YOU WOULD THINK THAT A condition as easy to predict and diagnose as presbyopia would also be simple to treat. But the reality is very different. Almost all eyecare practitioners (ECPs), including opticians, optometrists, and ophthalmologists, struggle to satisfy patients with the current technologies available for presbyopia.

Why? Presbyopic patients can have retinal detachments or advanced glaucoma, in addition to their presbyopia, but at the end of the day, what they really want is to see. Presbyopia is a visual disturbance that affects 100% of people at or after middle age; 1.8 billion people worldwide were estimated to have presbyopia in 2015.¹ Owing to the aging population and increased longevity, most people will spend approximately half their lives as presbyopes.² Presbyopia is therefore a common finding by ECPs.

Presbyopia is caused by reduced elasticity of the crystalline lens, which leads to a progressive, painless, gradual inability to focus nearby objects on the retina.^2-4 The hardening of the lens is caused by several factors, including changes in lens dimension, ciliary muscle contraction, the elasticity of the lens capsule, and the geometry of the zonular attachments. The end result is reduced accommodation.⁵ Presbyopia usually begins at 38-45 years of age.⁶ It can appear earlier or later depending on the distance refractive error — the distance at which the person would like to be able to read, with closer distances requiring more accommodation — and the pupil size. Presbyopia can also be exacerbated by the amount of near work, while systemic diseases, trauma, and medication side effects are other common modifiable risk factors for early presbyopia.⁷

Nonsurgical corrective devices for presbyopia include spectacles (multifocal, bifocal), single-vision contact lenses (CLs) with reading glasses and monovision CLs (usually the dominant eye corrected optimally for distance and the other or nondominant eye for near), as well as multifocal and bifocal CLs.⁸ Studies have documented the success, effectiveness, and visual benefits of these various treatments.^2,9 There is a well-known high dropout rate associated with the use of multifocal CLs, often due to an imbalance between distance and near vision, combined with a reduced tear film quality that affects comfort.

A survey of ECPs found that only 50% recommended CLs, and then only very occasionally, to their presbyopic patients.¹⁰ McDonnell et al reported negative effects of CLs on vision-related quality of life.¹¹ Patients 45 years old or older with presbyopia reported greater dependence on visual correction, reduced clarity of vision, and less satisfaction with their correction than younger nonpresbyopes, after adjustment for sex, race, and socioeconomic status. Add a compromised tear film to this mix, and CL dropout is a likely consequence.

In recent years, refractive and cataract surgery have been used to treat presbyopia, but none has been established as the definitive solution for it. Corneal procedures for presbyopia correction include monovision laser in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), conductive keratoplasty (CK), presbyopic LASIK (presbyLASIK), and more recently, the IntraCor technique and corneal inlays. Presbyopic correction can also be achieved by removing the lens. Anterior ciliary sclerotomy has also been mentioned for presbyopia correction. Currently, a unique and ideal solution for presbyopia remains elusive, despite the plethora of options. The search to restore true accommodation continues to be a challenge. In most of the procedures available, near vision clarity is achieved at the expense of far vision and vice versa. Sometimes both are achieved, but the quality of the image is compromised. Technological advancements in CLs, biomaterials, and surgical instruments have entered ophthalmic practice, but further improvements are required. Moreover, neuroadaptive responses in presbyopia have not been adequately studied. Understanding which patients have better neuroadaptive abilities may help in selecting the best treatment and management approach.¹²

What it really comes down to is understanding our patients’ goals. Ultimately, people want to see well at all distances, especially if they were previously able to do so. At some point in their lives, everyone will develop presbyopia, and most will seek visual correction. Some may compromise a little on their distance vision to avoid or delay the need for correction, while others will demand sharp vision at all distances and keep returning to their ECP in hopes of achieving this. Some people may have higher demands for near vision (eg, manicurists and surgeons). Others will forego near vision to maintain crisp distance vision (truck drivers, some sports players).

One of the most important goals is to establish patient expectations. We must set the stage with our patients and let them know that perfect vision is not achievable. The first thing I tell my patients is that I cannot give them perfect vision 100% of the time. They will either need a separate pair of glasses for each of their working distances or they will have to compromise on something. If they use progressive glasses or contact lenses, they may have distortion. If they use bifocal glasses, they will see very clearly at only 2 different working distances (similar to monovision with contact lenses). The need to use reading correction is usually perceived as a sign of aging since visual deterioration is expected with age.¹³ Spectacles may be the usual or more popular mode of near-vision correction. As for contact lenses, as long as they are comfortable and suitable for the patient’s lifestyle, patients will accept higher costs. Both patients and ECPs need to understand this. Available technologies to correct presbyopia provide no “guarantee” of patient satisfaction. Unfortunately, correcting presbyopia is far more complex than correcting other types of refractive error because putting a lens in front of, or in, the eye is often insufficient on its own. Successful treatment requires meeting specific patients’ visual demands in the vast majority of their daily activities. ■

References

1. Fricke TR, Tahhan N, Resnikoff S, et al. Global prevalence of presbyopia and vision impairment from uncorrected presbyopia: systematic review, meta-analysis, and modelling. Ophthalmology. 2018;125(10):1492-1499. http://dx.doi.org/10.1016/j.ophtha.2018.04.013 .
2. Charman WN. Developments in the correction of presbyopia I: spectacle and contact lenses. Ophthalmic Physiol Opt. 2014;34(1):8-29. http://dx.doi.org/10.1111/opo.12091 .
3. Glasser A, Campbell MC. Biometric, optical and physical changes in the isolated human crystalline lens with age in relation to presbyopia. Vis Res. 1999;39(11):1991-2015. http://dx.doi.org/10.1016/s0042-6989(98)00283-1 .
4. Balgos MJ, Vargas V, Alió JL. Correction of presbyopia: an integrated update for the practical surgeon. Taiwan J Ophthalmol. 2018;8(3):121-140. http://dx.doi.org/10.4103/tjo.tjo_53_18 .
5. Renna A, Alió JL, Vejarano LF. Pharmacological treatments of presbyopia: a review of modern perspectives. Eye Vis (Lond). 2017;4:3. http://dx.doi.org/10.1186/s40662-017-0068-8 .
6. Carnevali T, Southaphanh P. A retrospective study on presbyopia onset and progression in a Hispanic population. Optometry. 2005;76(1):37-46. http://dx.doi.org/10.1016/S1529-1839(05)70253-0 .
7. Jain IS, Ram JA, Gupta AM. Early onset of presbyopia. Am J Optom Physiol Opt. 1982;59(12):1002-1004. http://dx.doi.org/10.1097/00006324-198212000-00012 .
8. Bennett ES. Contact lens correction of presbyopia. Clin Exp Optom. 2008;91(3):265-278, http://dx.doi.org/10.1111/j.1444-0938.2007.00242.x .
9. Wolffsohn JS, Davies LN. Presbyopia: Effectiveness of correction strategies. Prog Retin Eye Res. 2019;68:124-143. http://dx.doi.org/10.1016/j.preteyeres.2018.09.004 .
10. Ewbank A. Who fits contact lenses? Optician. 2009;237:6204.
11. McDonnell PJ, Lee P, Spritzer K, Lindblad AS, Hays RD. Associations of presbyopia with vision-targeted health-related quality of life. Arch Ophthalmol. 2003;121(11):1577-1581. http://dx.doi.org/10.1001/archopht.121.11.1577 .
12. Torricelli AA, Junior JB, Santhiago MR, Bechara SJ. Surgical management of presbyopia. Clin Ophthalmol. 2012;6:1459-1466. doi:10.2147/OPTH.S35533
13. Hutchins B, Huntjens B. Patients’ attitudes and beliefs to presbyopia and its correction. J Optom. 2021;14(2):127-132. doi:10.1016/j.optom.2020.02.001

Dr. Kramer is a residency-trained optometrist in Miami FL who specializes in ocular surface disease and regular and specialty contact lens fitting. Her practice includes treatment of keratoconus, refractive surgical complications, corneal transplant surgery, eye trauma, chronic dry eyes, corneal dystrophies and degenerations, among others.