From the Guidelines
Presbyopia should be managed with a combination of nonsurgical and surgical approaches, with the most recent and highest quality study recommending the use of topical therapies, such as 1.25% pilocarpine ophthalmic solution, as a promising treatment option. The management of presbyopia can be divided into nonsurgical and surgical approaches, with nonsurgical management including eyeglasses, contact lenses, and pharmaceutical treatment 1. Topical therapy for treatment of presbyopia has been approved by the FDA, with 1.25% pilocarpine ophthalmic solution being a promising treatment option 1.
Nonsurgical Management
Nonsurgical management of presbyopia includes:
- Eyeglasses (reading glasses, bifocal, trifocal, or progressive lenses)
- Contact lenses (soft or rigid gas-permeable with aspheric bifocal or multifocal optics)
- Monovision strategies, which can be used with contact lenses or refractive surgery
- Pharmaceutical treatment, such as 1.25% pilocarpine ophthalmic solution, which stimulates ciliary muscle contraction and miosis 1
Surgical Management
Surgical management of presbyopia includes:
- Refractive surgery, such as LASIK monovision or corneal inlays
- Lenticular surgery using a variety of IOL implants, such as monofocal, aspheric, multifocal, accommodative, extended depth of focus, and light-adjustable IOLs 1
- Intraocular surgery, which can be used to address presbyopia by using monovision strategies or multifocal IOLs 1
Key Considerations
When managing presbyopia, it is essential to consider the patient's visual needs, expectations, motivation to be less dependent on eyeglasses, and willingness to accept potential compromises 1. Regular eye exams every 1-2 years are also important to monitor changes and adjust prescriptions as needed. Additionally, patients with pre-existing retinal disease are at increased risk of retinal detachment and retinal tear with miotics, including 1.25% topical pilocarpine, and should undergo a dilated fundus examination prior to initiation of therapy 1.
From the Research
Definition and Prevalence of Presbyopia
- Presbyopia is a global problem affecting over a billion people worldwide, with a high prevalence of unmanaged presbyopia, especially in developing countries 2.
- The prevalence of unmanaged presbyopia is as high as 50% of those over 50 years of age in developing world populations, and 34% in developed countries 2.
- Presbyopia is defined as "presbyopia occurs when the physiologically normal age-related reduction in the eye's focusing range reaches a point, when optimally corrected for distance vision, that the clarity of vision at near is insufficient to satisfy an individual's requirements" 2.
Correction Strategies for Presbyopia
- Strategies for correcting presbyopia include separate optical devices, bifocal or progressive addition spectacle lenses, monovision, simultaneous images, pinhole depth of focus expansion, crystalline lens softening, and restored dynamics 2.
- These strategies may be applied differently to the two eyes to optimize the range of clear focus for an individual's task requirements and minimize adverse visual effects 2.
- Spectacle and contact lens approaches are commonly used to correct presbyopia, with recent developments including variable-focus lens systems and surgical methods that modify the optics of the cornea or replace the crystalline lens 3.
Limitations and Emerging Therapies
- Currently available corrective methods have limitations, and none fully overcome presbyopia in all patients 2.
- Emerging therapies, including miotic agents and UNR844, a lipoic acid choline ester, are being investigated as non-invasive treatment options 4.
- There is a significant gap in the provision of vision correction for presbyopia, with a paucity of effective, non-invasive treatment options broadly accessible to presbyopic individuals 4.