Hyperopia and Presbyopia - part 5 potx

126 Hoang-Xuan and Malecaze Table 1 Visual and Refractive Outcomes Refractive Refractive Uncorrected Uncorrected outcome outcome VA postop VA postop Phakic IOL No. of Follow-up ES (D) ES (D) (D) Ϯ 0.50 (D) Ϯ 1.00 20/40 orbetter 20/20 or better type Authors eyes (months) preop postop (% eyes) (% eyes) (% eyes) (% eyes) Artisan Fechner (10) 67 78.1 ϩ6 to ϩ 18 Ϫ5 to ϩ 3.5 (1998) (12 to 120) (ϩ9.98 Ϯ 2.6) (ϩ0.07 Ϯ 2.03) Artisan Hoang-Xuan and 9 12 ϩ4.40 to ϩ l8.12 Ϫ0.75 to ϩ 0.75 66.7 100 67 11 Malecaze (2001) (unpublished data) ϩ6.61 Ϯ 0.35 Ϫ0.08 Ϯ 0.71 STAAR Rosen (11) 9 3 ϩ2.25 to ϩ 5.62 Ϫ0.12 to ϩ 0.50 88.8 89 44 (1998) STAAR Davidorf (12) 24 8.4 ϩ3.75 to ϩ 10.50 Ϫ3.88 to ϩ 1.25 58 79 63 8 (1999) (1 to 18) (ϩ6.51 Ϯ 2.08) (Ϫ0.39 Ϯ 1.29) STAAR Pesando (13) 15 12 ϩ4.75 to ϩ 11.75 Ϫ1.00 to ϩ 1.50 69.25 92.3 46.15 0 (1999) (6 to 18) (ϩ7.77 Ϯ 2.08) (ϩ 0.02 Ϯ 0.64) STAAR Sanders (14) 10 6 ϩ 2.50 to ϩ 10.88 Ϫ0.50 to ϩ 1.50 80 90 100 70 (1999) (ϩ 6.23) (ϩ 0.20 Ϯ 0.61) 127Hyperopic Phakic Intraocular Lenses Table 2 Safety of Hyperopic Phakic Intraocular Lenses Loss of Unchanged Gain of Phakic IOL BSCVA BSCVA BSCVA type Authors (% eyes) (% eyes) (% eyes) Complications Artisan Artisan STAAR STAAR STAAR STAAR 22.2 (1 line) 55.5 (Ͼ2 lines) 25 (1 line) 4 (Ͼ2 lines) 7.69 0 0 44.4 33 76.92 Fechner (10) (1998) Hoang-Xuan and Malecaze (2001) (unpublished data) Rosen (11) (1998) Davidorf (12) (1999) Pesando (13) (1999) Sanders (14) (1999) 22.2 (1 line) 22.2 (1 line) 22.2 (2 lines) 29 (1 line) 4 (2 lines) 4 (Ͼ2 lines) 15.38 2 (3 lines) One glaucoma and corneal edema (in two eyes of same patient) None Three pupillary block glaucomas Two pupillary block glaucomas One lens opacity None 2. STAAR Collamer Phakic IOL Four studies on hyperopic correction using the STAAR Collamer phakic lens have been published (11–14). These studies included 9, 24, 15, and 10 hyperopes respectively, the latter study (14) being a phase I clinical trial sponsored by the U.S. Food and Drug Administration. In total, 58 patients underwent STAAR Collamer phakic IOL implantation. Cumulative data show that preoperative SE ranged from ם2.25 to ם11.75 D. Mean follow-up ranged from 3 to 12 months. Postoperative SE ranged from מ3.88 to ם1.50 D; 58 to 80% of eyes were within 0.50 D of emmetropia and 79 to 92.3% of eyes were within 1.00 D of emmetropia. In Rosen’s study (11), the efficacy index was 0.98, which was superior to the index for myopic patients implanted with the same type of phakic IOL in series published by the same authors. Davidorf et al. (12) also compared their results favorably to the predictability in their series of high myopic eyes. Seven of 24 eyes (29%) (12) and one of 15 eyes (7.69%) (13) lost one or more lines of postoperative BCVA. Conversely, only 8% of hyperopic eyes operated on by Davidorf et al (12) demonstrated a gain in postoperative spectacle BCVA compared to the preoperative spectacle BCVA. This is explained by the loss of magnification induced by the surgery. G. COMPLICATIONS In Fechner’s series of the artisan lens, one patient had glaucoma and corneal edema in both eyes (10). In our study, no complications occurred and no change in endothelial cell density was noted after a follow-up of 1 year (personal communication). 128 Hoang-Xuan and Malecaze For the ICL, postoperative pupillary block glaucoma occurred in 3 of 24 eyes and in 2 of the 15 eyes in the series of Davidorf et al. (12) and Pesando et al. (13), respectively. This complication was due to iridotomies that were too small. H. SUMMARY Two types of phakic IOLs are available to correct hyperopia: the Artisan iris-claw lens and the STAAR Collamer PC IOL. These represent the only surgical refractive procedures capable of correcting hyperopia of ם4 D or more. There have been very few publications, but the results are encouraging. The predictibility, efficacy, stability, and safety of these procedures are excellent, as well as the quality of the resultant vision. The time of recovery is short and the surgeries are reversible. Long-term follow-up is, however, mandatory with respect to delayed complication such as iris atrophy at the fixation sites and progressive endothelial cell loss (iris-claw lens), and cataract and pigmentary dispersion (PC phakic lens). REFERENCES 1. Strampelli B. Sopportabilita di lenti acriliche in camera anteriore nella afachia o nei vizi di refrazione. Ann Ottamol Clin Oculist Parma 1954; 80:75–82. 2. Basuk WL, Zisman M, Waring III GO, Wilson LA, Binder PS, Thompson KP, Grossniklaus HE, Stulting RD. Complications of hexagonal keratotomy. Am J Ophthalmol 1994; 117:37–49. 3. Ehrlich MI, Nordan LT. Epikeratophakia for the treatment of hyperopia. J Cataract Refract Surg 1989; 15:661–666. 4. Lyle WA, Jin GJC. Hyperopic automated lamellar keratoplasty: complications and visual results. Arch Ophthalmol 1998; 116:425–428. 5. Koch DD, Kohnen T, McDonnell PJ, Menefee RF, Berry MJ. Hyperopia correction by noncon- tact holmium:YAG laser thermal keratoplasty; United States phase IIA clinical study with a 1-year follow-up. Ophthalmology 1996; 103:1525–1536. 6. Jackson WB, Casson E, Hodge WG, Mintsioulis G, Agapitos PJ. Laser vision correction for low hyperopia. An 18-month assessment of safety and efficacy. Ophthalmology 1998; 105: 1727–1738. 7. Arbelaez MC, Knorz MC. Laser in situ keratomileusis for hyperopia and hyperopic astigma- tism. J Refract Surg 1999; 15:406–414. 8. Kolahdouz-Isfahani AH, Rostamian K, Wallace D, Salz JJ. Clear lens extraction with intraocu- lar lens implantation for hyperopia. J Refract Surg 1999; 15:316–323. 9. Holladay JT, Gills JP, Leidlein J, Cherchio M. Achieving emmetropia in extremely short eyes with two piggyback posterior chamber intraocular lenses. Ophthalmology 1996; 103: 1118–1123. 10. Fechner PU, Singh D, Wulff K. Iris-claw lens in phakic eyes to correct hyperopia: preliminary study. J Cataract Refract Surg 1998; 24:48–56. 11. Rosen E, Gore C. Staar Collamer posterior chamber intraocular lens to correct myopia and hyperopia. J Cataract Refract Surg 1998; 24:596–606. 12. Davidorf JM, Zaldivar R, Oscherow S. Posterior chamber phakic intraocular lens for hyperopia of ם4toם11 diopters. J Refract Surg 1998; 14:306–311. 13. Pesando PM, Ghiringhello MP, Tagliavacche P. Posterior chamber Collamer phakic intraocular lens for myopia and hyperopia. J Refract Surg 1999; 15:415–423. 14. Sanders DR, Martin RG, Brown DC, Shepherd J, Deitz MR, deLuca MC. Posterior chamber phakic intraocular lens for hyperopia. J Refract Surg 1999; 15:309–315. 15. van der Heijde GL, Fechner PU, Worst JGF. Optische Konsequenzen der Implantation einer negativen Intraokularlinse bei myopen Patienten. Klin Mbl Augenheilk 1988; 193:99–102. 16. McDonald MB, et al. Ophthalmology 2002; 109:1978–1989. 13 Hyperopia and Presbyopia Topographical Changes STEPHEN D. KLYCE, MICHAEL K. SMOLEK, MICHAEL J. ENDL, VASAVI MALINENI, MICHAEL S. INSLER, and MARGUERITE B. McDONALD Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A. A. INTRODUCTION Techniques for refractive surgery have made tremendous strides since the pioneering work of Jose Barraquer and the introduction of radial keratotomy in the late 1970s (1). Traditional outcome measures for the efficacy of specific refractive surgeries are primarily uncorrected and best-corrected visual acuities and cycloplegic and manifest refractions. Corneal topog- raphy analysis has not been considered a primary outcome measure for clinical trials in the United States—this despite the fact that corneal topography is now the standard of care for preoperative screening of refractive surgical candidates and analysis of postopera- tive results and is a mainstay of anterior segment practice. Direct analysis by corneal topography has clearly shown the causes of visual loss after eventful refractive surgery. The best examples include the formation of central islands and peninsulas after surface ablation with the excimer laser (2) and induced generalized irregular astigmatism after automated lamellar keratectomy (3). In this chapter, the topographic characteristics of the presbyope and the current modalities for the correction of hyperopia are reviewed. B. KERATOFRACTIVE PROCEDURES FOR HYPEROPIA—TOPOGRAPHICAL CORRELATES Kohnen et al. (4) used computed videokeratography to demonstrate peripheral corneal flattening and central corneal steepening following noncontact Ho:YAG laser thermal keratoplasty (LTK) for the correction of hyperopia. Greater changes in corneal curva- 129 130 Klyce et al. ture and smaller amounts of topographical regression were noted when a two-ring laser treatment pattern was applied. When the topography was analyzed, several forms of in- duced astigmatism were observed: bowtie (both symmetrical and asymmetrical), irregu- larly irregular, and semicircular patterns. Only one eye in the entire study group was observed to have a homogeneous pattern. At present, noncontact LTK appears to be most promising for low hyperopia up to approximately 2 D. Regression of the effect appears to limit the procedure’s usefulness for refractive errors higher than 2 D. Furthermore, factors such as younger age (less than age 30) and increased preoperative corneal thickness may also contribute to faster rates of regression (5). Early hyperopic photorefractive keratoplasty (H-PRK) ablations consisted of small optical zones (approximately 4.0 mm) with small transition zones, creating an overall treatment zone diameter of 7 to 8 mm. Small optical zones increase the patient’s sensitivity to small decentrations. Likewise, small transition zones produce abrupt topographical and refractive changes between treated and untreated tissue. This “lack of smoothness” pro- motes more aggressive stromal and epithelial regeneration and thus refractive regression (6). It should also be noted that in myopic PRK, significant decrements in the character and magnitude of corneal optical aberrations have been found with larger optical and transition zones. Larger optical and transition zones result in a more natural physiological pattern of measured aberrations in myopic PRK (6), and a similar result would be expected in approaches to correct hyperopia. These considerations have led to larger optical zones of 6.0 mm, with overall hyperopic ablations now reaching 9.0 mm. With these considerations, induced aberrations after H-PRK have been carefully evaluated (7). Corneal topography after H-PRK showed a change from positive to negative spherical aberration on the order of 3 D. It is known that the positive spherical aberration of the cornea and the spherical aberration of the crystalline lens act in concert to decrease the overall aberrations of the eye. However, if hyperopic procedures over correct for corneal spherical aberration, a negative impact on visual function is expected. This effect can be seen in Figure 1. Even with larger ablation sizes, difficulties remain. By the nature of the procedure, the functional optical zone becomes smaller as the attempted correction increases in size. This is undoubtedly one of the most significant factors contributing to the poor success rate of both H-PRK and hyperopic laser assisted in situ keratomileusis (H-LASIK) for the correction of ם5.00 D or greater. Moreover, Choi et al. (8a) report an increased risk of irregular astigmatism based on topographic analyses when corrections above this level are attempted. The comfort level in this respect seems to be surgeon-related; therefore some surgeons limit attempted corrections to ם4.0 D or less. In reference to H-LASIK, a 9.0-mm ablation size requires the creation of a 9.5-mm flap. Although modern microkeratomes may provide for this flap size, some patients with small eyes or thin corneas are unsuitable candidates for this treatment. Larger flap diame- ters and larger amounts of correction increase the chances of striae formation, which can translate to irregular astigmatism on corneal topography. H-LASIK is gaining widespread use as a procedure to correct primary hyperopia as well as to modify consecutive hyperopia after overcorrection from LASIK for myopia; it is said to be safe and effective (8). Two typical case reports are given below to illustrate the topography obtained. Each patient underwent hyperopic LASIK with the VISX, Inc., Star Excimer Laser System. The diameter of the optical zone was 5.00 mm, with a total treatment zone of 9.00 mm OU. 131Changes in Hyperopia and Presbyopia Figure 1 H-LASIK effect on corneal topography and total eye aberration measured with NIDEK OPD-Scan. (1) (top left panel) standard corneal topography showing off-center treatment; (2) skias- copic (pointwise refraction) map: in the postoperative period, corneal aberrations for this eye account for the bulk of the total ocular aberrations; (3) placido image; (4) wavefront map showing induction of excess negative spherical aberration and coma. Case 1. A 66-year-old woman with no prior history of ocular surgery underwent H-LASIK for a refraction of ם0.75 ם 1.00 ן 170 OD and ם0.25 ם1.25 ן 180 OS. Her best spectacle- corrected visual acvity (BSCVA) was 20/20 (מ2) OU. The patient requested refractive surgery for monovision. Her preoperative K-readings were 44.3/44.5 at 118 OD and 44.4/44.8 at 163 OS. The laser was programmed to correct OD for ם1.00 ם 1.25 ן 170 and OS for ם2.50 ם 1.50 ן 180. The total ablation depth was 20 ␮m OD and 38 ␮m OS. Optical zone diameter was 5.00 mm. Her visual acuity without correction on postoperative day 1 was 20/200 OD and 20/80 OS. Two weeks postoperatively, her visual acuity without correction was 20/70 (מ1) OD and 20/200 OS and her BSCVA was 20/25 OD and 20/40 OS. The manifest refraction was מ0.75 ם 1.00 ן 050 OD and מ2.50 ם 0.75 ן 055 OS. At 4 weeks postoperatively, her visual acuity without correction was 20/30 (מ2) OD and 20/25 (מ2) OS. Her refraction at this time was מ0.75 ם 0.75 ן 055 OD and מ1.50 ם 0.75 ן 165 OS, with BSCVA being 20/25 OD and 20/25 (מ2) OS. Postoperative corneal topography 132 Klyce et al. A B Figure 2 H-LASIK 1-month postoperative topography for 66-year-old requesting monovision. (A) OD; attempted correction: ם1.00 ם1.25 ן 170. (B) OS; attempted correction: ם2.50 ם1.50 ן 180. 133Changes in Hyperopia and Presbyopia showed the extent of induced cylinder, revealed a steepening of the central 5 mm of the cornea, and produced simulated keratometry readings (SimKs) of 46.13/44.17 at 96 with a potential visual acuity (PVA) of 20/25 to 20/30 OD and 47.41/46.68 at 94 with a PVA of 20/20 to 20/30 OS (Figure 2). Case 2. A 26-year-old woman presented for refractive surgery evaluation. She had a refractive error of ם4.75 ם 0.50 ן 083 OD and ם5.25 ם 0.75 ן 095 OS. Her BSCVA was 20/25 OU. Her keratometry readings were 44.1/45.6 at 091 OD and 44.1/46.0 at 099 OS. The desired correction for the right eye was ם6.00 ם 0.50 ן 083 and for the left eye was ם6.00 ם 0.50 ן 105. Total ablation depth was 65 ␮m OU. Optical zone diameter was 5.00 mm. On postoperative day 1 her uncorrected visual acuity was 20/30 OD and 20/40 OS. Six months postoperatively, BSCVA was 20/25 (ם1) OD with no improvement with manifest refraction. BSCVA OS was 20/25 (ם1) with a manifest refraction of ם1.00 ם0.75 ן 165. There was some evidence of regression OS. Postoperative keratometry readings were 48.70/49.18 at 058 OD and 47.24/48.07 at 051 OS (Figure 3). Hence, H-LASIK seems a good choice of procedures at least for the temporary correction of hyperopia. Long-term stability will need to be demonstrated for this approach, as for others discussed in this chapter. Conductive keratoplasty (CK) is being developed as an alternative procedure for treating hyperopia. It is argued that if the collagen is heated to a carefully controlled critical temperature, the shrinkage and changes in corneal shape might be more permanent. Figure 3 Six-month postoperative corneal topography of H-LASIK patient showing good centra- tion OU. (Central green irregularities OS are temporary, from tear film breakup.) 134 Klyce et al. Figure 4 Preoperative and postoperative topographies after CK. Note large uniform area of in- creased power. Conductive keratoplasty uses radiofrequency energy to generate heat in the corneal periph- ery. As with LTK, the shrinkage of the collagen occurs from the production of a ring pattern of treatment spots around the corneal periphery. This shrinkage creates a purse- string effect to steepen the central cornea. One of the immediately appreciated benefits of CK over H-LASIK is the larger functional optical zone (Figure 4). C. MULTIFOCAL EFFECTS As the number of patients undergoing refractive surgery expands, the curious phenomenon of presbyopic patients presenting with functional near and far vision after refractive surgery is being more frequently reported for both myopic and hyperopic corrections. Described as a “multifocal” effect, this side effect of the surgery deserves scrutiny. It was Benjamin Franklin who conceived the first bifocal spectacle in 1874, initiating what is perceived to be a sequence of developments (Figure 5). Deliberate multifocality was introduced to the contact lens field prior to 1967 (9) and to the intraocular lens (IOL) arena before 1987 (10). While early models of IOLs and contact lenses exhibited pronounced aberrations that reduced contrast sensitivity, current renditions have enjoyed a measure of patient acceptance, at least with contact lenses. Unintentional iatrogenic multifocality was first identified with corneal topography in 11 eyes after radial kerato- 135Changes in Hyperopia and Presbyopia Figure 5 Historical use of multifocality in vision correction: Ben Franklin’s bifocal spectacles, bifocal contact lenses, bifocal IOLs, multifocality in radial keratotomy (11) and in photorefractive keratectomy for myopia (13). tomy, and although the possibility of complications from degradation of contrast sensitivity as well as monocular diplopia was anticipated, no patient complaints of this type were in fact reported (11). However, shortly after this report, additional analysis showed that certain patients with the multifocal effect after radial keratotomy could experience visually debilitating irregular astigmatism. This should be considered a complication of surgery (12). Multifocal effects have also been found following PRK (13) for myopia and contrib- ute to a form of artificial accommodation in pseudophakic eyes (14). It is well known that patients with an extreme amount of irregular corneal astigma- tism often refract over a large range of powers. This is the basis for the so-called multifocal effect; in spectacles, distinctly separate areas of the lens are prepared with different specific powers, whereas the power distributions of the multifocal cornea are more continuously graded and are analogous to gradations of refractive powers of the Varilux contact lens system. It might therefore be more accurate to describe the multifocal property as one of varifocality. A topographical multifocal effect can be assessed by direct examination of the distri- bution of corneal powers over the entrance pupil. The standard statistical metric for measur- ing the width of such distributions is the coefficient of variation; hence, an appropriate topographic definition of corneal multifocality is the coefficient of variation of corneal power (CVP) (15). The increase in the range or width of the distribution of central corneal [...]... differentiate H-LASIK from keratoconus Changes in Hyperopia and Presbyopia 139 E SUMMARY Corneal topographic analysis is helpful in elucidating the strengths and weaknesses of refractive surgical procedures, and surgery for hyperopia is no exception Centration is critical, and a large treatment zone size is technically difficult to achieve A hyperopic procedure’s stability can be objectively and precisely... 2מ‬degrees)‫ 5 ‬The lenticules corresponding to the negative-cylindrical and the positive-spherical treatments are shown with their meridian outlined in red and dark green, respectively The positive-cylinder approach minimizes the volume of ablation and induces no ablation at the center of the optical zone The cross-cylinder approach induces an additional volume of ablation compared to the positive-cylinder... aberrated wavefront and the ideal wavefront) for myopia, hyperopia, and astigmatism is well represented by a polynomial of second order These aberrations are therefore called second-order aberrations Following the same principle, coma is a third-order aberration and spherical aberration a fourth-order aberration (Fig 3) Laser surgery [photorefractive keratectomy (PRK) and laser-assisted in situ keratomileusis... of Aberration Changes in Hyperopia Versus Myopia In a study of 113 candidates for LASIK surgery, analyzing all aberrations, defocus and astigmatism were dominant When analyzing only higher-order terms, coma and spherical aberrations were the most significant Another study described the pre -and postwavefront measurements of patients submitted to LASIK for myopia or hyperopia and myopic PRK It was found... analysis of ablation depths and profiles in laser in situ keratomileusis for compound hyperopic and mixed astigmatism J Cataract Refract Surg 2000; 26(8):1123–1136  15 Wavefront Changes After Hyperopia Surgery MARIA REGINA CHALITA and RONALD R KRUEGER Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A A BASIS OF WAVEFRONT ANALYSIS 1 Definition of Wavefront and Aberrations In physical... (cylindrical refractive error), coma, spherical aberration, and other terms of higher-order aberrations Defocus and astigmatism are considered low-order aberrations and can be corrected with glasses, contact lenses, or refractive surgery (9) They correspond to approximately 85% of the average wavefront error Coma, spherical aberrations, and others are high-order aberrations (refractive distortions, that limit... correct hyperopia J Cataract Refract Surg 19 95; 22: 427–4 35 5 Alio JL, Ismail MM, Pego JLS Correction of hyperopia with noncontact Ho:YAG laser thermal keratoplasty J Refract Surg 1997; 13:17–22 ´ 6 Endl MJ, Martınez CE, Klyce SD, McDonald MB, Coorpender SJ, Applegate RA, Howland HC Effect of larger ablation zone and transition zone on corneal optical aberrations after PRK Arch Ophthalmol 2001; 119:1 159 –1164... Changes After Hyperopia Surgery A B Figure 7 (A) Trefoil pattern (B) Quadrafoil pattern 157 158 Chalita and Krueger Figure 8 LADARWave image showing defocus, astigmatism, and higher-order aberrations of a hyperopic patient Figure 9 Spherical aberration after hyperopic treatment showing negative asphericity, as represented by a flipped over sombrero Wavefront Changes After Hyperopia Surgery 159 Figure... into a model eye and doing ray tracing CTView V3.12 (Sarver and Associates, Merritt Island, FL) was used for this calculation Changes in Hyperopia and Presbyopia 137 Figure 8 After correction for distance vision with conductive keratoplasty for hyperopia, uncorrected near vision (UNVA N) also improves (p Ͻ 0.001) (Data courtesy of Refractec, Inc., lrvine, CA) in contrast sensitivity and symptomatic... keratectomy for hyperopia J Refract Surg 2001; 17:406–413 8 Ziff SL Multifocal contact lenses Am J Optom Arch Am Acad Optom 1967; 44:222–2 25 8a Choi RY, Wilson SE Hyperopic laser in situ keratomileusis: primary and secondary treatments are safe and effective Cornea 2001; 20:388–393 9 Keates RH, Pearce JL, Schneider RT Clinical results of the multifocal lens J Cataract Refract Surg 1987; 13 :55 7 56 0 10 Werblin . correction was 20/30 (מ2) OD and 20/ 25 (מ2) OS. Her refraction at this time was מ0. 75 ם 0. 75 ן 055 OD and מ1 .50 ם 0. 75 ן 1 65 OS, with BSCVA being 20/ 25 OD and 20/ 25 (מ2) OS. Postoperative corneal. without correction was 20/70 (מ1) OD and 20/200 OS and her BSCVA was 20/ 25 OD and 20/40 OS. The manifest refraction was מ0. 75 ם 1.00 ן 050 OD and מ2 .50 ם 0. 75 ן 055 OS. At 4 weeks postoperatively,. ϩ2. 25 to ϩ 5. 62 Ϫ0.12 to ϩ 0 .50 88.8 89 44 (1998) STAAR Davidorf (12) 24 8.4 ϩ3. 75 to ϩ 10 .50 Ϫ3.88 to ϩ 1. 25 58 79 63 8 (1999) (1 to 18) (ϩ6 .51 Ϯ 2.08) (Ϫ0.39 Ϯ 1.29) STAAR Pesando (13) 15 12