Of all the conditions an optometrist studies for board exams, presbyopia is not a particularly sweat-inducing topic. However, it’s one of the few conditions that every patient over a certain age will present with—and (almost) every one of these patients will be in search of one or more ways to manage it.
Luckily, we have more treatment options than ever to meet the presbyopic patient’s needs. This article will outline non-surgical and surgical options for presbyopia correction, either currently available in the US or approaching Food and Drug Administration (FDA) approval.
Brief overview of presbyopia
Presbyopia, part of the natural aging process, affects one’s ability to see near objects clearly due to the gradual loss of flexibility of the crystalline lens inside the eye. This usually becomes noticeable after age 45.1
One study estimated that 1.8 billion people in the world were living with presbyopia as of 2015. Of those, an estimated 826 million people had inadequate or no vision correction.2
How is presbyopia evaluated?
To assess presbyopia, start with a thorough history: ask what activities the patient struggles with and at what working distance they perform these activities. Undercorrected presbyopia can lead to eyestrain and headache. It is important to elucidate the causes of reported discomfort with a thorough ocular health exam.
Several clinical tests measure the magnitude of a patient’s presbyopia, including NRA/PRA, fused cross cylinder, and dynamic retinoscopy. Tests to determine a tentative add power result in similar outcomes,3 among these, age-expected addition (Table 1) serves as the most efficient starting point.4
Every tentative add power should be adjusted according to each patient’s specific needs. For example, a 65-year-old emmetropic presbyope who wears +2.50 readers but has a working distance of 50 centimeters may benefit from +2.00 readers instead.
Table 1 is one of several versions of age-expected add power charts; this chart was used for comparison against other add power determinations in Antona et al.5
| Age | Expected Add Power |
|---|---|
| 40 to 42 | +0.75 |
| 43 to 45 | +1.00 |
| 46 to 47 | +1.25 |
| 48 to 50 | +1.50 |
| 51 to 52 | +1.75 |
| 53 to 55 | +2.00 |
| 56 to 57 | +2.25 |
| 58 to 60 | +2.50 |
Table 1: Courtesy of Antona et al.
Treatment options for presbyopia
As we peruse our treatment options, remember that treatments can be additive. For example, some multifocal contact lens (CL)-wearing patients or extended depth of focus (EDoF) pseudophakic patients may benefit from using Vuity eye drops to enhance their near correction.
Non-surgical presbyopia treatments
There are three primary treatment non-surgical options currently available for presbyopia—spectacles, contact lenses, and presbyopia-mitigating drops—each having several variations within their category.
Spectacle lenses
Over-the-counter reading glasses vs. prescription reading glasses
State law dictates which power over-the-counter (OTC) readers can be bought without a prescription; usually, readers under +4.00 are available. Patients sometimes report that their OTC readers, although an appropriate power, “do not work for them,” which for some may be due to the one-size-fits-all optical center placement of these lenses.
I often encourage the option of prescription reading glasses, even if patients seem determined to remain Team OTC, as the visual improvement with custom-measured lenses and higher-quality optics can be dramatic for some. Either way, it is important to encourage enough pairs of glasses to meet all of a presbyopic patient’s visual needs and have additional pairs available if any important pair meets an untimely demise.
Lined bifocal lenses vs. progressive addition lenses
Both progressive addition lenses (PALs) and lined bifocal lenses can generally be made with add powers up to +4.00, though not all lens designs are available in all add powers (e.g., the Essilor Varilux family of progressive lenses offer maximum add powers of +3.50 or +4.00, depending on the design).6
For patients new to bifocals or PALs, set appropriate expectations and discuss adaptation. PAL non-adaptation is common, and there is no standardized method to assess which patients will adapt well. One study found that better vergence facility correlated with better PAL adaptation, and suggested that this could serve as an efficient, cost-effective method to predict patients’ adaptation to PAL lenses.7
Computer glasses
“Computer glasses” is an umbrella term that encompasses lenses of varying working distances and features. A simple computer lens may be a single-vision lens set for an intermediate working distance, i.e., 20 to 40 inches per the Occupational Safety and Health Administration (OSHA).8
Other computer lenses may correct for multiple distances, such as the Shamir Workspace progressive lens, which corrects for a 10-foot distance (think looking across an office space) and computer-viewing distance.9
AI-powered eye-responsive progressive lenses
Artificial intelligence (AI) is making its way into many facets of our lives, and that list now includes progressive lenses that combine a patient’s lens prescription with their unique visual behavior. AI meets glasses in the new Varilux XR Series.10
Contact lenses
Monovision vs. multifocal contact lenses
Monovision and multifocal contact lenses are two different options for correcting presbyopia with contact lenses. Monovision (dominant eye corrected for distance and non-dominant for near with single-vision contact lenses) does not work well for patients with vertigo or balance issues, and either may create bothersome glare in visually critical patients who drive frequently at night.
In one study of 49 patients, monovision correction provided better distance and near acuities, but multifocal lenses were subjectively preferred.11 Neither provides the magnification that eyeglass lenses provide, given contact lenses’ proximity to the cornea, which can leave some visually critical patients disappointed.
Many presbyopic patients do achieve success in contact lenses when their doctor sets their expectations properly—often, presbyopic CL fitting is both a science and an art.
Presbyopic contact lens designs
Multifocal CLs, available in soft plastics or rigid gas permeable (RGP) materials, include the following designs:
- Translating bifocal or trifocal lenses: Corneal RGPs.12
- Simultaneous vision: Concentric, aspheric, or diffractive.13
- Concentric lenses: Designs consist of rings of different focal point correction in either a gas permeable lens (usually center-distance) or soft lens (center-distance or center-near). For example, the Biofinity Multifocal (CooperVision) is available in either center-distance or center-near design, followed by an aspheric intermediate zone, then an outer zone that corrects near (if center-distance) or distance (if center-near).14
- Diffractive lenses: Designs also consist of concentric rings, but the rings are more numerous (especially with a higher add), thereby making the patient’s vision less dependent on pupil size.15
- “Aspheric” lens: Is one whose curvature changes gradually from its center (whereas a spherical lens has a consistent curvature). This allows these lenses to be thinner and to provide a larger zone of clear central vision. Aspheric lens designs include a front aspheric surface that corrects near vision and a back aspheric surface that corrects distance.13
- EDoF lenses: Designs exhibit a smoother transition in power between distance and near correction, resulting in a longer near working distance range. Interestingly, EDoF intraocular lenses (IOLs) for cataract surgery are a popular option, while only one soft EDoF contact lens option exists in the US (NaturalVue 1-Day), along with one corneal-scleral hybrid option (SynergEyes iD Multifocal EDoF).
- Presbyopia-correcting scleral lenses: Scleral lenses can correct for presbyopia, too, and are well-suited to do so given their stability and dryness-resistant fluid reservoir. Scleral lenses can have aspheric or concentric presbyopia-correcting designs, and the area of the add power zones is usually customizable.16
Presbyopia-mitigating drops
Strong attention is being turned towards a third non-surgical option to treat presbyopia: drops. These are poised to (or are already, in the case of Vuity) decrease certain patients’ dependence on reading glasses and/or presbyopia-correcting contact lenses.
Jessilin Quint, OD, MS, MBA, FAAO, says, “I offer my presbyopic patients all three non-surgical options for correction—glasses, contact lenses, and drops (if there are no contraindications, such as retinal pathology)—because I want to provide them with flexible options to meet a variety of goals.
But also, I want them to hear about these new drops directly from me, and be cleared by me to use them. I don’t want them to hear about these drops from their neighbors first, and trying their neighbors’ drops if I haven’t cleared them as appropriate candidates nor educated them on their use.”
Available miosis-inducing eye drops
Currently, there is only one FDA-approved eye drop indicated for presbyopia: Vuity. Vuity (AbbVie), pilocarpine 1.25%—FDA-approved October 2021 for once-daily dosing,17 then for twice-daily dosing in March 2023.18 Vuity reduces pupil size by 40 to 50% to increase depth of focus, while also stimulating ciliary body contraction.17
Patient screening is critical, as miotic use has (rarely) been reported with retinal breaks,19 and the formation of synechiae in active iritis.18 Vuity is FDA-approved for use in patients aged 40 to 55 to improve near acuity by three or more lines for up to 6 hours at a time, though individual results vary.18
Pipeline miosis-inducing eye drops
- CSF-1 (Orasis): A proprietary formulation of low-dose (0.4%) pilocarpine in a multi-faceted preservative-free vehicle, has a Prescription Drug User Fee Act (PDUFA) date of October 22, 2023.20
- In phase 3 clinical trials, 61.4% of participants (compared with 43.3% randomized to vehicle) achieved two lines or greater of near-corrected acuity without losing one line or more of distance-corrected acuity under mesopic (low light) conditions.21 These effects mostly held when checked at 8 hours after instillation (57.9% vs. 45.1% randomized to vehicle).21
- MicroLine (Eyenovia): A proprietary formulation of 2% pilocarpine that will come pre-packaged in Eyenovia’s Optejet microdosing spray dispenser that will dispense one-fifth the volume of a traditional eyedrop.17
- Brimochol PF (Visus Therapeutics): Combining 2.75% carbachol with 0.1% brimonidine tartrate, is the first fixed-dose combination product in presbyopia to achieve statistically significant “contribution-of-elements” (i.e., contribution of more than one active ingredient to achieve the desired effect), which is an FDA requirement for fixed-dose combination products.22 Carbachol is a muscarinic agonist, like pilocarpine, that induces miosis.23
- LNZ100, LNZ101 (Lenz Therapeutics): A preservative-free 1.75% aceclidine (LNZ100) and 1.75% aceclidine plus brimonidine (LNZ101), plan to provide a longer-lasting miotic drop to the market.
- Aceclidine is a muscarinic agent, as are pilocarpine and carbachol,24 but aceclidine is much more selective for the iris sphincter (28:1 vs. 5:1 for carbachol and 1.5:1 for pilocarpine) and less affinity for the ciliary body.25
- These qualities increase the ability to induce miosis and decrease the chances of inducing myopia and tension on other ocular tissues that can lead to adverse events.
- Additionally, it is thought that brimonidine (also being tested with carbachol in Brimochol, see above) may increase the duration of aceclidine’s pinhole effect while constricting conjunctival vessels to provide eye redness relief.17
- Aceclidine has already been used since the 1970s for intraocular pressure (IOP) control in Europe, but was not preferred in the US due to pilocarpine’s stronger IOP-lowering abilities.17
- Nyxol (Ocuphire Pharma): Phentolamine ophthalmic solution 0.75% is a non-selective alpha-antagonist that inhibits iris smooth muscle contraction (i.e., inhibits the iris dilator muscle).26
- It is being studied for three different indications: mydriasis reversal, presbyopia correction (with 0.4% pilocarpine), and night vision disturbance (e.g., glare) correction.26
Lens elasticity drops
While all of these listed topical treatments incorporate miosis as a primary mechanism of presbyopia control, another drop called Dioptin (lipoic acid choline ester chloride) that was being studied to increase lens elasticity had inconclusive results in its now-discontinued trials.27
Surgical presbyopia treatment options
Surgical options for presbyopia can be either cornea-based or lens-based.
Cornea-based presbyopia-correcting procedures
Monovision laser vision correction (LVC)
This includes photorefractive keratectomy (PRK), laser in situ keratomileusis (LASIK), laser epithelial keratomileusis (LASEK), and small incision lenticule extraction (SMILE) procedures. Presbyopes often ask whether LASIK could eliminate their need for readers. Laser vision correction is usually performed for distance correction, although monovision may be considered if a patient demonstrates adaptation.
To assess whether a patient is a proper LVC monovision candidate, “At least 2 weeks of trialing monovision correction in contact lenses prior to laser vision correction is a good target," according to Nataliya Pokeza, MD, a cornea and cataract surgeon practicing in Bridgeport, Connecticut.
PresbyLASIK
PresbyLASIK is a technique in which corneal tissue is ablated to correct distance and near vision, with a center near (common), center distance, or blended vision pattern.28
Corneal inlays
Corneal inlays are small devices surgically implanted within the nondominant eye’s corneal stroma to correct presbyopia via the pinhole effect.29 The Kamra corneal inlay (AcuFocus/SightLife) is indicated for emmetropic, phakic presbyopes aged 45 to 60.30
Laser-induced refractive index change
Laser-induced refractive index change (LIRIC, not yet approved) is an incision-less femtosecond laser technique that restructures the collagen matrix and thus refractive index of the cornea to correct refractive error.31
LIRIC requires pulse energies 100 to 1,000 times lower than traditional LASIK, resulting in less keratocyte and nerve death in the cornea.31 The LIRIC platform can correct spherical and cylindrical ametropia and higher-order aberrations.31
If approved, LIRIC could provide an LVC option for patients who prefer no incision (or with thinner corneas who cannot have LASIK), IOL touch-up following cataract surgery, and customized presbyopia-correcting contact lens manufacturing.31
Lens-based presbyopia-correcting implants
Intraocular lenses that replace the crystalline lens in the eye during cataract surgery or clear lens exchange continue to evolve rapidly. Monofocal IOLs are the default option, with which monovision can be created for patients who’ve demonstrated monovision adaptation.
Early presbyopia-correcting IOLs:
- Refractive IOLs: Several focal points corrected by about five alternating concentric zones.32 Examples include the Array (1997—the earliest FDA approval for a presbyopia-correcting IOL) and ReZoom (2005).32
- Bifocal or trifocal diffractive IOLs: Numerous concentric rings of diffractive ridges varying in height and width based on add power(s).32 ReSTOR (Alcon) was the first diffractive IOL approved in 2005.32
- Accommodating IOL: Only one example, CrystaLens (2003), which can alter focus based on ciliary muscle contraction.32
More recent/commonly used presbyopia-correcting IOLs:
- Extended depth of focus IOLs: These IOLs create a contiguous, elongated focal point providing a range of near vision without the effects on distance vision that diffractive or other designs may cause.33
- The Tecnis Symfony IOL (Johnson & Johnson Vision/AMO) was the first EDoF IOL approved in 2016.33
- IC-8 Apthera IOL: FDA-Approved July 2022, the IC-8 Apthera (AcuFocus) IOL utilizes a pinhole aperture and extended depth of focus optics to focus distance, intermediate, and near objects only in the non-dominant eye, after successful implantation of a monofocal or monofocal toric IOL in the dominant eye.34
- Potential candidates include patients whose pupils can dilate to a minimum 7mm diameter, patients without retinal disease (or without high risk), and no astigmatism or astigmatism that does not exceed 1.5 diopters.34
Light-adjustable lens (LAL)
The light-adjustable lens (RxSight), or LAL, is the first IOL that can be adjusted to correct spherical and cylindrical refractive error after cataract surgery using an in-office UV Light Delivery Device.35
LALs allow for patients to trial monovision post-cataract surgery for additional near correction before committing, which is preferable to pre-trialing monovision in the context of visually significant cataracts. Additionally, LAL creates a degree of extended depth of focus due to its asphericity.36
Most importantly: “LAL offers an advanced technology presbyopia-mitigating IOL option for patients with a diverse array of ocular comorbidities, including glaucoma, retinal pathology, and corneal conditions that increase the refractive uncertainty following cataract surgery for whom traditional diffractive and/or non-adjustable IOLs would be contraindicated,” says James Murphy, MD, a cataract and glaucoma surgeon practicing in New York and Connecticut.
Implantable collamer lens
The implantable collamer lens (ICL, EVO Visian ICL, Staar Surgical) is a small lens implanted between the iris and natural lens, which categorizes it as a posterior chamber phakic intraocular lens (pIOL). Meaning that it is used in eyes that have not developed cataracts and will still be phakic after the procedure.37
These lenses are usually used to correct or reduce high degrees of myopia or myopia and astigmatism (up to -2.50D cylinder [cyl]) in patients who are not candidates for other refractive procedures, and can also be used for post-cataract surgery touch-ups.
Advantages of this procedure include reversibility, no accommodation loss as is experienced with clear lens exchange, and a better safety profile than clear lens exchange.37 A presbyopia-correcting ICL design, the EVO Viva, was approved for use in Europe in 2020 and has not received approval for use in the United States.38
Final thoughts
As your patients’ eye doctor, you have a responsibility to provide them with options (whether from yourself or another local doctor offering complementary services) that will give them the best possible vision for all of their various work and play activities.
Presbyopia is not complicated, but it is not one-solution-fits-all. Correcting your patients’ presbyopia to the best of your abilities can have a tremendous impact on their quality of life every day.
Special Thanks To:
- Jessilin Quint, OD, MS, MBA, FAAO, owner of Smart Eye Care in Augusta, Bangor, and Farmingdale, Maine, and Smart Eye Med Spa in Farmingdale, Maine.
- Nataliya Pokeza, MD, who practices with Eye Group of Connecticut in Bridgeport, CT.
- James Murphy, MD, who practices with ReFocus Eye Health in Hamden, CT, Scarsdale Ophthalmology Associates in Scarsdale, NY, and Kwiat Eye & Laser Surgery in Amsterdam, NY.
Financial Disclosures:
- Dr. Moore is an incoming advisory board member for Orasis Pharmaceuticals.
- Relevant to her quote, Dr. Quint is a paid speaker for AbbVie.
- Relevant to her quote, Dr. Pokeza has no financial disclosures.
- Relevant to his quote, Dr. Murphy has no financial disclosures.
