The authors have no financial interest in the materials presented herein.

Correspondence: Robert Leonard Epstein, MD, MSEE, Mercy Center for

Corrective Eye Surgery, 5400 W Elm St, Ste 120, McHenry, IL 60050. Tel:

815.363.2020; Fax: 815.363.8040; E-mail: rlepstein@aol.com

Received: July 4, 2007; Accepted: June 18, 2008

doi:10.3928/1081597X-20090512-05

A

relatively more highly curved central cornea and

a relatively fl at midperipheral cornea has been

termed “central presbyLASIK” by Alió et al,

their surgical results using a proprietary ablation profi le with

6-month follow-up. Another proprietary central presbyLASIK

technique was described and patented by Ruiz

tested by Jackson

Peripheral presbyLASIK with a relatively fl atter central

cornea and more highly curved corneal midperiphery was

described by Avalos

peripheral presbyLASIK algorithm was described and patented

by Tamayo.

on a different peripheral presbyLASIK algorithm.

McDonnell et al

a multifocal effect after radial keratotomy. Moreira et al

the fi rst to report the use of laser refractive surgery to reduce

symptoms of presbyopia.

Monovision is a well-established optical correction technique

that employs the use of contact lenses and LASIK.

It works best for people who are only mildly presbyopic, but

vision at reading distance or at intermediate distance diminishes

with increasing age.

The goal of the present multi-year clinical study was to

determine the outcome of the combination of monofocal distance

vision correction on the dominant eye and peripheral

presbyLASIK on the non-dominant eye. PresbyLASIK ablations

were set to optimize acuity for reading and intermediate distance,

and the ablation was designed to be potentially easily

reducible to monofocal distance correction in case of patient

dissatisfaction. Ablations were designed to produce equal

Journal of Refractive Surgery

Monocular Peripheral PresbyLASIK/Epstein & Gurgos

vision between eyes at midrange working distance. A

related goal was for patients to attain unaided stereoacuity

at intermediate distance that was comparable

to the preoperative spectacle-corrected stereoacuity at

reading distance.

PATIENTS AND METHODS

S

This study was an open-label, interventional, prospective,

non-comparative evaluation. Institutional Review

Board approval was obtained. All patients were informed

and signed consent in accordance with the tenets

of the World Medical Association Declaration of

Helsinki. All patients had follow-up of at least 1 year.

Follow-up ranging from 1.1 to 3.9 years (average 27.4

months) on 103 patients (47 men and 56 women) is

reported. All patients who had retreatment were followed

for at least 1 year beyond retreatment.

D

Inclusion criteria were age 45 to 66 years, desire

for spectacle independence, distance best spectaclecorrected

visual acuity (BSCVA) of at least 0.8 in

each eye, central corneal thickness of at least 500 μm,

spherical equivalent refraction between

signifi cant presbyopic symptoms, and no sign of

cataract based on slit-lamp examination, no history of

radial keratotomy, pupil center within 2 mm of the corneal

apex light refl ex, suffi cient corneal thickness for residual

corneal bed thickness to exceed 275 μm, and no

US Food and Drug Administration (FDA) exclusions

for LASIK. Patients were classifi ed as either myopes or

hyperopes according to the spherical equivalent refraction

of the eye that received presbyLASIK ablation.

The study comprised 75 myopes with a mean preoperative

spherical equivalent refraction of

(range:

mean preoperative spherical equivalent refraction of

follow-up, mean patient age among myopes was

52.3

years (range: 47.9 to 65.4 years) among hyperopes. Scotopic

pupil diameter at the time of surgery ranged from

3.5 to 7.2 mm by Colvard pupillometer (Oasis Medical,

Glendora, Calif) and 3.65 to 8.55 mm by WaveScan

pupillometry (VISX, Santa Clara, Calif). All patients had

a corneal curvature between 39.00 and 47.50 D.

Peripheral presbyLASIK was applied to each patient’s

non-dominant eye. In the dominant eyes of the

hyperopic group, 6 eyes had no surgery, 2 eyes had

limbal relaxing incisions, and the remaining 20 eyes

had refraction-based LASIK. In the dominant eyes of

the myopic group, 4 eyes had no surgery, 1 eye had limbal

relaxing incisions, and the remainder had LASIK of

which 10 eyes had a wavefront-guided procedure and

60 had a refraction-based procedure. Dominance was

determined by history and the Miles test. Patient acceptance

of monovision was determined by history, the

application of 1.00 lenses over the patient’s distance

correction in the non-dominant eye, and in 2 cases, by

the application and multi-day testing of a 1.00-D soft

contact lens over the non-dominant eye worn along

with the regular distance spectacle correction.

All patients underwent initial procedures between

March 27, 2003, and December 9, 2004, with followup

until March 3, 2008. Our goal, which was achieved,

was to have 100% follow-up for

initially lost to follow-up, were telephoned,

called back to the offi ce, and returned (sometimes from

out of state) for a fi nal visit. All but one patient follow-

up occurred at our institute. Follow-up of patients

was performed by the authors (R.L.E., M.A.G.) and also

by Barbara J. Tazioli, COT, and Jung M. Rhee, MD, of

Mercy Health System and Bruce H. Brumm, MD, in

practice in Omaha, Nebraska.

M

Measures of the effectiveness of surgery included the

following: 1) patient reporting of the number of hours

per week that any form of spectacles was needed; 2)

scotopic distance vision measured with standardized

scotopic projection charts; 3) photopic unaided vision

at 80 cm and 40 cm on ETDRS charts; 4) photopic and

scotopic near point acuity with distance correction;

5) mesopic vision at 40 cm; and 6) wavefront-derived

refraction, manifest and cycloplegic refractions.

Measures of safety included: 1) patient reporting of diffi

culty with vision; 2) aberrometry; 3) Titmus stereoacuity

at working distance; and 4) postoperative contrast

sensitivity comparison between monofocally treated

and multifocally treated eyes.

Pre- and postoperative WaveScan scotopic pupil

size and total higher order aberrations, spherical aberration,

coma, and trefoil were also analyzed.

S

AND

In this study of our earliest series of patients who

had procedures performed during 2003 and 2004, the

ablation was divided into two parts to accomplish the

presbyLASIK ablation on the non-dominant eye. The

parts were 1) a myopic central ablation that was halted

at a pupil size–dependent ablation diameter, and 2) a

second ablation that was completed and set so that the

518

Monocular Peripheral PresbyLASIK/Epstein & Gurgos

algebraic sum of the dioptric power of the second ablation

plus the dioptric power of the fi rst ablation was

equal to the refraction being corrected. The method

for reversal of presbyLASIK, if necessary, consisted of

completion of the halted ablation.

All ablations took place using a VISX S4 laser operated

with standard temperature and humidity controls. All

ablations were centered over the pupil. Laser in situ

keratomileusis fl aps were created using a BD K-4000

microkeratome (Becton Dickinson, Franklin Lakes, NJ)

targeting a 10.0-mm fl ap and 4-mm nasal hinge, with

keratome ring and plate variations based on the preoperative

keratometry, corneal diameter, and microkeratome

manufacturer’s guide. Flap thickness was set at

130 μm or, in the case of thicker corneas, at 160 μm, so

the remaining corneal bed would be at least 275 μm. During

the year 2003, an automatic corneal shaper (ACS;

Bausch & Lomb Surgical, Miami, Fla) was used for

creating LASIK fl aps.

To obtain the maximum patient spectacle independence

in these presbyopic patients, we expected to perform

fi ne-tuning second ablations for patients who had

even the slightest perceptible ametropia causing any degree

of spectacle dependence or perceived suboptimal

vision, and patients agreed to that process. Retreatment

was performed no less than 10 weeks postoperatively,

and in one case, retreatment was delayed for 2 years for

symptoms of ametropia to develop before retreating.

Retreatments included refraction-based LASIK, wavefront-

guided LASIK, and limbal relaxing incisions.

F

Follow-up examinations included refraction, wavefront

mapping, measurements of stereoacuity, photopic

and mesopic uncorrected visual acuity (UCVA),

distance corrected near point acuity, and pupillometry.

A comparison of the postoperative contrast sensitivity

between monofocally and multifocally treated eyes

was performed.

Statistical analysis was performed with SPSS/15.0

for Windows (SPSS, Chicago, Ill). The Student

applied to compare data sample means, and differences

were considered statistically signifi cant when