Presbyopia (Age-Related Farsightedness)

What is Presbyopia?

Presbyopia is the decreased ability to focus up close as you get older. This aging process begins around age 40 and continues until your mid-60s. 

People with presbyopia typically have trouble seeing:

  • Close objects
  • Close work
  • Small print

Presbyopia is also called age-related farsightedness. This condition should not be confused with hyperopia (farsightedness), which can occur at any age. 

Presbyopia occurs regardless of what type of eyeglass prescription (refractive error) you already have. Here is a brief overview of different types of refractive errors:

  • Hyperopia (farsightedness) is the inability to see near.
  • Myopia (nearsightedness) is the inability to see far.
  • Astigmatism is when your eye has an egg-like, irregular shape. With astigmatism, you may have problems seeing at both distance and near.
  • Emmetropia is when you see well at a distance. People with emmetropia also see well up close and generally do not need glasses until presbyopia begins.
Icon of eyeball

How Presbyopia Occurs

The natural lens inside your eye helps you see up close or at a distance. A structure called the ciliary body is attached to the lens via little fibers called zonules. The ciliary body also contains muscles that control the lens. 

When the muscles relax, the lens flattens, letting you see far away. When the muscles flex, the lens rounds out, allowing you to see up close. This process is called accommodation.

With age, the natural lens starts to get thicker and stiffer. As a result, the ciliary muscles cannot adjust the shape of the lens very easily, affecting your ability to focus at near.

Studies show that your natural lens becomes 1000 times stiffer throughout life.

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Symptoms of Presbyopia

Signs of presbyopia can be more subtle than just blurry vision up close. You may experience a variety of symptoms, which include:

  • Eye fatigue while performing close-up tasks such as reading, computer, sewing, etc.
  • Headaches, particularly around your eyes or forehead.
  • Eye strain, squinting to see up close, and/or dry eyes.
  • Difficulty reading in dim light.
  • Holding reading material further out than usual, closer to arm’s length.

The onset and severity of presbyopic symptoms also depend on your refractive error:

  • Hyperopia (farsightedness). These patients tend to experience presbyopic symptoms sooner than patients with other types of refractive errors. This is because hyperopic patients may already have trouble seeing up close before presbyopia begins, and they usually become more farsighted with age.
  • Myopia (nearsightedness). Myopic patients will notice that reading becomes difficult while wearing glasses or contacts. These patients generally find that they can read without a prescription. The more myopic you are, the closer up your eyes can focus.
  • Astigmatism. Patients with astigmatism may have a similar experience to patients with myopia. They can often read reasonably well at near without glasses.
  • Emmetropia. These patients usually experience presbyopic symptoms sooner than myopic patients. Similar to hyperopes, they cannot see well up close and must rely on reading glasses. However, they still have normal distance vision.

Keep in mind that you can have a combination of refractive errors, such as hyperopia and astigmatism. Since your eyesight is unique, your experience may not correspond exactly to the symptoms described above. 

Icon of a pair of glasses

Presbyopia Treatment: Corrective Lenses

To diagnose presbyopia, you must visit your eye doctor for an eye exam. During the exam, they will run a few eye health and vision problem tests to determine if you have presbyopia. After you receive the diagnosis, treatment will be recommended, and may include:

Glasses

The primary way to treat presbyopia is with glasses. If you already wear glasses to see far away, your doctor may prescribe bifocal or progressive lenses. These lenses combine your distance and near prescription into one pair of glasses. Otherwise, you can choose to have one pair of glasses for reading and one for distance. 

If your distance vision is normal, your eye doctor can prescribe reading glasses for near tasks. You can also ask if over-the-counter reading glasses are suitable for your particular eyesight.

When you wear reading glasses, your distance vision will be blurry. You can either remove the glasses when you finish reading or ask your doctor to write a bifocal or progressive prescription if you prefer to keep your eyeglasses on. 

For contact lens wearers, there are a few different ways to correct presbyopia:

Wear Reading Glasses on Top of Contacts

If you already wear contacts to see far, you can continue with the same contacts if you prefer a clearer distance vision. When you need to read, you can use a pair of reading glasses on top of your contacts.

Multifocal Contact Lenses

These contacts combine your distance and reading prescription into each lens. Multifocal lenses are an excellent option if you do not want to wear glasses. However, some people find that their distance and near vision are not as clear, compared to the first method described above.

Monovision Contact Lenses

Monovision means wearing one contact lens to see distance, and one contact lens to see near. Similar to multifocal contacts, you may find that your vision is slightly less clear than with distance contacts. Monovision contacts can also affect your depth perception, especially with activities like driving and sports. However, many patients adapt well to monovision and do not have difficulties performing daily activities.

Icon of laser surgery

Correction of Presbyopia With Surgery

There are a few methods to treat presbyopia surgically. Not all patients with presbyopia are eligible for these procedures. You can consult your eye surgeon to see if you are a candidate. Presbyopia surgeries include:

Corneal Inlays

An inlay is a small implant that is placed in your cornea. For reference, the cornea is the clear structure on the front of your eye. The surgeon inserts the implant into your non-dominant eye, allowing you to see up close with that eye. Corneal inlays are generally for patients with minimal refractive errors and without cataracts. A cataract is an age-related change that occurs as the natural lens inside your eye gets cloudy. Your surgeon can remove the implant if you are not happy with the result.

Refractive Lens Exchange

This procedure is similar to cataract surgery. You are replacing the natural lens in your eye with an implant before the lens develops into a cataract. The surgeon will select an implant that will allow your eye to focus at a distance and at near. Refractive lens exchange is suitable for patients who are presbyopic or highly hyperopic. You do not have to worry about developing cataracts later on since this procedure removes your natural lens.

Laser Refractive Surgery

Laser eye surgery for presbyopia includes both PRK and LASIK. Similar to contact lenses, the eye surgeon can perform monovision LASIK or PRK. This option is suitable for presbyopic patients with myopia, astigmatism, or a moderate amount of hyperopia.

You may want to try monovision contacts and see how well you adapt before committing to this surgery. 

Author: Melody Huang, O.D. | UPDATED April 22, 2020

Resources

Alió, Jorge L, et al. “Refractive Lens Exchange in Modern Practice: When and When Not to Do It?” Eye and Vision (London, England), vol. 1, no. 10, 10 Dec. 2014, doi:10.1186/s40662-014-0010-2.

Heys, K. R., et al. “Massive increase in the stiffness of the human lens nucleus with age: the basis for presbyopia?” Molecular Vision, vol. 16, no. 10, 10 Dec. 2004, pp. 956–963. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/15616482

Moarefi, M. Amir, et al. “A Review of Presbyopia Treatment with Corneal Inlays.” Ophthalmology and Therapy, vol. 6, no. 1, June 2017, pp. 55–65., doi:10.1007/s40123-017-0085-7.

Peng, Michelle Y, et al. “Monovision LASIK in emmetropic presbyopic patients.” Clinical Ophthalmology (Auckland, N.Z.), vol. 12, 4 Sep. 2018, pp. 1665–1671., doi:10.2147/OPTH.S170759.

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