Presbyopia is a normal, age-related loss of the eye's ability to focus on near objects. It is caused by a gradual hardening and loss of elasticity of the lens. Various methods can be used to determine the near prescription addition needed for presbyopia, including taking into account the patient's amplitude of accommodation, age, working distance, and refractive error. Management options include single vision, bifocal, or progressive addition lenses, contact lenses, refractive surgery, and potential future pharmacological treatments.

1. Presbyopia : Refraction and
Management Guidelines
Moderators Presenter
Dr. Sanjeev Bhattarai Archana Sharma
Suraj Chhetri B. Optometry
Third Year

2. Objectives
•To describe different methods used in refraction for
presbyopia
•To explain about different management techniques
for presbyopia

3. Presentation layout
•Introduction
•Types of presbyopia
•Risk factors
•Symptoms and signs
•Methods of determining near add
•Refractive error and presbyopia
•Management of presbyopia

4. Introduction
•Presbyopia (from Greek presbys = old man
+ ops = see like, sight)
•Gradual, irreversible decrease in amplitude of
accommodation as expected with age
•Normal physiological state
•Eye exhibits a progressively diminished ability to
focus on near objects

5. Change in Accommodative amplitude
with age
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
Donder’s Table
Duane A. Studies in monocular and binocular accommodation
with their clinical applications. American Journal of
Ophthalmology. 1922 Nov 1;5(11):865-77.

6. Accommodative insufficiency and presbyopia
Accommodative insufficiency Presbyopia
Accommodative power is
significantly less than the
normal physiological limit
for the patient’s age
Physiological insufficiency of
accommodation is
normal for age
Asthenopic symptoms are more
prominent
Symptoms of decreased near VA
is more prominent

7. Prevalence
• Worldwide 1.9 billion people with presbyopia in 2020
• Expected to peak at approximately 2.1 billion in 20301
1
1Global Prevalence of Presbyopia and Vision Impairment from Uncorrected Presbyopia: Systematic Review, Meta-
analysis, and Modelling ,October 2018

8. Etiology of presbyopia
•Modulus of elasticity of lens capsule
decreases from youth to old age. The lens capsule
becomes progressively less stiff like an old,
stretched out rubber band.
•Modulus of elasticity of the lens substance
The lens substance becomes stiffer , more plastic
like, with increasing age
44% of loss of accommodation (Fischer)

9. Etiology
•Lens size/Volume
 increases progressively with age that makes lens
capsule function less effective.
The increased lens size/volume and the decreased
elasticity of lens capsule contributed to 55% of the
loss of accommodation. (Fischer)

10. Theories of presbyopia
Theories
Helmholtz
Schachar
Catenary

11. Helmholtz’s theory
Ciliary muscle contraction ceases
Posterior zonular fibres pull the
ciliary muscle backward
Increases tension on the zonular
fibres
Increase in lens diameter, decrease
in lens thickness and a flattening of
the anterior and posterior lens
surface curvatures
Decrease in optical power

12. Schachar theory
Ciliary muscle contracts
Equatorial zonular tension is
increased
Anterior and posterior zonules are
simultaneously relaxed
Central surfaces of the lens steepen
Peripheral surfaces of the lens
flatten

13. Catenary Theory
Ciliary muscle contracts
Initiates a pressure gradient
between the vitreous and aqueous
compartments
Anterior capsule and the zonule
form a trampoline shape or
hammock shaped surface
Steep radius of curvature in center
of the lens with slight flattening of
the peripheral anterior lens

14. Types of presbyopia
Presbyopia
Functional
Incipient
Premature Nocturnal
Manifest
Absolute

15. Types of Presbyopia
1. Incipient presbyopia
•Borderline, beginning, early or pre-presbyopia
•Earliest stage when symptoms or difficulty are first
encountered in near vision

16. Types of Presbyopia
2. Functional Presbyopia
•When faced with gradually declining
accommodative amplitude and continued near task
demands, adult patient eventually report visual
difficulties
•The age at which presbyopia becomes symptomatic
varies
•Due to variations in distance vision status,
environment, task requirements, nutrition, or disease
state

17. Types of Presbyopia
3. Premature presbyopia
•Presbyopia occuring at an earlier age than expected
for normal population
•Usually associated with ocular diseases , uncorrected
hyperopia

18. Types of Presbyopia
4. Nocturnal Presbyopia
Near vision difficulties result from an apparent
decrease in the accommodative amplitude in dim light
5. Manifest presbyopia
Presbyopia with some amplitude of accommodation
present
6. Absolute presbyopia
Presbyopia with amplitude of accommodation
completely absent

19. Risk factors
•Age
•Hyperopia
•Occupation
•Gender
•Ocular disease
•Drugs
•Iatrogenic factors
•Geographic factors

20. Symptoms
•Blurred vision at customary near working distance
•Ocular discomfort
•Headache and asthenopia
•Fatigue or drowsiness from near work
•Increased working distance
•Transient diplopia

21. Signs
•Reduced amplitude of accommodation
•Recession of near point of accommodation

22. Basic principles
•Find refractive error for distance and correct it first
•Find presbyopic correction needed in each eye
separately and add it to distance correction
•Near point should be taken consideration according
to profession of patient

23. Basic principles
•Over correction should be avoided
•Additional correction for intermediate distance may
be required
•Presbyopic add should leave certain percentage of
amplitude of accommodation (AA) in reserve

24. Accommodation amplitude in reserve (AA)
Amount of a new addition should permit a certain
percentage of amplitude of accommodation to
remain in reserve
Rule-of-thumb
- Leaving ½ of the AA in reserve
(Lawrence and Maxwell)
- Leaving ⅓ of the AA in reserve
(Sheard and Giles)

25. Methods of determining near add
1. Addition based on amplitude of accommodation
2. Tentative addition based on age
3. Plus build-up method
4. Bichrome method
5. Cross-cylinder method
6. Relative accommodation method
7. Dynamic Retinoscopy

26. 1. Addition based on amplitude of
accommodation
•Amplitude of accommodation decreases with age
- Presbyopia is reported when NPA exceeds 8 inches
(22cm) i.e, (AA) = 4.50D (Donders)
•Presbyopia exists when amplitude of
accommodation is less than 5D (Morgan)
•Amplitude of accommodation is measured using the
push-up or the minus lens to blur method.

27. Addition based on amplitude of
accommodation
Example 1 : Working distance (WD)= 40cm
RAF (AA) = 2.00D
What should be the near addition
Accommodation required for WD = 2.50 D
Accommodation in Reserve = 1.00D
Amount of accommodation left = 1.00D
Amount of Near addition = (2.50 –1.00)
= +1.50D

28. Addition based on amplitude of
accommodation
Example 2 :
Working distance (WD)= 25cm
RAF (AA) = 1.50D
What should be the near addition
Accommodation required for WD = 4.00 D
Accommodation in Reserve = 0.50D
Amount of accommodation left = 1.00D
Amount of Near addition = (4.00 –1.00)
= +3.00D

29. 2. Tentative addition based on age
Based on the assumption that , for a given age, the
amplitude of accommodation is a fixed value for all
patients.
Amplitude of accommodation to age (Hoffstetter)
•Maximum = 25.0 – 0.4 (age)
•Probable = 18.5 – 0.3 (age)
•Minimum = 15.0 – 0.25 (age)
Rule of 4’s
Amplitude= 4x4-(Age/4)

30. 3. Plus build - up method
•Can be done binocularly or monocularly
•Plus lens are increased in steps of 0.25D to the
amount necessary to first read the desired letters at
customary working distances
•The power of add is then increased in 0.25 D steps
to the amount preferred by the patient

31. 4. Bichrome method
• Based on the natural chromatic aberration of the eye
• For presbyopic patient red & green are focused
behind the retina with red farther away
• Patient’s distance correction is placed on a trial frame
•Bichrome target is placed at habitual near distance
(40cm)
•Tell the patient to look at letters on both green and red
background carefully

32. Bichrome method
• Ask the patient which side has the sharper and
clearer letters
- Green clear : add plus in 0.25 step
- Red clear : remove plus
- until patient sees letters
equally clear in both
background

33. 5. Cross – cylinder method
Target containing 4 to 5 vertical and horizontal
lines is presented to the patient
Can be done monocularly or binocularly
Place the best distance correction on the phoropter
(trial frame)
Put the cross cylinder grid at customary near
working distance (40cm) of the patient

34. Cross Cylinder method
•If patient is unable to see the lines initially, sufficient
plus lens power is added until the lines are
recognized so that horizontal and vertical lines
appear equally blacker
•Place the JCC in front of both of the patient’s eyes,
with the minus cylinder axis at 900 (Red marks
vertical) (+0.50DS/-1.00DC x 090)

35. Cross- cylinder method
•Cross cylinder creates artificial astigmatism with an
interval of Sturm of 1.00D
•If patient accommodates exactly for the target, both
sets of lines are equally clear
•If patient under-accommodates, the horizontal lines
appear clear ( add plus )
•If vertical lines are clear ( reduce plus )

36. 6. Relative Accommodation method
•Based on the concept of placing the accommodative
demand in the middle of the range of relative
accommodation
•To measure NRA and PRA,
- Patient’s distance refraction and a tentative add is
placed in the phoropter (Trial frame)
- the near point test card (N6 target) is placed at the
reading distance (usually 40 cm)

37. Relative Accommodation method
•NRA is determined by adding plus power lenses
binocularly until the patient is no longer able to read
the fine print on the test card
• PRA is determined by adding minus power lenses
until the patient is no longer able to read the fine
print
• Near add = (NRA+PRA)/2

38. 7. Dynamic Retinoscopy
•Patient is asked to fixate fine print at the plane of the
retinoscope.
•If near point of accommodation (NPA) is behind
peephole = “with movement” is observed.
•Convex lenses are then added until with movement
observed first disappears.
Amount of additional convex lenses needed for
neutrality after reduction of amount of lag i.e. +0.50
to +0.75) = amount of tentative near addition

39. Comparing methods of determining
addition in presbyopes
•All the techniques display similar behavior and
provide a tentative addition close to the final
addition
•Among the methods used, the age-expected
procedure is recommended, as this technique
produce results that correlate best with the final add
•Likelihood of error is high and supports the idea that
any tentative add has to be adjusted according to the
particular needs of each patient
CLINICAL AND EXPERIMENTAL OPTOMETRY 2008; B. Antona, F. Barra, A. Barrio, A. Gutierrez, E. Piedrahita, Y. Martin
Department of Optics II, Universidad Complutense, Madrid, Spain

40. Determination of Final Add
•Customary near working distance
•Nature of the near work
•Physical nature of the patient
•Illumination level
•Status of the accommodation-convergence
relationship
•Change in the amount of the addition

41. Relation with Refractive error
• Hyperope
- Near point is considerably further than emmetropes
-Thus effectively become presbyopic few years
earlier than myopes or emmetropes.
• Myope
- Develop presbyopia later in life
- Better to take off distance prescription for near work

42. Relation to refractive error
Anisometropic distance correction
•Unequal adds may also be prescribed
•Measure the ranges monocularly
•Bifocals may produce reading discomfort because of
an induced vertical prismatic effect in the reading
position
•Specially designed slab-off lenses or single vision
reading glasses may be required

43. Management of Presbyopia
1. Spectacles 2. Contact Lens
3. Surgery 4. Pharmacological treatment

44. 1. Spectacles
•Single vision lens
•Bifocal lenses
•Trifocal lenses
•Progressive addition lens
•Occupational lens

45. Bifocals
•Bifocals are available in a wide variety of segment
shapes and sizes from small , round segment to
segment that occupy entire lower half of spectacle
lens.
Executive

46. Trifocals
•Trifocals offer the
convenience of
intermediate vision
in a moderately
large field of view.

47. Progressive Additional lenses
•Progressive lenses offer a smooth transition in
power along a relatively narrow corridor on the lens
surface.
•Wavefront technology is the most advanced
technology used in progressive lenses nowadays

48. Latest progressive lenses
•Hoya ID Mystyle 2 and ID Lifestyle 3
•Independent Owners Network (ION) Love Our Lens
•IOT Camber Steady and Camber Mobile
•Shamir Autograph Intelligence
•Varilux X and Comfort Max
•Zeiss Individual Smart Life and DriveSafe

49. 2. Contact lens
•Monovision- Optical means of correction for
presbyopia in which one is optimally corrected for
distance vision(usually dominant eye) and other for
near.
•Extended or enhanced monovision- One eye is fitted
with distance correction and other receives a bi- or
multi-focal contact lens.
•Bifocal and multifocal lens design

51. 3. Surgical Options
Cornea based
procedures
Lens based
procedures
Sclera based
procedures
Monovision conductive
keratoplasty
Multifocal or
accommodating IOL
Anterior ciliary
sclerotomy(ACS)
Monovision LASIK Monovision with IOL Scleral spacing
procedures
Presbyopic bifocal
LASIK or LASIK-PARM
Scleral expansion
Presbyopic multifocal
LASIK (PML)
Corneal Inlays for
presbyopia
Intracor treatment
(Presbyopic femtosecond
laser ablation )

52. Surgical Options
Recently, a new type of scleral expansion implant,
Preview(PSI, Refocus, Dallas, Texas, USA) is being
evaluated as a treatment of presbyopia, in an FDA
monitored investigational device exemption(IDE)
clinical trial currently underway in the USA.1
1 Current management of presbyopia. Middle East Afr J Ophthalmology, 2014

53. Review
Pharmacological Treatment in Presbyopia
AGrzybowski A, Ruamviboonsuk V 3March , 2022
•Two main agents
1. Miotics
Pilocarpine 1.25% , Phentolamine 1% , Carbachol
2. Lens softeners
Lipoic acid choline ester 1.5%

54. Review
Pharmacological Treatment in Presbyopia
AGrzybowski A, Ruamviboonsuk V. 3 March , 2022
Miotics
Pinhole
effect
Increases
depth of
focus
Lens
softeners
Increases
elasticity of
lens
Targets
etiologic
mechanisms
Mode
of
action

55. Review
Pharmacological Treatment in Presbyopia
AGrzybowski A, Ruamviboonsuk V. 3 March , 2022
•In November 2021, U.S. FDA has approved 1.25%
pilocarpine hydrochloride ophthalmic solution
(AGN-190584) as an eye drop for treating presbyopia

56. Summary
•Presbyopia is normal physiological state
•Amount of a new addition should permit a certain
percentage of amplitude of accommodation to
remain in reserve
• Hyperopes become presbyopic few years earlier
than myopes or emmetropes
•Spectacles , contact lenses , surgery, and
pharmacological treatment are the options for the
management of presbyopia

57. Summary
•Recommendations are made on the basis of the pt.'s
specific vocational and avocational needs
•Success of treatment depends on
 lens power
 specific visual tasks and characteristics of the
patient
 appropriate patient education given by the
practitioner
 appropriate mode of correction

58. References
• Borish's Clinical Refraction William J. Benjamin, Irvin M.
Borish - 1998
• Clinical Procedures in Optometry J. Boyd Eskridge, John F.
Amos, Jimmy D. Bartlett - Medical - 1991
• Clinical Procedures in Primary Eye Care David B. Elliott-
2007

59. THANK YOU!