No matter whether you have nearsightedness, farsightedness, or astigmatism, or don’t need distance glasses at all, everyone begins to need reading glasses in their 40’s. This is a problem called presbyopia. Indeed, Baby Boomers comprise the largest segment of the presbyopic (ie reading glass) population. Presbyopia occurs when the lens inside the eye becomes stiffer, and less able to change shape and focus up close, with age. It’s the most common vision disorder in America and affects more than 60 million people over age 40. Early symptoms of presbyopia include difficulty reading very small letters such as on medicine bottles or reading in poor light situations. This progresses naturally as you get older to the constant dependency on glasses for reading and even for the computer.
Traditionally, reading glasses, bifocals, and bifocal or monovision contact lenses are used to correct the problem. Aside from glasses and contact lenses, at the Cornea and Laser Eye Institute – Hersh Vision Group, we offer 5 surgical options to improve reading vision. The choice of technique depends on your particular circumtance:
Corneal Inlays – KAMRA
Near Vision Multifocal LASIK
Monovision Blended LASIK
Near Vision CK
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KAMRA CORNEAL INLAY
A healthy, young eye is able to focus light from both far and near objects to create a clear image at all distances. By age 45, the eye’s natural lens is too stiff to focus on near points. As a result, near tasks like reading or computer work are blurry. This is a natural occurrence that affects us the rest of our life. The clinical term for the loss of near vision is presbyopia. It is possible to have poor near vision, but good distance vision.
The steepening of the natural lens in the eye brings near images into focus. The lens stiffens and is unable to focus as you age.
The KAMRA Corneal Inlay is a new procedure to help reduce the need for reading glasses. Dr. Peter Hersh was a principal investigator and the CLEI team participated in the clinical trials leading to FDA approval.
Smaller than a contact lens, the KAMRA Corneal Inlay looks like a black ring. There is a tiny aperture or hole in the center of the inlay. The inlay may help to improve vision in two ways.
- Creates a pinhole effect so near objects are clearer.
- Focuses light rays so you can see a wider range of vision near, intermediate (computer) and distance.
Ring shaped KAMRA inlay helps to focus near objects.
The KAMRA Procedure
During an out-patient procedure performed at The Cornea and Laser Eye Institute, Dr. Hersh, will implant the inlay in one eye. Using eyedrops to numb the eye, a laser is used to form a pocket for inlay placement. The Kamra inlay is then placed in position, as determined from your preoperative measurements. The procedure is not painful and you can return to normal activities the next day. If needed, the Kamra inlay can be removed.
You may be eligible for this procedure if you are:
- Between the ages of 45 and 60.
- Using reading glasses to read or work on the computer.
- Not using glasses or contacts to see far objects.
- In good physical health.
- Able to meet other medical criteria determined by Dr. Hersh
What to expect after KAMRA inlay placement
The amount of time it takes to see an improvement in near vision varies. Some see better in a few days. For others, it takes several months, or there may be no improvement at all. You can help your eye heal faster by using eye drops as prescribed. You will also be asked to practice reading without glasses. This activity will help train your inlay eye how to see near again.
The goal of the inlay is to reduce your need for reading glasses. However, you may continue to need glasses for reading very small print or in dim light.
If you are interested in learning if the KAMRA Corneal Inlay can reduce your dependence on reading glasses, contact the Cornea and Laser Eye Institute at 201-883-0505 or e-mail firstname.lastname@example.org.
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NEAR VISION MULTIFOCAL LASIK
This procedure is undertaken as in the typical LASIK procedure for nearsightedness, farsightedness, and astigmatism. It is designed to correct these problems while also decreasing the need for reading glasses in patients in the presbyopic age range. It also can benefit people who only wear reading glasses.
Near Vision Multifocal LASIK (or PRK) is designed to give patients who need reading glasses both functional distance and near vision. This laser procedure reshapes the cornea using optical principles which create an increased depth of field, with the goal of improving reading vision as well as any underlying distance vision refractive problem. After Multifocal LASIK, it may take several weeks for both distance and near vision to stabilize.
Of course, there is no guarantee that both good distance and/or near vision will be achieved and glasses or contact lenses (either distance vision, reading vision, or both) may still be required. Like other presbyopia correcting procedures, Multifocal LASIK is not meant to completely replace reading glasses, but to improve your nearpoint function for tasks like reading restaurant menus and seeing your cell phone in the car. Also, because the reading problem is age-related, and we cannot restore youthful function to your natural lens, there may be some distance vision compromise and some patients will like to have glasses, for instance, when night driving.
Although the Wavelight laser we use at CLEI is approved for the treatment of nearsightedness and farsightedness alone, it has not been FDA approved for Near Vision Multifocal LASIK. This means that there have been no formal studies submitted for the FDA approval process using the laser for this specific treatment and that the Near Vision Multifocal LASIK procedure is not “FDA-approved”.
MONOVISION (OR BLENDED VISION) LASIK
In this LASIK procedure, the dominant eye is corrected for distance vision and the nondominant eye is corrected more for near/intermediate vision. Using both eyes together, the brain blends the images to give an improved depth of focus. After Monovision LASIK, it may take several weeks for you to adapt to the new vision. And like other presbyopia correcting procedures, Monovision LASIK is not meant to completely replace reading glasses, but to improve your nearpoint function in general. The blended vision procedure is designed to avoid too large a discrepency in vision between your two eyes, with our goal to give you comfortable binocular vision after the procedure. Monovision is the most popular form of improving reading vision in the U.S.
NEAR VISION CONDUCTIVE KERATOPLASTY (CK)
Near Vision CK is another procedure for improved reading and near vision for people over age 40. In fact, CLEI was one of five centers in the U.S. asked to participate in the original clinical trials of CK. As part of these studies, Dr. Hersh performed the first CK on the East Coast in May of 1999. He presented study results at the FDA ophthalmic devices advisory panel in Washington, D.C. in November, 2001, leading to first FDA approval in 2002. Over the years, CK has proven to be a safe, effective procedure for the treatment of presbyopia and farsightedness, and we have since treated hundreds of patients.
CK uses radiofrequency (RF) energy, instead of a laser, to reshape the cornea and help patients with near vision and reading. CK may improve reading vision, improve eye fatigue at the end of the day or when reading in poor lighting, common problems of many Baby Boomers are beginning to notice the need for reading glasses as they get older.
The CK procedure is performed using a small probe, thinner than a strand of human hair, that releases radiofrequency (RF) energy. After application of a topical an esthetic (i.e., eye drops), radiofrequency (RF) energy is applied in a circular pattern to shrink small areas of corneal tissue. This circular shrinkage pattern creates a constrictive band (like the tightening of a belt), increasing the overall curvature of the cornea. The result is somewhat like wearing a bifocal contact lens. The use of RF energy is one of today’s most advanced surgical techniques. In addition to its use in CK, RF technology is being used in prostate cancer therapy, back surgery, even cardiovascular procedures.
Candidates for CK must meet the following criteria:
- Be over 40 years of age
- Wear reading glasses
- Not have had previous vision surgery
- Not have had any significant changes in vision for one year
- Not have any chronic eye disorders
- Not be pregnant or nursing
- Not have any chronic illness or disease
Before CK, of course, a complete examination is necessary. The CK procedure itself is comfortable. There may be a dry eye or foreign body sensation for a day or two afterwards. Once finished, you don’t have to wear a patch and can usually return to work the next day. Vision begins improving in about a week’s time. CK improvement may be temporary and decrease over time.Sometimes, repeat treatments can be done to further improve near vision function.
Conductive Keratoplasty (CK) for the Treatment of Presbyopia
By Peter S. Hersh, M.D.
Conductive keratoplasty, better known as CK, has recently been approved by the U.S. FDA for the treatment of presbyopia. Presbyopia is the age dependent loss of accommodative, or focusing, ability of the human crystalline lens resulting in the need for reading glasses. CK currently is the only FDA-approved procedure to treat presbyopia.
Unlike LASIK correction of nearsightedness and astigmatism, the correction of presbyopia is problematic, both practically and theoretically. Most clinical efforts have been directed toward optical arrangements which promote simultaneous near and distance acuity. One general approach is referred to as “monovision” or “blended vision” and achieves depth of focus with differential corrections on each eye, correcting one eye toward a near focal point.(1) This approach has been utilized clinically with contact lenses for years.(2) Ocular dominance first is determined by sighting tests; the non-dominant eye generally is selected for near vision treatment. Trial contact lens fitting with analysis of patient response is often used as a final basis for selection of the near point eye and to determine good candidates.
Conductive keratoplasty, or Near Vision CK, achieves this optical result surgically. CK utilizes high frequency, low-energy electric current to shrink corneal collagen. Initially developed by Mendez (3), the CK instrument and procedure were developed by Refractec, Inc (Irvine, CA). CK was originally approved in 2002 for the correction of hyperopia of up to +3.25 diopters. The one year results of the prospective, multicenter clinical trial of CK for hyperopia have been previously published.(4) CK was approved this year for the treatment of presbyopia.
The CK instrument delivers 350 kHz radiofrequency (RF) energy via a sterile, disposable, 450 micron guarded stainless steel probe which is inserted into a reusable handpiece. During each application, RF energy is delivered for 0.6 seconds at an energy level of 0.6 watts. The inherent electrical impedance of the corneal stroma results in heating of the tissue to approximately 65o C, the optimal temperature for collagen shrinkage.(5)
In the CK procedure, the surgeon places a series of circumferential spot applications, contracting corneal collagen like a belt in the midperiphery with resultant central corneal steepening. This causes an increase in the focal power of the eye, bringing near objects into better focus; hence, the need for reading glasses is diminished. The effect of CK is determined the number of spot applications, the number of rings of applications, and the diameter of application rings. Rings of 8 evenly spaced spots can be placed at 6 mm, 7 mm, and 8 mm. In addition, a second ring of 8 spots can be placed a 7 mm. Thus, treatments consist of 8, 16, 24, or 32 spots depending on the degree of correction desired.
Surgery is performed with topical anesthesia and takes approximately 10 minutes per eye. A lid speculum holds the lids open. The patient is asked to look at a fixation target and a CK marking instrument coated with gentian violet or methylene blue marks the application spots centered over the pupil. The spots are then applied consecutively. Afterwards, the patient uses artificial tear drops and sometimes an antibiotic and corticosteroid drop for one week. The patient may experience some foreign body sensation afterwards and fluctuation in vision for a few weeks after the procedure.
Candidates for CK should have correctable distance visual acuity to at least 20/40 in both eyes, and near visual acuity correctable to at least J3 in the non-dominant eye. They should be 40 years of age or older and require a presbyopic add of +1.00 to +2.00 D. CK results may not be permanent and patients, as they age, may again require reading glasses. CK retreatments may be performed, but results of retreatments have not been rigorously assessed, to date.
In an attempt to look at the clinical safety and effectiveness of CK for the treatment of presbyopia, a multicenter clinical trial studied 150 consecutive subjects. As in clinical use today, the treatment plan was designed to correct the non-dominant eye for near vision. (Thus, patients without distance vision problems usually require only one eye to be treated. Those with hyperopia in the other eye may require bilateral treatment.) This study was done as part of a Phase III multicenter clinical trial of the Refractec Viewpoint Conductive Keratoplasty system (Refractec, Inc., Irvine, CA) for the treatment of presbyopia.
Twelve month results of the CK presbyopia trial are available on 106 patients (unpublished preliminary data). At one year followup, 80% of patients had achieved newspaper-print size near vision or better. On subjective questionnaires, 97% of patients noted improvement in the quality of their vision and 84% ranked their near vision as being better after the procedure. Eighty-five percent of patients were satisfied, 11% were neutral, and 5% were dissatisfied with the outcome of the procedure. Of dissatisfied patients, 80% still could not see newpaper-size print, suggesting that the foremost criterium for success in the near vision CK procedure is achievement of good uncorrected near visual acuity. In regard to complications and side effects, at 1 year followup, 1 eye (0.9%) lost 2 or more lines of spectacle corrected visual acuity. Eleven percent of patients ranked their distance vision as being worse and approximately 20% noticed some compromise in depth perception, generally in a mild range.
In the News:
- Conductive keratoplasty offers hyperopes a non-laser alternative – November 1, 2000
- Conductive keratoplasty offers hyperopes a non-laser option – December 1, 2000
- FDA panel says CK is approvable for temporary reduction of hyperopia – January 1, 2002
- Physicians have options for correcting presbyopia at the corneal plane – June 25, 2010
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