EYECARE What’s New for Older Eyes Innovative Corrections Lead to New Directions By Jeff Hopkins / Contributing Editor Wednesday, June 28, 2023 2:00 AM RELATED CONTENT Advances in Multifocal Contact Lens Technologies Presbyopia Management In-Depth Vuity: The First Pharmacological Presbyopia Treatment Download a PDF of What's New for Older Eyes.Mankind has been grappling with the problem of presbyopia ever since people started living long enough to experience it. We are roughly 750 years into the era of reading glasses, 250 years into the multifocals era, 70 years into the progressive lens era, and 20 years into the customized progressive lens era. With all of these advancements, and particularly the explosion of technology in the past few decades, eyeglass dispensers and wearers might be forgiven for expressing some cynicism about claims of new advancements in the cause of clearer vision for presbyopes and their aging eyes. This would be a mistake, because, despite all the advancements that have come before, there is still progress to be made, and with the aid of new technologies and scientific achievements, the eyecare industry is making it. To better understand the new wave of products and strategies for treating presbyopia and what’s driving it, Vision Monday spoke with leading suppliers and eyecare professionals. They offered insights about some of the latest multifocal spectacle and contact lenses as well as new pharmaceutical options, and how they can help patients see better and feel better. As new treatments emerge not only for presbyopia but for related ocular conditions that affect aging eyes, Vision Monday’s parent, Jobson Optical Group, recently launched a new, online publication and website titled Review of Presbyopia and the Aging Eye. In addition to reporting news about these topics, the publication offers in-depth coverage of optical, contact lenses, dry eye, pharmacology, glaucoma, retina, refractive surgery, aesthetics and nutrition solutions by an experienced team of professional editors. VM rounded up some of the newest advancements in presbyopia treatment solutions in this Special Report. Capturing Visual Behavior With the advent of freeform manufacturing in the early 2000s, lens designers were able to incorporate data unique to an individual wearer into the design of a progressive lens, including all elements of their prescription, frame size and fitting measurements. While these could yield significant improvement in visual performance, they were essentially static measures of visual needs. Since then, the Holy Grail of lens design has been to measure key dynamic elements of the patient’s visual behavior. Using highly sophisticated design software, lens companies have taken a range of approaches to capture this information. Avatars and Digital Twins EssilorLuxottica’s EyeRuler 2 measures fitting parameters as well as near vision behavior.EssilorLuxottica’s latest progressive series, called Varilux XR, accounts for elements of visual behavior using an AI-powered algorithm that draws on a mass of wearer data in a personalized design. According to Jeff Harrell, vice president, Products for Essilor of America, “Varilux XR is a culmination of decades of R&D, and the massive amounts of data that we have about the human visual system, and not just the visual system in and of itself. Jeff Harrell“If you think about the eyes, the brain, the neck, the trunk—how they’re interacting together is the visual behavior of the individual. By having this behavioral artificial intelligence, we can closely predict the natural behavior of the individual, such that the design is going to be made to respond to their kind of visual behavior.” Personalizing the lens for the wearer’s visual behavior involves the use of a computer-generated “avatar,” first employed for the Varilux Comfort Maxi progressive. For the XR Series, Harrell said, “We’ve programmed the avatar to be what we would call a ‘digital twin’ of an individual based on the various combinations of prescription power that we see, to truly understand what design will give them the instantaneous sharp vision that they require, even in a dynamic environment.” The top-end lens in the XR series, called XR Track, allows for more personalization by measuring the individual’s wearer behavior. Harrell said, “The eyecare professional would have a device called the EyeRuler 2, and do a very quick measurement of near vision behavior.” This tablet-based tool takes measurements based on factors like viewing distance, reading behavior and lateral offset. After this test, said Harrell, “You know how they move their heads, their overall behavior allowing us to truly personalize that design for that unique individual versus leveraging the predictive model that we have based on the research.” Chloe TauaefaThe XR Series will launch nationally on June 27, but is currently being offered in select practices. One such practice is Creekview in Dallas, Texas. Creekview’s business manager, Chloe Tauaefa, ABOC, who works with the EyeRuler 2, described her experience with the EyeRuler 2. “It is an all-in-one device enabling personalized measurements with just two photos and a near vision behavior test that takes about 45 seconds. The Varilux XR series will be available in the Canadian market starting on July 5. “It is very user-friendly and provides monocular pupillary distance, fitting heights, vertex distance, pantoscopic tilt and wrap angle. I enjoy being able to provide each patient with a personalized experience and the EyeRuler 2 is by far the simplest digital tool I’ve ever used in my 36 years as an optician.” Millicent Knight, ODMaking the case for new lens technology can be challenging, because patients often find it hard to envision a better viewing experience. Millicent Knight, OD, FAAO, FAARM, FNAP, senior vice president, Customer Development Group, EssilorLuxottica North America, recommends that ECPs “Use relatable examples from patient’s everyday life to drive home the importance of upgrading their lenses. For example, your patients likely upgrade their smartphone regularly because they know technology is continually advancing and they want to enjoy the best experience. The same should be true when considering the technology they use for their most important sense: vision.” Using AI to Determine Patients' Visual Age Ranaan NaftalovichShamir pioneered the use of artificial intelligence in lens design about seven years ago. From a design standpoint, AI allows personalization based on a higher number of parameters in a timely manner. Said Ranaan Naftalovich, CEO and president of Shamir Insight North America, “At Shamir we try to do things that make people’s lives better, and artificial intelligence just helps us to get there faster. Autograph intelligence has 12 different designs. When you try to do a customized lens with 12 different designs, you have 430,000 options. With artificial intelligence you can do it (customization) much faster, and that’s what has allowed us to bring technology into the market much faster.” In addition to the design process, Shamir also uses AI to gather wearer data that informs the design. In 2022 Shamir invested in Blink, which has developed AI-driven eye-tracking technology that allows a better understanding of visual behavior. Said Naftalovich, “We have to use artificial intelligence to understand what is actually happening to us when we’re looking at the world in a dynamic situation.” This AI-derived data informs Shamir’s latest progressive design, Autograph Intelligence 2, in which the design incorporates the idea of “visual age,” which the company defines as “The physiological age of the eye (the required addition) and is generally correlated with the patient’s chronological age.)” This allows them to customize Autograph Intelligence 2 based on the patient’s stage of presbyopia in addition to many other factors specific to the individual wearer. Harmonizing Binocular Vision One of the basic problems of progressive design is achieving binocular clarity in a dynamic visual environment—binocular vision may be nearly perfect as the eye moves vertically through the lens, but vision from side-to-side is more challenging, especially in areas of the lens where peripheral astigmatism is an issue. Sophisticated design tools are required to ensure that both eyes are experiencing nearly the same optical powers at any angle of gaze, but the problem is even more complicated when the patient needs a different prescription for each eye. Hoya has addressed this challenge through the Binocular Harmonization technology in the id MyStyle 2 progressive design. Warren Modlin“Almost 70 percent of prescriptions are different in each eye,” explained Warren Modlin, Hoya Vision Care’s vice president, technical marketing. “If the eyes are looking through different prescriptions, you’ve got different amounts of magnification. If you’re spending hours in front of a computer with different images, the brain is going to fatigue, experience migraines or headaches or dryness that often is not recognized as being the result of two eyes trying to work together in order to harmonize an image.” Modlin said Binocular Harmonization technology is “the marriage of disparate images” that result from the difference in prescription between the two eyes. “That binocular harmonization algorithm always uses two eyes in two lenses to calculate the correct amount of prescription and where it should be in the corridor length, in order to send a clear single image to the brain.” Thomas Gosling, OD, owner of Optical Matters in Littleton, Colo., uses MyStyle 2 extensively in his practice. He identifies candidates for the lens by means of a questionnaire. “I list 10 main symptoms of eyestrain. I can look at that sheet and I can see that the patient is struggling, because they’re checking off boxes.” To help patients understand the binocular harmonization concept, “I explained to them that when you have a prescription for the two eyes that aren’t equal, there’s going to be a fight. It’s our brains that see, not our eyes. And the brain will tell you that it’s being challenged by showing you symptoms—headaches, eyestrain and fluctuation in vision in our eyes.” Assessing patient satisfaction with a lens can be difficult, because it is easier to notice the presence of symptoms than their absence. Dr. Gosling explained, “They may say, ‘I got an inexpensive second pair just to have as a backup, but I can’t wear them.’ You check the prescription and you tell them, it’s the same prescription, but the lens is not compensating for the problems that you’re having.” Virtual Reality for Real-Life Vision Horizon Optical, an optical technology company based in Barcelona, Spain, has developed its own approach to measuring patient’s visual behavior using an immersive visual reality experience called Mimesys. Pau Artus, Horizon’s innovation director, began with an examination of various progressive designs in the market, starting with the well-known distinction between “hard” and “soft” designs (Artus referred to these as “European” versus “Asian” designs, based on what he sees as the general preference among designers in those two continents.) “We started to see that some people would prefer one philosophy, one design over the other, but then the following person would prefer the opposite. All of them were really good designs—top, top, top brands. So we’re wondering, What’s behind that? Why would some people prefer softer designs, and some people would prefer harder?’ And the preferences were clear in most of the cases.” From there, he said, “We started to wonder if the way you look around and gaze at your surroundings had something to do with these preferences, not only in a static way, but also in a dynamic way.” Researchers thought categorizing wearers as head or eye movers could be a good starting point. “But we needed to go further, because you may not be looking the same way when you look at objects that are far from you, as other objects that might be near to you.” Researchers also considered that physical restrictions (e.g., shoulders and neck problems), might also play a role. Since the design preferences couldn’t be predicted, a test was needed to determine how people interacted with their visual environment. Said Artus, “We came up with the idea of using VR. It was affordable, but precise enough that we could track eye and head movements in a controlled environment. We measure the way interact with your environment while we project objects moving around, and we are able to calculate with precision the frequency of use for each of each part of the lens plane.” The result was the Mimesys system, which is currently available only in selected European countries, and was presented to the U.S. market this year at Vision Expo East. Wearing the VR headset, the patient chooses between two flying objects (a hummingbird or a drone). Artus said, “All you’re asked to do is just follow the follow the object flying around. In this way we are able to measure all the three significant distances for a progressive lens system we can then relate to some optical feature of the lens, and we have enough data to personalize.” The personalization process involves “morphing” the design on a continuum between hard and soft designs. “So we are able to smoothly transition from one design philosophy to the other in each part of the lens.” The Science of Wearer Satisfaction It goes without saying that the goal of any progressive lens is to provide the most satisfying visual experience. But how does one measure that? The obvious way is by having wearers self-report their subjective experience through wearer trials. But Tokai Optical Company, Ltd, a Japanese lens manufacturer with a history dating back to 1939, has taken a different approach with its NeuroSelect progressive lens series—measuring brain activity to develop a more satisfying lens. Magnetoencephalogram measures responses at the visual cortex.A Tokai spokesperson explained the process this way. “NeuroSelect lenses are designed to maximize a patient’s emotional response based on wearing scenarios. The NeuroSelect lens series was designed using brain activity measuring, which is essentially subjective feedback measured qualitatively. “This technology allows us to measure degrees of satisfaction and adaptation beyond self-reported and limited feedback scales of 1 to 5. It also allows a much broader scope of analytics; meaning this methodology allows us to research so many more scenarios and situations.” Brain activity was originally monitored using an electroencephalogram that measured alpha, beta and theta waves. According to the spokesperson, “This technology allowed us to analyze human sensibility into into ‘stress,’ ‘satisfaction,’ ‘sadness’ and ‘relaxation’. Using a single vision lens as a baseline, “Design modifications are introduced until the patient’s physiological and emotional response, measured by neurological feedback, provides the closest results to the control. “Using this control allows Tokai to have a realistic measure of success—lenses that are as close to SV as possible.” The company is now using a magnetoencephalogram to measure responses at the visual cortex. Tokai is now entering the U.S. market for the first time through an exclusive distribution agreement with Portland-based Pacific Artisan Labs. According to lab CEO Brandon Butler, this represents the first time Tokai has licensed an independent lab anywhere in the world. Brandon ButlerButler said he was drawn to the Tokai’s NeuroSelect series as a differentiator. “Most people look at the frame fit—the panto, the vertex and those kinds of things. And that’s how they adjust vision. Tokai looked at how the brain responds when you put these glasses on your face. It just makes a ton of sense, and I think that’s why they lead the world in terms of non-adapt ratio.” Butler expects to go live with the NeuroSelect series, and Tokai’s proprietary 1.76 lens materials, in early June. New Design Approaches Today, progressive lenses are the most popular form of vision correction, and, as we’ve seen, continue to evolve as researchers and designers find new ways to increase wearer satisfaction. At the same time, optical companies are pursuing innovations, that, in one way or another, stand outside the mainstream of eyeglass lenses for presbyopes. Rethinking the Curve One of the basic principles of ophthalmic optics is that there is an ideal curve for every prescription power. But the essence of progressive design is that the curvature of the lens changes from top to bottom in order to allow clear focus on objects in the foreground. This change in curvature has always been achieved by applying progressive optics to a lens blank with a standard, symmetrical base curve. Camber lens blank with changing curvature.Camber technology, developed by Younger Optics, changes this approach by applying the concept of changing curvature to the lens blank itself. A Camber lens blank does not consist of a single symmetrical curve, but one that constantly changes from top to bottom. Barcelona-based IOT, a lens design company, has now launched Camber Steady Plus, a new progressive lens using Younger’s Camber technology. According to Tina Lahti, IOT’s vice president of sales and marketing, using the Camber technology “means the front curve remains closer to the ideal for best optics as the patient’s power increases. Patients experience a wider near viewing area and improved cosmetics, especially for plus powers. “IOT’s latest designs for Camber lens blanks include Digital Ray-Path 2, which is groundbreaking technology, and Steady Plus Methodology, an improvement on our patented Steady methodology for control of unwanted mean power in the periphery. In addition to an excellent balanced design, Camber Steady Plus progressive lenses are also available in alternate configurations so opticians and optometrists can choose designs created for near, distance, or Intermediate vision. “These are by far the most technologically advanced progressive lenses ever offered by IOT and the response from eyecare professionals and their patients has been tremendously positive,” Lahti said. John GustafsonJohn Gustafson, ABO-AC, is the optical manager at Southwest Vision in St. George, Utah, recommends Camber Steady Plus to many patients. “The clarity of the lens is phenomenal. There’s very, very little swim very little swim in the lens at all. When I first tried it, it really felt more like I was wearing a single vision lens. It’s just a very smooth lens,” he said. When talking to patients about the lens, “I try not to get too technical. The doctors, the other opticians and I will just let them know that this is a lens that has the latest technology built into it just to give them the best optics possible. We tell them that they’re going to have a great experience when they come and pick these lenses up.” In Gustafson’s experience, “The response has been pretty phenomenal. We haven’t had anybody who’s had any issue with this lens so far.” He cited the example of a patient in his 60s who ordered a clear pair and a sunglass pair. “He’s never been happy with progressives before. He put them on and he started looking around. He got up he walked around a little bit and he came back he said, ‘This will be the first time I’ve picked up a progressive lens where I’m actually going to walk out the door wearing them.’ When I followed up with him a week or so later, he said that he said these lenses are working great.” Addressing the 'New Normal' While every presbyope’s visual behavior is different, the “digital lifestyle” that we live today has created a general shift in visual behavior that was not addressed in previous generations of multifocals, resulting in new designs to meet new visual demands. Zeiss SmartLife lenses are designed for a digital lifestyle.Zeiss Vision Care has recognized that digital device usage is an all-day activity that must be addressed in all-day progressives, as they have in their SmartLife line of customized progressives. According to Matt Woelbern, head of marketing for Zeiss Vision Care US, “Zeiss SmartLife is a complete lens portfolio, including innovative progressive lens designs to address the visual needs of today’s connected and on-the-move lifestyle. Frequent gaze changes to and from smart devices can lead to eyestrain. Zeiss SmartLife lenses are specially designed to support quick and easy peripheral vision for all-day comfort. Zeiss SmartLife lenses are made with freeform technology, customized to the patient’s Rx, and have four different levels of advanced technology.” Woelbern noted that Zeiss also offers Zeiss Light, an all-freeform progressive lens portfolio with three different technology levels, ranging from fixed fitting heights to an automatic variable corridor lens. Plus, Zeiss offers progressives for specialized activities, like DriveSafe lenses. Said Woelbern, “Zeiss DriveSafe Lenses are an everyday driving lens specifically designed to meet the visual needs of drivers while also being a great all-day lens solution.” For near and mid-distance viewing, Zeiss offers the Officelens, a complete portfolio of freeform computer/office lenses that are easily personalized for preferred working distances. Reimagining Multifocal Design Layout of Broadview NAL vs. traditional PAL.While progressive designs have improved enormously since they were first developed and offered to the public, they all have the same basic hourglass shape. But is this the only way to provide a continuous distance-to-near viewing experience? Not according to Michael Walach, CEO of Quest Vision Care Specialty Lab and inventor of the Broadview Natural Accommodation Lens (NAL). Walach described the design as “funnel-shaped” rather than “hourglass-shaped.” Instead of stable distance, a short corridor of power acceleration, and a stable near area, the NAL design changes power continuously in small increments through a continuous set of lateral aspheric power bands aligned vertically along the spine of the lens. Describing the difference between the PAL and NAL designs, Walach said, “All progressive lenses have a corridor of approximately eight millimeters. If the add is 2.00, for every millimeter going down, you increase the power by quarter diopter.” With the NAS design, the acceleration ramp is approximately 24 millimeters long and the power change per millimeter is imperceptible to the brain. In short, he said, “We mimic a natural accommodation from 20 feet all the way to 1.1 feet.” In the periphery, instead of unwanted astigmatism is replaced by peripheral defocus, Walach said, “So you are losing focus slightly, but it’s not weighty. And you don’t realize it that you are losing the focus, because it’s so little.” Michael Walach Surprisingly, the lens does not require a fitting height measurement. Walach explained that the lowest point of the lens varies.“What stays the same is that the upper wire is just with your eyebrows. So we start from the top because it’s incredibly consistent: one to three millimeters. Of course, lens shapes are different, but once we trace the frame, we adjust the design height. “We always put the engraving marks in the middle of the frame, regardless how we adjust the height. The prism reference point like on progressive lenses is also a reference point like on a single vision lens.” Walach believes this makes it a viable multifocal option for e-commerce, but that it provides opportunities both for brick-and-mortar locations and for the increasing number of practices who also have an online presence. “The message for eyecare practitioners is that the NAL is not your enemy, but your friend.” The Disappearing (Add) Act Reading glasses offer a wide, clear view of up-close objects. Multifocals provide ample, but smaller, areas of near power with the convenience of never having to change glasses. The optical industry has long sought what might be considered the best of both worlds—a lens with reading power that can be activated when it’s needed, but disappears when it’s not. Deep Optics, based in Petah-Tikva, Israel, has developed and marketed a lens that delivers this type of adaptive optics. Add power is generated by means of a thin layer of adaptive liquid crystals between two glass substrates. The crystals are activated electrically when the wearer swipes the lenses diagonally. As reported recently in Vision Monday’s affiliate Medscape, “When the lens is turned off, it has no optical function, and when it is turned on, it can be tuned to any relevant optical power, researchers reported at the Association for Research in Vision and Ophthalmology (ARVO) 2023 Annual Meeting.” The lenses are currently being marketed under the name 32°N, with a price tag of about $500. While these lenses are plano when deactivated, and require no prescription for purchase, a prescription version is in the works. Continual Innovation Takes Many Forms Charles Holland Duell, commissioner of the U.S. Patent Office at the end of the 19th century, is alleged to have said, “Everything that can be invented has been invented.” No doubt many have expressed a similar sentiment about the treatment of presbyopia throughout its long history. But it should be clear by now that the evolution of treatments continues, and runs the gamut from AI-driven refinements to radically new designs, and even to prescription medications. And since many of these innovations would have been hard to anticipate even a decade ago, it seems likely that there are many more just over the horizon. That’s good news for the industry, and for the patients it serves. So congratulations to Charles Holland Duell for being far too discerning to say what is, ironically, the only thing he is remembered for. (The quote actually comes from the British humor magazine Punch.) Instead, he said something that is sadly overlooked by history, but far more accurately reflects the continually evolving science of presbyopia treatment: “I almost wish that I might live my life over again to see the wonders which are at the threshold.”An earlier version of this article incorrectly referred to a new lens being released from Tokai and Pacific Artisan Labs as Neurolens. The correct name of the lens is NeuroSelect. Neurolens is a separate lens brand marketed by the Neurolens company, which is not affiliated with either Tokai or Pacific Artisan Labs.