YOU ARE LIKELY STARTING TO SEE MORE AND MORE PATIENTS that participate in some type of recreational activity that involves targeting or aiming. As the Baby Boomers and members of Generation X accumulate more disposable income and free time, many of them take up shooting as a hobby. Presbyopia will pose some challenges and limitations that can be extremely frustrating to these patients. Let’s take a closer look at the unique challenges that a presbyopic patient will encounter and how eye doctors can help.

There are endless aspects of the visual system that can be enhanced to help a patient acquire (meaning visually detect), target and track an object. For the most part, it was thought that many of these principles would not change after presbyopia, but this really depends on how deeply you want to assess visual changes in the aging eye. A recent article in the Journal of Sport and Performance Vision cites studies that show there are reduced visual metrics that drop off beyond near focus. These include but are not limited to contrast sensitivity, glare recovery, saccades, tracking and reaction times¹. These presbyopia-related metrics are poorly understood in performance vision and will apply to many dynamic vision tasks in the aging eye. In many ways, these variables will affect a photographer or even a daily driver as much as they affect a shooter. Most of these metrics are far more subtle and less devastating than the loss of near focus, so let’s concentrate on what the loss of near defocus does to a shooter.

To understand the effects of near defocus on a shooter, consider the type of shooting that most of your patients will be involved in. Keep in mind that shooting does not refer only to guns; it can include a variety of sports such as archery or even spear fishing. Most types of shooting fall into two categories—static and dynamic. There are also significant differences between rifle and pistol shooting that you should consider.

Static Shooting with a Rifle

A common type of shooting used in a situation like hunting will involve static shooting though a scope. Of all types of shooting, this one is least affected by presbyopia. The optics of the scope should be set at infinity, and the reticles—crosshairs, for example—that overlay the target should also be at that distance. As long as the shooter’s vision is fully corrected, a good sight picture should be as useful as for any pre-presbyope. The only real concern I have in this situation is dry eye. Dry eye prevalence increases in the presbyopic demographic, and dryness will degrade the image quality. This could hold true for any static target shooter, since they greatly reduce their blink rate while concentrating on a target. Reduced blink rate will lead to a break-up of the tear film and reduced vision quality. Dry eye can be an issue at elite levels in all categories of static shooting.

If the shooter is not using a scope, but open sights that are fixed to the rifle, then presbyopia can have a significant effect. As the butt of the rifle is typically pressed against the shoulder of the shooter, the near sight is often as close to the eye as 4 to 6 inches (10 to 15 cm), and the far sight anywhere between 17 to 20 inches (43 to 50 cm) from the eye. These are accommodative dioptric values of 7 and 2 diopters! In most cases, the near sight does not require the resolution that the far sight does, but it is used for alignment during aiming. As a patient’s presbyopia progresses, the process of aligning the front and rear sights becomes increasingly difficult. Stressful shooting tasks (timed competition shooting, for example) will amplify this difficulty, as will dynamic shooting tasks like trap or skeet.

Static Shooting with a Handgun

In general, handguns are far more difficult to shoot accurately than a rifle. Because the device is not braced against the body, aligning the front and rear sights is much more challenging. In addition, the distance between the front and rear sight is much shorter, making the subtlest misalignment more significant to the aim. The target distances will be much shorter for this type of shooting, but the technique of aiming is quite different than a rifle. Because alignment of the front and rear sights is more difficult, the shooter will focus on the front sight of the pistol as opposed to focusing on the target as in rifle shooting. This places more accommodative importance on the clarity of the front pistol sight located at the end of arms’ length. Early presbyopes tend to manage this very well, but advanced presbyopes can struggle significantly trying to clear the sight.

Static handgun shooting will also become problematic for the shooter because they must transfer their focus from the handgun sights to the target and back. This, in essence, is accommodative rock, and can greatly slow a presbyopic shooter’s target acquisition time.

There are some devices that can help the presbyopic handgun shooter tremendously. Red dot sights are aiming devices that have become popular for their accuracy and speed of acquisition. For presbyopes, they provide significant aid due to their ability to project an aiming dot onto the target. This allows the shooter to maintain their focus on the target and avoid almost all of the presbyopia-related limitations of handgun shooting.

Red dot and holograph sights—the same concept as red dot but using a projected holograph reticle—can also be fitted to tactical rifles, giving a forward-projected sight that benefits presbyopes in the same way that red dots do.

Dynamic Shooting (for both rifle and handgun)

The visual demands of dynamic shooting—when either the target, the shooter, or both are moving—are exponentially more complex than static shooting. Now, we are also concerned with factors like peripheral awareness, saccades, multiple object tracking and depth perception.

Vision correction for these patients is not straightforward. Most presbyopes use progressive lenses, but these lenses are problematic for shooters for multiple reasons. First, the design of the lens will require head movement in order to gain accommodation, destabilizing the aiming axis. Second, the peripheral distortion of the lens will affect the target as an object is tracked. And third, most of these lenses are not fit in appropriate shooting safety frames. That leaves the majority of shooters having to wear another pair of safety glasses over their progressives. The more refractive planes, the more image distortion occurs.

I prefer to have my shooters wear contacts for correction as opposed to spectacles. Beyond the advantage of easily accommodating proper safety eyewear, contact lenses have the benefit of reducing peripheral distortion. Presbyopes have their own challenges with this form of correction. Many patients in this age group are not eager to try contact lenses if they have not worn them before. This group of patients is also very detail oriented and sensitive to image quality. Although the new multifocal contact lenses are much better than they used to be, most shooters will feel that the static image quality was better with their glasses. Note that this is a separation that is almost negligible between monofocal contact lenses and spectacles. The trade off with image quality is often worth it for more dynamic vision and better safety.

If a patient desires surgical correction for presbyopia, we have had good success with new generation presbyopia-correcting IOLs. I have now had several competitive shooters win national competitions after refractive lens exchange. The barriers here are the risks of surgery, and cost.

One of the most significant developments for presbyopic shooters may be available to us in a year or two. Currently, several companies are developing eye drops indicated to treat presbyopia. The drops will work by constricting the pupil for several hours, providing a pinhole effect at near. I would not expect these drops to help an emmetrope read a pill bottle at 10 inches, but it certainly should give a big boost to clarity at the intermediate distance. For some, the constricted pupil may even provide increased clarity at distance. For shooters, this should allow the presbyopic eye to function as close to the pre-presbyopic performance level as possible.

I foresee almost every presbyopic shooter benefiting from presbyopia-correcting drops. The emmetropes are the easiest and most obvious group, but it will go beyond that. In tandem with these drops, spectacle wearers could benefit from optically superior single vision glasses in appropriate safety frames. The contact lens-wearing presbyope can also benefit from the clarity of single vision lenses. Even the presbyopia-corrected IOL patient should see an added benefit from using these drops.

It is important to understand the visual demands of your patients that shoot, both professionally and recreationally. Presbyopia will require adjustments for these patients, but every eye doctor has the tools to keep these patients on target. ■

References

1. Cunningham D, Smithson K, Nanasy A, Horn F. The Effects of Presbyopia on Performance Vision. Journal of Sport and Performance Vision. v3i1. 10, June 2021.

Dr. Cunningham practices at Dell Laser Consultants in Austin, Texas, and is a co-founder and partner at Sports Vision Pros. He currently trains civilian competition and tactical military and law enforcement shooters in vision performance.