PRESBYOPIA
PRESBYOPIA: PROGRAM
Presbyopia: program
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Definition
The start and influential factors
Symptoms and signs
Determination of the addition
Prescription
Resolution of clinical cases
PRESBYOPIA: DEFINITION
Presbyopia: definition
– Difficulty focusing on objects because of an
insufficient amplitude of accomodation for working
comfortably in NV, supposing a well compensated
refractive defect from far.
– It is a normal physiological state due to the loss of
the accomodative capacity with the passage of
time.
– The NPA moves away and the habitual work
distance remains outside of the zone of
comfortable and clear vision
PRESBYOPIA: THE START AND
INFLUENCING FACTORS
Presbyopia: factors I
• The age at which the presbyopia appears
depends on:
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The accomodative capacity of the person
The habitual work distance (near)
The visual demand at near distances
The refractive error
Nutritional and geographical factors
Presbyopia: factors II
• Accomodative capacity of the person
– A method used to determine the amplitude of
accomodation
– Intersubject variability
– Accomodation in comfortable vision
Presbyopia: factors III
• Habitual, near work distance:
– Habit and anthropometric characteristics
– At the beginning a slight distancing of the material
allows for comfortable vision
Presbyopia: factors IV
• The visual demand at near distances:
– Does not diminish the accomodative capacity
– Can make the symptoms more severe.
Presbyopia: factors V
• Refractive error in DV:
– Myopia / Hypermetropia
– Use of glasses / Contact lenses
Presbyopia: factors VI
• Nutritional and geographical factors
PRESBYOPIA: SYMPTOMS AND SIGNS
Presbyopia: symptoms and signs I
• Symptoms:
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Blurry vision in NV
Distancing the reading material
Ocular fatigue
Headaches
In principle it can include blurry vision in DV
(after working in NV)
Presbyopia: symptoms and signs II
• Signs:
– Reduced amplitude of accomodation in order to
work comfortably at the habitual reading distance.
– The amplitude of accomodation is determined with
the necessary refraction in DV and through any of
these methods:
• Methods (already seen)
Donders
Sheard
Hofstetter’s formula:
Average amp acc = 18,5 – age x 0,3
Presbyopia: symptoms and signs III
Examples:
Age
Rx
NPA
45
-1
cc
25cm
60
+4
cc

55
-4
sc
15cm
50
-2
sc
16,5cm
Averageexpected amp acc = 18,5 – age x 0,3
Amp
Acc
Real
Ano Acc
Comfortable
Amo
Acc
Average
Observations
Presbyopia: symptoms and signs III
Averageexpected amp acc = 18,5 – age x 0,3
Examples:
Age
Rx
NPA
Amp
acc
Real
Amp acc
Comfortable
Amp acc
Average
Observations
45
-1
cc
25cm
4,00D 2,00D
5,00D
Amp acc is normal for the age. Will
have presbyopia if the habitual work
distance is <50cm approx.
60
+4
cc

0,00D 0,00D
0,50D
Amp acc normal for the age.
Has absolute presbyopia
55
-4
sc
15cm
2,66D 1,33D
2,00D
Amp acc normal for the age.
NoC can see between 15 and
25cm approx.
50
-2
sc
16,5cm 4,00D 2,00
3,50D
Amp acc normal for the age.
NoC can see between 16,5 and
50cm approx.
PRESBYOPIA: DETERMINATION OF THE
ADDITION
Presbyopia: determination of the addition
I
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•
Trial method
Amplitude of accomodation method
Cross-cylinder (near) method
Bichromatic test method
Age method
Presbyopia: determination of the addition
II
• Trial method
– Patient with Rx in DV, test to 40 cm (or habitual
distance of NV) well lit
– Mono and/or binocularly
• Cover LE and go on adding +0.25D in the RE until
the patient sees clearly
• The same for LE
• Refine the result adding  0.25D binocularly
Presbyopia: determination of the addition
III
• Amplitude of Accomodation method
– Takes into account that 1/2 the amplitude of accomodation
(amp acc) remains in reserve
– With the adequate Rx for DV, determine the amp acc
through the push-up method
– Apply the formula:
• Addition = 1/dt (m) - amp acc/2
dt = work distance
– Example:
• Amp acc=2D; dt= 33 cm
• Ad=1/0,33 - 2/2= 2 D
Presbyopia: determination of the addition
IV
• Cross-cylinder method from near:
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Patient with Rx for DV
Dim lighting
Grid optotype at habitual distance in NV
Cross-cylinder with negative axis at 90°. Ask
which lines he/she sees more clearly:
• We hope they are the horizontal lines
• Add positive lenses until verticle and horizontal lines
are seen equally clearly
– Can be done monocularly or binocularly
Presbyopia: determination of the addition
V
• Bichromatic method:
– Patient with Rx for DV
– Bichrome test at the habitual distance in NV
– Ask on which background the patient sees the letters
more clearly
• We hope it is the green background
• Add positive spheres until he/she says “better on the red
background”
• Reduce positives until he/she sees equally in both eyes
– In case of doubt allow slightly better vision in the red
background
Presbyopia: determination of the addition
VI
• The age method:
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Empirical method based on clinical experience
Patient with Rx for DV
Reading test at a habitual distance in NV
There are approximated addition tables depending
on age
– Refine the result adding  0.25D binocularly
Presbyopia: determination of the addition
VI
• The age method:
– The tables can vary according to geographical zone
Table proposed by Borish (1970))
Empirical table in Spain
A GE
A ddition a t
A ddition
A GE
(years)
40cm
at 33cm
(y ears)
(a pp ro x )
40
+0 .2 5 D
+1. 0 0 D
40 - 45
+0,75 a +1, 00
45
+0 .7 5 D
+1. 5 0 D
45 - 50
+1,00 a + 1,75
50
+1. 2 5 D
+2 .0 0 D
50 - 55
+1,75 a +2,25
55
+1. 7 5 D
+2 .5 0 D
55 - 65
+2,50
60
+2 .0 0 D
+3 .0 0 D
> 65
65
+2 .2 5 D
70
+2 .5 0 D
A ddition at
40cm
+2.50 a +2,75
Presbyopia: determination of the addition
VII
• All of the previous methods are approximate
• It is essential to make necessary adjustments
with trial frames in a situation as similar to
real life as possible
• Demonstrate the steps of the accomodation
check
• Explain to the patient:
– The need for distinct compensation in DV and NV
– The expected evolution
PRESBYOPIA: PRESCRIPTION
Presbyopia: prescription I
• It is important to determine the best form of
compensation for the person’s visual needs:
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Monofocal in NV
Bifocal
Progressives
Occupational lenses
Presbyopia: prescription criteria I
• Monofocal lenses
– Useful for static, long-term tasks
– The glasses should be taken off to see from distances
• Bifocal lenses
– For NV and DV
– Inform about image jump and displacement
• Progressive lenses
– For DV, NV and intermediate distances
– There are peripheral areas with optical aberrations
– Very precise adaptation
PRESBYOPIA: CASES
Presbyopia: case 1-I
• JAR, 46-year-old woman. High school teacher.
• MC: Difficulty focusing on text in NV. Best
vision when she distances the text. In DV she
says she sees well with her glasses.
• PH: Has worn glasses since the age of 9. No
significant changes in the last 20 years. No
illnesses or ingestion of medication.
• FH: Unimportant.
Presbyopia: case 1-II
• Habitual Rx and AV in DV and NV:
– RE: -4,50; 20/20; NV: 20/30
– LE: -5,00; 20/20; NV: 20/30-2
• Binocularity in habitual conditions:
– Cover test:
• DV: Ortho
• NV: Low exophoria
– Proximal convergence: 5/10cm
Presbyopia: case 1-III
• Retinoscopy:
– RE: -4,50
– LE: -5,00
• Subjective DV and AV:
– RE: -4,50; AV: 20/20
– LE: -5,00; AV: 20/20
• Addition in NV: +1,00; AV 20/20 in both eyes.
Good comfort.
– Vision check: from 20 to 60cm approximately
• Ocular health exams: within normal limits
Presbyopia: case 1-IV
• Complete diagnosis of the case
• Proposed treatment and plan of revisions
• Possible evolution of the condition
Presbyopia: case 1-V
• Complete diagnosis of the case
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Simple myopia in both eyes
Presbyopia
Binocularity: within normal limits
Other tests are within normal limits
Presbyopia: case 1-VI
• Proposed treatment:
– A change to the prescription in DV is not justified.
– An addition in NV of +1,00D is necessary.
– After discussing the possible options, a monofocal for NV is
decided upon:
• RE: -3,50
• LE: -4,00
– Use for tasks in NV.
– Show the patient that with them the vision in DV is
inadequate.
– Revision in 1½-2 or before if there are symptoms.
– Explain the condition to the patient.
Presbyopia: case 1-VIII
• Possible evolution of the condition:
– Stability of the refractive defect in DV
– Need for a new graduation for NV in about 2 years
due to increase in the presbyopia.
Presbyopia: case 2-I
• MPA, 52-year-old male. Taxi driver.
• MC: When he wants to read for a while he
notices blurry vision in NV even with his
glasses. Greater difficulty in low lighting.
• PH: Wears bifocals when working and for NV
since he was 6 or 7. No illnesses or ingestion
of medication.
• FH: Irrelevant.
Presbyopia: case 2-II
• Habitual Rx and AV in DV and NV:
– RE: +0,50; AV:20/25; NV: +1,75; AV: 20/30-2
– LE: +0,50; AV:20/25; NV: +1,75; AV: 20/40
• Binocularity in habitual conditions:
– Cover test:
• DV: Ortho
• NV: Ortho
– Proximal convergence: 10/15cm
Presbyopia: case 2-III
• Retinoscopy:
– RE: +1,50-0,50x180º
– LE: +1,75-0,25x180º
• Subjective DV and AV:
– RE: +1,50-0,50x180º; AV: 20/20
– LE: +1,75-0,25x180º; AV: 20/20
• Addition in NV: +1,75; AV 20/20 in both eyes.
Habitual work distance: 45cm
– Vision check: from 30 to 55cm approximately
• Ocular health exams: within normal limits
Presbyopia: case 2-IV
• Complete diagnosis of the case
• Proposed treatment and plan of revisions
• Possible evolution of the condition
Presbyopia: case 2-V
• Complete diagnosis of the case
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Low hypermetropis manifested in both eyes
Low, direct astigmatism in both eyes
Presbyopia
Binocularity: within normal limits
Other tests within normal limits
Presbyopia: case 2-VI
• Proposed treatment:
– After discussing the possible options, progressives
have been decided upon:
• RE: +1,50-0,50x180º; Ad: +1,75
• LE: +1,75-0,25x180º; Ad: +1,75
– Habitual use.
– Revision within 1½-2 years or before if symptoms
reappear.
– Explain the condition to the patient.
Presbyopia: case 2-VIII
• Possible evolution of the condition:
– Stability of the refractive defect in VA
– Need for a new graduation for NV in a few years due
to slight increase in the presbyopia.
PRESBYOPIA: BIBLIOGRAPHY
Presbyopia: Bibliography
• Amos JF. Diagnosis and management in vision care.
Butterworth-Heinemann, 1987
• Milder B, Rubin ML. The fine art of prescribing
glasses (2nd edition). Triad Publishing company, 1991
• Brookman KE. Refractive management of ametropia.
Butterworth-Heinemann, 1996
• Werner DL, Press LJ. Clinical pearls in refractive care.
Butterworth-Heinemann, 2002
• Eskridge JB, Amos JF, Barlett JD. Clinical procedures
in optometry. Lippincott Co, 1991.
Presbyopia: web pages
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http://www.emedicine.com/oph/topic724.htm
http://www.emedicine.com/oph/topic699.htm
http://www.tarso.com/Presbyopia.html
http://www.nlm.nih.gov/medlineplus/spanish/ency/ar
ticle/001026.htm
• http://www.agingeye.net/otheragingeye/presbyopia.p
hp
• http://en.wikipedia.org/wiki/Presbyopia
• http://www.eyetopics.com/articles/48/1/Presbyopia