BackgroundTo evaluate the effects on near and intermediate visual performance after bilateral Laser Anterior Ciliary Excision (LaserACE) procedure.MethodsLaserACE surgery was performed using the VisioLite 2.94 μm erbium: yttrium–aluminum–garnet (Er:YAG) ophthalmic laser system in 4 oblique quadrants on the sclera over the ciliary muscle in 3 critical zones of physiological importance (over the ciliary muscles and posterior zonules) with the aim to improve natural dynamic accommodative forces. LaserACE was performed on 26 patients (52 eyes). Outcomes were analyzed using visual acuity testing, Randot stereopsis, and the CatQuest 9SF patient survey.ResultsBinocular uncorrected near visual acuity (UNVA) improved from +0.20 ± 0.16 logMAR preoperatively, to +0.12 ± 0.14 logMAR at 24 months postoperatively (p = 0.0014). There was no statistically significant loss in distance corrected near visual acuity (DCNVA). Binocular DCNVA improved from +0.21 ± 0.17 logMAR preoperatively, to +0.11 ± 0.12 logMAR at 24 months postoperatively (p = 0.00026). Stereoacuity improved from 74.8 ± 30.3 s of arc preoperatively, to 58.8 ± 22.9 s of arc at 24 months postoperatively (p = 0.012). There were no complications such as persistent hypotony, cystoid macular edema, or loss of best-corrected visual acuity (BCVA). Patients surveyed indicated reduced difficulty in areas of near vision, and were overall satisfied with the procedure.ConclusionsPreliminary results of the LaserACE procedure show promising results for restoring visual performance for near and intermediate visual tasks without compromising distance vision and without touching the visual axis. The visual function and visual acuity improvements had clinical significance. Patient satisfaction was high postoperatively and sustained over 24 months.Trial registrationNCT01491360 (https://clinicaltrials.gov/ct2/show/NCT01491360). Registered 22 November 2011.

PurposeTo determine the long-term visual outcomes of six eyes of 3 patients up to 13 years following the Laser Anterior Ciliary Excision (LaserACE) procedure.MethodsThree male patients of ages 59, 59, and 60 presented for evaluation at Storm Eye Institute, Medical University of South Carolina at 8, 10, and 13 years after the LaserACE procedure for presbyopia, respectively. All 3 patients had a history of laser vision correction (LVC) prior to LaserACE treatment. Visual performance was evaluated using ray-tracing aberrometry, specifically higher-order aberrations, visual Strehl of the optical transfer function (VSOTF), depth of focus (DoF), and effective range of focus (EROF). VSOTF was computed as a function of defocus using a through-focus curve. Subjective DoF was overlaid on the VSOTF through-focus curve to establish the best image quality metric threshold value for correlation between subjective and objective DoF. EROF was determined by measuring the difference in diopters between the near and distance DoF curves, at 50% of VSOTF.ResultsDistance-corrected visual acuity, distance-corrected intermediate visual acuity, and distance-corrected near visual acuity for all patients remained at 20/20 or better up to 13 years postoperatively. EROF averaged 1.56 ± 0.36 (D) for all eyes.Conclusions and ImportanceLaserACE provided improvement in near vision functionality in these LVC patients with long-term stability. The LaserACE procedure is not on the visual axis, therefore these patients could still receive correction to their hyperopic regression.

Presbyopia corrections traditionally have been approached with attempts to exchange power, either at the cornea or the lens planes, inducing multifocality, or altering asphericity to impact the optical system. Treatments that affect the visual axis, such as spectacle and contact lens correction, refractive surgeries, corneal onlays and inlays, and intraocular lenses are typically unable to restore true accommodation to the presbyopic eye. Their aim is instead to enhance ‘pseudoaccommodation’ by facilitating an extended depth-of-focus for which vision is sufficient. There is a true lack of technology that approaches presbyopia from a treatment based or therapy based solution, rather than a ‘vision correction’ solution that compromises other components of the optical system. Scleral surgical procedures seek to restore true accommodation combined with pseudoaccommodation and have several advantages over other more invasive options to treat presbyopia. While the theoretical justification of scleral surgical procedures remains controversial, there has nevertheless been increasing interest and evidence to support scleral surgical and therapeutic approaches to treat presbyopia. Enormous progress in scleral surgery techniques and understanding of the mechanisms of action have been achieved since the 1970s, and this remains an active area of research. In this article, we discuss the historic scleral surgical procedures, the two scleral procedures currently available, as well as an outlook of the future for the scleral surgical space for treating presbyopia.

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To investigate the postoperative inflammatory and wound-healing responses after laser scleral microporation for presbyopia. Methods: Thirty porcine eyes were used for the optimization of laser intensities first. Six monkeys (12 eyes) received scleral microporation with an erbium yttrium aluminum garnet (Er:YAG) laser, and half of the eyes received concurrent subconjunctival collagen gel to modulate wound-healing response. The intraocular pressure (IOP) and the laser ablation depth were evaluated. The animals were euthanized at 1, 6, and 9 months postoperatively. The limbal areas and scleras were harvested for histologic analysis and immunofluorescence of markers for inflammation (CD11b and CD45), wound healing (CD90, tenascin-C, fibronectin, and HSP47), wound contraction (α-smooth muscle actin [α-SMA]), vascular response (CD31), nerve injury (GAP43), and limbal stem cells (P63 and telomerase). Results: In the nonhuman primate study, there was a significant reduction in IOP after the procedure. Overall, the ablation depth was 76.6% to 81.2% at 1 month and slightly decreased to 71.5% to 72.7% at 9 months. Coagulative necrosis around the micropores, as well as expression of CD11b, CD45, tenascin, fibronectin, HSP47, and GAP43, was distinct at 1 month but subsided with time. Collagen gel treatment significantly suppressed the upregulation of CD11b, CD45, fibronectin, and tenascin-C. The expression of CD90, α-SMA, and CD31 was minimal in all eyes. Conclusions: The study demonstrated the course of inflammatory and wound-healing responses following laser scleral microporation. The tissue responses were small and self-limited, resolved with time, and were suppressed by concurrent collagen treatment. It provides a useful understanding of this new procedure. Translational Relevance: The results would be helpful in the laser parameter modification to improve the long-term treatment stability.