Presbyopia is caused by the natural aging process which results in a decreased ability to focus on near objects over time. It typically begins around age 40 and progresses over 10-12 years. Symptoms include blurry near vision and eyestrain with reading. Management options include multifocal glasses, contact lenses, or refractive surgery like LASIK or multifocal IOL implants to help restore near vision. Determining the needed addition is done through trial lenses, cross-cylinders, or age charts to find the optimal prescription for both distance and near vision.

3. History
• It is a Greek word "presbys" meaning "old
person.
• Presbyopia is a symptom caused by the
natural course of aging.

4. Definition
• Latin definition
– Presbyopia = “old man’s eye”

5. Definition
• Decrease in the amplitude of accommodation
or loss of accommodative ability with age

6. Etiology
• Natural part of the aging process
• Onset at approximately 40 years of age and
over though may be earlier in low hyperopes

7. Progression
• Once presbyopia occurs, it increases over a
period of 10 to 12 years, after which it
stabilizes

8. THE VISION WITH PRESBYOPIA
Distance Intermediate Near

9. Causes
• Decrease of accommodative power
• Nuclear sclerosis- Lens become harder

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,

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

17. PRESBYOPIA: DETERMINATION
OF THE ADDITION

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

31. Factors affecting Presbyopic Addition
• Profession
• Desire reading distance
• Working environment.
• Illumination.
• Pathological conditions of Eye

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

34. Management
• Spectacles
– Single vision reading glasses
– Multifocal lenses containing near Add
• Bifocal lenses
• Trifocal lenses
• Progressive addition lenses

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

37. Happy reading