Journal of Refractive Surgery

Review 

Presbyopic Excimer Laser Ablation: A Review

Larissa R. Stival, MD; Marisa N. Figueiredo, MD; Marcony R. Santhiago, MD, PhD

Abstract

PURPOSE:

To provide an overview of the efficacy and safety of available presbyopic excimer laser ablation profiles.

METHODS:

Literature review.

RESULTS:

Monovision with excimer laser traditionally applies near correction to the non-dominant eye. Different excimer laser presbyopic approaches include the increase in depth of focus, through the controlled change of spherical aberration or asphericity, or multifocal ablation patterns with central or peripheral near vision zones. The studies investigating different excimer laser ablation patterns applied in previously myopic eyes revealed high levels of efficacy with all ablation profiles (between 68% and 99% achieving binocular uncorrected distance visual acuity [UDVA] of 20/25 or better, and between 70% and 100% achieving uncorrected near visual acuity [UNVA] presenting J3 or better). In hypermetropic eyes, most of the studies revealed high levels of efficacy with different platforms (between 78% and 100% achieving binocular UDVA of 20/25 or better and between 70% and 100% achieving UNVA presenting J3 or better). Loss of two or more lines of corrected distance visual acuity varied between 0% and 10% in the myopic eyes and between 0% and 14% in the hyperopic eyes.

CONCLUSIONS:

There is evidence that excimer laser presbyopic strategies accomplish spectacle independence at reasonable levels. There are reliable and safe options for both myopic and hyperopic eyes with satisfactory outcomes regarding near and distance vision.

[J Refract Surg. 2018;34(10):698–710.]

Abstract

PURPOSE:

To provide an overview of the efficacy and safety of available presbyopic excimer laser ablation profiles.

METHODS:

Literature review.

RESULTS:

Monovision with excimer laser traditionally applies near correction to the non-dominant eye. Different excimer laser presbyopic approaches include the increase in depth of focus, through the controlled change of spherical aberration or asphericity, or multifocal ablation patterns with central or peripheral near vision zones. The studies investigating different excimer laser ablation patterns applied in previously myopic eyes revealed high levels of efficacy with all ablation profiles (between 68% and 99% achieving binocular uncorrected distance visual acuity [UDVA] of 20/25 or better, and between 70% and 100% achieving uncorrected near visual acuity [UNVA] presenting J3 or better). In hypermetropic eyes, most of the studies revealed high levels of efficacy with different platforms (between 78% and 100% achieving binocular UDVA of 20/25 or better and between 70% and 100% achieving UNVA presenting J3 or better). Loss of two or more lines of corrected distance visual acuity varied between 0% and 10% in the myopic eyes and between 0% and 14% in the hyperopic eyes.

CONCLUSIONS:

There is evidence that excimer laser presbyopic strategies accomplish spectacle independence at reasonable levels. There are reliable and safe options for both myopic and hyperopic eyes with satisfactory outcomes regarding near and distance vision.

[J Refract Surg. 2018;34(10):698–710.]

Presbyopia is an age-related condition in which accommodation gradually decreases and the eye is no longer able to focus, which consequently reduces the visual acuity for near distance.1 The complexity involved in its causes and the difficulty to fully comprehend its variances makes presbyopia one of the most challenging visual defects to address.

The most satisfactory results when attempting to attenuate presbyopia can be achieved through excimer laser ablation of the cornea either unilaterally, as a monovision procedure, or bilaterally, through a multifocal ablation pattern. The number of different techniques and the variety of approaches arises from the lack of effectiveness of methods in restoring actual accommodation.1,2

The classic monovision technique with the excimer laser speaks for itself: one eye, usually the dominant one, contributes to distance vision and the other to near vision through a level of controlled myopia. The excimer laser ablation patterns may further incorporate a form of treatment that divides the cornea into distance and near viewing circles or even modifies asphericity and spherical aberration in a controlled manner, yielding values that increase the depth of focus, improving near vision while maintaining image quality.

The purpose of this study was to review the currently available presbyopic excimer laser ablation methods. We categorized the techniques through which the excimer laser treatment addresses presbyopia as follows: monovision, excimer laser presbyopic approaches that increase depth of focus through the controlled change of spherical aberration or asphericity, and multifocal ablation patterns with central or peripheral near vision zones.

Monovision

Monovision with an excimer laser aims to use one eye (usually the dominant eye) for distance vision and the fellow eye for near vision, resulting in intentional anisometropia and, theoretically, providing satisfactory levels of spectacle independence.1 The amount of tolerable anisometropia has been debated for years. Controlled monovision traditionally follows a nomogram for near addition, with the degree of anisometropia increasing from approximately −1.50 diopters (D) for a 45-year-old patient up to −2.50 D for a 65-year-old patient.3

Table 1 summarizes the results of the monovision studies.

Published Studies of Monovision

Table 1:

Published Studies of Monovision

This strategy has been successfully used for a long time by contact lens wearers, but its disadvantages include eventual intolerance, residual aniseikonia (although lower than with spectacles), and recent findings of better visual results after LASIK.3–5 The constant optical correction also enables a more natural and faster neuroadaptation.5

As we have seen with multifocal intraocular lens (IOL) selection in the modern world, the patient's occupation, daily activities, reading and sports habits, age, and lifestyle in general determine the patient selection for monovision and the optimal amount of target correction. In this regard, the lowest anisometropia that meets the patient's needs, normally less than 2.50 D, should be selected.1,6 The lower the anisometropia, the higher the rates of patient tolerance. In addition, the best results are commonly associated with perfect distance correction of the dominant eye, stereoacuity reduction of less than 50 seconds of arc, and distance esophoric shift of fewer than 0.6 prism diopters.6–8

There has been some debate about the actual role of ocular dominance in the rates of patient satisfaction with monovision.1 It seems to be more critical to make sure the chosen distance vision eye is successfully corrected with no or minimal residual errors.3,8,9 Patient preference or unpredicted refractive surgical outcome can lead to crossed monovision, in which the so-called dominant eye ended up corrected for near vision.3,9 Under the circumstances of crossed monovision, Braun et al.1 showed lower distance and near vision success rates, whereas other studies revealed similar results after LASIK3,8 or pseudophakic monovision.9

There is no clear relationship between eye sighting dominance and the ability to suppress blur.3,8,9 When there is a clear dominance, correcting the dominant sighting eye for distance improves vector tasks and produces less amplitude of esophoric shifts. This could be appealing when choosing monovision. However, regardless of the eye chosen for near correction, patients with alternating dominance will continuously present with an interocular blur suppression, as opposed to those with strong sighting preferences.5 The type of dominance also plays a role in the neuroadaptation time. Two studies10,11 combined sighting dominance with binocular rivalry dominance and found that eyes that were fusing both styles of dominance presented higher rates of neuroadaptation. Dim light conditions with larger pupils make interocular blur suppression less effective.12

A refractive target of −1.25 to −1.50 diopters (D) in the non-dominant eye typically has a minimal effect on stereovision and provides a reasonable working level of spectacle independence, as long as the dominant eye obtains excellent uncorrected distance vision (UDVA).

It is possible to infer from different authors' outcomes that excimer laser monovision provides a reliable option for near vision in presbyopic patients with either LASIK1,3–9,13,14 or photorefractive keratectomy,15 generating satisfaction rates that range from 80% to 98%.1,3,8,13–15

Schallhorn et al.16 investigated eyes receiving LASIK monovision and found that 85% of eyes with preoperative moderate to high myopia (mean preoperative: −5.00 D) and 90% of eyes with low myopia (mean preoperative: −2.00 D) achieved a binocular UDVA of 20/20 or better, and 99% and 100%, respectively, achieved binocular uncorrected near visual acuity (UNVA) of 20/40 or better. In their study, the monovision generated an average of −1.41 D residual myopia in the moderate to high myopia group and −1.35 D in the low myopia group. The authors also found better results when eyes with moderate to high myopia received LASIK for monovision compared to refractive lens exchange.

Excimer laser monovision is more commonly offered to myopic patients and represents a viable and safe option for presbyopia in hyperopic eyes, with rates as high as 96% achieving binocular UNVA of 20/40 or better.13,16 Even when not targeted for monovision, hyperopic LASIK results in better UNVA than expected, probably because hyperopic ablation shows some degree of multifocality.17

Hyperopic eyes tend to have higher rates of enhancements to achieve satisfactory results, which is probably related to the ablation pattern.13 As opposed to central ablation, corneal flattening, and undercorrection in myopic eyes, it is necessary to overcorrect and steepen the central cornea to generate controlled myopia in a previously hyperopic eye. This sometimes limits the number of eyes that are within the range possible to safely overcorrect and decreases the predictability.

Accommodative strabismus or diplopia is another concern with hyperopic eyes eventually receiving monovision.18 A thorough preoperative examination looking for prior use of prisms, aniseikonia, and strabismus should become routine for a monovision refractive surgery candidate. Hyperopic (or myopic) patients who have experienced weak capacity of fusion, manifest strabismus, or history of corrected strabismus in either childhood or adulthood are at a higher risk of decompensation and deviation.18

Limitations of monovision include compromising visual function, such as reduced low contrast and contrast sensitivity, inability to incorporate an intermediate vision correction without compromising distance or near vision, small-angle esotropic shift, and reduced stereopsis.16 The potential loss in stereopsis should be emphasized before surgery, and the patient's occupation and activities must be strongly considered when selecting this strategy. In general, there seems to be a reduction in stereoacuity, especially when anisometropia is greater than 2.00 D.18

Compared with balanced binocular correction, monovision produced comparable results regarding contrast sensitivity at relatively low spatial frequencies. Results can be slightly worse at higher spatial frequencies but still within the normal range.14 Protocols that in addition to the myopic residual error also change the corneal asphericity may theoretically result in worse performance in contrast sensitivity and stereoacuity.19 In any case, with more than 2.00 D of anisometropia, contrast sensitivity for binocular viewing is lower than the baseline monocular condition. Photopic conditions and smaller pupil sizes could soften this deleterious effect because monovision correction performs similarly at visual acuity tests for both high and low contrast targets.20

When comparing LASIK monovision and extended depth of focus IOL implantation, Schallhorn et al.16 also found a trend toward worse dry eye symptoms after presbyopic IOL implantation in the myopic group as opposed to worse dry eye symptoms after LASIK monovision in the hyperopic group. Halos, glare, and starburst symptoms were always worse after presbyopic IOL implantation. The myopic patients also reported better near task scores after LASIK monovision compared to the presbyopia-correcting IOL. There was no difference for distance visual acuity. Except for patients with moderate to high myopia, where monovision LASIK had higher satisfaction rates, satisfaction scores were similar between monovision LASIK and refractive lens exchange in their study.

Only a few studies specifically investigated potential differences in monovision results in eyes with femtosecond laser–assisted LASIK and conductive keratoplasty. A retrospective study comparing the visual outcomes, complications, and patient satisfaction revealed re-treatment rates of 3% and 50% after femtosecond laser–assisted LASIK and conductive keratoplasty (P < .0001), respectively. Eyes with conductive keratoplasty monovision had more regression and induced astigmatism. At 12 months, 62.5% of the femtosecond laser–assisted LASIK group and 34.4% of the conductive keratoplasty group reported being satisfied.21

Excimer Laser Profiles Combining Increase in Depth of Focus and Monovision

There are techniques that combine an increase in the depth of focus through a controlled change of asphericity and spherical aberration that could be applied either to both eyes (distance and near eye; laser blended vision)22–25 or only to the non-dominant eye (custom Q),26,27 with monovision or micromonovision in the non-dominant eye. Theoretically, all profiles working with this strategy are intended to control the spherical aberration so that postoperative spherical aberration remains within a range that provides an increased depth of field, without affecting contrast sensitivity and quality of vision.

Laser Blended Vision

The non-linear aspheric monovision ablation, termed laser blended vision (Carl Zeiss Meditec, Jena, Germany), induces a controlled amount of spherical aberration in both eyes (distance and near eye) to increase the depth of field and make the non-dominant eye slightly myopic (nearly −1.50 D).22–25 The profile incorporates a precompensation factor for the induction of spherical aberration. This factor considers, for each eye, the expected induction of spherical aberration given the intended correction, the level of naturally occurring preoperative spherical aberration, the patient's age, and the tolerance of accuracy depending on the manifest refraction. According to the authors,22–25 this pre-compensation factor is restricted by an overall limit to avoid the induction of topographical central islands. Reinstein et al. described the laser blended vision technique with satisfactory results in emmetropic,22 myopic,23 and hyperopic24 populations. Considering that a multifocal ablation could lead to reduced contrast sensitivity, the authors suggested an ablation modulus with a small degree of asphericity associated with micromonovision in emmetropic patients, who have low or no refractive error. This approach would improve near sight without compromising the quality of vision from far away that these patients have always had.22

Using this protocol, the intended postoperative refraction is plano for the dominant eye and in the range of −1.50 D for the non-dominant eye for the majority of patients, irrespective of the patient's age. However, the target for the non-dominant eye could be reduced to 0.75 D if the tolerance is low, until the patient reports no cross-blur, or increased to 2.00 D if required to achieve sufficient near vision.22–24 The laser blended vision ablation pattern applies a proprietary aspheric ablation profile, which incorporates a controlled amount of spherical aberration determined according to the patient's age, preoperative spherical aberration, and the amount of refractive correction. The purpose of this strategy is to control the induction of spherical aberration to a level that would provide an increased depth of field, theoretically, with no significant decline in contrast sensitivity.

One year after the final treatment, the mean residual spherical equivalent (SE) refraction was −0.01 D in the dominant eye and −1.49 D in the non-dominant eye in the emmetropic group, −0.05 and −1.33 D, respectively, in the myopic group, and +0.04 and −1.32 D, respectively, in the hyperopic group. This strategy was equally effective regardless of the initial ametropia, with 99% of the patients presenting binocular UDVA of 20/25 or better and 95% binocular UNVA of J3 or better, with no reduction in contrast sensitivity.22–24 The authors stated that 91% of the eyes in the emmetropic group, 92% in the myopic group, and 79% in the hyperopic group were within ±0.50 D of the target. The reported re-treatment rate was 12% in the emmetropic group, 19% in the myopic group, and 22% in the hyperopic group. The hyperopic group presented the highest gain after re-treatment, increasing from 87% to 95% of eyes reaching J3 or better.24 Regardless of the initial ametropia, this strategy presented stability after 1 year and, more importantly, safety because there was no loss of two lines or more of CDVA in any group.22–24 Zhang et al.25 found similar results in a myopic population with shorter follow-up.

Table 2 summarizes the results of the laser blended vision studies.

Published Studies With Laser Blended Vision

Table 2:

Published Studies With Laser Blended Vision

Custom Q Algorithm

The central presbyopic LASIK with corneal asphericity (Q) modulation by the custom Q algorithm (Alcon Laboratories, Inc., Fort Worth, TX) induces a controlled amount of negative asphericity in the non-dominant eye. The dominant eye is corrected for distance vision with the optimized algorithm and the non-dominant eye is corrected with the custom Q software set to a postoperative refractive target of −0.50 D combined with a change in the asphericity (ΔQ) target between −0.60 and −0.80. Q factor modulation, and particularly a ΔQ toward a more negative Q factor (hyperprolateness), would theoretically improve the depth of focus and near vision without significant changes in image quality. This treatment aims to change the mean asphericity by adjusting the number of mid-peripheral laser pulses. The optical zone is planned at 6.5 mm in all cases, with a transition zone of 1 mm.26–29

Wang Yin et al.26 evaluated the custom Q nomogram in hyperopic patients and found that, after 12 months, 100% of patients (with a mean residual SE refraction of 0.10 D in the dominant eye and −0.70 D in the non-dominant eye) achieved a binocular UDVA of 20/25 or better and a binocular UNVA of J3 or better. Refraction varied in the non-dominant eye from −1.30 D at 1 month to −0.70 D at 12 months of follow-up. Interestingly, on average the eyes targeted to ΔQ −0.8 presented significantly better binocular UDVA (20/16 vs 20/20, P < .001) and similar, and satisfactory, binocular UNVA (J2). The study also found a significant correlation (P = .04) between the target ΔQ and the achieved ΔQ. Despite some variation in the near eye refraction, it seems to be a safe procedure because only 1.2% of the eyes lost two or more lines of CDVA.

The rationale for this treatment considers three theoretical aspects28: that the theoretical amount of change in spherical aberration ΔC40 to achieve an increase in depth of focus without compromising distance vision and image quality would be somewhere close to −0.4 μm; the previously described correlation between the theoretical required change in corneal asphericity (ΔQ) to achieve a specific target change in Zernike corneal spherical aberration; and the required change in asphericity for hyperopic corrections and to achieve this intended change in spherical aberration ranges between ΔQ = −0.55 and −0.70, depending on the preoperative corneal asphericity and paraxial defocus correction.

Courtin et al.27 evaluated hyperopic eyes 6 months after custom Q treatment for presbyopia. The optimized algorithm was used for the dominant eye and the non-dominant eye was targeted to correct the hyperopia and the minimum addition to achieve J2. The target Q-value was planned to achieve a change in corneal asphericity value between −0.60 and −0.70 for a normalized 6-mm pupil size. They found that 99% of patients (with a mean residual SE refraction of 0.32 D in the dominant eye and −1.06 D in the non-dominant eye) achieved a binocular UDVA of 20/25 or better and 93% achieved a binocular UNVA of J3 or better. The mean ΔQ in the non-dominant eye was −0.61 and the subsequent spherical aberration change was −0.49 μm, revealing the predictability of this treatment. There was stability between 3 and 6 months and no eyes lost two or more lines of CDVA. The re-treatment rate was 10.8%.

A previous study29 including hyperopic and myopic eyes, using the custom Q nomogram, changing corneal asphericity in both the dominant and non-dominant eye, and targeting the non-dominant eye to a ΔQ of −1, found good results for distance and near vision but reduced optical quality. This finding confirms that optimal results balancing presbyopia correction and quality of vision are achieved with an asphericity change between −0.6 and −0.8, and there is a limit after which optical quality decreases. The authors did not present the specific values, but stated that more than 90% of the eyes achieved binocular uncorrected UDVA and UNVA of 20/25 or better.

Table 3 summarizes the results of the custom Q studies.

Published Studies With Custom Q Algorithm (Hyperopic Eyes)

Table 3:

Published Studies With Custom Q Algorithm (Hyperopic Eyes)

Multifocal Ablation Pattern with Near and Distance Vision Zones

Three different multifocal ablation patterns with well-defined near and distance vision zones have been proposed to address presbyopia depending on how the excimer laser is applied, dividing the cornea into distance and near viewing circles: transitional multifocality,30,31 peripheral near vision multifocal pattern,2,32–35 and central near vision multifocal pattern.36–38 Hybrid techniques theoretically combine the benefits of mono-vision and central near vision multifocal pattern.

Transitional Multifocal Pattern

The transitional multifocality strategy bases its efficacy on the creation of a deliberate decentration of a hyperopic ablation profile, increasing vertical coma. This technique gained some popularity during the 1990s, but most surgeons have abandoned it due to the potential reduction in visual quality associated with a dramatic increase of higher order aberrations in general and coma in particular.30

Gobin et al.31 reported a postoperative UDVA equivalent to or better than preoperative CDVA in 82% of cases, and UNVA was one line better in patients treated for both hyperopia and presbyopia than those only treated for hyperopia. Although the so-called “transitional” multifocality presented some results improving near vision, unsolved questions related to uncontrolled induction of coma aberrations reduced its applicability. The literature about this method is scarce.

Peripheral Near Vision Multifocal Pattern

Despite differences inherent to specific platforms, this type of ablation creates a central area for distance vision and a mid-peripheral zone for near vision.2,32–35

Telandro2 reported the results of a multifocal ablation profile using the peripheral zone for near vision in preoperatively myopic and hyperopic eyes 3 months after surgery. The author found that 100% of both previously myopic (with a residual SE refraction of −0.19 D) and hyperopic (with a residual SE refraction of −0.50 D) eyes achieved bilateral UNVA J3 or better, whereas only 73% and 58% presented J2 or better, respectively. Although the study did not report the results for UDVA, he stated that 66.7% of the eyes in the myopic group and 75.2% in the hyperopic group were within ±0.50 D of emmetropia. As far as safety, no eyes in the myopic group and 1% in the hyperopic group lost two or more lines of CDVA.

Uy and Go32 showed that, 6 months postoperatively, 68% in the previously myopic group (with a residual SE refraction of −0.40 D) achieved UDVA of 20/25 or better and 95% achieved bilateral UNVA of J3 or better, whereas 100% in the previously hyperopic and emmetropic group (with a residual SE refraction of +0.15 D) achieved bilateral UDVA of 20/25 or better and 83% achieved bilateral UNVA of J3 or better. Functional vision, defined as the combination of 20/30 or better of UDVA with J3 or better UNVA, was achieved in 83% eyes that were previously myopic and in 87% eyes that were hyperopic or emmetropic. Interestingly, the authors noted a higher induction of spherical aberration in the previously myopic group compared to the hyperopic and emmetropic groups (0.312 vs 0.016 μm), which may explain a higher proportion of eyes with J3 or better. The reported re-treatment rate was 2% in the myopic group and 0.8% in both the hyperopic and emmetropic groups. The authors did not evaluate safety.

El Danasoury et al.33 investigated the results of a peripheral near zone 1 year after surgery in myopic and hyperopic eyes. In the previously myopic group (with a residual SE refraction of −0.48 D), 78% achieved UDVA of 20/25 or better and 84% achieved UNVA of J3 or better, whereas in the previously hyperopic group (with a residual SE refraction of +0.10 D), 83% achieved UDVA of 20/25 or better and 79% achieved UNVA of J3 or better. The authors stated that 60% of the eyes in the myopic group and 75% in the hyperopic group were within ±0.50 D of emmetropia. As far as safety, 2% of the eyes in both groups lost two or more lines of CDVA. The reported re-treatment rate was 28% in the myopic group and 19% in the hyperopic group. The authors also evaluated scotopic contrast sensitivity and found no difference when comparing preoperative and postoperative results in either group, and 48% of previously myopic eyes and 54% of previously hyperopic eyes were satisfied or very satisfied with their postoperative UNVA.

After a mean follow-up of 27 months, Epstein and Gurgos34 found 70% of patients in the previously myopic group (with a mean residual SE refraction of −0.04 D in the dominant eye and −1.24 D in the non-dominant eye) achieved a binocular UDVA of 20/20 or better and 65% achieved binocular UNVA of J1 or better. In the previously hyperopic group (with a mean residual SE refraction of −0.04 D in the dominant eye and −1.24 D in the non-dominant eye), 68% of patients achieved a binocular UDVA of 20/20 or better and 71% achieved binocular UNVA of J1 or better. No eyes lost two or more lines in the myopic group, but 14% of eyes in the hyperopic group did. The re-treatment rate was 27% and 28%, respectively.

Pinelli et al.35 analyzed the results of a peripheral algorithm for the correction of presbyopia in hyperopic patients only. Six months postoperatively, with a residual SE refraction of −0.42 D, mean binocular UDVA was 1.06 ± 0.13 (20/19) for distance and UNVA was 0.84 ± 0.14 (20/23) for near. Unfortunately, the authors did not provide the specific percentage of eyes that achieved 20/20 or 20/25, but 75% of the eyes were within ±0.50 D of emmetropia. The study investigated the safety of the procedure through a safety index (ratio between mean postoperative/mean preoperative CDVA) and found a binocular distance safety index of 1.11 and a binocular near safety index of 1.0, indicating a safe procedure. More specifically, only two eyes (4.5%) lost one line of CDVA. Optical quality metrics may be a concern because contrast sensitivity decreased at a wide range of spatial frequencies and corneal aberration analysis showed a slight increase in coma and decrease in spherical aberration.

Table 4 summarizes the results of the peripheral near vision multifocal pattern studies.

Published Studies With Peripheral Near Vision Multifocal Pattern

Table 4:

Published Studies With Peripheral Near Vision Multifocal Pattern

Central Near Vision Multifocal Pattern

In the central near vision multifocal ablation pattern, a hyperpositive area is created for the near vision at the center, whereas the periphery is left for distance vision. One distinctive advantage is that a central hyperpositive area can be created at the center of the cornea with minimal corneal excision associated with myopic or hyperopic treatments or even for emmetropia. The main limitation of this technique is the lack of adequate alignment among the line of sight, the central pupil, and the corneal vertex, making this ablation pattern also prone to the induction of coma aberrations. Normally this strategy is applied bilaterally targeting plano.36–38

Alió et al.36 investigated the results of a central near vision zone ablation pattern 6 months after surgery in hyperopic eyes. They found (with a residual SE refraction of −0.34 D) that 88% achieved UDVA of 20/25 or better and 92% achieved UNVA of J3 or better. The authors stated that 64% of the eyes were within ±0.50 D of emmetropia. As far as safety, 14% of the eyes lost two or more lines of CDVA. The reported re-treatment rate was 12%. The authors also reported reduced contrast sensitivity at higher spatial frequencies, whereas night halos were reported by 12% of patients.

Jackson et al.37 evaluated an aspheric ablation profile with central near vision in presbyopic patients with hyperopia. At 12 months, 100% of patients (with a mean residual SE refraction of +0.21 D) achieved a binocular UDVA of 20/25 or better and UNVA of J3 or better. Refraction was stable for 1 year. The authors reported that 88% of the eyes were within ±0.50 D of emmetropia. Ten percent of the eyes lost two or more lines of CDVA. Mean contrast sensitivity measured under mesopic conditions was significantly reduced at higher spatial frequencies, but the contrast sensitivity function remained within the normal range of the population. The authors also measured the reading performance and, despite no difference in reading speed, reading acuity and critical print size were better 3 months after surgery.

Table 5 summarizes the results of the central near vision multifocal pattern studies.

Published Studies With Central Near Vision Multifocal Pattern (Hyperopic Eyes)

Table 5:

Published Studies With Central Near Vision Multifocal Pattern (Hyperopic Eyes)

Hybrid Techniques

Hybrid techniques are designed to combine the benefits of monovision and central near vision multifocal pattern and suppress, or at least minimize, the related disadvantages. The hybrid modifications studied in the literature are: Supracor (Bausch & Lomb/Technolas, Munich, Germany) and PresbyMAX (SCHWIND eye-tech-solutions, Kleinostheim, Germany) (reduced multifocality in distance eye combined with full multifocality and monovision in the near eye).

Supracor. This relatively new ablation pattern uses the Zyoptix tissue-saving algorithm to perform the individual distance correction (adjusted according to a nomogram) in a 6-mm optical zone followed by the Supracor component, which involves additional pulses in both eyes to create a hyperpositive area in the central 3-mm zone. In this nomogram, both eyes also are targeted to −0.50 D and no distinction between the dominant and non-dominant eyes is made in the treatment calculation. Theoretically, this technique results in approximately 2.00 D of near addition with controlled higher order aberrations, yielding high levels of satisfaction.39–43

Ryan and O'Keefe39 analyzed the results of this algorithm for the correction of presbyopia in hyperopic eyes. At 6 months (with a mean residual SE refraction of −0.69 D), 78% of eyes achieved a binocular UDVA of 20/25 or better. Near vision was measured as the smallest print the patient could read comfortably on the Vocational Reading test, and 91% of eyes achieved a binocular UDVA of N8 (midpoint of the chart equivalent to similar to J3 on the Jaeger chart) or better. Ninety-one percent of eyes reported adequate levels of uncorrected reading ability and 93% of eyes required no reading glasses. There was stability between 3 and 6 months and only 4.3% lost two or more lines of CDVA. Although 22% of eyes required a re-treatment in the dominant eye to enhance UDVA, the authors reported that 96% patients were happy that they had the procedure.

In a similar study, Cosar and Sener40 found that, at 6 months (with a mean residual SE refraction of −0.33 D), only 36% of eyes achieved a binocular UDVA of 20/25 or better, whereas 89% achieved J2 or better. As far as safety, 10% of eyes lost two or more lines of CDVA.

As opposed to the previous studies, Saib et al.41 investigated a protocol where Supracor was applied in both eyes but with a distinction between the dominant and non-dominant eyes in the treatment calculation, with the nomogram and with micromonovision of −0.50 D induced in the non-dominant eye only. At 1 year postoperatively, they found that 100% of patients (with a mean residual SE refraction of 0.00 D in the dominant eye and −0.51 D in the non-dominant eye) achieved a binocular UDVA of 20/25 or better and 95% achieved binocular UNVA of J2 or better. With a different nomogram, spherical aberration changed from +0.21 to −0.06 μm in dominant eyes (P < .05) and from +0.21 to −0.14 ± 0.18 μm in non-dominant eyes (P < .05). Only 4% of eyes lost two or more lines of CDVA and the re-treatment rate was 13.5%.

Ang et al.42 found that (with a mean residual SE refraction of −0.43 D) 100% of eyes achieved a binocular UDVA of 20/25 or better and 93% achieved a binocular UNVA of J2 or better. After 6 months, 6% of eyes lost two or more lines of CDVA and the re-treatment rate was 5.7%.

Table 6 summarizes the results of Supracor reported outcomes.

Published Studies With Supracor (Hyperopic Eyes)

Table 6:

Published Studies With Supracor (Hyperopic Eyes)

PresbyMAX. With this technique, a bi-aspherical corneal multifocal ablation termed PresbyMAX, also based on the creation of a central hyperpositive area for near vision and leaving the pericentral cornea for distance, was introduced. The bi-aspheric multifocal profile is created over an optical zone of 6.5 mm. The individual distance refractive correction is applied over the entire optical zone with an automatically adjusted central treatment zone (approximately 3 mm) to be hyperpositive. This hyperpositive shape is influenced by the amount of addition (ie, the higher the addition, the more dominant the central area). The planned addition varies according to the patient's age from +0.75 to +2.50 D. A circumferential transition zone of gradually changing power connects the mid-peripheral cornea corrected for distance with the central area corrected for near. The term “bi-aspheric“ refers to the aspherical optimization of the central corneal area for near vision and the mid-peripheral cornea for far vision. In this multifocal ablation pattern, both eyes equally contribute to providing visual acuity at all distances by actively participating in the visual process for creating binocular vision. No differences between the dominant and non-dominant eyes are applied. The profile also includes the aim of micromonovision (approximately 0.50 D) myopic defocus for distance correction, equally for both eyes.44–48

Two studies45,46 evaluated the results of this original profile 6 months after surgery in myopic and hyperopic eyes. Uthoff et al.45 showed that, 6 months postoperatively, 70% of eyes achieved binocular UDVA of 20/25 or better and 80% achieved binocular UNVA of J3 or better in the previously myopic group (with a residual SE refraction of −0.68 D); 100% achieved UDVA of 20/25 or better and 80% achieved UNVA of J3 or better in the previously hyperopic group (with a residual SE refraction of −0.13 D); and 80% achieved UDVA of 20/25 or better and 90% achieved UNVA of J3 or better in the previously emmetropic (with a residual SE refraction of −0.43 D). The refraction was within ±0.50 D of the target in 70% of the myopic eyes, 60% of the hyperopic eyes, and 90% of the emmetropic eyes. The safety rates were similar regardless of the original ametropia. Ten percent of eyes lost two lines or more of CDVA and the binocular distance safety index was 0.9 in all groups. The treatment was stable between 3 and 6 months. The authors estimated a re-treatment rate between 7% and 10%.

Baudu et al.46 found (with a residual SE refraction of −0.32 D) that 70% of eyes achieved binocular UDVA of 20/25 or better and 94% achieved binocular UNVA of J3 or better in the myopic group and 74% achieved binocular UDVA of 20/25 or better and 87% achieved binocular UNVA of J3 or better in the hyperopic group (with a residual SE refraction of −0.13 D).

Luger et al.47 investigated myopic and hyperopic eyes but analyzed them as a single group only. They found that, at 1 year postoperatively, 70% achieved binocular UDVA of 20/25 or better and 94% achieved binocular UNVA of J3 or better. Also, 73% of eyes were within ±0.50 D of the target refraction. Three percent of eyes lost two or more lines of CDVA. Stability was achieved by 6 weeks of follow-up.

Chan et al.48 presented the 1-year results of combining monocular bi-aspheric ablation profile (PresbyMAX) in the non-dominant eye and a contra-lateral monofocal distance correction in patients with bilateral hyperopia and presbyopia. At 1 year, 87% of patients achieved 20/25 or better binocular UDVA and 90% achieved binocular UNVA of J3 or better. Ten percent of eyes lost two lines or more of CDVA after 1 year. Re-treatment was performed in 14% of patients to improve near vision within postoperative 6 months to 1 year. The re-treatment included a non–wavefront-guided aspheric ablation to tune near refraction of the non-dominant eye to the desired value. No eye required reversal treatment over 1 year.48

Table 7 summarizes the results of PresbyMAX reported outcomes.

Published Studies With PresbyMAX

Table 7:

Published Studies With PresbyMAX

Femtosecond Laser in Presbyopia

Although not related to excimer laser ablation, which is the main scope of this review, the Intracor femtosecond laser platform (Technolas Perfect Vision GmbH, Munich, Germany) is also an option for presbyopia treatment. The concept is based on the creation of intrastromal corneal concentric cylindrical ring cuts centered on the pupil. The principle of the procedure relies on the intraocular pressure to push forward the innermost part of the cornea, resulting in central steepening that induces negative spherical aberration and potentially increases the depth of focus without changes in the periphery and mid-periphery. It also creates a “monovision” because it is targeted to generate a mild myopia of −0.50 D.49–52

Holzer et al.50 reported a mean logMAR UNVA of 0.26 (between J2 and J3) and a loss of one line of CDVA in 42% and two lines of CDVA in 8.3% of eyes. Most patients complain of halos in the early postoperative period that disappear with time.51 A longer follow-up study showed that, after 3 years, there was an improvement in UNVA associated with a significant reduction in CDVA compared to preoperative values. This same study revealed that less than 50% had UDVA of 20/25 or better and approximately 75% had binocular UNVA of J3 or better.52

The main concerns with this strategy are that the long-term safety and stability of the central induced steepening remains unknown, contrast sensitivity and quality of vision have been reported to be reduced, refractive error cannot be corrected simultaneously, and a re-treatment is not currently possible. Plus, the real benefits of an entirely intrastromal ablation should be questioned because there are reports of ectasia after intrastromal femtosecond laser treatment.53

Discussion

Potential disadvantages or limitations of any ablation that would induce changes in corneal asphericity or spherical aberration or that would create multifocal (central or peripheral) patterns include potential deterioration of optical quality metrics, and induction of uncontrolled aberrations, reduced contrast sensitivity, and subsequently some degree of impairment of distance visual acuity.54,55

However, the modern available ablation patterns theoretically apply aspheric treatments that are able to control the amount of change in spherical aberration or asphericity to where it increases the depth of focus without significant reduction of contrast sensitivity.56 It seems important to not hesitate to re-treat the patient after 3 months to make sure the target is achieved or closer. Symptoms such as halos or glare seem to dissipate with time.29 Central near vision ablations apparently have some advantage compared to peripheral near profiles.57

The different techniques reviewed in this study revealed high rates of eyes achieving the combination of binocular UDVA 20/25 or better and UNVA of J3 or better, showing satisfactory levels of spectacle independence. As expected, monovision seems to be an interesting option regardless of the initial ametropia (myopic of hyperopic), as long as the distance vision eye is successfully improved with no or minimal residual errors. Excimer laser monovision may present more clear benefits for myopic eyes compared to extended focus IOL.7,16

The studies investigating different excimer laser ablation patterns applied in previously myopic eyes revealed high levels of efficacy with laser blended vision, the peripheral near vision multifocal pattern, and the central near vision multifocal pattern combined with monovision.2,23,25,32–34,45,46

Although the myopic eye has always had good results with monovision, the increase in options is impressive. However, it is for the hypermetropic eye that the new strategies seem to bring excellent and reliable new opportunities. The studies investigating different excimer laser ablation patterns applied in previously hypermetropic eyes revealed high levels of efficacy with laser blended vision, the custom Q platform, the peripheral near vision multifocal pattern, the central near vision multifocal pattern, and the central near vision multifocal pattern combined with monovision with either Supracor or PresbyMAX.2,24,26,27,32–34,36–42,45–48

Loss of two or more lines of CDVA varied between 0% and 10% in the myopic eyes and between 0% and 14% in hyperopic eyes.

Typical of the increased range of pseudoaccommodation phenomena, the neuroprocessing period theoretically would be a little more extended after the peripheral near vision multifocal pattern, whereas this process occurs for a more limited period and only for distance vision after the central near vision multifocal pattern. This could potentially signify a shorter period to achieve better results with near vision.57

Although possible with other strategies, reversion is more straightforward and practical with monovision for myopic eyes. The use of a contact lens or a new treatment that would smooth the surface, complete a myopic procedure, or flatten a previous hyperopic treatment is also an option that should be discussed with the patient.

Conclusion

Although each modality has its advantages and disadvantages, there have been significant developments in excimer laser ablations for presbyopia during the past decade, enabling a reliable combination of satisfactory vision for near and distance. Because a unique and ideal solution is not yet available, patient selection remains paramount for success and characteristics such as age, occupation, lifestyle, the patient's neuro-adaptive capacity, and the eye's condition are essential issues for the identification of the most appropriate surgical procedure.

Monovision is still highly rated by patients and surgeons. Although the depth of focus acts as a useful marker, acuity at average near vision distances is a more suitable metric that is closely related to patients' real expectations and concerns. The combination of monovision and increase in the depth of focus, the multifocal ablation patterns, and the hybrid strategies seem to have the potential for the correction of presbyopia based on the performance of excimer ablation profiles creating negative asphericity. There is evidence that patients for whom these methods are used achieve near vision spectacle independence at reasonable levels. Further studies are still needed to dismiss some long-term concerns related to optical quality and stability.

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Published Studies of Monovision

StudyNo. (Eyes)Mean Age (y)F/U (mo)SE (D)Binocular UDVA20/25Binocular UNVAJ3AccuracySafetyRe-treatment
Emmetropic eyes
  Ayoubi et al.21325518−1.38NA65% ≥ J575%100%3%
  Schallhorn et al.16126513−1.6290% ≥ 20/2096% ≥ J590%97%3%
Myopic eyes
  Braun et al.1300511−0.25 DO, −1.27 ND26%93%65%NA35%
  Jain et al.384497−0.04 DO, −1.95 NDNANA88%NA2%
  Goldberg72165224NA95%100% ≥ J263%NA12%
  Reilly et al.8164556−0.01 DO, −1.24 ND100%97% ≥ J2NANA28%
  Goldberg132285128NA79%100%NANA10%
  Garcia-Gonzalez et al.1474546+0.08 DO, −0.97 ND97%67%NANANA
  Schallhorn et al.16aL = 188; M-H = 352513−1.62L = 89% ≥ 20/20; M-H = 84% ≥ 20/20L = 100% ≥ J5; M-H = 98% ≥ J5L = 90%; M-H = 83%L = 100%; M-H = 100%NA
  Wright et al.15424415NA95%100%NANA26%
Hyperopic eyes
  Braun et al.144521−0.04 DO, −1.21 ND26%93%40%90%50%
  Goldberg7585224NA100%100% ≥ J265%NA24%
  Schallhorn et al.16550513−1.6277% ≥ 20/2095% ≥ J586%95%NA
  Alarcón et al.29b504912NA90% ≥ 20/20NA92%NA12%

Published Studies With Laser Blended Vision

StudyNo. (Eyes)Mean Age (y)F/U (Mo)SE DO (D)SE ND (D)Binocular UDVA20/25Binocular UNVAJ3AccuracySafetyRe-treatment
Emmetropic eyes
  Reinstein et al.222965512−0.01−1.4999%99%95%100%12%
Myopic eyes
  Reinstein et al. 233104912−0.05−1.3399%99%92%100%19%
  Zhang et al. 2580433−0.08−1.41100%95%93%100%NA
Hyperopic eyes
  Reinstein et al. 242585612+0.04−1.3299%95%79%100%22%

Published Studies With Custom Q Algorithm (Hyperopic Eyes)

StudyNo. (Eyes)Mean Age (y)F/U (Mo)SE DO (D)SE ND (D)Binocular UDVA20/25Binocular UNVAJ3AccuracySafetyRe-treatment
Wang Yin et al. 261385412+0.10−0.70100%100%NA98.8%13%
Courtin et al. 2798576+0.32−1.0699%93%NA100%11%

Published Studies With Peripheral Near Vision Multifocal Pattern

StudyNo. (Eyes)Mean Age (y)F/U (Mo)SE (D)Binocular UDVA20/25Binocular UNVAJ3AccuracySafetyRe-treatment
Myopic eyes
  Telandro277393−0.19NA100%67%100%NA
  Uy & Go3236466−0.4068%95%NANA2%
  El Danasoury et al.33784612−0.4878%84%6098%28%
  Epstein & Gurgos34755227−0.04 DO, −1.24 ND70% ≥ 20/2065% ≥ J1NA100%27%
Hyperopic eyes
  Telandro 283533−0.50NA100%75%99%NA
  Uy & Go 3230566+0.15100%83%NANA1%
  El Danasoury et al.33484912+0.1083%79%75%98%19%
  Epstein & Gurgos 34285627+0.21 DO, −0.86 ND68% ≥ 20/2071% ≥ J1NA86%28%

Published Studies With Central Near Vision Multifocal Pattern (Hyperopic Eyes)

StudyNo. (Eyes)Mean Age (y)F/U (Mo)SE (D)Binocular UDVA20/25Binocular UNVAJ3AccuracySafetyRe-treatment
Alió et al. 3650586−0.3488%92%64%86%12%
Jung et al. 3828536+0.3393%64%NA96%NA
Jackson et al. (6m) 3760536+0.1893%93%87%90%NA
Jackson et al. (12m)37505312+0.21100%100%88%90%NA

Published Studies With Supracor (Hyperopic Eyes)

StudyNo. (Eyes)Mean Age (y)F/U (Mo)SE (D)Binocular UDVA20/25Binocular UNVAJ3AccuracySafetyRe-treatment
Ryan & O'Keefe 3946576−0.6978%91%46%96%22%
Cosar & Sener 40123576−0.3336%89% ≥ J2NA90%NA
Saib et al. 417454120.00 DO, −0.51 ND100%94% ≥ J2NANA13%
Ang et al. 4269516−0.43100%93% ≥ J2NA94%6%

Published Studies With PresbyMAX

StudyNo. (Eyes)Mean Age (y)F/U (Mo)SE (D)Binocular UDVA20/25Binocular UNVAJ3AccuracySafetyRe-treatment
Myopic eyes
  Uthoff et al. 4520516−0.6870%80%70%90%7% to 10%
  Baudu et al. 46164536−0.3270%9477%74%a19%
Hyperopic eyes
  Uthoff et al. 4520546−0.13100%80%60%90%7% to 10%
  Baudu et al. 46552536−0.1374%8791%75%a19%
  Chan et al. 48725312−0.03 DO, −1.12 ND8790NA100%14%
Luger et al. 47b665312−0.4770%94%73%97%NA
Authors

From the Department of Ophthalmology at University of São Paulo, São Paulo, Brazil (LRS, MNF, MRS); the Department of Ophthalmology, University of Southern California, Los Angeles, California (MRS); and the Department of Ophthalmology, Federal University of Rio de Janeiro, São Paulo, Brazil (MRS).

Dr. Santhiago is a consultant for Ziemer (Port, Switzerland) and Alcon Laboratories, Inc. (Fort Worth, TX). The remaining authors have no financial or proprietary interest in the materials presented herein.

AUTHOR CONTRIBUTIONS

Study concept and design (LRS, MRS); data collection (LRS, MNF, MRS); analysis and interpretation of data (LRS, MRS); writing the manuscript (LRS, MNF, MRS); critical revision of the manuscript (MRS); supervision (MRS)

Correspondence: Marcony R. Santhiago, MD, PhD, Instituto Central, 255 Enéas de Carvalho Aguiar Av., Ophthalmology Department, Federal University of São Paulo, São Paulo, Brazil. E-mail: marconysanthiago@hotmail.com

Received: December 12, 2016
Accepted: July 25, 2018

10.3928/1081597X-20180726-02

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