Adrian Glasser

Presbyopia and the optical changes in the human crystalline lens with age.

Lenses from 27 human eyes ranging in age from 10 to 87 years were used to determine how accommodation and age affect the optical properties of the lens. A scanning laser technique was used to measure focal length and spherical aberration of the lenses, while the lenses were subjected to stretching forces applied through the ciliary body/zonular complex. The focal length of all unstretched lenses increased linearly with increasing age. Younger lenses were able to undergo significant changes in focal length with stretching, whereas lenses older than 60 years of age showed no changes in focal length with stretching. These data provide additional evidence for predominantly lens-based theories of presbyopia. Further, these results show that there are substantial optical changes in the human lens with increasing age and during accommodation, since both the magnitude and the sign of the spherical aberration change with age and stretching. These results show that the optical properties of the older presbyopic lens are quite different from the younger, accommodated lens.

Biometric, optical and physical changes in the isolated human crystalline lens with age in relation to presbyopia

The biometric, optical and physical properties of 19 pairs of isolated human eye-bank lenses ranging in age from 5 to 96 years were compared. Lens focal length and spherical aberration were measured using a scanning laser apparatus, lens thickness and the lens surface curvatures were measured by digitizing the lens profiles and equivalent refractive indices were calculated for each lens using this data. The second lens from each donor was used to measure resistance to physical deformation by providing a compressive force to the lens. The lens capsule was then removed from each lens and each measurement was repeated to ascertain what role the capsule plays in determining these optical and physical characteristics. Age dependent changes in lens focal length, lens surface curvatures and lens resistance to physical deformation are described. Isolated lens focal length was found to be significantly linearly correlated with both the anterior and posterior surface curvatures. No age dependent change in equivalent refractive index of the isolated lens was found. Although decapsulating human lenses causes similar changes in focal length to that which we have shown to occur when human lenses are mechanically stretched into an unaccommodated state, the effects are due to nonsystematic changes in lens curvatures. These studies reinforce the conclusion that lens hardening must be considered as an important factor in the development of presbyopia, that age changes in the human lens are not limited to the loss of accommodation that characterizes presbyopia but that the lens optical and physical properties change substantially with age in a complex manner.

The mechanism of accommodation in primates

OBJECTIVE To study the accommodative mechanism in primates using monkeys, in light of a recently proposed novel accommodative mechanism in primates and a concomitant controversial surgical procedure for the reversal of presbyopia, DESIGN Experimental study. METHODS Accommodation was induced by stimulation of an electrode surgically implanted in the midbrain and by topical ocular application of muscarinic agonists. Pharmacologic disaccommodation was achieved by topical application of a muscarinic antagonist. Movements of the lens equator and the ciliary body were imaged during accommodation and disaccommodation using ultrasound biomicroscopy and goniovideography, and the images were analyzed to determine the direction and the extent of the movements. RESULTS Despite the systematic eye movements occurring with electrical stimulation and the nonsystematic eye movements occurring with pharmacologic stimulation, in all instances the ciliary body and the lens equator moved away from the sclera during accommodation. CONCLUSIONS Movement of the accommodative structures is consistent with the classic mechanism of accommodation described by Helmholtz, and contrary to that recently proposed by Schachar.

Accommodation measurements in a prepresbyopic and presbyopic population

Purpose: To study the efficacy of several subjective and objective methods of accommodation measurement in normal prepresbyopic and presbyopic populations to identify appropriate methods for measuring the outcome of accommodative restorative procedures. Setting: University of Houston, College of Optometry, Houston, Texas, USA. Methods: Thirty‐one normal subjects with a mean age of 43.7 years (range 31 to 53 years) participated. Accommodation was measured monocularly using 3 subjective approaches—the push‐up test, minus lenses to blur, and a focometer—and 2 approaches measured with a Hartinger coincidence refractometer, in which accommodation was stimulated with minus lenses to blur and topical pilocarpine 6%. Results: The push‐up method overestimated accommodative amplitude relative to objective measures in 28 subjects. Two subjective methods, minus lenses to blur and the focometer, produced comparable results, but with lower amplitudes in younger subjects and higher amplitudes in older subjects compared with objective methods. Comparable results were obtained when accommodation was stimulated in 1 of 2 ways and measured with the Hartinger. Pilocarpine elicited stronger accommodative responses than distance blur for subjects with low accommodative amplitudes. Pilocarpine 6% produced stronger responses in subjects with light irides than in those with dark irides. Conclusions: Hartinger‐measured accommodation provides more realistic measurement of accommodative amplitude than the subjective methods tested, especially in the presbyopic population. In presbyopic subjects, the subjective tests resulted in accommodative amplitudes up to 4.0 diopters greater than those measured with objective tests. Measurements of accommodative amplitude are best achieved with objective methods to stimulate and measure accommodation.

Subjective and objective measurement of human accommodative amplitude

Purpose: To assess objective and subjective methods to measure accommodation in a young human population. Setting: Research laboratory, University of Houston, College of Optometry, Houston, Texas, USA. Methods: Accommodation was measured in the right eye of 15 young subjects (9 women and 6 men) whose ages ranged from 23 to 28 years and 1 36‐year‐old subject. The mean age of all subjects was 26 years. Accommodation was stimulated and measured with 4 techniques. Two subjective measures (focometer and minus‐lens procedures) were used. Accommodation was also stimulated with minus‐lens‐induced blur and with pilocarpine 6% and measured objectively with a Hartinger coincidence refractometer. Results: Accommodative amplitudes measured with the 2 subjective methods agreed with each other but differed from the objectively measured amplitudes. Objectively measured accommodative amplitudes were similar in all subjects, with a mean of about 7.0 diopters. Accommodation stimulated with pilocarpine reached a maximum 33 minutes after administration. Individuals with light irides showed a stronger accommodative response to pilocarpine than subjects with dark irides. Conclusions: Subjective measures of accommodation tend to overestimate true accommodative amplitude. Methods exist to measure accommodation objectively. These include stimulating accommodation with trial lenses or pilocarpine 6% and measuring the accommodative response with an objective optometer such as a Hartinger coincidence refractometer. Objective measures of accommodation should be used to determine whether accommodation can be restored in presbyopes.

Restoration of accommodation: surgical options for correction of presbyopia

Accommodation is a dioptric change in the power of the eye to see clearly at near. Ciliary muscle contraction causes a release in zonular tension at the lens equator, which permits the elastic capsule to mould the young lens into an accommodated form. Presbyopia, the gradual age‐related loss of accommodation, occurs primarily through a gradual age‐related stiffening of the lens. While there are many possible options for relieving the symptoms of presbyopia, only relatively recently has consideration been given to surgical restoration of accommodation to the presbyopic eye. To understand how this might be achieved, it is necessary to understand the accommodative anatomy, the mechanism of accommodation and the causes of presbyopia. A variety of different kinds of surgical procedures has been considered for restoring accommodation to the presbyopic eye, including surgical expansion of the sclera, using femtosecond lasers to treat the lens or with so‐called accommodative intraocular lenses (IOLs). Evidence suggests that scleral expansion cannot and does not restore accommodation. Laser treatments of the lens are in their early infancy. Development and testing of accommodative IOLs are proliferating. They are designed to produce a myopic refractive change in the eye in response to ciliary muscle contraction either through a movement of an optic or through a change in surface curvature. Three general design principles are being considered. These are single optic IOLs that rely on a forward shift of the optic, dual optic IOLs that rely on an increased separation between the two optics, or IOLs that permit a change in surface curvature to produce an increase in optical power in response to ciliary muscle contraction. Several of these different IOLs are available and being used clinically, while many are still in research and development.

Amplitude dependent accommodative dynamics in humans

Dynamics of accommodation (far-to-near focus) and disaccommodation (near-to-far focus) are described as a function of response amplitude. Accommodative responses to step stimuli of various amplitudes presented in real space were measured in eight 20-30 year old subjects. Responses were fitted with exponential functions to determine amplitude, time constant and peak velocity. Despite the intersubject variability, the results show that time constants of accommodation and peak velocity of disaccommodation increase with amplitude in all subjects. The dynamics of accommodation and disaccommodation are dependent on amplitude, but have different properties in each case.

Accommodation and presbyopia.

Accommodation is a dioptric change in power of the eye that occurs to allow near objects to be focused on the retina. The ability to accommodate is lost with increasing age in humans and monkeys. This phenomenon, called presbyopia, is the most common human ocular affliction, and its pathophysiology remains uncertain. The progressive loss of human accommodative amplitude begins early in life and results in a complete loss of accommodation by age 50 to 55 years. Presbyopia is correctable by various optical means and, although not a blinding condition, its cost in devices, lost productivity, and (more recently), for surgical interventions is considerable. The classic theory of accommodation in humans proposes that the ciliary muscle moves forward and axially in the eye during contraction, releasing tension on the anterior zonular fibers and allowing the lens to become more spherical and thicken axially. During disaccommodation, the ciliary muscle relaxes, allowing the elastic choroid to pull the ciliary muscle posteriorly, increasing the tension on the anterior zonules to flatten the lens. Alteration of every component of the accommodative apparatus has been proposed to explain presbyopia. Rhesus monkeys and humans exhibit a similar accommodative mechanism and lens growth throughout life and develop presbyopia with a similar relative age course. Theories to explain the pathophysiology of presbyopia fall into two main categories, involving dysfunction of either the lens or the ciliary muscle. Another theory is based on a proposed mechanism of accommodation different from that which is classically accepted. We summarize what is known about the anatomy and aging of the accommodative apparatus and how such changes might contribute to the loss of accommodative amplitude.

Dynamic accommodation in rhesus monkeys

The dynamics of Edinger-Westphal (EW) stimulated accommodation were studied in two young rhesus monkeys to understand the relationships between accommodative amplitude and rates of accommodation and disaccommodation. Accommodative responses were recorded with infrared photorefraction at five different amplitudes spanning the full EW stimulated accommodative range available to each eye. Combined exponential and polynomial functions were fit to the accommodation and disaccommodation responses. Derivatives of these functions provided the maximum rates of accommodation and disaccommodation as well as time constants for each amplitude. Maximum rates of EW stimulated accommodation and disaccommodation were found to increase linearly with amplitudes from 0.58 to 17.41 D in the two monkeys. The results suggests that the rate of EW stimulated accommodation is dictated by the amplitude. We conclude that if dynamic accommodative responses are to be compared in monkeys of different ages it is necessary to compare responses for the same accommodative amplitudes in order to draw conclusions about age related changes.

Accommodation dynamics in aging rhesus monkeys

Accommodation, the mechanism by which the eye focuses on near objects, is lost with increasing age in humans and monkeys. This pathophysiology, called presbyopia, is poorly understood. We studied aging-related changes in the dynamics of accommodation in rhesus monkeys aged 4-24 yr after total iridectomy and midbrain implantation of an electrode to permit visualization and stimulation, respectively, of the eyes accommodative apparatus. Real-time video techniques were used to capture and quantify images of the ciliary body and lens. During accommodation in youth, ciliary body movement was biphasic, lens movement was monophasic, and both slowed as the structures approached their new steady-state positions. Disaccommodation occurred more rapidly for both ciliary body and lens, but with longer latent period, and slowed near the end point. With increasing age, the amplitude of lens and ciliary body movement during accommodation declined, as did their velocities. The latent period of lens and ciliary body movements increased, and ciliary body movement became monophasic. The latent period of lens and ciliary body movement during disaccommodation was not significantly correlated with age, but their velocity declined significantly. The age-dependent decline in amplitude and velocity of ciliary body movements during accommodation suggests that ciliary body dysfunction plays a role in presbyopia. The age changes in lens movement could be a consequence of increasing inelasticity or hardening of the lens, or of age changes in ciliary body motility.