Presbyopia

Overview

What is presbyopia?

The medical term presbyopia is Greek for “old eyes.” As if you needed one more reminder of how many candles there were on your last birthday cake, right? But before you start obsessing about your ebbing youth, relax. Remember that the loss of clear up-close vision happens to all of us eventually. It’s not a disease, it’s as normal as wrinkles. And there’s an upside! There are eyeglasses — even funky fashionable ones! Or those clever “studious type” specs you’ve been eyeing. Today, whether it’s contact lenses or vision correction surgery, there are so many choices that it may make this rite of passage a little less of a bummer. Don’t worry, whatever you choose, you’ll be reading menus again in no time.

Presbyopia is part of the natural aging process of the eye, and can be easily corrected. Technically, presbyopia is the loss of the eye's ability to change its focus to see objects that are near. Presbyopia generally starts to appear around age 40 and gets progressively worse until around your late 60s, when it usually levels off. It doesn’t usually affect your baseline distance vision.

Presbyopia generally affects men and women equally. Since presbyopia will continue throughout your life, it’s important to understand that it can complicate other common vision conditions like farsightedness, nearsightedness and astigmatism. Eye experts call these common eye focus conditions refractive errors. But there’s good news ahead.

Understanding your eye health and getting regular eye exams will help you continue to see clearly and comfortably.

Symptoms and Causes

What are the symptoms of presbyopia?

Curse dim lighting! That along with being tired seem to make it even harder to focus on every tiny little thing. When did everything get so small? Even though it seems like these changes came on all of a sudden, slight changes in the lens of your eye and your focusing ability have been happening since you were a child.

Symptoms of presbyopia you might notice:

  • The need for more light while reading.
  • Blurred vision at a normal reading distance.
  • The need to hold reading material at arm's length.
  • Headaches from doing close work.
  • Eye strain.

What causes presbyopia?

Presbyopia occurs when the aging lens of your eye becomes less flexible and can no longer focus on objects up-close.

Think of your eye like a camera. The lens in the camera has the ability to autofocus on objects whether they are near or far. The lens in your eye works much the same way. It works together with your cornea to focus light. First, your curved cornea bends light into your eye. Then a tiny circular muscle surrounding your lens either contracts or relaxes to change its shape to bring things into focus. If the item is far away, the muscle around your lens relaxes. If it’s near, the muscle contracts, allowing you to focus on nearby items, like a menu or a book. As your eye ages, however, the lens continues to grow and add layers of cells — resembling an onion! This process thickens the lens and makes it less able to flex the way it once did. This causes close items to blur.

What are the risk factors for getting presbyopia?

Although the primary risk factor for getting presbyopia is age, certain drugs and disorders can cause presbyopia to appear in people under age 40. When this happens, it’s called premature presbyopia.

If you haven’t turned 40 yet and notice you can’t focus on things up close, you may have an underlying ocular or health issue and should contact a healthcare provider as soon as possible.

Risk factors for premature presbyopia include:

  • Farsightedness (see the next section below).
  • Medications. Some medications can increase your risk, including allergy medications, attention-deficit medications, antianxiety drugs, antidepressants, antipsychotics, antispasmodics and diuretics.
  • Diseases. Diabetes, multiple sclerosis, dysautonomia and others increase your risk of developing premature presbyopia.
  • History of head trauma.

If I am already farsighted, will I develop presbyopia sooner?

Maybe. Being farsighted is one of the risk factors for getting premature presbyopia. Farsightedness (hyperopia) is often confused with presbyopia, but the two are different. Presbyopia occurs when the eye's lens loses flexibility. Farsightedness occurs when the eyeball is too short. This results in an underfocused image that requires the help of the lens to re-focus it. If the farsightedness is significant, you can experience blurry near-vision much younger than age 40.

Can I have presbyopia and myopia (nearsightedness) at the same time?

Yes, and this is very common, given that nearly a third of Americans of all ages are nearsighted to some degree. Nearsightedness means that you’re eyes are naturally “over-focused”, allowing for clear near-vision but blurred distance-vision. However, even if you are nearsighted and in your 40s, you will still feel the effects of presbyopia while wearing either your glasses or contacts. On the plus side, people with glasses who are mildly nearsighted take advantage of their “built-in readers” and often take their glasses off to read!

Diagnosis and Tests

How is presbyopia diagnosed?

Your eye care provider can diagnose presbyopia by a thorough eye exam. An important part of this exam will be a refraction assessment to measure how well you see objects at specific distances. The refraction assessment tells your provider whether you have presbyopia and/or astigmatism and whether you are nearsighted or farsighted.

Your provider will likely dilate your eyes with special eye drops to get a better look into the inner parts of your eyes. The drops are painless, but you may be sensitive to light for two to three hours afterward. If you don’t have sunglasses, your doctor will provide some plastic, disposable sunglasses to wear. Ideally, try to bring a friend or family member to drive in case you are unable to immediately after the exam.

At age 40, if you have no symptoms of eye disease, you should schedule an eye exam every two to four years. As you age, your presbyopia gradually worsens, so you will want to schedule eye exams more often as you reach new milestone birthdays. By the time you reach 65, you will want to have eye exams annually. If you have family history of eye disease or diabetes, you should have an annual eye exam, regardless of age.

Management and Treatment

How is presbyopia treated?

Presbyopia cannot be cured. But today you can choose from a wide variety of options to correct your vision. Discuss the best choice for you with your eye care provider. Depending upon your overall health and lifestyle, your provider may suggest any of the following, including prescription glasses, contact lens, reading glasses, progressive addition lenses, bifocals or several types of eye surgery to help you see things up close again.

Your many vision correction options include:

Eyeglasses. Whether or not you’ve been wearing glasses for other vision issues or not, now may be time to switch to a more comfortable type for your changing eyes.

  • Prescription readers. If you have no other vision issues, reading glasses may be all you need. They should be worn only for doing up-close work, like reading.
  • Bifocals. Often prescribed for presbyopia, bifocals are eyeglasses that have two different prescriptions in one spectacle lens. The upper part of the lens contains the distance prescription, while the smaller, lower portion of the lens holds a prescription to help you see objects up close.
  • Trifocals. Trifocals have three lenses: one each for seeing close-up, in-between and far away.
  • Progressives. Progressives are multifocal lenses, similar to bifocals, but have a more gradual shift between the prescriptions. Many people choose progressives when they don't want a visible line on their glasses.
  • Office progressives. Like their name suggests, these glasses are designed for doing near work in the office, such as computer work or writing. When you get up from your desk, you remove them so you can see into the distance.

Readers. Yes, we all call them cheaters. Welcome to the club. If you didn’t need eyeglasses before turning 40 for distance or any other reason, readers may be all you need to read a menu or thread a needle. You can pick them up at most drugstores. Nonprescription readers range from powers of +1.00 diopter (D) to +3.00 D. Choose the lowest magnification that makes small print look clear. You’ll probably want more than one pair to keep handy on your nightstand or any other place you may read or do up-close work, like sewing.

Contact lenses. There are a variety of contact lenses that can help you see better with presbyopia.

Choose the contacts that help you see most comfortably:

  • Bifocal contact lenses. A true bifocal lens helps you with just two focal points, usually near and far. They come in soft or hard materials (gas permeable).
  • Multifocal contact lenses. Multifocal lenses are similar to bifocal lenses and the terms are often used interchangeably, but a multifocal lens can include more than two focal points, including the intermediate zone of about 3 feet. They also come in soft or gas permeable versions.
  • Monovision contact lenses. With a set of monovision lenses, one eye wears a lens that aids in seeing objects at a distance, while the other wears a lens that aids in near vision. It can take up to two weeks for your brain to adjust to this method of seeing.
  • Modified monovision contact lenses. With modified monovision, you wear one lens for either near or far vision. In the other eye, you wear a multifocal lens that helps you see at all distances.

Refractive surgery.

Discuss your eye health, family history and lifestyle with your provider before you decide if surgery is right for you, and which option fits your lifestyle best. If you use glasses only part of the time, such as only for reading, eye surgery may be more risk than reward — even though refractive surgery is considered a minimally-invasive outpatient surgery with low risk in the hands of a trained ophthalmologist.

The following three laser procedures correct presbyopia by using monovision (one eye corrected for distance, the other corrected for near vision):

  • LASIK surgery: Laser in-situ keratomileusis, or LASIK, is a popular surgical approach used to correct vision in people who are nearsighted, farsighted or have astigmatism.
  • PRK surgery: You may be a good candidate for a photorefractive keratectomy (PRK) procedure if you have moderate to high nearsightedness, farsightedness and/or astigmatism. PRK is a slightly shorter, simpler laser surgery that removes less corneal tissue than LASIK.
  • SMILE surgery: With a small-incision lenticule extraction (SMILE) procedure, your surgeon uses a very precise laser to create a disc-shaped piece of tissue inside the cornea that can be removed through a small incision.

Lens replacement: Some people are better suited for procedures that remove the natural lens in a technique similar to cataract surgery, called refractive lens exchange (RLE). Depending upon what type of implant is used, all forms of vision correction can be achieved, including nearsightedness, farsightedness, astigmatism and presbyopia.

Corneal inlays: This is a newer, but less common option for surgically correcting presbyopia. Your ophthalmologist inserts a very small plastic ring into your cornea to allow your eye to achieve both distance and near vision. It works by creating a “pinhole camera effect” and effectively reduces blur (similar to squinting your eyes to see better). The inlay is typically inserted in only one eye.

Prevention

How can I prevent presbyopia?

While you can’t prevent presbyopia any more than you can avoid aging, there are everyday steps you can take to boost your eye health and slow down how fast it gets worse as you age. Keeping your eyes in top shape may also lower your risk for developing other more serious eye problems down the road, such as age-related macular degeneration (AMD).

Try these tips for top eye health:

  • Adequate lighting will substantially help reduce eyestrain.
  • Annual eye exams. Your prescription and ocular health can change rapidly, so make sure to see your provider regularly. Discuss with your provider any change in symptoms that could be a sign of something more serious.
  • Keep track of symptoms by writing them down.
  • Eat a healthy, balanced diet that contains plenty of green leafy vegetables (see below).
  • Exercise several times weekly.
  • Drink enough water to stay hydrated.
  • Limit alcohol.
  • Stop smoking.
  • Wear sunglasses. Shades do more than make you look cool. They protect your delicate eye tissue from harmful UV (ultraviolet) rays.

Which foods should I eat to keep my eyes as healthy as possible?

Your eyes rely on nutrients from the foods you eat to maintain vital eye tissues and functions. In addition to limiting alcohol and caffeine, you should make sure to stay hydrated by drinking enough water.

You should also try to eat foods that are rich in:

  • Vitamin A. You need enough of the antioxidant vitamin A in your diet (or through a supplement) to maintain the surface of your eyes and healthy vision. There are vitamin A-rich sources for every diet preference. Plant-based choices include vegetables like sweet potato, leafy green vegetables and carrots. Or you may choose animal-based foods, such as cheese, oily fish or liver.
  • Vitamin C. The best foods for getting your daily dose of vitamin C are fruits and vegetables, including oranges, grapefruit, strawberries and broccoli.
  • Vitamin E. If you already have AMD, make sure to get enough vitamin E. Studies have shown that this vitamin plays a role in slowing down the disease.
  • Lutein. Eat your leafy green vegetables to make sure you get enough lutein which helps your eyes filter harmful blue light that can damage your retinas.

If you know you aren’t getting the right vitamins because your diet hasn’t included enough healthy foods, you can take a multivitamin instead. Remember though that vitamins that come in a pill are not as well absorbed by the body as those that occur naturally in fresh foods.

A note from Cleveland Clinic:

Aging is a privilege, and privileges rarely come without a price. But when it comes to aging eyes and the ability to see up close, reading glasses, contact lenses or a simple surgery are but a small sacrifice. There are so many sight-correction options today that once you choose what’s right for you, you’ll be able to focus again on all your favorite things in fine detail — whether it’s reading the latest novel, painting your own “Picasso” or sewing a special new outfit.

Last reviewed by a Cleveland Clinic medical professional on 06/08/2020.

References

  • American Optometric Association. Presbyopia. (https://www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/presbyopia) Accessed 04/27/2020.
  • National Eye Institute. Refractive Errors. (https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/refractive-errors) Accessed 04/27/2020.
  • American Academy of Ophthalmology. What Is Presbyopia? (https://www.aao.org/eye-health/diseases/what-is-presbyopia) Accessed 04/27/2020.
  • American Academy of Ophthalmology. How Does The Eye Focus? (https://www.aao.org/museum-eye-openers/how-does-eye-focus) Accessed 4/28/2020.
  • Patel, I., & West, S. (2009). Gender differences in presbyopia. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760279/) Community eye health, 22(70), 27.
  • American Academy of Ophthalmology. IOL Implants: Lens Replacement After Cataracts. (https://www.aao.org/eye-health/diseases/cataracts-iol-implants) Accessed 5/1/2020.
  • Rasmussen HM, Johnson EJ. Nutrients for the aging eye. (https://pubmed.ncbi.nlm.nih.gov/23818772/) Clin Interv Aging. 2013; 8:741-748.

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