BCLA CLEAR Presbyopia: Management with corneal techniques.

Corneal techniques for enhancing near and intermediate vision to correct presbyopia include surgical and contact lens treatment modalities. Broad approaches used independently or in combination include correcting one eye for distant and the other for near or intermediate vision, (termed monovision or mini-monovision depending on the degree of anisometropia) and/or extending the eye's depth of focus [1]. This report reviews the evidence for the treatment profile, safety, and efficacy of the current range of corneal techniques for managing presbyopia. The visual needs and expectations of the patient, their ocular characteristics, and prior history of surgery are critical considerations for patient selection and preoperative evaluation. Contraindications to refractive surgery include unstable refraction, corneal abnormalities, inadequate corneal thickness for the proposed ablation depth, ocular and systemic co-morbidities, uncontrolled mental health issues and unrealistic patient expectations. Laser refractive options for monovision include surface/stromal ablation techniques and keratorefractive lenticule extraction. Alteration of spherical aberration and multifocal ablation profiles are the primary means for increasing ocular depth of focus, using surface and non-surface laser refractive techniques. Corneal inlays use either small aperture optics to increase depth of field or modify the anterior corneal curvature to induce corneal multifocality. In presbyopia correction by conductive keratoplasty, radiofrequency energy is applied to the mid-peripheral corneal stroma, leading to mid-peripheral corneal shrinkage and central corneal steepening. Hyperopic orthokeratology lens fitting can induce spherical aberration and correct some level of presbyopia. Postoperative management, and consideration of potential complications, varies according to technique applied and the time to restore corneal stability, but a minimum of 3 months of follow-up is recommended after corneal refractive procedures. Ongoing follow-up is important in orthokeratology and longer-term follow-up may be required in the event of late complications following corneal inlay surgery.
Competing Interests: Declaration of competing interest Jennifer P. Craig, Connie Chen, Obinwanne Chukwuemeka Jr, Lucia Pelosini, Michael T.M. Wang, Mohammed Ziaei have no declarations of competing interest. Allon Barsamm is a paid Consultant for Schwind eye tech solutions. Neema Ghorbani-Mojarrad provides consultancy to CooperVision, Eyerising International and Hoya and has had grant funding from CooperVision, Eyerising International, Hoya, Menicon, Rodenstock and SILMO Academy. Florian Kretz provides consultancy to Carl Zeiss Meditech, Teleon, VSY, BVI and Elios. Langis Michaud provides consultancy to Johnson and Johnson Vision, Bausch + Lomb. Johnny Moore provides consultancy to Zeiss and Cristalens. Andrew M J Turnbull is a paid consultant for Rayner, Thea, Scope and Bausch + Lomb. Stephen J. Vincent has had grant funding from CooperVision and Menicon. James S. Wolffsohn has received grant funding from Alcon and Rayner, is a paid consultant for Alcon, Atia Vision and Bausch + Lomb, and has stock ownership in Wolffsohn Research Ltd.
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