Regarding the Surgical Reversal of Presbyopia
(SRP) Surgery for Presbyopia, Vol 108,
Number 12, December 2001, 2161–2
Dear Editor:
I appreciate Dr. Kaufman’s expertise in considering evi-
dence of observed changes with dynamic accommodation. I
have also witnessed firsthand Dr. Shachar’s defense of his
theory of accommodation, have observed SRP surgery per-
formed, have colleagues who have performed a significant
number of procedures, and have in fact treated a (single)
patient of my own. I have also rejected SRP as a technique
I would advocate for my own patients.
Although I agree with Dr. Kaufman that proving that
dynamic accommodation is restored based on the evidence
provided by SRP implantation to date is hardly an over-
whelmingly compelling dataset, I am concerned by infer-
ences that easily could be drawn from his comments that (1)
static multifocality rather than dynamic accommodation
likely is the mechanism by which SRP effects clinical
change in near vision, and (2) that a Hemholz model should
be considered to be well supported by existing data.
Separating the theory of SRP from current practice is, in
my opinion, key. Reducing theory to practice is never easy
given clinical constraints, and SRP segments as currently
configured represent at best a compromised attempt to trans-
late theory into a clinically safe and effective procedure. At
least conceptually, SRP is essentially a first-generation at-
tempt to reduce the theory of zonular contraction at the lens
equator as causing dynamic accommodation to practice. If
proof were obtained easily, 100 years of controversy would
not exist. The Hemholz theory is not entirely consistent with
dynamic accommodation, so we must expect any theory at
best to offer new insight and not necessarily final evolved
understanding. If zonules simply relax as per Hemholz, for
example, the entire lens equator would be expected to drop
posteriorly when supine, which has not, to my knowledge,
ever been shown to be the case. Anterior bulge of the vitreous
remains a vague and unsupported concept as well, so it is
unlikely to explain the Hemholz inconsistency of zonular
relaxation with such planar stability of the lens diaphragm.
The SRP segments are notoriously difficult to position to
test SRP theory via its current practice, to induce stretch of
zonules at the lens equator. Ciliary anatomy varies from
individual to individual and, in fact, quadrant to quadrant.
The technique is surgically difficult to reproduce consis-
tently in accordance with desired anatomic change in my
view. It requires exquisite control of band depth, beyond the
control possible with surgical implementation as currently
performed. In a 900-␮m sclera, for example, placement at
300 ␮m is likely to be clinically inadequate, whereas place-
ment deeper than 600 ␮m creates difficulty completing the
insertion and could conceivably result in a scleral perfora-
tion. The procedure is essentially a freehand estimate of
depth, with an estimate of proper distance from the limbus
rather than exact localization of ciliary body as well. Fi-
nally, the use of segments of proscribed length is largely
dictated by concerns regarding anterior segment ischemia,
by definition compromising the theory by which such ex-
pansion would normally occur over 360°, and suffers from
certain problems with maintaining positional location as
well as orientation of SRP bands over time. It also, in my
view, results in considerable at least short-term tear-film
disturbance and scarring of the conjunctiva.
The theory that zonular contraction rather than relaxation
may effect dynamic accommodation in fact is not new—it
owes its origin to Dr. Tschernig, who proposed his theory
nearly 100 years ago. He went on to speculate that anterior
bulge of the vitreous is also an important component of
dynamic accommodation. However, Dr. Shachar has, in my
opinion, added an important modification, discovery, or at
least demonstrated an application of physics that may very
well be relevant and key to unlocking the century-old mys-
tery of dynamic accommodation. His observation on the
effect of increased diameter change in an optic composed of
an elastic boundary within which is a deformable solid or
fluid to produce increased convexity in apparently a very
sensitive manner to my knowledge had not been understood
or at least appreciated for its potential clinical relevance
until his analysis.
Dr. Shachar offers a simple, compelling demonstration
of the basic physics he contends may be at work with any
zonular contraction theory: while looking at a disc-shaped
milar balloon with a convex anterior surface in which one’s
face is clearly reflected, stretching the edges even slightly
produces dramatic increase in convexity of the anterior
surface, with considerable shrinkage of the reflected image.
I and most others who witnessed the demonstration ex-
pected stretching of the edges to cause flattening of the
anterior curvature and image elongation, and to see the
opposite occur and so sensitively and dramatically under-
scores the basic physics of his theory. The concept is that
peripheral stretch of certain fluid, gel-filled, or deformable
optics like the lens moves the internal contents of the
deformable medium (in this case, air; in the case of the lens,
its own peripheral gel-like cortex) centripetally, and that
even very small volumes of such movement could effect
large degrees of increase in convexity. In my opinion, this
radical shift in conventional thinking should not be dis-
missed lightly. It is certainly tantalizing to believe this
apparently very sensitive translation of fluid volume cen-
trally to effect considerable anterior curvature change could
somehow be involved in dynamic accommodation, and in
my view current SRP testing does not prove or disprove this
concept’s validity.
Dr. Kaufman’s key point, that no evidence of dynamic
accommodation has been shown after SRP implementation,
is, I believe, a moot point because it simply stirs the pot
without proving or disproving the merits of this theory. It is
rather unfortunate to take this approach to analyzing such a
fascinating theory as that of Drs. Tschernig and its modifi-
cation as I see it by Dr. Shachar because it is too soon, if a
predominantly accepted point of view would discourage
what I perceive as potentially important research in this
area. If such an evaluation as made by Dr. Kaufman is, in
fact, to be made on early results, it is also far too cursory of
an evaluation of existing data. For example, encircling
bands used initially by Dr. Shachar et al were reported to
induced more than 10 diopters (D) of accommodation in an
apparent dynamic range, that is, without, I believe, restric-
tion to a single near point. The degree of multifocality that
would be required to cover such a range makes clinically
effective distance and quality near vision unlikely to have
been possible in such cases, or at least is suggestive that
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 Ophthalmology Volume 110, Number 5, Month 2003
dynamic accommodation may have occurred or, if not, a
nearly identically useful clinical substitute (in some of these
cases, anterior segment ischemia eventually occurred, re-
quiring segment removal and a compromise shortening of
SRP segments). Proof, no; but again, tantalizing evidence
for which further clinical information would be desirable.
Further comment from Dr. Shachar on the clinical observa-
tion of near point range in such patients, for example, may
suggest that the degree of circumferential stretch may be
very important to reducing Shachar’s theories to more ef-
fective practice.
In my single experience, treating a ⫹0.62 D 46-year-old
hyperope with 20/30 distance vision and 12-point near, she
achieved consistent 20.20 distance acuity and approxi-
mately 8-point near. To me, this suggests more than static
multifocality to explain both distance and near improve-
ment. If it was a change in central curvature, this was not
documented in this or other cases in which distance vision
tends to remain largely consistent with preoperative refrac-
tion after SRP. Possibly a subtle change in asphericity could
somehow account for the observed changes. Proof of a
concept as revolutionary as a clinically effective means of
treating presbyopia via zonular contraction will not easily
dismiss 100 years of controversy if it is in fact to be found,
but more importantly, I believe that Dr. Kaufman attempts
to dismiss the nonconventional, perhaps counterintuitive
concept of zonular contraction as being premature, and
polarizes understanding as being either for or against such
supporting theories. It is too soon in my opinion to edito-
rialize reasonably on the merits of SRP, or of Dr. Shachar’s
theory, or of any other theory that my eventually replace it
regarding fluid volume dynamics and peripheral lens stretch
and their role in dynamic accommodation. We simply can
accept that Hemholz’s theory provides inadequate explana-
tion of all aspects of dynamic accommodation and periph-
eral expansion of the lens through zonular contraction,
causing central movement of a finite volume as part of an
explanation for dynamic accommodation, which is tantaliz-
ing and deserves more study.
Pioneering ideas, when and if they do occur, may require
decades, if not generations, to put into practice accurately
and safely. The SRP procedure, and Dr. Shachar’s “revi-
sion” of Dr. Tschernig’s original concept based on what I
view as a compromised effort to reduce his theory to prac-
tice, is in its infancy. Evolution of SRP bands and tech-
niques may, in fact, provide better clinical consistency. At
that point, it may become easier to subject this treatment to
rigorous analysis of whether dynamic accommodation or
static multifocality is, in fact, the principle cause of the
clinical effects observed.
If, in fact, Drs. Tschernig and Shachar are correct and the
tantalizing demonstration with a simple milar balloon
proves to be a valid representation of the basic physics by
which anterior curvature lens change occurs, future methods
likely will be developed to allow for better means to effect
zonular contraction over a more complete circumference. I
confess to having an interest and indeed patent application
on such an approach. At that point, what is now a difficult-
to-prove theory with spotty clinical supporting data could
become a well-accepted means to treat presbyopia. The
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truth is, Hemholz’s theory never explained many aspects of
accommodation, and that is reason enough to investigate
proactively credible alternate theories further.
That lens volume displacement centrally could contrib-
ute to dynamic accommodation via peripheral lens stretch
deserves further analysis in my opinion. Like many great
ideas, Dr. Tschernig’s original contention that zonular con-
traction effects dynamic accommodation is not, in my opin-
ion, proven or disproven to date. It may be that with mod-
ification, as per Dr. Shachar, or above and beyond that of
Dr. Shachar, it can eventually be reduced to effective prac-
tice. We should appreciate the potential of this approach
more fully in my opinion and patiently should await further
evidence before abandoning zonular contraction, peripheral
lens stretch, and fluid volume displacement centrally as
legitimate mechanisms for restoring dynamic accommoda-
tion.
JERRY HORN, MD
Chicago, Illinois
Author reply
Dear Editor:
Dr. Horn’s letter illustrates the passion this subject gener-
ates. We do not need more history lessons and reviews of
past work and theories, but rather new data. We should stop
the endless debates and do more experiments with our
newer technologies. No one questions the mylar balloon
optics or the possibility that the viscoelastic properties of
the lens may allow it to behave similarly, but there is as yet
no convincing evidence that it does so either in vitro or in
vivo. Let’s have more refereed science and less verbiage.
PAUL L. KAUFMAN, MD
Madison, Wisconsin
Dear Editor:
Many of the great advances in ophthalmology and other
disciplines have been driven by scientific curiosity. The
universality of accommodation and its failure with age are
enigimas that continue to challenge thoughtful investigators
and that have been the exclusive subject of my own research
for the past decade.
In his editorial, Dr. Kaufman1 states that according to my
theory, the anterior zonules tense during accommodation.
This is an inaccurate statement and needs to be addressed.
There are three sets of zonuules. My theory states that only
the equatorial zonules are under increased tension during
accommodation, whereas both the anterior and posterior
zonules relax.2
Nonlinear finite element analysis clearly demonstrates
that the Helmholtz theory requires more force than is phys-
iologically possible3 and that the predicted surface changes
are not consistent with the clinically observed negative shift
in spherical aberration that occurs during accommoda-
tion.3,4 Based on mathematical modeling, I have proposed a
method by which the mechanism of accommodation could
be augmented. It involves increasing the effective working
distance of the ciliary muscle by increasing the diameter of
the ciliary ring.5
The procedure of scleral expansion involves operating on
the surface of the sclera, in the region of the pars plana. This