Med.m. Dr. Jolanta Bendoriene Presbiopija ir KL Med.m. Dr. Jolanta Bendoriene Ladies and gentelman, today I would like to talk about optical principles of presbyopic contact lenses

Presbiopija paveikia kiekvieną virš 40 m Presbiopija paveikia kiekvieną virš 40 m. Kiekvienas nori jaustis ir atrodyti jauniau

Senstanti populiacija Europos šalyse apie 1/5 populiacijos yra 45 – 60 m.

Akomodacija ir amžius Duane Presbiopija atsiranda dėl standėjančio lęšiuko ir jo kapsulės, kai nebegali keisti savo formos Krumplyno raumuo nebe taip gerai susitraukia

PRESBIOPIJA Lęšiukas yra kaip gelis, todėl gali keisti formą Lęšiuką laiko Zino raiščiai ir kruplyno raumuo Krumplyno raumenys reguliuoja akomodaciją

Senstanti akis Blogėja matymas Siauresnis vyzdys Nebe toks skaidrus lęšiukas ir ragena Sumažėjęs kontrasto jautrumas Blogiau toleruoja šviesos blyksnius ir blogesnį apšvietimą Lėtesnė tamsinė adaptacija Sumažėjusi ašarų sekrecija a number of other changes influence the vision capacity of the aging eye. Visual acuity begins to decline after 50, the decline worsens at age 65 due to adverse metabolic effects of photoreceptors, decreased pupil size and reduced transparency of the lens and cornea. Contrast sensivity and ability to deal with glare reduces. Dark adaptation is slower and accompanied by an increase in light scatter. Wetting and lubrication may be disturbed by the environment.

Geram matymui reikalinga dar tikslesnė korekcija Akis jau ne taip gerai prisitaiko prie “mažiausio išsibarstymo taško” Aging eye needs more precise correction because the eye no longer is capable of adjusting the circle of least confusion on the retina. Approximate correction, not corrected astigmatic error, use of simultaneous vision bifocals, and monovision become much more important to vision in older eyes.

Pagrindinis faktorius – suteikti pacientui realistinius lūkesčius ir priimti tam tikrus kompromisus Patient motivation is most important. Vision is not so good like with spectacles, but patient is more free. The key to success is preparing the patient for compromise and instilling realistic expectations.

PRESBYOPIJA KL tinka jau esantiems KL nešiotojams, bei tiems kurie nekenčia akinių Galima kombinuoti akinius ir KL

Tinkamas lęšis tinkamam pacientui kiekvieno paciento skirtingi poreikiai, ir reikai skirtingo sprendimo jei suprantama, kaip lęšis “veikia”, tai ir didesnė sėkmė The key to success with presbyopic contact lenses is to select the right lens for right patient Which viision is most important during the day: distance, reading or intermediate?

Presbiopijos korekcijos būdai akiniai KL ir papildomi skaitymo akiniai Monovision Modifikuotas monovision Bifokiniai, multifokiniai KL There can be different solutions in presbypia correction Distance contacts with near over correction in spectacles- best for patients who unwilling to compromise, high refractive errors Monovision correction – full correction for dominant eye for distance and correction of the nondominant eye for near. There are some compromise in depth perception and binocularity. An advantage –all practitioners can do it. Modified monovision – bifocal lens in one eye and distance correction in the fellow eye This can give good vision at various distances, and it is less time-consuming and less expensive for both patients and practitioners than bifocals. Monovision does often disturb depth perception, especially as the bifocal add power increases. Bifocal or multifocal contact lenses can eliminate some of this difficulty, and they allow a more equal image size and quality between the two eyes and can cover a broader range of prescription needs. Monovision and bifocal/multifocal contact lenses are not mutually exclusive but rather complementary approaches. 1

MONOVISION Monovision gana paprastas ir patogus būdas Viena akis koreguojam toliui, kita artumui Norimas vaizdas matomas selektyviai, o kitas ignoruojamas

MONOVISION Privalumai Sėkmė 70% to 80% Tai apie 20% daugiau nei su bifokiniais MKL Lengva ir nebrangu

MONOVISION Trūkumai Kiek blogesnis matymas ar toliui ar artumui, gylio suvokimas prastesnis Ne kiekvienas išmoksta ignoruoti vieną vaizdą Žinoma, daug pacientų to nejaučia Didesnė problema naktį vairuojant dėl “halo”

MONOVISION Kompromisai Tikslesniam matymui akiniai gali būti nešiojami papildomai Vairavimui gali naudoti papildomus akinius

BIFOKALAI / MULTIFOKALAI MKL Privalumai ir trūkumai Privalumai prieš monovision: Geresnis tarpinis matymas geresnis stereopsis Binokulinis matymas geresnis Kompromisai: Matymas kiek blogesnis ar nepastovus Švelniai blogesnis stereopsis Pakitęs binokulinis balansas

Presbiopinių KL rūšys Alternuojantis dizainas (rotaciniai asimetrinis presbiopinis dizainas) Simultaninis matymas (rotaciniai simetrinis dizainas)

Alternuojantis matymas Tiesi akių padėtis Tolio D Artumo Tolio Alternating or translating vision with CL is very similar to bifocal spectacles. There are two zones- uper part of lens for distance, lower part for near distance. The lenses move on the cornea with voluntary movements of the eyes allowing vision through the reading area in downgaze and the distance area when looking straight ahead. Remember that all designs need to translate and move to allow sharp acuity in different areas of gaze. Monovision is also type of alternating vision, when patient learns to suppress centrally or ignore vision from eye that is out of focus. Žemyn N Artumo 1

BIFOKALAI / MULTIFOKALAI MKL Alternuojantis dizainas Mažas artumo segmentas Kai keičiasi žvilgsnio kryptis žemyn, lęšis pakyla aukštyn Geras matymas Gali būti tik kieti KL

Rotaciniai asimetrinio dizaino KL Segmentuoti bifokalai: vienos dalies ar sulieto segmento priekiniame, užpakaliniame paviršiuje Atipininiai bifokalai Rotationally asymmetric lenses exist primarily in the rigid lens arena due to the inability of soft lens to translate effectively on the eye. Rigid bifocals are either segmented similar to flat top bifocal in spectacles or single cut like in executive bifocal. When fitting these lenses proper segment height must be set and adequate translation obtained. they can work well with adds above +2.00.

Rotaciniai asimetrinio dizaino KL- kieti A translating design is appropriate for patients with heavy near work or critical distance needs correct higher amounts presbyopia. In general, RGP multifocals provide better vision than soft lenses. There is no intermediate distance vision. The sheer diversity of lens designs means that when your first lens of choice doesn't work, an alternative design may offer winning results.

Kaip pasiekiamas Kl stabilumas Prizminis balastas Apačios nupjovimas Apatinės dalies slab–off prizmės, viršutinės slab-off prizmės, ar abi Rotationaly asymmetric lenses can not be allowed to rotate and ADD portion must be below the pupil in straight gaze There are several methods of achieving proper rotational stability: Prism ballast – Base Down vertical prism, which creates thicker and heavier lower portion of the lens Inferior weights are very rarely used Inferior truncation, superior truncation or both Inferior slab –off prism, superior slab off prism or both Today axis orientation of the contact lens usualy is stabilised by one, two or three design features

BIFOKALAI / MULTIFOKALAI MKL Simultaninis dizainas Tolio ir artumo vaizdai matomi vienu metu Smegenys turi atskirti ryškų vaizdą nuo neryškaus Lęšiui nereikia slankiotis, gali suktis

BIFOKALAI / MULTIFOKALAI MKL Koncentrinis dizainas Centre – tolio ar artumo stiprumas Gali būti MKL ar KKL Lęšis turi gerai centruotis ir mažai judėti ‘Multi-concentric’ dizainas priklauso nuo vyzdžio pločio

Rotaciniai simetrinio dizaino KL- dažniau minkšti KL Simultaneous image design multifocal lenses can be concentric, aspheric or diffractive. Simultaneous image designs are available in soft or rigid materials. Those lenses are able to rotate on the eye. They are relatively easy to manufacture, and are less costly to the practitioner and patient. Koncentriniai Aasferiniai Difrakciniai

Tolio vaizdas ryškesnis Simultaninės bifokinės sistemos D N D With the simultaneous image design, theoretically the retina receives input from multiple distances at the same time with different clarity of the images. The visual system and brain must determine which image is most important and adjust to give good vision at a particular distance. Some translation may occur, and many of the newer rigid lenses rely on this to enhance the image at all distances. As fixation is directed to either a distance or a near target, one zone produses a focused image while the other produses a blurred image that overlaps with focused one. An out -of-focus image overlies the focused retinal image at any object of regard, at distance or at near. This process is called simutaneus vision. It is wrong understanding that in simultaneus vision distant and near images are in focus on the retina at the same time. D N D Tolio vaizdas ryškesnis

Artumo vaizdas ryškesnis Simultaninės bifokinės sistemos D N D D If a simultaneus vision provides usable vision for both far and near , 50% of the light will be in focus at either distance. This also means that 50% will be out of focus at either distance.in fact part of light is lost due to difraction, light scater. Sufficient difference between two images in intensity and color are necessary that one be supressed It seems that changes of pupil size and centration of lens occur under necessary circumstances so that focused light exceeds 50%. The quality of simultaneus vision must be poorer than might be in alternating vision. N D Artumo vaizdas ryškesnis

Priklausomybė nuo vyzdžio vyzdžio dydis, pozicija ir KL centravimasis labai svarbu tinklainės apšvietimui, kontrastui, neryškumui Decentruotas Centruotas The term pupil dependency has been introduced to denote the critical influence of pupil size, position, and contact lens centration on levels of retinal illumination, glare, and contrast when wearing bifocal contact lenses.

Rotaciniai simetrinės presbiopinės sistemos Koncentrinis bifokalas: Tolio centre Artumo centre Progresiniai (asferiniai) multifokalai: Difrakcinis bifokalas Stenopinio plyšio bifokalai Lenses are usually nonprismatic and require excellent centration. Normally these designs lack good intermediate acuity, unless the aspheric design is utilized.

Koncentriniai bifokalai Tolio centre artumo centre Vienos dalies ar sulietų segmentų Priekinio ar užpakalinio segmento Most of bifocals are one piece. Fused bifocal are made from higher refractive index material fused in lower index material lens. Most materials are not thermoplastic and can not be fused. Refractive power distribution can be placed on the front surface, back surface, or both. In front surface design junction between different zones can cause discomfort during blinking, tear pooling, most of bifocals have back surface designs.ADD usually is limited to +1,5D With a concentric design, a central zone of distance or near power focus is surrounded by one or more rings that contain the opposite power (Figure 2).

Centre tolio dizainas Tolis Artumas D A concentric bifocal consists of two optical zones of different refractive powers. The first zone is circular in the center of the lens and is surrounded by second annular zone of different power.Depending on center power lenses can be distance/center or near/center. Artumas 1

Centre artumo dizainas Tolis D N Near center bifocal Artumas 1

Simultaninis dizainas Tolio Artumo Multizonos

Vyzdžiui draugiškas dizainas Vyzdžio dydis: Tolis multizone bifocals, there are not two but more annular zones distance and near, and if lens is decentered , eye can see The most significant new concentric design is the previously-mentioned Acuvue Bifocal. Instead of the conventional two-zone concentric design, this lens is multi-zone with five alternating distance and near zones, starting with distance power in the center (Figure 11). The multi-zone design better provides distance and near power coverage of the pupil as it dilates or constricts with contact lens movement. Add powers are available from +1.00D to +2.50D in 0.50D increments, and it is a bi-weekly planned replacement modality. Artumas

Modifikuotas monovision Ne dominuojanti akis Dominuojanti akis

Rotaciniai simetrinis dizainas Progresinis (asferinis) multifokinis: Tolio centre Artumo centre Asferinis priekinio ar užpakalinio paviršiaus Priekinis paviršius – artumas centre Užpakalinis paviršius – tolis centre an aspheric design is the best choice for computer users and for beginers. RGP aspheric multifocals. This modality works best on astigmatic corneas. Also, it's more difficult to achieve higher adds, for example, above +2.00. Soft multifocals. These lenses work best in low presbyopes, with adds of less than +1.75. They may be appropriate for first-time and part-time lens wearers. With soft lenses, you generally get better vision by using a modified-monovision approach. In general, soft multifocals provide reduced distance vision compared with rigid designs Aspheric designs use an aspheric front or back surface to create the multifocal effect (Figure 3). As a rule, front surface aspheric designs are center-near and back surface aspherics are center-distance. Each type has its own merits, as center-near designs tend to favor near and intermediate vision, while center-distance lenses usually give better distance focus. Which one to choose depends on the patient's individual needs and ocular characteristics (Figure 3). Back surface simultaneous aspheric multifocals options usually have limitations at near, but sharper distance visual acuity, while anterior aspheric lenses are the converse. Simultaneous non-aspheric lenses may be the traditional concentric design with the distance power central (centrad) or peripheral (reverse centrad). Centration is the key with any hydrogel multifocal. Patients must be able to use the distance and near areas of individual designs, and many patients need to experience different soft lens designs before achieving a successful fit.  

BIFOKALAI / MULTIFOKALAI MKL Asferinis simultaninis dizainas Progresiškai keičiasi asferinis paviršius Centro artumo dizainai efektyvesnis nei centro tolio dizainai Efektyvesni su maža ADD ir gera centracija KL

Progresinis dizianas Optical Zone Surface Model Near Intermediate 3D representation. NOT the shape of the lens surface – centre thickness not significantly different from standard spherical lens. Represents POWER variation on surface. Distance (Mag = 16,700x)

Progresinis (asferinis) multifokalas Vienas ADD ; Efektyvumas iki 3.00 D In progressive or aspericc designs refractive power gradualy increases into plus or minus from periphery to the center. Aspheric surface can be front or back. They are really multifocals than bifocals, can be soft or rigid. Aspheric Though aspheric soft designs do provide intermediate vision, it is sometimes necessary to use a modified monovision approach for maximum acuity. As with RGP aspherics, soft aspherics may have a center-distance or a center-near design. While RGP aspherics are usually center-distance designs, soft aspherics are mostly center-near. Center-distance soft aspherics include the V/X (Aero Contact Lens), which is available in two base curves and two lens diameters with adds to +3.00D. Like most soft bifocal/multifocal lenses, centration is essential to good vision. Specialty Progressive (Specialty Ultravision) is a planned replacement, center-distance aspheric design. It has two base curves and an effective add of +3.00D with a modified monovision fitting approach. Center-near aspheric designs include Softsite (Unilens). It offers two base curves, front aspheric adds to +2.50D and is lathe cut. The Additions (Sunsoft) multifocal has three add ranges, one each for low, medium and high power requirements. This front surface, aspheric, center-near design is replaced quarterly. Quattro (Blanchard) is a quarterly replacement aspheric lens, with a center-near configuration and fitted using the modified monovision philosophy. Focus Progressive (CIBA Vision) is a center-near aspheric with a two-week to one-month replacement schedule. It is approved for both daily wear or extended wear for up to one week. CIBA Vision recently unveiled Focus Dailies Progressive which, as the name implies, is discarded daily. The parameters are +5.00D to ­6.00D in the same 69 percent water nelifocon A material as the original Focus Dailies. However, it is available only in the 8.6mm base curve. The UltraVue 2000 4-cycle (Opti-Centre Laboratories) lens has a center-distance design (for the dominant eye) and a center-near design (for the non-dominant eye). The new CooperVision Frequency 55 Multifocal has a similar design. Soft Toric, Bifocal/Multifocal Designs These lenses are available as concentric or aspheric designs with center-near or center-distance configurations. UCL Multifocal Toric (United Contact Lens) has an aspheric back surface which generates a center-distance design. The front surface contains the cylinder power to correct astigmatism up to 3.00D. The Horizon 55 BiCon Toric (Westcon Contact Lens) is a concentric center-near lens that can correct up to 5.00D of astigmatism and +3.00D of add. Essential Soft Toric Multifocal (Blanchard Contact Lens) has a front aspheric, center-near design with posterior toricity and anterior double slab-off for stability. Using a slight modified monovision fit, effective adds to +2.75D can be achieved. The UltraVue 2000 Multifocal Progressive Toric (Opti-Centre Laboratories) is available with a center-distance design and a center-near design for the dominant and non-dominant eyes, respectively, with adds to +3.50D. It utilizes modified monovision. 1

Difrakcinis bifokalas With diffractive design (Figure 4), light entering the eye is diffracted to produce the images the retina receives (Figure 5). The diffractive design has a distance center and a series of diffractive phase-plates that surround it. As the add power increases, the number of phase-plates increases, and they get closer together cia trūksta difrakcijos paveikslo iš geltono segtuvo 1 str Diffractive The Echelon (Ocular Sciences) is the only diffractive lens available. As it works via phase-plate optics to diffract rather that refract the images, it is a nearly pupil-independent design which has three add powers but only one base curve and diameter.

BIFOKALAI / MULTIFOKALAI MKL Difrakcinis simultaninis dizainas Daugybė židinių tinklainėje Tolio ir artumo dioptrijos sukuriamos dėka difrakcijos Nepriklauso nuo vyzdžio pločio Mažesnis kontrastas ir neryškumas prieblandoje

Sumažėja kontrastas dėl persidengiančių vaizdų F Z N Z F F Z N Z F

Kombinuoti dizainai Segmentuoti asferiniai multifokalao Užpakalinis paviršius asferinis ADD +1,0D Priekinis paviršius bifokinis Geras tolio matymas per viršutinę lęšio dalį Asferiniė dalis pagerina tarpinius atstumus Priekinis paviršius artumui Laboratories recently introduced the X-Cel ESSential-Solution segmented aspheric multifocal. The posterior surface in this design is made using the aspheric S-Form technology that is the basis for Blanchard's GP and GP Xtra Multifocal. The posterior geometry specific to this new product generates about 1.00D of add power. The front surface is cut like X-Cel's Solution Bifocal with a crescent-shaped segment configuration. Visual benefits of this combination are many., the and the anterior segmented reading area provides crisp acuity for near tasks. segment position can be altered to many different heights customized to the patient's unique ocular measurements.

BIFOKALAI / MULTIFOKALAI MKL Modifikuotas monovision Pvz.: Vieno židinio lęšis ir bifokinis lęšis Vienas bifokinis KL į tolį, kitoks artumui

BIFOKALAI / MULTIFOKALAI MKL Modifikuotas monovision Viena akis toliui, kita artumui, bet abi multifokiniais KL Vienai akis – ADD centre, kitai – periferijoje Sustiprina binokulinį matymą

Modifikuotas monovision Nedominuojanti akis Dominuojanti akis

Sėkmės dažnis Monovision sėkmingesnis nei bifo ar multifokiniai KL Simultaniniai KL geriau,kai maža ADD Gylio suvokimas ir binokulinis matymas geresnis su progresiniais KL

Informacija Lęšis yra geras, bet kompromisas tarp matymų slypi dizaine Panašiai kaip refrakcinė chirurgija- naudingas matymas

Bandomasis lęšis Akinių receptas, jei Cyl, perskaičiuoti sferinį ekvivalentą Padaryti vertex korekciją Pridėti pusę ADD Galima naudotis lentele

Startas Focus® Dailies Progressives Pirmieji lęšiai Tolio korekcija Pusė ADD Selection of FIRST lenses. Expect to change them. Startas

patikrinti matymą Įdėti pirmus lęšius, palaukti 10 min toliui artumui Always assess with both eyes open On a scale of 1-100%, how is your distance vision? etc

Pradžioje galima žiūrėti į stambesnes raides toliui, vėliau tikslinant į smulkesnes

Svarbu Tikrinti tik binokuliariai Much more realistic than using a phoropter – these cut down the light entering the eye and also are not natural for reading through.

Svarbu nedengti be foropterio

Naudoti natūralią aplinką matymui-subjektyvus matymas

patikslinimas visada binokuliariai +0.25/-0.25 gali turėti daug reikšmės matymui toliui maksimalus pliusas po patikslinimo binokuliariai, patikslinti tik dedant lęšį papildomą ant vienos akies

Ar neišvirkščias Correct Inverted The darker visitint of Focus ® PROGRESSIVES provides an easy method to determine if the lens is inside out. This method relies on the observation of the blue tint on the edge of the lens. Holding the lens perpendicular to the line of sight, a lens which is right side up (not inverted) will have a blue hue at the edge. An inverted lens will have a faint or absence of tint at the edge. This technique also applies to Softcolors. Correct Inverted Blue edge Less Blue or clear edge

Optimalaus matymo lentelė OD: ___________ OS: ____________ OS OD Binok artis tolis This is the grid I always use to help me remember what steps I have taken to get to the final lenses. If you use it like this you can look back in your notes and they make sense !!! OD ___________ OS ____________

Atvejis 1 Refrakcija: R: +2.50 L: +2.75 Add: +2.50D Bandomieji : R: +3.75 L: +4.00 Nepakankamai gerai toliui

OS OD Binok Artis tolis -0.25 0.00 (-0.25) 0.00 -0.25 0.00 OD: + 3.75 OS: + 4.00 OS OD Binok Artis tolis -0.25 0.00 (-0.25) 0.00 -0.25 0.00 OD: + 3.75 OS: + 3.75

Toliui gerai, bet arti nepakanka OD: + 3.75 OS: + 3.75 OS OD Bin A T 0.00 +0.25 +0.25 +0.25 0.00 +0.25 OD: +4.00 OS: +3.75

Atvejis 2 Refrakcija OU +2.00 Add: +2.00DS Band lęšiai +3.00 Iš arti gerai, bet prasčiau toliui

OS OD Bin A T 0.00 -0.50 -0.50 0.00 -0.25 0.00 OD: + 3.00 OS: + 3.00

Gerai artumui, bet blogai toliui Right: + 2.50 Left: + 3.00 OS OD Bin A T -0.25 0.00 -0.25 0.00 0.00 0.00 OD: + 2.25 OS : + 3.00

Jei toliui dar blogai – ant OD paprastas, ant OS progresinis

AIR OPTIXTM AQUA MULTIFOCAL 3 ADD System AIR OPTIXTM AQUA MULTIFOCAL 3 ADD stiprumų sistema : low, medium ir high add LO ADD MED ADD HI ADD ≤+1.00D +1.25D to +2.00D >+2.00D The AIR OPTIX AQUA MULTIFOCAL three ADD system was designed with you and your contact lens wearers in mind. This lens system allows you success with your presbyopic contact lens wearers from the beginning of their presbyopic experience through all stages of presbyopia. They can remain in the same lens material, same lens feel, same lens handling and same lens comfort throughout all stages of presbyopia. AIR OPTIXTM AQUA MULTIFOCAL 3 ADD System *CIBA VISION, data on file 2008. Compared to the leading Silicone Hydrogel Multifocal Lens and Monovision, based upon subjective ratings by emerging presbyopes. 66

pagrindas Realistiniai lūkesčiai Bandomasis lęšis iš lentelės Tirti tik binokuliariai Lentelė patikslinimui 0,25D daro didelius pasikeitimus Nesistengti idealiai iškoreguoti per 1 kartą In summary: The profile that these fitters assembled of a typical successful patient was a hyperope, with less than a 2.25 diopter add, who may or may not have previously worn contact lenses. Every eligible patient should be given the option of Focus Progressives because the opportunities for success are roughly equal between spectacle wearers, contact lens wearers, and those with no previous correction. Setting realistic expectations for the patient, and receiving proper training on how to fit Focus Progressives, were both considered critical for success. As claimed, the lens is easy to fit. 80% of patients are wearing the less 4 days per week or less. 85% of fitters believe that having Focus Progressives in their practice has provided incremental revenues.

Laisvė Verta bandyti Nereikia akinių sportui šventėms nesenstantiems

Presbiopinių KL parinkimas – aukščiausia kvalifikacija Fitting of presbyopic contact lenses can be most rewarding area of contact lens practice.

Komunikacija realistiniai lūkesčiai