New Treatments for Presbyopia Erin D. Dunphy, O.D.

Presbyopia As we age, the lens stiffens making it harder and harder to focus on near objects symptoms typically begin between the ages of 40 and 45

The Numbers 1.7 Billion people in world have presbyopia In the United States- 152 million -99 million wear some type of vision correction as the population ages these numbers are increasing Many want better choices than glasses or contacts

Other options options

Let them have drops! there are many ongoing studies investigating eye drops to aid in accommodation

EVO6 by Novartis designed to restore the lenses flexibility It is a prodrug- a medication that after administration is metabolized into a pharmacologically active drug

EVO6 lipoic acid choline ester 1.5% penetrates the cornea and breaks down into lipoic acid and choline The lipoic acid converts to dihydolipoic acid which breaks down the disulphide bonds in the lens which INCREASES LENS FLEXIBILITY

Cool Chemistry EVO6

Placebo Controlled Study 50 patients treated daily with EVO6 for 90 days 25 patients were given a placebo EVO6 showed a statistical difference from the placebo By day 90, 82 % of the participants treated with EV06 had 20/40 near vision versus only 48 % in the placebo group

EVO6 Study The comfort of the drop was well tolerated and there was no loss of distance acuity Other tools require us to adapt to imbalance or simultaneous multiple points of focus there was no change in pupil size or IOP More studies of larger groups and over a longer time period need to done but the results are promising

EVO6 Fountain of Youth this drop could potentially halt or reverse lens hardening which would allow the lens to maintain or regain its ability to accommodate

A place for us presbyopia correcting drops may be used in conjunction with other available options, such as low powered readers or low powered multifocal contacts if used with low powered multifocal contacts the idea is there will be less blur in the distance

Liquid Vision Drop made by Presbyopia Therapies Combines aceclidine- a miotic and Tropicamide a cycloplegic to create a super pinhole effect and moderate accommodation The miotic causes the pinhole effect and creates strong accommodation and distance blur but in combination with tropicamide moderates the accommodation at the same time the combination is uses to improve near and far vision

Liquid Vision Drop fast acting , 30 minutes! meant to be used daily and as a complement to current options put drops in, drive to work and be able to see the computer in to early afternoon, then put in another drop Still in FDA trials expected on the market in 2021

Liquid Vision liquid vision

FOV Tears a presbyopia correcting drop approved in Columbia and is going through approval in Argentina, Peru and Spain It is a combination of parasympathetic, alpha agonist 1 and 2, an anti-cholinesterase and and NSAID it affects the ciliary muscle- causes a physiological accommodation and a dynamic pseudo- accommodation- dynamic miosis that changes with light intensity

FOV tears FOV

Study results A small study found the drops lasted 4-5 hours at first but this increased to 8 hours with use of the drop over a long period of time the onset of the drop’s effects accelerated with longer use of the drop, by the 3rd month 70 percent stated it took only 5-10 minutes to take effect improved near acuity by 2-3 lines at first after 3 months study subjects improved 1-2 more lines of acuity and improved a line in the distance as well

Study results after 3 months the patient’s near vision improved one to two additional lines distance improved by one line and intermediate vision was 20/25 by the third month of use, 100 percent of the participants were totally independent of their near vision correction for normal activities

Monocular Drop small pilot study of presbyopes with 20/20 uncorrected distance vision were give 3% carbachol and .2% brimonidine separately and in combination to their non-dominant eye The drop constricts the pupil increases depth of focus with the pinhole effect disadvantage is that it is monocular and their is some dimming of vision due to the small aperture optics

Market for drops Results from the recent studies seem promising May be especially useful in the early stages of presbyopia for patients that want to delay their dependency on readers or glasses could introduce new patients into a practice- patients that self treated with readers will need to see an eye doctor for annual exams for these Rx drops

You Can’t Read This

Presby LASIK Creating a corneal flap and applying a variable ablative treatment pattern to the stoma creating a multifocal cornea Peripheral presby LASIK- the central corneal is treated for distance acuity and peripheral corneal tissue is removed to create a negative asphericity to increase depth of field

Peripheral PresbyLASIK may be limited to hyperopes, low myopes and emmetropes due to the amount of peripheral tissue that needs to be ablated in higher myopes

Central PresbyLASIK Creates a hyperpositive area in the central cornea for near acuity while reserving the peripheral cornea for distance Pupil dependent and targets a similar purpose to diffractive multifocal lenses- leaving the central cornea of near vision the only LASIK approved in the United States at this time is monovision LASIK, more studies need to be done on these alternative options

Disadvantages Unwanted diffractive effects, improper centration progression of loss of effect from the biomechanical properties of the cornea one study reported reduced contrast sensitivity in these patients

Intracor a femtosecond laser ablates only the intrastromal corneal tissue it is delivered in a series of concentric disruptive cylindrical rings within the posterior stroma that extend out to mid stroma intraocular pressure then induces corneal steepening on the anterior corneal surface

Intracor Pattern depends on patient's refractive error, improves distance and near acuity without disrupting the epithelium Short recovery time and anterior stromal fibers are preserved more investigation needs to be done

Intracor Intracor

Intracor Intracor

Corneal Inlays they improve near vision without hindering distance vision in emmetropic presbyopes April 2015- FDA approved Kamra inlay Acufocus thin , small disc as a 1.6 mm central opening that acts as a pinhole to increase the patient’s depth of field and improve near vision with little effect on distance vision

Kamra has thousands of microperforations in the donut- shaped inlay to allow nutrients to pass through the implant within the cornea this pseudo-random distribution of perforations ensures the delivery of more focusable light rays to the retinal plane better optical regulations and improves vision in dimmer environments

Kamra Inlay it can be removed in clinical trials the near acuity pre-op to post-op improved form J 8 to J 2 Distance vision was maintained at 20/20 to 20/25

Inlay Issues some reports of glare at night challenges with viewing the retina during retinal surgery

Inlay surgery

Raindrop hydrogel plastic inlay placed in the cornea of the non dominant eye under a LASIK style flap using a femtosecond laser It changes the curvature of the front of the cornea so the front of the eye acts like a multifocal lens It was approved in 2016 by the FDA

Flexivue Inlay another hydrophilic inlay that is placed in the non dominant eye and is offered in powers from +1.50 to +3.00 works well for emmetropic presbyopes

Disadvantages sacrifices some distance vision people must have good distance vision to be a candidate corrects for 1.5 to 2.5 diopters of reading

New Contacts for Presbyopia E Vision smart optics electronic contact lens have a prototype that adds a liquid crystal material to a conventional lens that can be tuned to different focal lengths over 3 diopters through embedded electrodes the electronic portion of the lens is less than 5 mm

AMAZING WHAT that’s like a bionic eye!!!

E Vision the patients can adjust it 3 diopters in either direction giving them a 6 diopter range, pre set distances can be programmed for far, near an intermediate changes within 200 milliseconds

E vision they automatically tint in sunlight WOW! They should hold a charge during the days wear charging kit comes with the cleaner

Extended Depth of Focus CL approved by the FDA in 2017 the design uses higher order aberrations to improve image quality over a range of distances while minimizing ghosting and haloes It is supposed to perform independently of a patient’s natural aberrations and changes in pupil size

EDOF

Google and Alcon’s Smart Lens the two companies are partnering to develop a lens with embedded sensors, microchips and other miniaturized electronics Alcon expects the lens to help restore the eyes natural autofocus for near objects in the form of an accommodative contact lena or an IOL implanted during cataract surgery

New Progressive Digital Design with advanced computer algorithms the corridor length can be designed to custom fit the patients frame of choice with the appropriate width of distance and near portion this can reduce unwanted distortions and improve adaption leading to high patient satisfaction

Essilor’s Varilux Portfolio includes technology to provide sharper vision in all lighting conditions and easier transition between distance and near zones and a reduction in swim

Future is Clear! With the increasing numbers of presbyopes due to the aging of the population, many patients will be seeking better options than those that are currently available.

Future options Continued advancement in multifocal IOL’s, eye drops to increase accommodation corneal inlays PresbyLASIK electronic contacts advancements in glasses options

Thank you! Thanks for attending. GO CUBS!