Surgical Correction of Presbyopia

Lenticular, Corneal, and Scleral Approaches

Michael Greenwood, MD; Shamik Bafna, MD; Vance Thompson, MD

Disclosures

Int Ophthalmol Clin. 2016;56(3):149-166. 

In This Article

Scleral Implants

Another alternative to correct presbyopia is scleral modifications and implants. This approach is based on research that found movement of the sclera during accommodation, which decreases with increasing age.[27] As the optical axis remains unimpeded, the advantages of a scleral approach include no changes to distance vision, no glare, halo, or other optical aberrations. Patients also maintain a continuous range of focus from far through intermediate to near as a result. Disadvantages of this technique include manipulation of the conjunctiva through a 360-degree peritomy. Currently, 2 devices are under investigation.

The AceVision LaserACE (Newark, CA) uses an Er:Yag laser with fiber optic probe with a 600 μm spot size to create 9 microexcisions in the 4 oblique quadrants. The proposed mechanism of action is a restoration of mechanical efficiency of the natural accommodative mechanism and improved biomechanical mobility to achieve accommodative power.

Early data in 64 eyes of 32 patients aged 42 to 69 years who underwent the LaserACE procedure showed that 89% of the patients were J3 or better, and 81% were J2 or better without correction at near vision, and 95% were J5 and 85% were J3 for intermediate vision. Overall, 78% of the patients were spectacle-independent for near vision, and 98% were spectacle independent for intermediate vision. No complications were reported in this study (Dementiev 2008 ESCRS).

The VisAbility scleral implant (Refocus Group, Dallas, TX) uses a different approach. This implant uses 4 small implants placed in scleral tunnels, 4 mm posterior to the limbus. The hypothesized mechanism of action is a retensioning of the posterior zonules, giving the ciliary muscles more efficiency in reshaping the lens in presbyopic patients.

Unpublished data from the US IDE clinical trials showed an improvement in CDVA to J3 (20/40) or better at 1, 3, 6, 12, 18, and 24 months postoperatively in 63%, 62%, 70%, 81%, 85%, and 88% of the eyes, respectively. In Europe, where the VisAbility Implant System is being used, improvement of CDVA to J3 (20/40) or better at 1, 3, 6, and 12 month postoperative visits was found in 70%, 85%, 92%, and 93% of the eyes, respectively (Stonecipher K. Latest system used in Europe improves the outcomes, precision and consistency of scleral implant surgery for presbyopia, ESCRS 2015).

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