Ophthalmic Physiologic Optic - 2013 - Charman - Developments in The Correction of Presbyopia I Spectacle and Contact

Ophthalmic & Physiological Optics ISSN 0275-5408
INVITED REVIEW
Developments in the correction of presbyopia I: spectacle

and contact lenses
W. Neil Charman
Faculty of Life Sciences, University of Manchester, Manchester, UK
Citation information: Charman WN. Developments in the correction of presbyopia I: spectacle and contact lenses. Ophthalmic Physiol Opt 2014;
34: 8–29. doi: 10.1111/opo.12091
Keywords: contact lenses, near additions, Abstract

presbyopia, spectacle lenses, variable power
Purpose: To outline the refractive problems associated with presbyopia and to
Correspondence: W. Neil Charman review the basis and relative merits of currently-available methods for their cor-
E-mail address: neil.charman@tesco.net rection, with detailed consideration of spectacle and contact lens approaches.
Contents: In the developed world, most of the present population will spend
Received: 22 July 2013; Accepted: 24
roughly half their lives as presbyopes. The well-known presbyopic changes with
September 2013; Published online: 10
age in amplitude of accommodation and required near addition are briefly
November 2013
reviewed, together with the less widely acknowledged slow drifts that occur in dis-
tance refraction. The desirability of restoring to presbyopes clear vision for objects
at any distance, ideally corresponding to vergences within the range of at least 0 to
5 D, in any viewing direction, is stressed. A general outline is given of possible
corrective methods. Methods which satisfy the needs of a 50 year-old may not be
suitable for the 80 year-old. Corrections may involve both fixed- and variable-
focus lens systems, and surgical methods which modify the optics of the cornea,
replace the crystalline lens with different fixed optics, or attempt to at least partially
restore active accommodation. Some more recent methods of spectacle and con-
tact lens correction are described in more detail. Particular attention is given to
recent commercially-developed spectacles in which the corrective power can be
varied actively by either mechanical (liquid-filled deformable lenses or Alvarez
lenses) or electrical (liquid crystal lenses) means to allow objects at different dis-
tances to be seen clearly. Contact lens corrections show less progress and are still
preferred only by a minority of older patients, most of whom are early presbyopes.
Summary: The rising proportion of presbyopes in the population, covering an
age span of around 40 years, represents both a problem for those concerned with
giving their patients the best vision possible at both far and near viewing distances
and a commercial opportunity. Traditional single-vision distance and near, bifo-
cal, and progressive spectacle lens solutions, together with contact lens modalities
for presbyopic correction, are being challenged by a variety of new approaches. It
remains to be seen whether the latter will receive wide acceptance in practice.
Introduction air, he will see the letters far better, and they will seem
larger to him. …For this reason, such an instrument is
‘It may be observed that old people hold objects that they
useful to old persons…’1
wish to examine further from the eye…. If anyone exam-
ines letters or other minute objects through the medium Although the English friar Roger Bacon, writing around
of crystal or glass or other transparent substance, if it be 1250 AD, was undoubtedly drawing on the earlier Arabic
shaped like the lesser segment of a sphere, with the con- work of Alhazen and other authors, and the problems that
vex side being towards the eye, and the eye being in the older people experience with near vision had been widely
8 © 2013 The Authors Ophthalmic& Physiological Optics © 2013 The College of Optometrists
Ophthalmic & Physiological Optics 34 (2014) 8–29
14751313, 2014, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/opo.12091 by Cochrane Poland, Wiley Online Library on [05/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
W N Charman Presbyopia correction
described in antiquity, he seems to have been the first Euro-

Changes with age in accommodation and refraction
pean author both to state the problem and to provide a
possible solution. More dramatically, at about the same Amplitude of accommodation and age
time some unknown European craftsman conceived the Although many others contributed, it was to be the work of
idea of mounting two such positive lenses in a suitable Thomas Young in 1804 which clarified the nature of the
frame to create the first reading spectacles for presbyopes processes underlying accommodation,3,4 while Donders, in
(Figure 1). These early, hand-held spectacles were uncom- 1864, carefully charted the loss in subjective amplitude of
fortable, hard to keep in position and cosmetically unat- accommodation with age and analysed the changing
tractive. It was not until the 18th century that frames were demands for a reading correction.5 Strikingly, Donders
given folding side-arms, supported by the ears, of the type (ref. 5, p.214) remarked ‘The more I investigate the subject,
that is familiar today. the more fully I am convinced that at a given time of life the
Progress in understanding the nature of refractive error, range of accommodation is an almost law-determined quan-
accommodation and presbyopia was relatively slow in suc- tity’. His average data are shown in Figure 2, along with
ceeding centuries, but one striking advance in presbyopic some estimates from later authors.6–8 Exact values depend
correction was made (or perhaps publicised) by that great upon the methodology used,8–13 but there is little indica-
American polymath, Benjamin Franklin. As an ametropic tion of any marked changes in the form of the curve over
presbyope, needing spectacles for both distance and near the past 150 years, in spite of differences in nutrition,
vision, he was irritated by his need to constantly alternate greater longevity and an earlier age of puberty. Objective
between his two pairs of spectacles. Writing when on diplo- amplitudes are a little lower at all ages, due to the contribu-
matic service in Paris to a friend in 1784, he records tion of ocular depth-of-focus to subjective amplitudes.12 It
appears that the decline with age in the objective ampli-
‘Finding this change troublesome, and not always suffi-
tudes of individual patients may be almost linear, the
ciently ready, I had the glasses cut and a half of each
reduction after the onset of presbyopia in the gradient of
kind associated in the same circle. By this means, as I
the average subjective amplitude/age curve with age
wear my spectacles constantly, I have only to move my
(Figure 2) being associated with the averaging process
eyes up or down, as I want to see distinctly far or near,
after the age at which some individuals have lost all
the proper glasses being always ready. This I find more
accommodation.14
particularly convenient since my being in France, the
glasses that serve me best at table to see what I eat not
being the best to see the faces of those on the other side of Near additions
the table who speak to me; and when one’s ears are not
Although the accommodation system is still active, the
well accustomed to the sounds of a language, a sight of
reduced amplitude at the age of about 40 is such that most
the movements in the features of him who speaks helps
people start to experience problems with near vision and to
to explain; so that I understand French better by the help
need some form of reading addition. For convenience, the
of my spectacles.’
age of onset of presbyopia is sometimes taken as that at
Franklin’s split bifocals were the precursors of a wide which the subjective amplitude of accommodation falls
range of bifocal, trifocal and progressive lenses for the pres- below 3 D.15 Usually the objective amplitude has declined
byope.2 to zero at the age of about 52.12,14,16 Increases in spectacle
reading addition may still be beneficial beyond this age,
since the effective magnification provided by shorter read-
ing distances compensates for the loss of visual acuity in
the older eye.14,16,17 Pointer has recently reviewed clinical
aspects of the measurement of accommodation and the
estimation of near additions: his summary plot of mean
near addition as a function of age in the United Kingdom
is shown in Figure 3,18 together with some similar data
from the Americas.19,20 Clearly various additional factors,
such as physical stature, the nature of their visual tasks and
working distances, will affect the additions given to individ-
ual patients. In particular there are systematic differences in
the mean adds given to men and women of the same
Figure 1. St Luke in spectacles (ca. 1400 AD). Detail from a German age,19–22 the slightly higher adds given to women probably
altarpiece by Conrad van Soost. being mainly due to differences in arm length.16
© 2013 The Authors Ophthalmic& Physiological Optics © 2013 The College of Optometrists 9
Presbyopia correction W N Charman
16
14
12
Donders (1865)
Duane (1912)
Amplitude (D)
10
Turner (1958)
Kragha (1986)
8
0
0 10 20 30 40 50 60 70 80 90
Age (years)
Figure 2. Monocular subjective amplitude of accommodation as a function of age, after the authors indicated.5–8
interpretation of the results shown, since most of the data

Changes in distance correction with age
are transverse, and there may be some bias in the selection
One further age-dependent refractive factor is of impor- of the subjects studied. Further, effects may vary with the
tance for presbyopic corrections: the distance correction. initial refraction, with some myopes showing anomalous
The ever-prescient Donders5 suggested that, rather than behaviour.31–33 However, as shown in Figure 4, there is
remaining stable through adult life, the mean refraction broad agreement among different authors that from the age
across the population tended to become more hyperopic of 30–40 years there is typically a slow drift towards hyper-
in later years. Later work has confirmed this trend23–30 opia (at about + 0.04 D/year), the total hyperopic shift typ-
(Figure 4). Some caution must be excercised in the ically amounting to about 1–2 D by the age of 70. At older
ages the refraction may be affected by advancing cataract,
the exact effects depending upon the type and severity of
3 the cataract. With nuclear cataract there is a tendency
towards more myopia and with cortical cataract towards
increased astigmatism.34 This main cause of the hyperopic
2.5
trend is thought to be lenticular change, although other fac-
tors may also be involved,35,36 including an increased axial
Mean near addition (D)
2 length.35 There is also a trend for ocular astigmatism to

change by around 1 DC in the against-the-rule direction
1.5 between the ages of 40 to 80 years.27,37 Thus, at least in
Pointer 1995
the phakic eye, presbyopic corrections must be flexible
Kragha & Hofstetter 1986 enough to cope with changes in both the required distance
1
Hofstetter 1949 correction and the addition. This is straightforward with
Pointer fits
spectacle and contact lens corrections, which can easily be
0.5 modified, but may be more difficult with some surgical
techniques, which by their nature are never completely
0 reversible.31,38
40 45 50 55 60 65 70 75 80
Age (years)
The need for improved methods for presbyopic
Figure 3. Mean near addition as a function of age as found in three correction and constraints on their characteristics
studies.18–20 The dashed lines are linear regression fits to the Pointer
data in the ranges 40–55 and 55–80 years and suggest that addition With increasing longevity, most people in the western
power increases more slowly after the age of about 55 years (Poin- world can look forward to spending almost half their lives
ter18,22). as presbyopes. Current worldwide numbers are probably
3.5
Mean spherical error (D)

Slataper 1950
2.5
Hirsch 1952
2 Sorsby 1961
Hirsch 1958
1.5 Saunders 1981
1 Lavery et al. 1988
Fledelius 1988
0.5 Saunders 1986
0
–0.5
–1
0 20 40 60 80 100
Age (years)
Figure 4. Changes in the average value of mean spherical error as a function of age according to different authors.23–30
around 2 billion39 and in the UK about 42% of the residual accommodation it is conventional to assume that
population is presbyopic (i.e. aged >45 years).40 Although one half or one-third of the available amplitude is held in
spectacles continue to meet the basic needs of vast majority reserve,16 although some have suggested that this may be
of these individuals, and there has been much progress in, too conservative and that 80% or more of the available
for example, the design and fabrication of progressive amplitude may be continuously exerted without eye-
lenses, many presbyopes would concede that spectacle cor- strain.41 If we consider presbyopic correction by methods
rections have their limitations, in terms of such factors as other than spectacle lenses, there is no reason why all the
the necessity of directing the visual axes in a particular additional near power should not be provided by the
direction for adequate near vision, inadequate vision at correction. Similarly, although in spectacles fixed high
intermediate or very close distances, appearance, or the additions are generally avoided because the limited depth-
inconvenience of always having to have spectacles to hand, of-focus in dioptric terms translates to a very small range of
a particular problem for the forgetful elderly presbyope. object distances over which adequate focus is maintained, a
For these and other reasons, an increasing range of alterna- corrective device which actively changed its powers might
tive methods of correction has been explored in recent allow much shorter working distances to be usefully
years. As in the case of spectacles, many of these involve employed, thus simulating the performance of young sub-
compromises in such aspects as the quality of vision jects with large amplitudes of accommodation. In any case,
achieved at different distances, appearance, comfort, conve- a power change of at least +3.00 D is required to cope with
nience and cost. In considering the utility of the various the needs of older presbyopes and, in the context of surgical
correction methods either currently available or under attempts to restore active ‘accommodation’, Schor42 has
development it is important to remember that each patient suggested that any method needs to yield a subjective
will use different criteria to judge the effectiveness of their amplitude of at least +5.00 D, on the basis that it should be
correction, based on their current visual needs during their possible to hold roughly half the accommodation in
work and leisure hours, their lifestyle and self image. More- reserve.16 As noted above, this demand for a substantial
over, these individual criteria will inevitably change as the accommodation reserve may be unduly conservative,41 and
presbyopic years advance: a correction which suits the a more modest effective amplitude may still be useful.
active 50 year-old may not be acceptable when he or she is The general question of the correction of possible ways
a time-worn 80 year-old. of correcting presbyopia is now considered.
When prescribing spectacle additions it is, of course,
assumed that the additional optical power required for
General approaches to correction
vision at the patient’s normal near working distance is pro-
vided by a combination of the spectacle addition and resid- Clearly the most fundamental approach is to slow the phys-
ual accommodation, with the balance between the iological changes which lead to presbyopia. The most
contributions changing in favour of the spectacle power as important of these changes are thought to occur in the lens
the individual ages. In assessing the contribution from but other parts of the natural accommodation system may
Multifocal Table 1. Existing and proposed methods for correcting presbyopia.

Modify corneal phakic IOL Note that the same basic methods (e.g. monovision, simultaneous
contour, vision) can be implemented in a variety of ways.
Ortho-K?
Contact Method Passive Active

Accommodating or
lens
Multifocal IOLs
(MFCL Spectacles Separate distance Bifocals, varifocals (gaze
etc) or direction
reading changed). Mechanically/
electrically switched lens
power change.
Spectacle Refill or photodisrupt lens Contact Monovision/ Alternating/translation (gaze
Corneal
lens lenses simultaneous direction changed). Electrically
inlay
(bifocal,
progressive,
vision bifocal, switched powers?
variable etc) Scleral multifocal,
expansion Orthokeratology?
Corneal Monovision/
Figure 5. Main methods for correcting presbyopia that are either avail- surgery simultaneous
able or under current development. Methods in red involve external (surface) bifocal/multifocal
lenses, those in black involve some form of surgical intervention. Corneal Pinhole/
surgery simultaneous
(inlay) bifocal/multifocal
Phakic IOL Monovision
also be involved.43 At present there appear to have been no
Simultaneous
successful demonstrations of strategies, such as diet, bifocal/multifocal
which might accomplish this retardation of the loss of IOLs/lens/ Simultaneous Accommodating IOLs
accommodation, although nutrient intake is, for example, ciliary bifocal/multifocal Restoration of accommodation
known to affect the development of early age-related lens body IOLs by lens/scleral treatments?
opacities.44 There is some weak evidence that environmen-
tal factors, such as high temperatures or, perhaps, excessive
Spectacles
sunlight might modestly accelerate the onset of presbyo-
pia,45–48 so that protective measures might perhaps have Conventional designs
some benefit, although this remains unproven and the real- Conventional spectacle correction is the most mature
ity of any effect has been challenged by some authors.19 In technology49 and will only be briefly discussed here. While
any case, it should be remembered that individuals who separate single-vision ‘reading spectacles’ are passive
have just become presbyopic may have many years of life devices, bifocals, trifocals and progressive lenses can be
before them, so that the onset of presbyopia needs to be considered to provide an ‘active’ method of correction.
delayed by several years to have a worthwhile impact. The non-zero vertex distance means that the spectacle lens
In the remainder of this review it will be assumed that lies about 25 mm in front of the eye’s centre of rotation
‘correction’ involves either the provision of additional opti- and there is no direct coupling between the lens and
cal power for near vision, using external optics or by surgi- movements of the eye, Thus any eye movement actively
cal modification of the powers of the optical components directs the visual axis through a different area of the lens
of the eye, or surgical intervention designed to restore or and, as pioneered by Franklin’s bifocals, if two or more
enhance the accommodative ability of a presbyopic eye. appropriate lens powers are distributed across the lens sur-
The purely optical correction may either be passive, in that face each can be selected by an appropriate change in gaze
a fixed correcting power is provided, as in a conventional direction. The less desirable corollary of this approach is
single-vision reading spectacles, or active, where the power that clear vision of objects at a particular distance
can be varied in either a stepwise or continuous fashion. demands an appropriate relationship between the spectacle
The basic possibilities either currently available or under lens and the visual axis, so that additional head or body
active development are summarised in and Figure 5 and movements may be required to view the object of interest.
Table 1. Those involving external spectacle or contact To improve vision at intermediate distances, progressive
lenses are well-established (although still under develop- lenses offer a smooth transition in power along a relatively
ment), whereas all of the surgical techniques have a rela- narrow corridor on the lens surface, albeit with the penalty
tively short history and are, to a greater or lesser extent, of additional unwanted astigmatism away from this corri-
unproven. The non-invasive methods will now be discussed dor.50,51 Design and manufacture of progressive lenses has
in more detail, with the surgical methods being described now reached a high level of sophistication, with free-form
in a second paper. surfacing and computer design allowing customization to
the requirements of the individual wearer52–54: again, how- lack of appropriate material for the flexible wall of the
ever, this involves some penalty, in this case the need for lens.
very careful glazing and fitting of the spectacle frame if the More recently, Douali and Silver63 have described spec-
advantages of the customization in terms of improved tacles fitted with a pair of full-aperture lenses of 42 mm
vision are to be fully achieved, the fitting being particu- diameter, each having two flexible 23 micron thick mem-
larly important. branes enclosing a volume of silicone oil (refractive index
In spite of their convenience, several problems are 1.579). The volume of liquid and hence the surface curva-
associated with bifocal or progressive lens wear. The limi- tures of each lens can be adjusted by turning a small wheel
tations on the eye directions in which clear vision of dis- on either side the frame. These spectacles (originally
tant or near objects can be obtained, have already been Adspecs, now called p.o.v.TM, Adaptive Eyewear, London,
referred to. Image jump as the wearer’s fixation axis UK, http://www.adaptive-eyewear.org/) are designed for
crosses the top edge of the bifocal and distortion of self-adjustment as a single-vision correction for refractive
peripheral vision with the progressive lens may make error (or reading) in countries lacking trained optome-
judgement of object position and movement through the trists, rather than as variable-power presbyopia corrections,
local environment less certain. This in turn can lead to the adjustment mechanisms normally being removed after
significantly increased risk of accident in elderly, at-risk the patient reports his or her vision as being optimal. Self-
individuals, particular when descending stairs.55 These optimised corrections appear to correlate well with conven-
risks are reduced by the wear of single-vision distance tional refractive results.63 The basic concept has now been
spectacles56 (see Elliott for review57). extended in the form of Adlens variable focus spectacles
(Adlens, Oxford, UK, http://www.adlens.com/), where the
individual adjustment screw for each lens is retained at
Mechanically-varied power
each side of the frame. In this case the flexible membrane is
A single-vision lens of variable power would allow clear enclosed between rigid front and back polycarbonate
vision at a variety of distances with minimal constraints on plates, adjustment of the volume of fluid within the cham-
the viewing direction. There is a long history of attempts to ber formed between the membrane and the rear plate
produce such a lens.58,59 One obvious approach, dating allowing both positive and negative spherical powers to be
back to at least 1785,60 is to use a combination of positive obtained. A further variant, specifically designed for pres-
and negative lenses, with powers F1 and F2 D and variable byopes, was originally patented by Kurtin.64 This is now
separation d metres. In a thin lens approximation, the com- being marketed in the form of Superfocus (originally Tru-
bined back vertex power is then (F1 + F2–dF1F2)/(1-dF1). If Focal) spectacles (Superfocus LLC, Van Nuys, CA, USA,
we make F2 = F1, this reduces to dF12 =ð1 dF1 Þ dioptres http://www.superfocus.com/). The lenses in these spectacles
and, if we assume that d is small enough for the denomina- each comprise two closely-spaced lenses, a fixed-power
tor to approximate to unity, the back vertex power or near front element constituting the distance correction and a
addition provided by the combination is dF12 . For example, variable power fluid-filled rear element, the power of the
with component lens powers +20 and 20 D and a separa- rear lenses for the two eyes being simultaneously and
tion of up to 10 mm, the maximum addition available is equally adjusted by a small lever or slide on the bridge of
about 4 D. It is straightforward to incorporate a distance the spectacles (Figure 6). The maximum add power is
correction if required. It is obvious, however, that these about +2.75 D. Each front lens is held in place magnetically
variable power combinations inevitably suffer disadvan- and is removable so that the prescription can be modified
tages in terms of bulk, weight and cosmesis, although the or replaced by photochromic or other chosen tints: this
principle has found application in automatic focusing tele- arrangement also allows for the correction of astigmatic as
scopes for low-vision patients.61 Binocular design of such well as spherical distance error. Some theoretical aspects of
systems is complicated by the convergence required for this type of variable power lens have been discussed.63,65,66
near vision.58,61 Practical limitations of both the Adspec and the
A further, more useful, early concept is that of the Superfocus spectacles include the need for the lenses to
liquid-filled deformable lens. In its commonest form, the be circular and to be fitted in specifically designed
liquid is contained between a rigid front wall, which may frames which enclose the mechanism for pumping the
provide a sphero-cylindrical and prismatic correction and fluid filling. As yet, there are no independent published
a flexible rear wall. The curvature of the flexible wall is studies of the effectiveness and long-term acceptability
controlled by varying the volume of liquid. Alternatively of these spectacles in practice. It may be that unwanted
the surface may be flexed by direct mechanical force. prism caused by the fact that the distance between the
Numerous designs of this type were produced in the late lens centres remains fixed while convergence varies as
19th and 20th centuries58,59,62 but were hampered by the objects at different distances are viewed poses problems
Slide for simultaneous focus t1 ¼ ay2 ðx dÞ þ ða=3Þðx dÞ3 þ bðx dÞ þ c

adjustment of both fluid-filled lenses Flexible, fluid-filled,
variable-power
lens for addition
t2 ¼ ay2 ðx þ dÞ ða=3Þðx þ dÞ3 bðx þ dÞ þ c
Adding these and simplifying
t1 þ t2 ¼ 2adðx2 þ y2 Þ þ ½2c 2bd 2ad3 =3 ð1Þ
The second term is obviously a constant and again corre-

sponds to a parallel plate of zero power. Since x2 + y2 = r2,
where r is the polar distance from the lens centre, compari-
son with the sag formula shows that the first term corre-
Sphero-cylindrical sponds to the thickness variation of a spherical lens. For
front lens for
distance correction example the sag formula for a spherical surface of radius of
curvature R tells us that at a radial distance r, the sag is
Figure 6. Essentials of the design of Superfocus spectacles (Superfocus given by t = r2/2R, so that, by comparison with Equation
LCC, Van Nuys, CA, USA www.superfocus.com). (1), 1/2R = 2ad, and R = 1/4ad If the components have
refractive index n, this Alvarez lens has power 4ad(n-1), so
for some wearers with higher prescriptions: a patent sug-
that both positive and negative powers can be obtained by
gests ways of overcoming this by the inclusion of appro-
altering the direction of shear. If the lenses are sheared in
priate variable prism albeit at the expense of greater
the y direction, a 45/135 crossed cylinder results. The range
complexity.67 Manual adjustment of the lens powers is
of spherical powers given can obviously be selected either
required for clear vision of objects at different distances,
by limiting the range of d, or by biasing it by incorporating
with separate adjustments being necessary for individual
additional spherical power in one of the sliding elements.
eyes with the Adlens. Inadvertent failure to properly
Although Alvarez had been inspired by the idea of a vari-
adjust the lens powers could potentially cause hazard in
able correction for presbyopia,68,69 his early lenses were
situations such as driving. Gravity may have some effect
never used in spectacles, probably because in their original
on the form of the flexible surfaces of the lenses but
form they were too bulky, but they were successfully incor-
analysis suggests that the resultant power variations are
porated in the design of the Humphrey Vision Analy-
not significant.63,65
ser,69,71 an instrument for subjective refraction which,
An alternative approach to variable spectacle lens powers
although effective,72 was never widely adopted. However,
is provided the Alvarez and the related Lohmann lenses,
the concept has re-emerged in recent years and at least two
in which two components in close axial proximity are
companies now produce spectacles incorporating variable-
translated laterally with respect to one another.68–70 The
focus lenses of the Alvarez type: Focusspecs (Focus on
principle of Alvarez’s original lens is ingenious but straight-
Vision, Eindhoven, the Netherlands, www.focus-on-vision.
forward and requires that, with the components in the ‘zero
org, see Figure 7), Emergensee (Adaptive Eyeware, London,
power’ position, the thickness, t1 and t2 of the two elements
UK, http://www.adaptive-eyewear.org/) and Slidelens
should be given by the following cubic functions of the area
(Adlens, Oxford, UK, http://www.adlens.com/). Interest-
coordinates x and y with respect to the coincident centres
ingly, like the original Adspec, these are all currently direc-
of the elements
ted to the needs of the developing world or as emergency
replacement spectacles and are designed to be relatively
t1 ¼ þaxy2 þ ax3 =3 þ bx þ c
cheap and to be set to a fixed power for either distance or
near vision, although the potential for later power adjust-
t2 ¼ axy2 ax3 =3 bx þ c ment for each individual eye remains in place.
As an indication of the optical quality of the lenses as
where a, b and c are constants. It is evident that, initially, currently produced, Figure 8 plots the measured variation
the combined thickness (t1 + t2) of the two lenses is inde- of mean spherical power and horizontal prism across a hor-
pendent of x and y and corresponds to a parallel plate of izontal diameter of a left-eye Focusspec lens when it is set
thickness 2c and zero power. to near-maximum, medium, and near-minimum power.
Suppose now the two plates are sheared along the x-axis The measurements were made manually with a projection
by the same distance d but in opposite directions. The focimeter having a 4 mm measurement aperture. The full
thicknesses at any point now become: horizontal diameter of the lens is about 40 mm and zero of
particularly at the lowest setting (Figure 8a): significant

astigmatism was also present in this region. The prism val-
ues (Figure 8b) are close to those expected on the basis of
Prentice rule and the powers of Figure 8a, except that there
appears to be a small amount of fixed prism. Measurements
across a vertical diameter showed similar characteristics.
If these designs are to be developed as variable-power
designs for presbyopes, there is a need for more robust
frames and a single control to produce equal power varia-
tion in both lenses. It might be desirable to combine a fixed
Figure 7. The Focusspec (Focus on Vision, Eindhoven, the Netherlands, sphero-cylindrical distance correction for each eye with a
www.focus-on-vision.org). The lateral translation of the components of variable Alvarez addition, analogous to the arrangement
each Alvarez lens is achieved by rotating the worm gears on each side used in the Superfocus liquid-lens spectacles (Figure 6).
of the frame. Note the different magnifications given by the two lenses,
Although this would result in some increase in weight, lens
which have been set to powers corresponding to the two ends of the
thickness and complexity this would be outweighed by
available range (about +0.5 and +4.5 D). Spectacles with power range
1.0 to 5.0 D are also available. Weight is under 20 gm. It can be improved optical and visual performance. The advantages
seen that the limits to the useable optical area of each lens are smaller of Alvarez over fluid-filled lenses are that, in principle, dif-
than the full aperture. ferent frame shapes can be used and there may be greater
robustness over long periods of use. Methods for optimis-
ing their optical and mechanical design have recently been
the scale is set at the midpoint of this distance. Only about discussed73,74 and a possible fully-adjustable frame has been
30 mm of this diameter is available for clear vision. Within described,75 although the latter is functional rather than
this distance, optical power and image quality are reason- being cosmetically attractive. While Alvarez lenses have so
ably stable at each lens setting, except on the temporal side far been more commonly used, Barbero73 suggests that
(a) 5
4.5 y = 0.004x + 4.264
4 R2 = 0.058
3.5
Power (D)
3 y = 0.006x + 2.516
2.5 R2 = 0.046
2
1.5 y = 0.034x + 0.822
1 R2 = 0.517
0.5
0
–20 –15 –10 –5 0 5 10 15
Position on horizontal diameter (mm)
(b) 6
2
Prism power
0
y = –0.061x – 0.634
–2 R2 = 0.967
–4 y = –0.236x – 1.045
R2 = 0.996
–6 y = –0.398x – 1.381
R2 = 0.991
–8
–20 –15 –10 –5 0 5 10 15
Position on horizontal diameter (mm)
Figure 8. Focimeter measurements of (a) Mean sphere power (D) and (b) prismatic effect (D) of a Focusspec lens along its horizontal diameter. Nega-
tive values of position represent the nasal side of the left-eye lens. The prism plots in (b) imply powers of 3.98, 2.54 and 0.61 D, very similar to the
powers in (a). The lines are least-squares regression-line fits to the data. (W.N. Charman, Unpublished data).
Lohmann lenses, which have a slightly different cubic layer of reduced thickness and improved performance
surface profile, may be a little thinner and have superior (Figure 9b) but the total lens thickness was still relatively
optical performance. Lohmann himself has suggested a dif- large. More recently refractive lenses have been produced
fractive variant of his lens but these appear to have mark- in which the liquid crystal layer is of constant thickness
edly inferior chromatic properties.70 (about 60 microns) but the parabolic variation in optical
path across the lens surface is achieved by a more complex
electrode structure giving a spatially varying field across
Electrically-varied lenses
the liquid crystal layer, hence creating a refractive index
At the present time all of the proposed ophthalmic lenses gradient across the lens surface79,80 (Figure 9c): as yet no
of this type are based on liquid-crystal technology. ophthalmic application appears to have been attempted.
Although such crystals were first described in the 19th Further reductions in lens thickness can be achieved by
century76 their exploitation in lenses of variable power making the lens have diffractive rather than refractive
began in the mid 20th century. Many different liquid crys- power. The electrodes take a form similar to that of a zone
tal materials, possessing a range of properties, such as plate (Figure 9d). In the unswitched state the liquid crystal
refractive index, switching time and temperature stability, layer, a few microns thick, acts as a parallel plate, the opti-
are now available. The important feature of the usually cal path through the layer being constant across the lens
disc or rod-like molecules of these crystals is that their area. Under the action of a modest voltage difference
alignment can be changed under the influence of a small (around 2 V) the refractive index of those volumes of
electric field, allowing the polarization properties and liquid crystal between the elements of the electrodes
refractive index of the medium to be varied. Fowler and changes, producing a spatial variation in the optical path-
Pateras77 give a valuable introduction to the principles length. The layer then acts as a phase zone-plate or kino-
involved and describe the earlier patent literature and form with a power depending on the electrode geometry
experiments with potential ophthalmic devices up to 1990. and the wavelength of the light used.81,82 (Figure 9d). By
As might be expected, these early lenses were essentially using more complex electrode structures, diffraction effi-
shallow, disk-shaped cells containing the liquid crystal, ciency can be improved83 and lenses with multiple switched
one or both enclosing plates having a curved surface to powers, e.g. for distance, intermediate and near can be
give the basic optical power (Figure 9a). The power of the obtained.84–86
device was altered when the refractive index of the liquid For a simple zone-plate design, the radius rm of the m th
crystal was changed by application of a field between elec- zone is given by
trodes covering the internal surfaces of the enclosing
plates. These lenses suffered from a variety of problems 2
rm ¼ 2mk=F
associated with the relatively large thickness of the liquid-
crystal material and its variation across the area of the where k is the wavelength and F is the desired power. It can
lens: non-uniform fields across the area of the lens; slow be seen that rm reduces as F increases and that, for the same
response times; high scattering and poor temperature sta- value of rm, the power increase linearly with k. The effective
bility.78 Fabrication in Fresnel form gave a liquid-crystal constringence for any such a diffractive lens is therefore
around 3.5, in contrast to values of +25 to +65 for com-
mon refractive materials. Thus any diffractive lens suffers
from considerable chromatic aberration. The longitudinal
(a) (b)
chromatic aberration is, perhaps not a major problem,
since it is opposite in sign to the eye’s own longitudinal
chromatic aberration.87 Transverse chromatic aberration is,
however, likely to be a much more serious drawback for
(c) (d)
any diffractive spectacle lens.81 Applying Prentice’s rule
with decentration c cm, the lateral colour, DP, when the eye
is rotated to look through non-axial regions of the lens is
Figure 9. Schematic diametric sections showing the development of
different designs of variable-power liquid crystal lens. In each case the DP ¼ cFy =Vprism dioptres
thicker lines represent the electrodes, separated by a spacer, the blue
area the liquid crystal material (a) Simple positive lens of variable
where Fy is the spherical power of the lens in the yellow.
power68 (b) Variable positive lens in Fresnel form68 (c) Constant thick-
ness liquid crystal layer but parabolic index gradient induced by making
Davies and Waidoo88 have suggested a tolerance of about
the electrodes non-parallel70 (d) Diffractive lens with one electrode in 0.25 prism dioptres for lateral colour, so that the maximum
zone plate form.81,82 permissible value of c is about
cmax ¼ 0:25V=Fy 0:9=Fy cm fulfilled. It seems likely that this approach may have been
made redundant by the success of free-form surfacing tech-
Thus for a switched diffractive lens of nominal add niques.
power 1 D the maximum value of c before colour fringing
becomes serious is about 1 cm. If the lens vertex distance is
13 mm and the centre of rotation of the eye is about Discussion
12 mm behind the cornea, this decentration corresponds While subject to some limitations, particularly regarding
to an eye rotation of about 23 degrees. For other add pow- required viewing directions and, possibly, imperfect inter-
ers the useful field will be inversely proportional to the add mediate vision for the older presbyope, conventional spec-
power. Although it appears that colour fringing effects tacles continue to provide a reliable and thoroughly-proven
become less noticeable after periods of lens wear, loss in method of presbyopic correction, with optical characteris-
visual acuity still occurs.89 It can be seen, then, that a tics that can easily be adjusted to meet the changing needs
switched, diffractive, full-aperture (diameter = 50 mm) of the aging presbyope.
reading addition, capable of offering clear near vision in Nevertheless, after more than a century of patents and
any direction, is probably not achievable, even if the chal- prototypes, practical variable-power spectacle lenses are
lenges of manufacturing the increasingly narrow outer dif- now commercially available that are, in principle, suitable
fractive zones required in large aperture lenses can be for presbyopic correction and overcome some of the above
overcome. limitations. Full-aperture spherical power change over a
It is probable that it is these considerations that have led range of several dioptres can now be achieved with both
to the optical characteristics chosen for the first commercial mechanically-actuated liquid-filled and Alvarez lenses,
spectacles to use switched diffractive near additions although at present only one variant is intended for presby-
(emPower, Pixeloptics, Roanoke, VA, USA, http://www. opic use, the others being designed for low cost or emer-
pixeloptics.com). These devices appear to have progressive gency use with the correcting power being set at a fixed
bifocal lenses of relatively low nominal add power, which value. Development of more refined spectacles incorporat-
are intended for distance and intermediate vision. For near ing fixed sphero-cylindrical distance corrections would
vision a liquid-crystal diffractive segment incorporated in appear to be straightforward and would allow the distance
the lower, intermediate area of the carrier lens is switched correction to be properly centred for the binocular inter-
on. Switching time is about 7 msec and electrical power is pupillary distance (PD) of the wearer. Given the constraints
supplied by a rechargeable battery in the side arms of the implicit in the mechanical arrangements in both types of
frame. The additional optical power provided is a modest variable-focus lens, a fixed centration might have to be
+0.75 D. Switching is either achieved manually or hands- accepted for the variable-power addition, leading to some
free via an accelerometer, by tilting the head downwards. unwanted prism. Pointer92 recently found mean far inter-
Although the technology is elegant, near vision can only be pupillary distances (FIPDs) of about 62 and 65 mm for UK
achieved in the lower field. females and males respectively: the corresponding mean
near interpupillary distances were about 59 and 62 mm, i.e.
Other possibilities some 3 mm smaller than the FIPD. Studies suggest that the
horizontal prism induced by IPD errors of this magnitude
A variety of other designs of variable-focus lens for various might make long-term spectacle wear intolerable if the
purposes are available but, at least at present, have charac- magnitude of the spherical prescription exceeded about
teristics which make them unsuitable for ophthalmic appli- 3 D.93
cations. For example, fluid lenses in which the optical As yet there is no published information on the long-
power is derived from the curvature of the interface term acceptability by presbyopes of these variable-power
between two immiscible fluids with differing refractive spectacles or on the important question of the robustness
indices, one being conductive, the other insulating, work and longevity of their mechanisms. The key point is
well. Application of a voltage across the insulating liquid whether the advantage of potentially good distance, inter-
results in a change of curvature and hence a change in mediate, near and, perhaps, very near vision in any direc-
power of the lens. However the lens apertures are too small tion offsets such disadvantages as the need to make
and the depths too large for ophthalmic use. Hopes that frequent manual adjustments in focus, cost, limited frame
gradient index materials might offer improvements in pro- designs and general cosmesis, and a modest increase in
gressive lens design, by providing an alternative method of weight.
producing variation in optical path through different At present, in the only available spectacles with electri-
regions of the lens through local changes in the refractive cally-switched lenses, the variable-power elements are of
index rather than lens thickness90,91 have not so far been limited aperture and are incorporated as a supplementary
near segment in the near area of a progressive lens. naked eye is poorer. Ideally, then, it is important that any
Although this allows head posture to be used to switch the presbyopic CL should not compromise the retinal image
lens on and off, it has obvious limitations in terms of the further, e.g. by reducing the retinal illuminance or image
directions in which clear near vision can be obtained. Nev- contrast.105
ertheless, there has been rapid progress in this area and it The main alternative methods of providing a contact lens
may be that switched refractive lenses of larger diameter (CL) correction for presbyopia have been clearly recognized
and multiple alternative powers will become available. for more than 50 years.106 They are:
(1) CLs to correct distance refractive errors, with single-
vision spectacles to provide the required near addition
Contact lenses
(2) Monovision, in which one eye is corrected for distance
Presbyopes have long been recognized as a large potential (usually the dominant eye) and one for near, and the
market for contact lenses but, for various reasons, attempts various modifications of the method
to exploit this opportunity have so far enjoyed only limited (3) Bi- or multi-focal CLs based on either simultaneous-
success.94,95 This is illustrated in Figure 10, which summa- or alternating -image (vision) principles.
rises recent data, obtained from 38 countries across the Among these methods, only the alternating-image tech-
world, on the relative frequency of contact lens fittings to nique places constraints on viewing direction. While the
different patient age groups.95 Clearly fittings are much less general optical principles have been understood for many
frequent in older age groups, the relative frequency dimin- years, there has been steady refinement in the design, mate-
ishing to almost to zero after the age of 75. rials, manufacture, and methods of testing of lenses. Many
Many good reviews of the principles and practice of pres- of the basic concepts of correction used in presbyopic CLs
byopic CL fitting are available96–99 and fitting will not be have been transferred (often without acknowledgement) to
discussed here. It is important, however, to recognise that later surgical methods. CLs, however, have the obvious
successful CL wear by the older patient depends upon more advantage that it is straightforward to change the prescrip-
than optical factors alone. Age-dependent ocular changes tion or the attempted method of correction if the initial
such as decreased tonus of both upper and lower eyelids, a method chosen fails to satisfy the patient’s needs.
reduced palpebral aperture, and decreased lacrimal produc-
tion and tear stability may all influence the success of CL
Spectacles for near work
wear.100 The reduced pupil diameter and increased lenticu-
lar absorption in older eyes mean that retinal illuminance The combination of distance-correcting single-vision CLs
at the age of 60 is only a third of that in a 10 year-old,101 with a pair of ‘reading’ spectacles is the simplest solution
and the increased ocular aberration102 and scattering of for an existing CL wearer, and is also possibly the least
light103,104 mean that the retinal image quality in the older expensive. In spite of the fact that it cannot cater for the
120
100
Relative number of fittings
80
60
40
20
0
15–24 25–34 35–44 45–54 55–64 65–74 ≥ 75
Age (years)
Figure 10. The relative frequency of contact lens fittings to different age groups, as found by Morgan et al.95 The relative frequency is taken as
100% for the age group 15–24 years.
needs of the patient who does not wish to wear spectacles, tolerated, younger presbyopes will have some residual
it appears to be the most popular method currently accommodation, A D. This allows a larger refractive differ-
employed in practice by presbyopic CL wearers.95 ence, (A + B) D, to be tolerated between the corrections
for the two eyes, the range of adequate vision being
extended to 2(A+B). In practice it appears that interocular
Monovision
differences up to about 1.5 D are usually accepted but that
Monovision has been well reviewed by several authors.107– higher ‘adds’ are more problematical.107–109
109
The principle is illustrated schematically in Figure 11.110 Although the above assumptions are over-simplistic, they
The ‘distance’ eye is corrected so that it is left with slight emphasise that the ocular DOF plays an important role.
residual myopia and the other eye is corrected for ‘near’. The smaller pupils associated with higher levels of lighting
Since each eye has its own depth-of-focus (DOF), within are obviously helpful in that they increase the DOF and
which acuity exceeds some acceptable level, if the difference hence the overlap of the through-focus acuity curves of the
between the two refractive states is appropriately chosen individual eyes.
and interocular suppression occurs, so that the more The problems with intermediate vision with higher adds
blurred image can be ignored, satisfactory vision can be can also be eased, and the dioptric range of acceptable
achieved over a continuous range of dioptric distances vision enhanced, by fitting one or both eyes with some
which is greater than the power of the reading addition. form of bifocal or multifocal to effectively increase their
Nominally, suppression allows binocular acuity to match DOFs. This should also improve binocular vision and ste-
that of the better eye, although this does not appear to be reoacuity, since the two retinal images will be more similar.
possible for all patients.111 The situation in which only one eye receives a bi- or multi-
If we make the very simple assumptions that the full focal is often termed extended or enhanced monovision: if
DOF of each eye is B dioptres and that there is no residual distance vision is more important to the patient than near
accommodation, it is clear that if poor intermediate vision vision the ‘distance’ eye receives the single-vision correc-
is to be avoided, the maximum difference between the tion, the ‘near’ eye receiving the single-vision lens if close
refractive states of the two eyes (the ‘add’) should be B. tasks are more important. In modified monovision both
The total range of acceptable vision is then 2B dioptres eyes wear bi- or multi-focals, the dominant eye often being
(Figure 11), with the ‘distant’eye covering the dioptric of centre-distance design, while the other is centre-near
range 0-B D and the ‘near’ eye B to 2B D. The value of the (see below). A further possibility is partial monovision in
DOF depends upon the pupil diameter and the criterion which the near add is reduced, with some loss in near per-
used for acceptable vision, but is typically taken to be formance but improved intermediate vision: supplemen-
around 0.5–0.75 D for photopic pupil diameters.112 tary spectacles are required for more critical near work.
Although this suggests that only rather low ‘adds’ will be As might be expected some loss in stereoacuity occurs in
monovision particularly for higher adds. In general, how-
ever, for monovision adds below about +2.50 D, visual and
task-related performances with supra-threshold stimuli
under photopic conditions appear to be broadly compara-
ble to those of patients with balanced binocular corrections,
although they are inferior under conditions of low illumi-
nation and contrast.109 There is also evidence that monovi-
sion wearers may be at increased risk of tripping and
similar gait-related accidents.113
Bifocal and multifocal CLs

A huge range of different refractive and diffractive optical
designs is now available in different rigid and soft materi-
als96–99,114: several of these can be obtained in toric forms
for the correction of higher levels of astigmatism. These
designs are summarized schematically in Figure 12. With
Figure 11. The through–focus changes in visual acuity for each eye in
the exception of the alternating-image (vision) design, for
monovision, assuming that no accommodation is possible. The ver- which various segment shapes are available, all the lenses
gence range over which satisfactory vision is obtained can be larger depend upon the simultaneous-image principle. Concentric
than the difference between the two refractive states (i.e. the ‘add’).110 simultaneous-image designs may have power which varies
bifocal with a +2.00 D add, in which the pupil diameter is

such that the effective outer ‘distance’ area equals that of
the ‘near’ zone, is shown in Figure 13. The approximations
of geometrical optics have been used116 for rays passing
through a square grid in the pupil and both centred and de-
centred cases are illustrated. Although in practice diffrac-
tion and monochromatic and chromatic aberrations
modify these PSFs, they do not alter their essential nature.
Examples of measured power profiles for some soft con-
Figure 12. Presbyopic contact lens designs. The red, green and yellow
centric refractive multifocals (MFCLs) along a lens radius
areas represent areas for distance, near and intermediate vision respec- are shown in Figure 14.121 The left-hand profiles are for
tively. In the case of the diffractive lenses bifocals the distance and near lenses which have either a smoothly varying profile or a
corrections both occupy the entire optic zone (after Kallinikos et al.99). profile with an abrupt power change at the edge of the cen-
tral near zone. The lenses on the right have profiles that
smoothly with zonal radius, as a result of aspheric surfaces, alternate between the nominal distance (in these cases zero)
or discontinuously, and may be of basic centre-near or cen- and near powers. Note that current manufacturing pro-
tre-distance design. They are designed to be well centred. cesses can achieve quite abrupt steps in power.
It is of interest that the step changes in three of the lenses
in Figure 14 are superimposed on a profile which corre-
Simultaneous-image lenses
sponds to negative spherical aberration of about 0.18 -
In simultaneous-image bifocals, some areas of the lens have D/mm2. This is opposite in sign but only a little greater in
a power corresponding to the required distance correction magnitude than the typical value of ocular spherical aberra-
and the rest of the optical zone provides the near correction of about +0.10 D/mm2 for a 50 year old.102,121,122
tion. The dimensions of the zones are such that the area of Since for a well-centred lens the spherical aberrations of
the entrance pupil of the eye is partially covered by both lens and eye are approximately additive,123 for these lenses
distance and near corrections. It has long been recognized the eye-MFCL combination would in general have low
that the limitation of this approach is that during vision of basic levels of spherical aberration. Any on-eye multifocal
both distant and near objects the in-focus image formed by effect would be expected to arise primarily from the ‘step’
rays passing through the ‘correct’ part of the optical zone is segments, rather than the parabolic power change.120 Exact
superimposed on the out-of-focus image due to the ‘wrong’ effects will, however, depend upon the individual eye, since
part. For example, in a simple two-zone centre-distance there is a substantial spread in individual values of ocular
bifocal as illustrated in Figure 12, the image of a distant spherical aberration at any age.
point will be a point surrounded by an out-of-focus blur Almost all refractive simultaneous-vision designs involve
annulus due to the near portion of the lens, whereas at near different powers being associated with different circular or
there will be a point image on which is superimposed a blur annular regions of the lens. Thus their overall on-eye per-
circle due to the central distance portion of the len.115–117 formance depends on which portions of the lens are used
The result of this superposition of in- and out-of-focus in forming the foveal image, i.e. on the pupil diameter. Of
images is that the contrast of smaller details in the desired particular interest are the proportions of the overall light
in-focus image is degraded by the light from the out-of- contributing to the distance and near images: these depend
focus image. Fortunately high-contrast acuity is relatively upon the relative areas of the two or more corrections
robust against contrast loss, but difficulty may be experi- within the pupil. In general, it seems reasonable that in a
enced when tasks involving low object contrasts are bifocal approximately equal amounts of light should con-
involved.118,119 Effects with aspheric or other MFCLs are tribute to the distance and near images, although this may
more complex but the end result is always that unwanted not be the case in modified monovision when different
light which has passed through those regions of the lens lenses are worn on the two eyes.
with the ‘wrong’ power degrades the in-focus image formed To illustrate the impact of pupillary changes, Figure 15
by the appropriate parts of the lens, and lowers the contrast shows the proportion of the total pupil area covered by the
of smaller details to an extent which depends upon the rela- distance correction as a function of the pupil diameter in
tive areas of the two corrections within the effective pupil. the case of two of the lenses (Purevision and OASYS high
All concentric MFCLs have asymmetric point-spread func- adds) whose profiles appear in Figure 14. One of these is a
tions (PSFs) if they become decentred, resulting in possible centre-near, two-zone bifocal the other has a multizone
‘shadowing’ effects in their images.115,116 An example of the design. The centre-near bifocal becomes strongly biased
through-focus changes in the retinal PSF of a centre-near towards distance correction as the pupil gets larger, so that
Figure 13. The form of the through-focus retinal point-spread functions according to paraxial optics for (top row) a single vision distance correction,
in which the out-of-focus images are simple blur circles which scale with the dioptric error of focus, and for a centre-near bifocal with +2.00 D add
when centred to the pupil and decentred by the distances indicated. The pupil diameter is 3.32 mm and the near zone diameter is 2.35 mm. (Repro-
duced from Charman and Walsh116).
2.5 2.5
PV multifocal Oasys for presbyopia
PV Low OASYS Low
2.0 PV High 2.0 OASYS Med
OASYS High
Average sagittal power (D)
1.5 1.5
1.0 1.0
0.5 0.5
0.0 0.0
Near correction Distance correction

(outer zone) (central zone)
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
Radial distance (mm) Radial distance (mm)
Figure 14. Power profiles along a radius of some MFCLs of nominally 0.00 D distance power. The lenses on the left are Purevision (PV) low and high
add multifocals (Bausch & Lomb, Rochester, NY, USA, http://www.bausch.com) and those on the right are Acuvue OASYS low, medium and high add
lenses (Vistakon Division of Johnson & Johnson Vision Care, Jacksonville, FL, US, http://www.acuvueprofessional.com). The apparent increase in
power at low radial distances for the low add OASYS lens is a measurement artefact (after Plainis et al.120).
the contrast of detail in the ‘near’ image will be low when ter87,124: unfortunately, in practice, with these lenses some
the pupil is large. The multizone design is less affected by 20% of the light is diffracted into unwanted orders of dif-
pupil changes. Diffractive bifocals have the potential advan- fraction, reducing the contrast of the desired images.87
tage that the two diffractive powers can each be considered Pupil diameter when a distant object is observed is
as being distributed across the full area of the lens, so that affected primarily by illumination and age but is also varies
the proportions of light contributing to the near and far with other factors, such as emotion.125 Figure 16 gives some
images are constant and independent of pupil diame- typical experimental data for mean monocular pupil
Percentage of pupil for distance correction Figure 16, since it reduces with binocular observation, by
120
around 0.5 mm, for the photopic range of luminance illus-
PV High
100
OASYS High
trated.127 Moreover, for the same photopic range, the pupil
diameter decreases as the size of the stimulus field
80
increases: for field diameters up to at least 25 degrees, the
60 pupil diameter depends on the corneal flux density (i.e. the
product of the field luminance and its subtended area)
40
rather than simply on the luminance.128,129 For a 25 deg
20 field diameter, the corneal flux density would be some
6.259 higher than for the conditions used in Figure 16,
0
implying that the pupil diameters might be some 0.8 mm
–20 smaller, depending somewhat on age. A further important
0 1 2 3 4 5 6 7 8
factor is the viewing distance. Although a presbyope may
Pupil diameter (mm)
no longer be able to accommodate when observing near
Figure 15. Percentage of the total light contributing to the distance objects, convergence and pupil miosis still occur, so that
image as a function of pupil diameter for two of the lenses whose the near pupil is smaller than the distance pupil.130 Watson
power profiles are shown in Figure 14 (Pure Vision and OASYS high and Yellott131 have recently attempted to produce a unified
adds). It has been assumed that the lenses are centred to the pupil. formula giving the expected pupil diameter in terms of the
various relevant parameters. It must, of course, be remem-
diameter as a function of photopic light level for different bered that at any age there is substantial inter-patient varia-
age groups under monocular conditions and with a 10 tion in pupil diameter and that, for each individual,
degree stimulus field.126 Note that diameters become smaller pupillary unrest will contribute to time-varying changes in
as presbyopia advances. The range of luminance illustrated image quality.132
runs from the lowest photopic level to that encountered on It can be appreciated from the above that, with any
a bright sunny day: for comparison, recommended lumi- MFCL, the quality of the retinal image even for a well-cen-
nance levels for internally-illuminated ophthalmic test tred lens will result from the interaction of the lens power
charts are usually around 120 cd/m2. Figure 16 suggests profile, the pupil diameter, the amount of residual ocular
that the average presbyopic pupil for distance vision is unli- accommodation available, and the ocular spherical aberra-
kely to be >5 mm in diameter under most well-lit condi- tion.133 Lens decentration and other aberrations of the lens
tions: a pupil diameter >6 mm would only be expected and eye may further complicate the issue (e.g. Figure 13).
with younger presbyopes and under rather poorly-lit con- Thus it is not surprising to find that the same MFCL
ditions. In fact, in everyday life the pupil diameter at any performs differently on different eyes, with consequent
luminance level will usually be smaller than those shown in inter-patient variations in acceptance of the correction. It
Figure 16. Mean monocular entrance pupil diameter as a function of luminance, at various ages. The circular stimulus field was 10 degrees in diame-
ter (based on data from Winn et al.126).
may be that prediction of likely future success of particular

Other possibilities
designs could be improved by more careful measurements
of the individual patient’s residual accommodation, aberra- Simultaneous-image lenses effectively extend the lens-eye
tions and pupil diameter as well as in the assessment of the DOF. It is known that one way to extend the DOF of any
fit achieved.133–135 Dai136 has argued that the goal should single-vision lens is to modify the amplitude and phase dis-
be to optimise vision over the full required range of object tribution of the light passing through its pupil, using some
vergences of interest, rather than simply at distance and a suitable form of rotationally-symmetric filter, i.e. apodising
chosen near vergence. the lens. For example, the annular diffractive zone-plate
One important way of minimising the effects of pupil structure applied to a diffractive lens modifies the phase
change on binocular visual performance is to combine a distribution so that constructive interference occurs at the
centre-near lens in one eye with a centre distance in the distance and near foci. However, rather than attempting to
other: several manufacturers produce lens series in both produce two separate foci, an apodisation can be applied to
forms for this purpose. For very small pupils this yields a the lens which produces a single focus which is effectively
monovision situation but for nominal photopic pupils the extended over a large dioptric interval, i.e. a large DOF. An
eyes are more balanced, so that good stereoacuity can be obvious example is the ‘pinhole’ lens where the light ampli-
achieved.137 tude distribution across the lens is modified by making the
An interesting question is whether, after extended peri- lens opaque except for a circular aperture which is smaller
ods of simultaneous vision, adaptation occurs to the low- than the natural eye pupil, so that the lens provides a small
contrast images, resulting in improvements in acuity and artificial pupil. This achieves the desired increase in DOF
contrast sensitivity. There is some evidence that such but unfortunately has disadvantages, such as a reduction in
improvements over time do occur with MFCLs (although retinal illuminance and a loss in visual field.96 Following
not with monovision)138 but systematic long-term studies earlier suggestions on the value of amplitude apodisa-
have yet to be carried out. tion,140,141 it has recently been claimed that the DOF of a
MFCL with negative spherical aberration of the type dis-
played by the Pure Vision low add lens in Figure 13 can
Alternating vision
usefully be improved by amplitude apodisation with a
Bifocal CLs based on this principle are designed to Gaussian profile,142 i.e. effectively applying a rotationally-
change position with respect to the pupil when a change symmetric neutral density gradient tint with 100% trans-
is made between distance and near fixations. The mittance on axis and decreasing transmittance with
intended translation is usually, but not always, in the ver- increasing zonal radius. Again, however, any amplitude
tical direction, the orientation of the lens being stabilized apodisation adversely reduces retinal illuminance. Rather
by prism or lens truncation. With gaze in the ‘straight than manipulating the distribution of light amplitude
ahead’ direction the distance portion of the lens lies in across the lens, it appears to be more promising to alter the
front of the pupil. On downgaze, the lens is supported phase distribution. Zalaevsky and his colleagues have
by the lower lid and the eye and its pupil rotate down- recently demonstrated a soft contact lens in which a binary
ward behind it, so that the image-forming light pencils profile is engraved on the lens surface, the pattern being
pass through the near correction located in the lower half described as ‘two annular rings with widths of a few hundred
of the lens. Ideally, then, excellent distance and near microns each and a … depth of less than 700 nm’.143,144 This
vision can be obtained, since the full pupil can be cov- is designed to produce a focus which extends over about
ered by a correction of the appropriate power. The major 3 D as a result of the constructive interference of light from
problem is the degree of relative lens movement achieved different zones of the lens. There is no loss of light, astig-
in relation to the pupil diameter, particularly if soft lens matism is masked, and, unlike diffractive lenses, there is no
materials are used. There may also be problems with lens abnormal longitudinal chromatic aberration. Good visual
rotation and stability. Ideally a translation about equal to results are claimed, it being suggested that blur adaptation
the pupil diameter is required and this represents a con- plays a role in the interpretation of the images.144 What is
siderable challenge, unless illumination levels are high not clear is the sensitivity of the performance of these lenses
and the pupil is small. If the movement is too small, to the diameter of the eye pupil, or the extent to which the
both distance and near corrections lie within the pupil loss in image contrast implicit in the method would be tol-
area and the resulting retinal PSFs are degraded and erated by patients. Numerous other designs of apodising
asymmetric.115,116,139 Even if successful, alternating-image filter have been suggested to enhance the DOF of optical
CLs obviously suffer from the same problem as spectacle system (e.g. Yang et al.145) and it may be that some of these
bifocals in that near vision is only possible when the gaze could usefully be applied to enhance the DOF of CLs with-
is directed in the appropriate direction. out excessive loss of light.
A new approach to extending DOF in contact lenses is hyperopic OK, while the dominant eye is left emmetropic
offered by what has been called the ‘light sword optical ele- (i.e. extended or enhanced monovision).151 Hyperopic OK
ment’.146–148 This can be regarded as a lens in which the results in a steepened central cornea surrounded by an
power varies with the orientation of the semi-diameter, so annular region where flattening occurs, so that its optical
that successive lens sectors show a gradually changing effect is analogous to the wear of a centre-near aspheric
power. It is claimed that the DOF as judged by preservation MFCL (Figure 17a). In the published study,151 the mean
of the Strehl ratio148 or visual tests147 is substantially daytime binocular near vision at 0.3 m in a group of
enhanced over a range of pupil diameters. As yet develop- emmetropic presbyopes (mean age 52 years) changed from
ment of such lenses is at an early stage. about J9 (N10) to J3 (N5.5) after seven nights of overnight
A different possibility, which is analogous to the diffrac- monocular hyperopic OK, while binocular distance acuity
tive bifocal in that its performance is unaffected by pupil was unaffected (at about 0.0 logMAR). Interesting ques-
diameter as both distance and near corrections are simulta- tions arise about the symmetry, centration and long-term
neously present over the full pupil area, is the birefringent stability of the corneal changes, and the optimal design for
bifocal.149 This uses a lens material which is uniaxially bire- the rigid OK lenses to produce the required corneal power
fringent, possessing both ordinary and extraordinary profile.152 Myopic OK produces a central corneal flattening
refractive indices, no and ne, in the direction perpendicular and an annular zone of steepening,153 analogous to a cen-
to its optic axis. The lens is constructed so the optic axis tre-distance MFCL (Figure 17b) and it may be that other
for the birefringence lies perpendicular to the optical axis forms of OK-based monovision are possible in at least
of the lens and eye. Light traveling through the lens is some patients with appropriate initial refractive errors. It is
therefore refracted according to both ne and no, giving the
lens two powers, (no–1)C and (ne–1)C, the add effect being
(no–ne)C, where C is the difference in surface curvatures (a) 46
and the lens is assumed to be thin. Evidently for any
Tangential corneal curvature (D)
desired value of add, the lens must have a specific pair of 45

ordinary and extraordinary powers. Thus to obtain any 44
required distance correction, an additional non-birefrin-
gent element of appropriate power must be added, increas- 43
ing the overall lens thickness. Like the diffractive bifocal, 42

the two powers extend across the full lens surface so that
41
their properties are independent of pupil diameter. How-
Post-OK
ever image contrast and the modulation transfer function 40 Pre-OK
are still reduced, as an in-focus near image formed by one
39
power is degraded by the superimposed out-of-focus image –5 –4 –3 –2 –1 0 1 2 3 4 5
formed by the other power. Although attempts have been Horizontal location (mm)
made to produce liquid single crystal hydrogels as suitable
(b) 46
materials for such lenses, with partial success,150 there
Tangential corneal curvature (D)
appears to have been no further progress with this concept.

45
As in the case of spectacles, electrically-switched liquid
crystal CLs have been proposed but a practical design has 44
yet to appear (ref. 96, pp. 1054–1055). While the smaller 43
diameter of a CL and its good centration reduce some of
the problems associated with this method, there are obvi- 42
ous difficulties in terms of the required lens thickness, oxy- 41

gen transmission to the cornea, and power supplies and Post-OK
40
connections. Pre-OK
A further approach which may, like refractive surgery, 39
appeal to those presbyopes who, for whatever reason, wish –5 –4 –3 –2 –1 0 1 2 3 4 5
to function in their daily lives without wearing either Horizontal location (mm)
glasses or contact lenses is orthokeratology (OK). It has

Figure 17. (a) Examples of the changes in the tangential corneal curva-
recently been shown that emmetropic presbyopes can ture across the horizontal meridians of individual patients after (a)
obtain satisfactory standards of distance and near vision by hyperopic orthokeratology152 (OK) and (b) myopic OK.153 In each case
hyperopic OK monovision, in which the anterior corneal the red curve is that found before OK, the black curve that after OK
contour of the non-dominant eye is reshaped by overnight treatment.
notable that the power profiles of Figure 17 approximate to 4. Atchison DA & Charman WN. Thomas Young’s contribu-
a mixture of primary (fourth-order Zernike wave aberration to visual optics: the Bakerian lecture “On the mecha-
tion) and secondary (sixth-order Zernike) spherical aberra- nism of the eye”. J Vision 2010; 10: 16, 1–16.
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Benard et al.154 have shown to give a more usefully Refraction of the Eye. (Translated by W.D.Moore). The
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Ophthalmic Physiologic Optic - 2013 - Charman - Developments in The Correction of Presbyopia I Spectacle and Contact

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Ophthalmic & Physiological Optics ISSN 0275-5408

Developments in the correction of presbyopia I: spectacle

Keywords: contact lenses, near additions, Abstract

described in antiquity, he seems to have been the first Euro-

interpretation of the results shown, since most of the data

2 length.35 There is also a trend for ocular astigmatism to

Mean spherical error (D)

Multifocal Table 1. Existing and proposed methods for correcting presbyopia.

Contact Method Passive Active

Slide for simultaneous focus t1 ¼ ay2 ðx dÞ þ ða=3Þðx dÞ3 þ bðx dÞ þ c

Adding these and simplifying

t1 þ t2 ¼ 2adðx2 þ y2 Þ þ ½2c 2bd 2ad3 =3 ð1Þ

The second term is obviously a constant and again corre-

particularly at the lowest setting (Figure 8a): significant

Bifocal and multifocal CLs

bifocal with a +2.00 D add, in which the pupil diameter is

Near correction Distance correction

may be that prediction of likely future success of particular

desired value of add, the lens must have a specific pair of 45

ing the overall lens thickness. Like the diffractive bifocal, 42

appears to have been no further progress with this concept.

ous difficulties in terms of the required lens thickness, oxy- 41

glasses or contact lenses is orthokeratology (OK). It has

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