Presbyopia

• Presbyopia


  The inability of the human eye to focus on objects up close that results with aging
• Presbyopia


  • Not a disease as such, but a condition that affects everyone at a certain age
  • Starts usually at the age of 40-50
  • "short arm syndrome"
• Presbyopia


  • A condition whereby the amplitude of accommodation diminishes with increase in age where clear & comfortable vision at nearpoint is not achievable
  • Recession of near point with increase in age
• Helmholtz-Hess-Gullstrand Theory (H-H-G Theory)


  1. Lens based

  2. Attributes all of the loss in acc. to biomechanical changes in the lens capsule & lens and none to the ciliary muscle

  3. The amount of ciliary muscle contraction (or effort/innervation) required to produce a unit change in acc. remains constant with age
• Donder's-Duane-Fincham Theory (D-D-F Theory)


  1. Muscle based

  2. The amount of ciliary muscle contraction needed to produce a unit change in acc. progressively increases with age

  3. Reduced amplitude is due to progressive weakening of the ciliary muscle itself
• Etiology of presbyopia


  • Weakening of the ciliary muscles
  • Hardening of the nucleus of the lens
  • Sclerosis of the lens fibers and capsules
  • Less elasticity of the capsule
  • Range of accommodation is diminished
• Causes of sclerosis

  • Nutritional changes
  • Action of UV rays
  • Exposure to intense infrared radiation
• Classification of presbyopia


  • Incipient Presbyopia
  • Functional Presbyopia
  • Absolute Presbyopia
  • Facultative Presbyopia
  • Pre-mature Presbyopia
  • Nocturnal Presbyopia
• Incipient Presbyopia


  • The earliest stage at which symptoms or clinical findings document the near vision effects of the condition
  • Performs well on vision testing
• Functional Presbyopia


  • Adult patients eventually report visual difficulties when faced with gradually declining accommodative amplitude and near task demands
  • Some patients are symptomatic at an early age (premature presbyopia)
• Absolute Presbyopia


  • As a result of the continuous gradual decline in accommodation, functional presbyopia progresses to absolute presbyopia
  • Virtually no accommodative ability remains
• Facultative Presbyopia


  Condition which can still be overcome by a hard or forced ciliary effort
• Pre-mature Presbyopia


  • Accommodative ability becomes insufficient for the patient's usual near vision tasks at an earlier age than expected
  • Due to environmental, nutritional, disease-related, or drug-induced causes
• Nocturnal Presbyopia


  • Near vision difficulties result from an apparent decrease in the AA in dim light
  • Increased pupil size and decreased depth of field are usually responsible for this
• Signs of presbyopia


  • Recession of near point
  • Vertical wrinkles on the forehead
  • Pupils are constricted, but upon dilation in poor illumintaion, near vision blurs
• Symptoms of presbyopia


  • Inability to see near distances distinctly
  • Reading material is placed farther away from its usual distance
  • Occipital headache
  • Diplopia
  • Pain around the eyes
  • Lacrimation or tearing
  • Dizziness
• Hyperopes, even if corrected, usually exhibit refractive difficulty first


  The corrected hyperope still enters presbyopia ordinarily ahead of the corrected myope or emmetrope
• If the distant acuity was poor, as occurred occasionally with the very aged

  The patient would make no effort at all to accommodate, since no gain resulted
• If the distant acuity was not too poor


  No effort would be made because no blur was recognized
• While the optic extent of presbyopia will be reasonably constant for all individuals of a given refractive status and age


  The time of onset of complaints occasioned by presbyopia will vary with the usage of the eyes and the physical attributed of the patient
• Determination of proper add


  1. Amplitude of accommodation

  2. Near chart VA

  3. Cross cylinder technique
• Corrections for presbyopia


  • Bifocals
  • Reading glasses
  • Progressive Addition lenses (PAL)
  • Multifocal CL
  • Surgical Reversal of presbyopia with Scleral Expansion Bands
  • Laser Thermal Keratoplasty
• Surgical Reversal of presbyopia with Scleral Expansion Bands


  • The surgeon inserts four plastic segments just below the surface of the sclera, which increases the distance between the muscles that focus the lens and the lens itself
  • The extra distance augments the tension of the muscle allowing better job in focusing the lens
• Laser Thermal Keratoplasty (LTK)


  Mild laser hear is used in a three-second procedure to shrink collagen in the periphery of the cornea to steepen the eye's surface for correction of near vision in farsightedness or presbyopia
• Considerations affecting the correction


  • Proper decentration
  • Height segment for multifocals to avoid prismatic effect
  • Reading power with accordance to patients' work
  • The use of age as tentative guide as to what power should you start at
  • With the use of contact lenses, some people choose to correct one eye for near and one eye for far (Monovision)
• Monovision


  Eliminates the need for bifocals or reading glasses, but can interfere with depth perception