10. Symptoms and Signs
• Presbyopic patients need to hold books,
magazines, newspapers, menus and other
reading materials at arm's length in order to
focus properly.
• When they perform near work, such as
embroidery or handwriting, they may have
headaches or eyestrain, or feel fatigued.
11. Symptoms
• Blurry vision at near
• Difficult or impossible to accommodate
sufficiently for near work
12. • Presbyopia, like other focus defects, becomes
much less noticeable in bright sunlight.
• This 'healing effect' is the consequence of
miosis, so that depth of focus, regardless of
actual ability to focus, is greatly enhanced,
13.
14. Increasing Near Point of Accommodation
with Age
Age (years) Distance (cm)
10 7
20 10
30 14
40 20
50 40
15. Amplitude of Accommodation and Age
(Donder’s Table)
Age (years) Amplitude (D) Age (years) Amplitude (D)
10 14.00 45 3.50
15 12.00 50 2.50
20 10.00 55 1.75
25 8.50 60 1.00
30 7.00 65 0.50
35 5.50 70 0.25
40 5.00 75 0.00
16. Near Work
• Comfortable vision at near uses less than or
equal to half of the available amplitude of
accommodation
• Near work becomes difficult when the
amplitude of accommodation is less than
5.00D
18. Presbyopia: determination of the
addition
• Trial method
• Amplitude of accomodation method
• Cross-cylinder (near) method
• Bichromatic test method
• Age method
19. Presbyopia: determination of the
addition
• Trial method
– Patient with Rx in DV, test to 40 cm (or habitual
distance of NV) well lit
– Mono and/or binocularly
• Cover LE and go on adding +0.25D in the RE until the
patient sees clearly
• The same for LE
• Refine the result adding 0.25D binocularly
20. Presbyopia: determination of the
addition
• Amplitude of Accomodation method
– Takes into account that 1/2 the amplitude of accomodation (amp acc)
remains in reserve
– With the adequate Rx for DV, determine the amp acc through the
push-up method
– Apply the formula:
• Addition = 1/dt (m) - amp acc/2
dt = work distance
– Example:
• Amp acc=2D; dt= 33 cm
• Ad=1/0,33 - 2/2= 2 D
21. Presbyopia: determination of the
addition
• Cross-cylinder method from near:
– Patient with Rx for DV
– Dim lighting
– Grid optotype at habitual distance in NV
– Cross-cylinder with negative axis at 90°. Ask
which lines he/she sees more clearly:
• We hope they are the horizontal lines
• Add positive lenses until verticle and horizontal
lines are seen equally clearly
– Can be done monocularly or binocularly
22. Presbyopia: determination of the
addition
• Bichromatic method:
– Patient with Rx for DV
– Bichrome test at the habitual distance in NV
– Ask on which background the patient sees the letters
more clearly
• We hope it is the green background
• Add positive spheres until he/she says “better on the red
background”
• Reduce positives until he/she sees equally in both eyes
– In case of doubt allow slightly better vision in the red
background
23. Presbyopia: determination of the
addition
• The age method:
– Empirical method based on clinical experience
– Patient with Rx for DV
– Reading test at a habitual distance in NV
– There are approximated addition tables
depending on age
– Refine the result adding 0.25D binocularly
24. Presbyopia: determination of the
addition
• The age method:
– The tables can vary according to geographical zone
AGE
(years)
Addition at
40cm
Addition
at 33cm
40 +0.25 D +1.00 D
45 +0.75 D +1.50 D
50 +1.25 D +2.00 D
55 +1.75 D +2.50 D
60 +2.00 D +3.00 D
65 +2.25 D
70 +2.50 D
Table proposed by Borish (1970)) Empirical table in Spain
AGE
(years)
Addition at 40cm
(approx)
40 - 45 +0,75 a +1,00
45 - 50 +1,00 a +1,75
50 - 55 +1,75 a +2,25
55 - 65 +2,50
> 65 +2.50 a +2,75
25. Presbyopia: determination of the
addition
• All of the previous methods are approximate
• It is essential to make necessary adjustments
with trial frames in a situation as similar to
real life as possible
• Demonstrate the steps of the accomodation
check
• Explain to the patient:
– The need for distinct compensation in DV and NV
– The expected evolution
26. Near-point of accommodation
• Amplitude of accommodation = 40/near point
of accommodation
• Near-point of accommodation of 10 cm
• 40/10, which equals 4.00 D
27. According to Age
• Age/ 10 – 3= Tentative Add power
• Ex = 40/10-3
4-3=1
Tentative Add Power = +1.00
28. Positive & Negative relative accommodation
• NRA=Positive spherical lenses.
• PRA=Negative spherical lenses.
• Ex=Patient can read fine print with +1.00Dsph
• The minimum plus +0.50 Dsph
• Maximum plus +2.00Dsph
• The mid point of +0.50 to +2.00 is +1.25Dsph
• The tentative add power is +1.25 Dsph
32. BOGOTA LASER REFRACTIVE INSTITUTE
BOGOTA COLOMBIA
SOUTHAMERICA
GUSTAVO E. TAMAYO MD
BASIC PRINCIPLES OF PRESBYOPIA
33. Management
– Converging or plus lenses for near work only in
spectacles or contact lenses
• Changes in prescriptions are required every two to
three years for presbyopia
– Surgery
35. Management
• Contact lenses
– Single vision contact lenses with glasses
– Monovision contact lenses
– Bifocal and multifocal contact lenses
– Modified monovision contact lenses
36. Management
• Surgery
– Laser in-situ keratomileusis (LASIK)
• More for presbyopic hyperopia than presbyopia myopia
at the moment
– Multifocal intraocular lens (IOL)
– Conductive keratoplasty (monovision)
– Scleral expansion
