What is Presbyopia?
Surgical Treatment Options - LASIK Surgery & Keratoplasty
Non-Surgical Treatment Options

Everyone will develop a condition called presbyopia beginning between the ages of 40 and 50 even if you have undergone LASIK surgery or PRK. Presbyopia is the inability of the eye to focus at all distances. This is usually noticed when fine print starts to blur.

There are varied explanations for presbyopia. Most doctors believe the stiffening of the eye's lens contributes to the condition. Other theories suggest that presbyopia could also be related to continued growth of the lens or atrophy of the muscles controlling the lens.

In the past, the usual remedy was to wear reading glasses or special multifocal contact lenses (bifocal or progressive) for presbyopia. Nowadays, surgical remedies for presbyopia also are available for certain candidates.

One of the first effective surgical options was producing what is known as "monovision" during LASIK surgery. But other surgical procedures such as conductive keratoplasty or CK (see below) also have been approved by the FDA, which gives patients additional options for correcting this common vision problem.

One way to treat presbyopia is by producing monovision. Normally, both your eyes work together equally when you look at an object, to produce what's called binocular vision. However, most people have a dominant eye that your brain tends to favor for "sighting" (for example, most right-handed people are right-eye dominant). Contact lens fitters often take advantage of this "one-eye dominance" to produce monovision (think of it as the opposite of binocular vision) with the fit contacts: one eye is fit for distance vision (typically the dominant eye) and the other for near vision.

Therefore, in monovision, one eye does more work (sighting) than the other. If one of your eyes is set for distance vision and the other is set for near vision, the distance eye will do most of the work when looking at objects in the distance, and the near vision eye will do most of the work when looking at objects close by.

Some LASIK surgeons will produce monovision in their presbyopic patients by purposely leaving the non-dominant eye slightly nearsighted so that these patients can see up close without glasses (out of one eye). Many are wary of the technique because not everyone can become accustomed to the absence of binocular vision. It's best to try monovision with contact lenses or trial lenses in the doctor's office first to be sure you can adapt.

Monovision and Conductive Keratoplasty (CK) CK uses low-level, controlled radio-frequency energy to shrink collagen found in the periphery of the cornea. This steepens the central cornea, in effect lengthening a too-short eyeball. In 2002, the FDA approved CK for the temporary reduction of farsightedness, then received approval in April 2004 for the temporary improvement of near vision in people with presbyopia. CK is also a monovision technique used to help one eye see better up close, while the other eye is not touched (if you are already nearsighted, that eye would wear a contact lens to see at distance). It's a good idea to try monovision with contact lenses or a trial lens in the doctor's office before going ahead with CK, to make sure you'll adapt to it. After the three-minute procedure you'll likely notice improvement, but it can take a few weeks before you reach the final level of vision correction. One attractive feature of CK is that it is minimally invasive. Some patients experience tearing, foreign-body sensation, and/or vision fluctuation, but this is usually temporary.

How CK works: After using numbing eye drops to eliminate any possibility of pain, the eye doctor imprints the cornea with a circular treatment pattern. The ink will wash away later. Then, using a tiny probe, the eye doctor applies radio waves in the circular pattern to shrink some of the collagen in the cornea. The circular treatment pattern acts like a belt that tightens around the cornea, increasing its curvature for better near vision. (Drawings provided by Refractec, Inc.)

In laser thermal keratoplasty, mild laser heat is used in a three-second procedure to shrink collagen in the periphery of the cornea to steepen the eye's surface for correction of near vision in farsightedness or presbyopia. End results are similar to CK (see above).

In this procedure, four plastic segments made out of polymethyl methacrylate (PMMA) are inserted just below the surface of the sclera, which increases the distance between the muscles that focus the lens and the lens itself. Researchers think the extra distance augments the tension of the muscle, thus allowing it to do a better job of focusing the lens.

Results from early phase clinical trials involved five patients, all of whom were able to read newspaper print after scleral expansion bands were inserted. Modifications have been made to the earlier implants, and clinical trials as of 2006 were continuing. Overall, some eyes that have received the implants show improvement, and some do not.

Laser presbyopia reversal involves using infrared lasers to make eight spoke-like excisions in the tissue near the lens (sclera) to thin it and give the lens more room to operate.

The company pioneering this new technology, SurgiLight, Inc., studied 100 eyes of 55 patients who had the procedure. Preoperatively, they all had near prescriptions of +1.5 D to +2.5 D, with an average improvement of 1.9 diopters after surgery.

Another study found that most patients' accommodative range increased by 1.00 to 2.50 diopters within two weeks of surgery. There was minimal regression 18 months later.

The company is currently conducting clinical trials.

One currently available option for presbyopia correction involves removing the eye's natural lens and inserting an artificial one in a procedure identical to cataract surgery. While this surgical procedure is not FDA-approved specifically for presbyopia correction, it may be available off label for qualified candidates. The surgical procedure, known as refractive lens exchange (RLE) or clear lens extraction, is becoming more popular because of the recent availability of three FDA-approved multifocals such as the ReSTOR, ReZOOM or Crystalens or accommodative artificial lenses capable of correcting presbyopia.

[Read more about refractive lens exchange and cataract surgery.]

Different zones in a multifocal artificial lens correct vision at near, intermediate, and far ranges. In an investigational procedure known as multifocal or presby LASIK surgery, zones are established in a similar way on the eye's clear front surface (cornea) to correct presbyopia. Multifocal LASIK surgery is an investigational procedure, which is not FDA-approved. U.S. clinical trials investigating the effectiveness and safety of the procedure currently are being conducted.

If you need help seeing up close and in the intermediate distance, you'll find many new bifocal and multifocal lens options.

Offering the convenience of contact lenses as well as the ability to see close up and far away, multifocal and bifocal contacts help active Baby Boomers adjust to any situation without eyeglasses.

People who perform certain tasks at home or at work may need special-purpose multifocal lenses. One example is a bifocal lens with a near-focus segment in the top half, for a mechanic who needs to look up a lot. By improving your eyes' focusing power, these special lenses can reduce eyestrain and fatigue.

No lines! They let you see at all distances, from far away to up close, without the irritation of transitional lines. The right progressive lenses can help your eyes focus the way they would if you didn't need vision correction at all.

If you're over 40 and beginning to experience blurry vision at near, reading glasses can be a quick fix. They work as a great adjunct to distance vision-correcting contact lenses.