The typical story: Your patient just celebrated their 40th birthday, they wake up, pick up their phone, and suddenly they cannot see the words. They come booming into your office demanding to know what just happened. The answer: presbyopia did.
The process of presbyopia actually does not happen that fast; it is actually a slow reduction in your eyes' ability to accommodate (or focus) at near. This naturally happens as the lens of your eye loses elasticity and is not as easily able to change shape to accommodate where you look.1 The reason that presbyopia ‘hits’ everyone at different ages is because it is not just this change in our lens that causes the blurriness, there are other factors that we must consider that include a person’s refractive error (corrected/uncorrected) and visual demands (e.g., small font, computer work vs. construction).
The most common sign of presbyopia is reduced vision at near, but there is also reduced contrast and reduced processing speed that effects presbyopic patients.2 The best way to understand if your patient has joined the 1.8 billion people worldwide3 that suffer from presbyopia is to conduct a full comprehensive eye exam.
The diagnosis is presbyopia, NOW what?
The number one question I get from patient’s in this age group—especially those that have never worn glasses before—is “Can I do eye exercises to strengthen my eyes to not need glasses?" Well, the simple answer is “NO,” but let’s talk about these vision correction exercises because there is a ton of information out there that touts you can.
As with anything, there are different approaches of how to treat presbyopia with eye exercises. One popular training methodology that was highlighted in the NYTimes is to tackle the perceptual piece to reading. It works on training the brain to gather the words on a page more efficiently, therefore reducing blur and improving contrast sensitivity, which in turn will increase your reading speed and improve the overall reading experience.
The chart below (Figure 1)2 highlights the changes of this experiment, done by Polat et al. on 13 subjects, aged 50+/-1.1 years old, to show pre-therapy vs. post therapy (20 sessions) visual function compared to a "young eye." You can see improvements across the board.
Figure 1
There are also apps that give you a training regimen similar to this, such as GlassesOff or UltimEyes, that advertise improvement after a few months of work. GlassesOff reports users can read letters up to 1.6 times smaller. UltimEyes works on the same premise of improving processing speed, but targets the younger, pre-presbyopic demographic. This app was developed after Dr. Alan Seitz, a neuroscientist, worked with University of California, Riverside baseball team that showed improvements in their performance on the field. It is important to highlight that both of these apps are improving brain function, NOT changing the eyeball itself.
The Bates Method
Another popular method that has been around since the 1920’s is “The Bates Method” that believes vision changes are due to mental and visual straining habits.
Developed by ophthalmologist William Bates, this method was originally meant to reduce nearsightedness, but he has a whole section dedicated to presbyopia. His methodology, that includes ‘sunning’ (looking directly at the sun with your eyes) and palming (pressing your eyes with the palm of your hand), has never been scientifically proven to improve visual conditions and can harm the eye. Even if you are looking at the sun with eyes closed, you’re increasing your risk for skin cancer (lesions around the eye and eyelids account for 5-10% of all skin cancers).
Palming, on the other hand, can cause temporary increases in the eye’s pressure, which if done enough and with different predispositions, can lead to the progression of glaucoma.
The Bates Method tries to treat the cause of changing vision, and although it still has a huge following even in 2021, it has been debunked time and time again.
Is there any harm in doing eye exercises?
The takeaway question here: Is there any ‘harm’ in doing these exercises? No, not really. Some of these treatment approaches do indeed improve your brain’s processing speed and contrast sensitivity, therefore making you a more efficient reader.
Though the one thing I will say, anecdotally, is I am an optometrist that specialized in vision therapy and rehabilitation. I work every day with patients to improve their accommodative (focusing muscle) function and their perceptual skills. I have seen pre-presbyopic patients who suffered a traumatic brain injury (TBI) that report near vision blur almost immediately following the accident (there is a high prevalence of accommodative dysfunction post-concussion). After a course of vision therapy, they report that they no longer need the small reading glass prescription given, but it is often just a temporary fix because, unfortunately, anatomy is anatomy and there are just some aging processes we can’t deny.
Ok, so what presbyopia options are there?
Figure 2: Photo courtesy of Allergan
Glasses and contacts
Glasses: The simplest option out there is to get a pair of reading glasses that you pop on and off when you need to see something up close. Other options include traditional bifocals with the line, but my recommendation always is a progressive style lens that corrects for distance, near, and everything in between. The reason I always gravitate towards this lens design is because our world is dynamic: We are looking at our computer screens, our devices and then in the distance. The progressive style lens corrects for all those distances without requiring multiple glasses changes.
Contact Lenses: Another wonderful option we have is multifocal contact lenses or monovision contacts. Multi-focal contacts work like progressive glasses where both eyes are corrected for distance, intermediate and near. These lens options include daily wear, monthly wear and there are even options available now for astigmatism correction within these multifocal lenses.
Each company has a slightly different design to their contact lenses, but all basically work on training your brain how to utilize the ‘right’ part of the lens to see clearly depending on the distance you are looking at.
Monovision contacts: This is a unique modality design that has one eye corrected for distance and one eye that is corrected for near. This option does come with some draw backs as the two eyes are never really working together and some may experience glare at nighttime and difficulty with depth perception
Surgery
There are a few options here:
LASIK/PRK: Depending on your refractive error, you can consider slightly under correcting a myopic (nearsighted) prescription or opt for a monovision end result (try this in contacts first, please).
Cataract Surgery: Again, depending on the state of your lens, you may have cataracts developing that would be safe to remove. During cataract surgery, you have so many options for the types of lenses that can be implanted to get you to your vision goals.
Corneal Inlays: This is a very new procedure, but essentially tiny devices are implanted into the cornea that correct for presbyopia. There are multiple designs that work on creating different refractive powers (like a multifocal contact lens) or work on creating a pinhole like effect to improve vision. There are a lot of stipulations for who would be a good candidate for the surgery and currently KAMRA is the only FDA-approved corneal inlay (Figure 3). Studies with KAMRA tout improved near vision by up to two lines, without the disruption of distance vision.11
Figure 3: Photo courtesy of AAO.Org
Therapeutics
There are two types of therapeutics out there to treat presbyopia: ones that aim to work on the anatomy of the eye to reduce the natural age-related changes and the other that is trying to pharmacologically change the depth of focus to address the symptoms of presbyopia, known as ‘phaco-refractive treatments.’ The former is far away from a feasible treatment option, but the latter of phaco-refractive treatments are getting there.
The formulation of these drops are utilizing miotics paired with other classes of drops (e.g. NSAIDs, steroids, vasoconstrictors, antihistamines) to highlight the benefits of each, while minimizing the side effects of others. There are currently six US FDA Trials (AbbVie/AGN-190584, AGN-199201), Visus, Orasis, Ocuphire, Presbyopia Therapies, and Eyenovia) and 1 Non-US FDA ( FOV Tears) that are currently being studied: Dr. Ken Lau highlights these in depth in this article for Optometry Times.
The take-home here is that therapeutics to treat presbyopia will be a viable treatment option in our near future. It is important to understand how these drops work and how this can change the landscape of our approach to care for presbyopic patients.
The best way to talk to patients about presbyopia
I usually start with the line, “Well, you have reached that special time in your life when things are harder to see at near…” This usually garners a laugh and a joke that this is not the most ideal change to be happening. I have found by approaching this subject empathetically often results in the patient being more open to hearing what I am telling them and the options that they have. Many people hear presbyopia and think “bifocal” and everyone will see their glasses with a line.
By having a good understanding of all the options out there for your patients, you can discuss what makes the most sense for them.
Sources
- Boyd, Kierstan. “What Is Presbyopia?” American Academy of Ophthalmology, 17 Dec. 2020, https://www.aao.org/eye-health/diseases/what-is-presbyopia.
- Polat U, et al. Scientific Reports. 2012 Feb 23; Scientific Reports 2(278):278 PMID: 22363834 PMCID: PMC3284862DOI: 10.1038/srep00278
- Ophthalmology. 2018 Oct;125(10):1492-1499. doi: 10.1016/j.ophtha.2018.04.013. Epub 2018 May 9
- Vision Research. 2009 Oct; 49 (21): 2566-2573. Doi: https://doi.org/10.1016/j.visres.2009.06.005
- “ Glasses Off: The Science”, http://www.glassesoff.com/thescience.html
- “The Sun & Your Eyes” Skin Cancer Foundation, June 2019, https://www.skincancer.org/skin-cancer-prevention/sun-protection/eye-protection/
- Ophthalmic Physiol Opt. 2011 Jul;31(4):398-403. doi: 10.1111/j.1475-1313.2011.00845.x. Epub 2011 May 4.
- Pollack, Philip. “ The Truth About Eye Exercises” Chilton Company, Inc. 1956, https://babel.hathitrust.org/cgi/pt?id=uc1.b4399673&view=1up&seq=7
- Green, W et al “Accommodation in mild traumatic brain injury.” Journal of Rehabilitation Research & Development 2010. 47(3): 183-200. PMID: 20665345 DOI: 10.1682/jrrd.2009.04.0041
- Mukamal, Reena. “ Corneal Inlays: A Surgical Alternative to Reading Glasses”, 24. March 2021, https://www.aao.org/eye-health/treatments/corneal-inlays-alternative-to-reading-glasses
- Yilmaz OF et al. J Cataract Refract Surg. 2011;37(7):1275-1281. PMID: 21570249 DOI: 10.1016/j.jcrs.2011.01.027
- MedLine Plus. Pilocarpine Ophthalmic. Available at: https:// medlineplus.gov/druginfo/meds/a682874.html. Accessed 10/26/20.
- Lau, Khan. “ Treatments for Presbyopia Coming Soon” Optometry Times Journal, Nov digital edition 2020, Volume 12, Issue 11, https://www.optometrytimes.com/view/approach-patients-with-low-vision-on-an-individual-basis
