Presbyopia

Aastha Parekh
 Introduction
• Accommodative ability gradually
decreases with age and is
completely lost by 50-55 years of
age leading to presbyopia

• Onset is usually anticipated by age

of 40 years

• Affects functional vision

• Most prevalent ocular affliction -

affects 100% population
 Theories of Presbyopia
• Helmholtz-Hess-Gullstrand theory:
Presbyopia is due to stiffness of the lens and not changes in ciliary muscle
Ciliary muscles remain active and functional with age

• Donders-Duane-Fincham theory:
Prebyopia is due to decrease in the ciliary muscle contractility with age and not due
to lens capsule Orleans substance
 Etiology

• Lenticular Changes
- Lenticular sclerosis
- Changes in ocular elasticity
- Changes in zonular insertion angles

• Extralenticular changes
- Neuromuscular changes
- Ciliary muscle changes
 Symptoms
• Blurred near vision

• Drowsiness after prolonged near work

• Compliant to hold reading material far

• Asthenopia due to increased accommodative

effort

• Diplopia due to increased accommodative

convergence

• ‘’ My arms are not long enough to see close

anymore’’
 Types of Presbyopia
• Incipient Presbyopia

• Functional Presbyopia

• Absolute Presbyopia

• Premature Presbyopia

• Nocturnal Presbyopia
 Incipient Presbyopia

• Earliest when symptoms just begin

• Also called early presbyopia or pre-presbyopia

• Accommodation present by need efforts to see at near

 Functional Presbyopia

• Reports difficulty in near work

• Requires near vision correction

• Might still have little amount of accommodation present

 Absolute Presbyopia

• No accommodative ability left

• Requires near vision correction

 Premature Presbyopia

• Insufficient accommodative ability for usual near vision tasks at an earlier age than
usual

• Can be due to disease, environmental, drug induced or nutritional deficiencies

 Nocturnal Presbyopia

• Near vision difficulties at night or in dim light

• Due to increased pupil size and decreased depth of focus

Near point of accommodation and age

Age (Years) Distance (cms)

10 7

20 10

30 14

40 20

50 40
 Amplitude of accommodation and age
(Donder’s Table)

Age (Years) Amplitude (D) Age (Years) Amplitude (D)

10 14.00 45 3.50

15 12.00 50 2.50

20 10.00 55 1.75

25 8.50 60 1.00

30 7.00 65 0.50

35 5.50 70 0.25

40 5.00 75 0.00
Predicted add as per age
Age Predicted Near Add

40 1.00

42 1.25

45 1.50

48 1.75

50 2.00

52 2.25

55 2.50

60 3.00
 Accommodative Reserve

• There is a considerable interest to restore accommodation in presbyopic eyes

• This concept utilises the existing ciliary muscle activity to produce refractive change

• Reserve as per working distance:

- Half reserve for working distance greater than 40 cms
- One third in reserve for working distance less than 40 cms
 Methods of determing add

• Addition based on amplitude of accommodation

• Tentative add based on age

• Plus build up method

 Addition based on AOA
Method 1

• We know, AOA decreases with age

• Presbyopia is reported when NPA exceeds 22 cms, i.e. AOA = 4.50 D (Donders)

• Presbyopia exists when AOA is less than 5 D (Morgan)

 Example
• Working distance = 40 cm

• Amplitude of accommodation = 2.00 D

• What should be the near addition?

• Amplitude required for working distance = 2.50 D

• Accommodation in reserve = 1.00 D

• Amount of accommodation left = 1.00 D

• Near Addition = (Required Amplitude - amount of accommodation left)

= 2.50 - 1.00
= 1.50 D
 Example
• Working distance = 25 cms

• Amplitude of accommodation = 1.50 D

• What should be the near addition?

 Example
• Working distance = 50 cms

• Amplitude of accommodation = 1.00 D

• What should be the near addition?

 Tentative addition based on age
Method 2

• Amplitude of accommodation as per age (Hostetter’ formula)

- Maximum = 25 - 0.40 (age)
- Average = 18.5 - 0.3 (age)
- Minimum = 15.0 - 0.25 (age)

• Amount of near add calculated by keeping certain amount of acc0mmodation in

reserve
Condensed table of Hostetter’s age and AOA
Minimum expected Range of near add in D or
Range of Age (Years)
amplitude (D) 40 cms

40-44 5.00 to 4.00 +0.75 to +1.00

45-49 3.75 to 2.75 +1.00 to +1.50

50-54 2.50 to 1.50 +1.50 to +2.00

55-59 1.25 to 0.25 +2.00 to +2.25

60 and above 0 +2.25 to +2.50

 Plus build up method
Method 3

• Done monocularly or binocularly

• Plus lenses are increased in steps of +0.25 D to the amount necessary to the amount
necessary to read the desired letters to a customary working distance

• Monocular build up usually over estimates the value

 Management
• Converging lens or plus lens for near work
- Spectacles
- Contact lenses

• Surgery
 Spectacles

• Single vision reading glasses

• Multifocal lenses containing near addition

- Bifocal lenses
- Trifocal lenses
- Progressive addition lenses (PALs)
 Contact Lenses

• Single vision contact lenses with glasses

• Bifocal contact lenses

• Multifocal contact lenses

• Monovision contact lenses

• Modified mono vision contact lenses Multifocal Contact Lenses

 Monovision and Modified Monovision
Monovision Modified Monovision

Dominant eye - Distance Dominant eye - Distance

Non dominant eye - Near Non dominant eye - Bifocal lens for near
Sometimes distance portion of bifocal lens can be modified
Subject fuses two images to achieve binocular vision
for intermediate power as per need
Limitations include compromised visual quality, contrast
Success depends on need and adaptation of patient
sensitivity, stereopsis
 Surgery

• Laser in-situ keratomileusis (LASIK)

• Multifocal Intra-ocular lenses (IOL)

• Conductive keratoplasty (Monovision)

• Accommodative intra-ocular lenses (AIOLs)

• Femto-second laser lentotomy

• Pharmacological lens softening

• Scleral expansion