
future developments, 317 Ki67, 175
324 Index

LADARWave Lens
device, 159 capsule, 30
image, 155, 156, 158 crowding, 211
Lamella diamond blade, 228 opacification, oxidative stress, 5859
Lamellar deposits, 112 origin, 210
Lamellar flap, 4 proteins, 59
Lamellar keratitis, diffuse, 299 Lenticule, schematic representation, 144147
Laser-assisted in situ keratomileusis Lenticule ablation, 142
(LASIK), 1, 6, 90, 96, 261 model, 149
complications, 292298 Light-adjusted intraocular lens (IOL),
contrast sensitivity, 165168 282283
future developments, 315316 Light-difference threshold, 163
induced hyperopia, LTK, 91 Limbus, marking, 225, 226
multifocal, future developments, 317 Living contact lens, 4
Laser peripheral iridotomy, 181 Longitudinal spherical aberration (LSA), 73
Laser scleral relaxation, 11 LTK (See Laser thermal keratoplasty (LTK))
Laser thermal keratoplasty (LTK), 6, 8392
complications, 91 Magnetic resonance imaging (MRI)
contact, 8588, 86 ciliary muscle, 51
visual outcome, 8687 crystalline lens, 51
contact and noncontact, 85 Magnification, visual acuity, 2223
Medennium, 6
contact Ho:YAG, safety, 8687
Merceline horizontal mattress suture, 216
continuous-wave diode, 9192
Miller-Nadler Glaretester, 243
contraindications, 8586
Minimally invasive surgery, 254
contrast sensitivity, 165168
Monochromatic aberrations defined, 151152
corneal collagen stability, 85
Monovision
history, 8384
after refractive surgery satisfaction,
holmium:YAG, 129, 164
191192
Ho:YAG, 129
defined, 9
Hyperion noncontact, 97
factors influencing, 197198
keratocyte response, 85 failures, 195
LASIK-induced hyperopia, 91 presbyopia, 6768
log contrast sensitivity values, 167 success rates after contact lenses, 190
mechanism, 8485 task performance, 197
noncontact, 85, 86 visual performance, 195196
complications, 300303 Monovision refractive surgery
visual outcome, 8788 outcomes, 190
noncontact Ho:YAG, safety, 87 presbyopia, 189198
patient selection, 8586 preoperative counseling, 192193
PRK-induced hyperopia, 9091 Monovision trial, 193
refraction, 168 Moria LSK microkeratome, 166
Sunrise Procedure, 6 MRI
surgical procedure, 86 ciliary muscle, 51
technique, Hyperion noncontact, 97 crystalline lens, 51
temperature, 84 Multicomponent intraocular lens, 280282
tissue elasticity, 8485 Multifocal contact lenses, 38, 68
visual outcomes, 8687 Multifocal effects, 134136
YAG, 96 historical, 134136
LASIK. (See Laser-assisted in situ Multifocal hyperopic-presbyopic
keratomileusis (LASIK)) photorefractive keratectomy (PRK),
Late flap dislocation, 299 203
Index 325

Multifocal intraocular lens Navarro aspheric eye, 269270


refractive lens exchange, 249258 Near point, 1718
Multifocal intraocular lens (IOL), 249 Near reading test, 44
decreased contrast sensitivity, 238 Near vision accommodation, 1920
design, 250 Neural networks, 137138
glare and halo, 240 Noncontact holmium:yttrium-aluminum-
impression, 237238 garnet laser thermal keratoplasty
incorrect power, 240 safety, 87
presbyopia, 237248 Noncontact laser thermal keratoplasty, 85, 86
clinical results, 242 complications, 300303
complications, 245248 visual outcome, 8788
contraindications, 240241 Nonsteroidal anti-inflammatory drugs
contrast sensitivity, 243 (NSAID), 224
contrast visual acuity, 244 Non-wave diode laser thermal keratoplasty
exclusion criteria, 241 (LTK), 96
halo and glare, 243, 247248
incision, 241 Ocular aberrations, 3132
indications, 240241 Optical zone design, 141142, 144
insufficient near vision, 248 Ora serrata, 29
IOL decentration, 246247 Oxidative stress
IOL position, 241 cataracts, 5859
IOL power miscalculation, 245246 lens opacification, 5859
occupation, 241
patient expectations, 241 Papillary constriction, 31
patient satisfaction, 244, 245 Paraxial eye, 262
patient view with model eye, 245 Pars plana, 29
Pars plicata, 29
posterior CCC, 241242
Perfect thermal lesion, 178
preferred surgical techniques, 241245
Peripheral corneal collagen
spectacle usage, 243244
thermokeratoplasty, 178
theoretical benefits, 238240
Peripheral vision, 196
theoretical caveat, 238240
Phacoemulsification, 254
vision simulation system, 245
Phaco-Ersatz, 260261
visual acuity, 242243
simultaneous ametropia correction,
types, 238 259274
Multifocal laser-assisted in situ Phakic intraocular lens, 6
keratomileusis, future developments, in and CLE with IOL implants,
317 complications, 303307
Multifocal myopia-presbyopia hyperopia, 119128
photorefractive keratectomy, 203 complications, 127128
Multifocal presbyopic photorefractive contraindications, 120122
keratectomy videokeratography, 205 indications, 120122
Musculus crystallinus, 39 posterior chamber phakic IOL, 120
Mylar balloon, 48 preoperative preparation, 122
Myofibroblasts, 175176 STAAR Collamer phakic IOL, 125, 127
Myopia surgical technique, 122125
ablation, 71 visual outcomes, 125128
correction types, 119120
vs. hyperopic corrections, 176179 Phorias, 197
profile, 156159 Photic phenomena, 256
error, 18 Photorefractive keratectomy (PRK), 5, 90,
vs. hyperopia aberration, 159 202, 261
intracorneal ring, 7 complications, 292298
refractive correction, 138 future developments, 315316
spherical aberration, 160 induced hyperopia, LTK, 9091
326 Index

Pilocarpine, 38, 256 Quadrafoil pattern, 157


Plastic polymethylmethacrylate band, 220 Quantel Axis II immersion biometry unit,
Polymethylmethacrylate (PMMA) lenses, 202 253
Posterior chamber phakic intraocular lens, 6
Postoperative pupil check, scleral expansion Radial keratotomy (RK), 219220, 255, 261
procedures, 231 Radial thermokeratoplasty, 84
Presbyopia, 2, 6768, 219 Radiofrequency-based conductive
accommodative amplitude measurements keratoplasty, 96
after, 287290 Radiofrequency energy, 83
aging, 5758 Range of accommodation, 2021
amplitude of accommodation, 20 REACT, 59
bifocal contact lens, 9, 68 Refilling model, 270272
correction, 89 proportional expansion, 271272
future developments, 317318 spherization, 271
keratofractive procedures, topographical Refractec, for reducing hyperopia, 255
correlates, 129135 Refractive error, 247
monovision, 6768 aging, 57
monovision refractive surgery, 189198 contact lens vs. refractive surgery, 64
eye determination for distance, 193194 simultaneous ametropia correction, Phaco-
preoperative counseling, 192193 Ersatz, 263
multifocal corneal approach, 201208 Refractive index, 262263
historical and experimental, 201202 Refractive lens exchange
results, 204207 scattergram, 252
techniques, 202204 with multifocal intraocular lens, 249258
multifocal intraocular lens, 237248 clinical results, 250252
optics, 1726 complications, 255
restoration, background, 260 patient selection, 252253
scleral relaxation, 209214 postoperative course, 256
surgery, 3 preoperative measurements, 253254
complications, 291309 refractive surprise, 255256
Presbyopic photorefractive keratectomy, 204 surgical technique, 254
PRK (See Photorefractive keratectomy targeting emmetropia, 255
(PRK)) Refractive procedures, 233
Progressive aspheric spectacle lens (PAL), Refractive surgery
260 cataract surgery, 237
Proportional expansion, refilling model, vs. contact lens, 6364
271272 monovision, satisfaction, 191192
Pseudocycloplegia, 56 Regression, 294, 302303
Pterygia, 178 H-LASIK, 181
Pulsed holmium:yttrium-aluminum-garnet H-PRK, 181
laser, 84 mechanisms, 178182
Pupil block hyperopic phakic intraocular Retinoscopic reflex, 287, 289
lenses, 122 Retreatments, 80
Pupil check, postoperative scleral expansion Rigid gas permeable (RGP) lens, 6667
procedures, 231 advantages, 66
Pupillary constriction, 31 astigmatism, 67
Pupil size, hyperopic phakic intraocular disadvantages, 66
lenses, 122 selection, 6667
Pure cylindrical hyperopic errors, correction, RK, 219220, 255, 261
144145 RMS, 73
Pure spherical hyperopic errors, correction, Roche European-American Cataract Trial
141144 (REACT), 59
Push-up test, 38, 44 Root mean square (RMS), 73
Index 327

SAI, 73 Snellen letters, 22


Scarring, middle periphery, 79 Snellen visual acuity, 22
Schachar model, 209 Soft contact lens, 6465
Schachars scleral band procedures, 287 advantages, 65
Schachars theory of accommodation, 34, astigmatism, 67
4753, 220 disadvantages, 65
challenged, 50 selection, 6566
evidence against, 4243 Soft toric lenses, 67
Schachar theory of presbyopia, 2 Spectacle, bifocal, first, 134
evidenced against, 43 Spherical hyperopia, ablation, 148
Scheimpflug optics, 56 Spherical hyperopic error ablation, 143
Sclera Spherization, refilling model, 271
origin, 210 Sphingolipid, 59
slit-lamp erbium:YAG, 12 Spreading dissection, 213
Scleral belt loops, 228, 229 Square diamond blade, 227
dissect, 227229 Staar Collamer implantable contact lens, 6
scleral expansion procedures, 226 Staar Collamer phakic intraocular lens
Scleral expanding bands hyperopic phakic intraocular lenses, 125,
future developments, 317 127
Scleral expansion, 219233 Staar Collamer posterior chamber phakic
anesthesia, 225 intraocular lens implant, 305
clinical results, 232 Star Excimer Laser system, 130
complications, 232 StatView, 165
conjunctival closure, 231 Stellate iron lines, 178
conjunctival dissection, 225226 Stereoacuity, 196
current method, 224225 Steroids, hyperopic phakic intraocular lenses,
early procedures, 219220 124
eye exercises, 231232 Stocker-Busacca line, 178
glaucoma, 233 Suarez spreader, 109
patient selection, 223 Summit Apex Plus Laser, 166
postoperative pupil check, 231 Sunrise Ho:YAG laser, 164
scleral belt loops, 226 Sunrise LTK Procedure, 6
scleral expansion segments, 229230 Surface asymmetry index (SAI), 73
Scleral expansion segments, 229230 Swan-Jacob gonioscopy, 42
dimensions, 230
placement, 230 Temperature, laser thermal keratoplasty, 84
Scleral expansion surgery Thermal keratoplasty, 83
accommodation, 44 astigmatism, 164
Scleral relaxation, 2 cornea, slit-lamp photograph, 301
presbyopia, 209214 future developments, 316317
Shack-Hartmann wavefront sensor, 152 hyperopia, 164
history, 153154 peripheral corneal collagen, 178
principles, 154 radial, 84
Sighting preference, 197 Thermal lesion, perfect, 178
Silicone expansion plugs, 214 Thornton Triple Edge diamond knife, 212
Simultaneous ametropia correction Tissue elasticity, laser thermal keratoplasty,
Phaco-Ersatz, 259270 8485
results, 263267 TNF alpha, 174
Simultaneous vision principle, 9 Transition zone
Sinskey hook, 109 design, 142145
Slab off, 67 lack, 79
Slit-lamp, sclera incision, erbium:YAG, 12 Trefoil pattern, 157
328 Index

Tscherings studies, 3436 [Visual acuity]


Tscherings theory of accommodation, 33 binocular, 196
Tucker, 125 magnification, 2223
Tumor necrosis factor (TNF) alpha, 174 Snellen, 22
uncorrected, 110
UBM, 49, 212 Visual fields, 196
corneal image, 180 Volume calculations, 272
UCVA, 110 Von Helmholtz, Hermann Ludwig Ferdinand,
Ultrasound biomicroscopy (UBM), 49, 212 28
corneal image, 180
Uncorrected visual acuity (UCVA), 110 Wave aberration, detection, 153154
Uncrossed monovision vs. crossed Wavefront, defined, 151
monovision, 194195 Wavefront changes, hyperopia surgery,
Unfolder injector, 250 151159
Wavefront measurements and aberration
Variable-contrast charts (VCVAC), 243 changes
Varifocality, 135 conventional hyperopic LASIK, 154156
Varilux contact lens, 135 Wound healing, hyperopic corneal surgery,
VCVAC, 243 173183
Vector Vision CSV1000E, 165
ViewPoint Conductive Keratoplasty CK Zeiss IOLMaster, 253
system, 97 Zemax EE, 50
Vision, peripheral, 196 Zernike modes, 153
Visual acuity, 300 Zonular fibers, 2930
best spectacle-corrected, 110 Zonule, aging, 60