Management of Presbyopia
Presbyopia management includes both nonsurgical and surgical approaches, with eyeglasses, contact lenses, and FDA-approved pilocarpine 1.25% (Vuity) being the primary first-line options for most patients. 1
Nonsurgical Management Options
Eyeglasses
- Reading glasses: Single vision lenses for near tasks
- Bifocal lenses: Distinct segments for distance and near vision
- Trifocal lenses: Three distinct optical zones for distance, intermediate, and near vision
- Progressive lenses: Gradual change in power from top to bottom without visible lines 1
Contact Lenses
- Multifocal contact lenses: Provide simultaneous vision for distance and near
- Monovision contact lenses: One eye corrected for distance, the other for near
- Modified monovision: Multifocal lens in one eye and distance lens in the fellow eye 1
Pharmaceutical Treatment
- Pilocarpine HCL 1.25% (Vuity): FDA-approved topical therapy that works by stimulating ciliary muscle contraction and miosis
- Important safety note: Retinal detachment and retinal tear have been reported with miotics
- Precaution: Dilated fundus examination is advised prior to initiation to check for retinal holes, tears, or breaks
- Risk factor: Patients with pre-existing retinal disease are at increased risk 1
Surgical Management Options
Keratorefractive Surgery
- Excimer laser photoablation: Most widely used surgical approach
- Includes PRK, LASEK, epi-LASIK, LASIK, and refractive lenticule extraction
- Monovision correction: Distance correction for dominant eye, near correction for non-dominant eye
- Best candidates: Patients over 40 who prioritize freedom from optical aids and accept reduced stereoacuity
- Preoperative assessment: Trial with contact lenses to determine desired refractive endpoint 1
Corneal Inlays
- Kamra inlay: FDA-approved aperture inlay that enhances depth of focus
- Note: Raindrop inlay was withdrawn from market due to complications 1
Intraocular Surgery
- Refractive lens exchange: Removal of crystalline lens with IOL implantation
- IOL options:
- Monofocal IOLs (for monovision)
- Multifocal IOLs
- Accommodative IOLs
- Extended depth of focus IOLs
- Light-adjustable IOLs
- Toric IOLs (for astigmatism correction) 1
Clinical Decision Algorithm
Initial assessment:
- Determine patient's visual needs, lifestyle, and occupational requirements
- Assess ocular health, including retinal examination
First-line options (start with least invasive):
- Eyeglasses (reading, bifocal, trifocal, or progressive)
- Contact lenses (if patient is suitable candidate)
- Pilocarpine 1.25% (for patients seeking pharmaceutical option)
Consider surgical options when:
- Patient desires freedom from optical aids
- Patient is intolerant to contact lenses
- Patient has specific lifestyle needs not met by nonsurgical options
Preoperative testing for surgical candidates:
- Monovision trial with contact lenses
- Dominant eye testing
- Thorough ocular examination including corneal topography and retinal evaluation
Important Considerations and Pitfalls
Monovision caveats:
- May reduce contrast sensitivity and stereopsis
- Patients with previous strabismus, phorias, or intermittent tropias may develop diplopia
- Even with successful monovision, patients may still need glasses for night driving 1
Surgical risks:
- Refractive lens exchange carries risk of retinal detachment (1.5-8.1% in myopic patients)
- Other potential complications include endophthalmitis, suprachoroidal hemorrhage, cystoid macular edema, corneal edema, and IOL dislocation 1
Patient expectations:
- No current solution fully overcomes presbyopia in all patients 2
- Patients should understand that compromise is often necessary between distance and near vision
Global impact:
By following this structured approach to presbyopia management, clinicians can help patients select the most appropriate correction strategy based on their individual needs, ocular health, and lifestyle requirements.