Focus on treatment options for age-related presbyopia

“I can’t see to put on makeup!” “I can’t see the food on my plate!” “I can’t see the dashboard!” “I can’t see my cell phone!”
 
People who say such things may be suffering from presbyopia.

Presbyopia is an age-related worsening of the ability to focus on near objects that typically starts after age 40. Victims progressively hold objects further and further away until their “arms are too short.” Eyestrain and headaches accompany this normal part of aging caused by decreased elasticity of the lens and its muscle.

Many of those afflicted are balancing careers, children, and aging parents. They need to see their digital devices for scheduling and to drive to multiple events at all times of the day and night. This can cause great frustration and anxiety — and, in some cases, safety issues.

The most common solution is to use reader glasses or to add a bifocal to an existing spectacle. Some may use multifocal or monovision contact lenses. Yet many desire to reduce their dependency on wearing glasses or contact lenses.
 
Nonsurgical options. For those many years into presbyopia, pupil-modulating drops like pilocarpine or carbachol narrow the pupil, causing a pinhole that sharpens distance and increases the depth of focus to improve near vision. Vuity (pilocarpine 1.25 percent) was recently approved by the FDA but only lasted for 6 hours in 16-18 percent of patients. A pilocarpine spray and skin application are currently under investigation. Several new formulations combining carbachol (which narrows the pupil) and brimonidine (which prevents pupil widening) are under investigation as well.
 
Surgical options. Eyeball rigidity causes a rigid sclera (white of the eye) that in turn stiffens the lens. A minimally invasive laser technique called microporation can punch microscopic holes into the sclera, which has the effect of softening the eye and relaxing the lens muscle to allow the lens to change shape and focus up close better. This technique continues to be under investigation.

Alternatively, the natural lens can be replaced before it forms a cataract. This offers a permanent solution and eliminates the possibility of cataracts in the future because the artificial lens remains clear as the eye ages. Implantable lenses can be trifocal, accommodating, small aperture (awaiting FDA approval), extended depth of focus (EDOF), or even monofocal lenses that could be targeted for monovision if the patient had used monovision in contact lenses previously. Success depends on the health of the eye as well the patient’s lifestyle, hobbies, and other activities. The brain must also adapt to the new lenses.

Thankfully, those who have lost their ability to focus on near objects now have more options than reader glasses to help them see more clearly.L
CATHY SCHANZER, M.D., was originally a Texan and completed her ophthalmology training at Baylor College of Medicine in Houston. Subsequently, she practiced in Memphis for 30 years, incorporating three surgery centers into a large group. She currently practices with the Guthrie Medical Group in Sayre, PA, when not volunteering in Africa. She is a member of the Catholic Medical Association.