Learn about the non-surgical and surgical options available to manage presbyopia when you also have a retinal condition.
Are you having trouble seeing things up close recently? Do you think you may be suffering from presbyopia?
Recently, I came across an advertisement for Vuity, an eye drop approved for presbyopia. This coupled with my parents, who also have retinal conditions and presbyopia, made me curious to know the treatment options available today.
In this article, let’s explore the various treatment options for presbyopia – eyeglasses, contact lenses, the presbyopia eye drop, and surgical procedures.
What is presbyopia?
Presbyopia is the gradual loss of our eyes' ability to focus on nearby objects, often a frustrating aspect of aging. Generally, people start noticing their vision problem due to presbyopia between the early to mid-40s and it continues to worsen until around age 65.
Symptoms of presbyopia can include:
- Holding reading material farther away to make the letters clearer
- Blurred vision at a normal reading distance
- Eyestrain or headaches after reading or doing close-up work
These symptoms might feel more pronounced when you're tired or in dimly lit areas.
So, what causes presbyopia? Our eyes depend on the cornea and lens to focus light reflected from objects. The cornea is the transparent, dome-shaped front surface of the eye, while the lens is a clear, flexible structure about the size and shape of an M&M candy. Both of these parts bend light entering the eye to focus images on the retina, which is located on the inside back wall of the eye.
The lens can change shape with the help of a circular muscle that surrounds it called the ciliary muscle. When looking at distant objects, the ciliary muscle relaxes. And when focusing on nearby objects, the muscle constricts, allowing the lens to curve and adjust its focusing power. Presbyopia occurs as the lens hardens with age, losing its flexibility and making it difficult to focus on close-up images.
The prevalence and severity of presbyopia increase with age, affecting up to 85% of individuals aged 40 or older. In 2015, around 1.8 billion people worldwide had presbyopia, with the number expected to peak at approximately 2.1 billion by 2030. And it is estimated that 94% of those with significant near vision disability due to uncorrected presbyopia reside in developing countries.
Uncorrected presbyopia also poses significant concerns, particularly regarding falls among older adults. Old adults with visual impairing conditions, such as cataracts, presbyopia, glaucoma, and macular degeneration, have a higher likelihood of falling.
Presbyopia treatment options
Presbyopia can be managed by nonsurgical and surgical approaches, including optical treatments, eye drops, keratorefractive, and intraocular refractive procedures. Let’s have a look at the different options. [1]
1. Optical-Based Treatments
Eyeglasses are the most common way to address vision issues caused by presbyopia. Reading glasses may suffice for those with good uncorrected vision before presbyopia, but it's still important to see an eye doctor for an eye examination before purchasing. Prescription eyeglasses are necessary for individuals who already require corrective lenses or find nonprescription glasses insufficient. There are a few main categories of prescription eyeglasses:
- Reading glasses: Designed specifically for reading and taken off when not in use.
- Bifocals and trifocals: Lenses with separate areas for distance and reading vision, with trifocals also offering an additional middle-distance vision correction.
- Progressive lenses: These lenses provide multiple powers for distance, middle distance, and close-up corrections without visible lines.
Even though glasses can help you see better, as you get older they might not be able to make your eyes work as well as they used to. Sometimes you might need multiple prescriptions in one pair of glasses, but that can be more expensive and only let you see clearly in certain areas or fields of view.
Contact lenses offer another solution for presbyopia. However, this option may not be suitable for people undergoing eye injections or who had eye surgery due to the increased likelihood of having dry eye. For people appropriate, there are several contact lens options available:
- Bifocal and multifocal contact lenses: These lenses provide distance and close-up correction, with multifocal lenses offering a more gradual transition between corrections.
- Monovision contact lenses: One eye is corrected for distance vision, and the other eye is corrected for close-up vision.
- Modified monovision: A combination of bifocal or multifocal contact lenses in one eye and a distance contact lens in the other, allowing for both distance vision and reading.
2. Pharmaceutical treatments
Vuity (pilocarpine 1.25% ophthalmic solution) is a recently approved innovative treatment for presbyopia by the FDA in Oct 2021. The eye drop is a miotic that targets specific eye muscles, causing them to contract. This muscle contraction helps the lens of the eye change shape creating a pinhole effect, and allowing for better focus on nearby objects.
Two Phase III studies were conducted to evaluate the safety and effectiveness of Vuity in individuals with presbyopia. Results showed that the once-daily eye drop was effective in improving close-up vision within 15 minutes of use, with the effects lasting for 6 to 10 hours. The most commonly reported side effects were mild headaches and eye redness. Some people also reported blurred vision, eye pain, eye irritation, and tearing.
However, it is important to note that miotics have been associated with rare cases of retinal detachment, vitreous detachment, retinal tears, and vitreomacular traction. These complications can lead to possible vision loss or other sight-threatening conditions, such as macular pucker and macular hole. Therefore, individuals with retinal conditions are at an increased risk of their condition worsening, making miotics eye drops unsuitable for them.
3. Surgical procedures
Surgical procedures for presbyopia are usually considered when other treatments such as glasses, contact lenses, or medications are no longer effective or suitable for the patient. It is usually considered after a thorough eye examination and discussion with an eye care professional.
Keratorefractive surgery, commonly referred to as LASIK, is a popular and effective way to correct presbyopia for adults, which involves reshaping the cornea to improve vision. There are several other types of keratorefractive surgery available, including LASEK, PRK, and SMILE. PRK was the first type of keratorefractive surgery approved by the FDA. It removes the outer layer of the cornea to reshape the underlying tissue. LASIK and LASEK both create a flap in the cornea with a laser and reshape the underlying tissue, while SMILE removes a small disc of tissue from the cornea to reshape it.
Common risks and complications of keratorefractive surgery include over or under-correction, dry eyes, glare, halos, light sensitivity, visual fluctuations, visual correction regression, corneal scarring, and corneal over-thinning.
Corneal inlay is another surgical option for presbyopia. These are small plastic rings with a central opening that are inserted into the cornea of an eye. They work by allowing focused light to enter and improve close-up vision. These inlays were found to significantly improve reading performance. However, side effects include a small decline in distance vision or the development of corneal haze.
Phakic intraocular lens implantation (PILI) is another option for correcting refractive error. This procedure involves the implantation of an IOL directly into the eye without removing the natural lens. PILI provides clear vision without the need for glasses or contact lenses.
Like any surgical procedure, there are potential risks and benefits to consider. Possible risks or complications include discomfort, inflammation, infection, retinal detachment, corneal edema, iritis, cataract development, visual fluctuations, and elevated eye pressure leading to glaucoma. Some patients may also experience blurred or halos around lights.
Refractive lens exchange (RLE) involves removing the natural lens in each eye and replacing it with a synthetic lens, known as an intraocular lens (IOL). This new lens is designed to correct refractive errors and improve vision. However, it is important to note that the FDA has not approved the use of a pseudophakic IOL for solely correcting refractive errors in cases where there are no visually significant cataracts present.
RLE can cause a decrease in the quality of near vision and possible side effects, such as glare and blurring. Similar to cataract surgery, this procedure carries the risk of inflammation, infection, bleeding, and glaucoma.
It's worth mentioning that there are different types of IOLs available. In patients with retinal conditions or a risk of retinal detachment, certain IOLs, such as silicone, multifocal, or hydrophilic acrylic lenses, should be avoided due to their potential complications. Therefore, it is important to discuss with your doctor the different types of IOLs available and determine the best one for your specific needs.
4. Monovision Consideration
Monovision is a vision correction technique that involves optimizing one eye for distance vision and the other eye for near vision. This enables the brain to adapt and utilize the appropriate eye for different tasks, ultimately improving near vision and reducing dependence on reading glasses.
While it can be used in conjunction with most of the above-mentioned surgical procedures, it is crucial to consult with your eye doctor to determine if it is suitable for you. Your eye doctor can assess your individual needs and provide personalized guidance on the best treatment options for your vision.
Key takeaways
Presbyopia is a common condition that affects many older adults. And uncorrected presbyopia poses significant concerns, particularly regarding falls among older adults.
While eyeglasses are popular, advancements in contact lenses, pharmaceuticals, and surgical procedures provide additional options for presbyopia correction.
Unfortunately, both of my parents have retinal conditions and are not suitable for the Vuity eye drop. But, on the bright side, now I have a better understanding of how my wife and I may benefit from Vuity!
In all seriousness, it's exciting to see new developments in presbyopia treatment, and I look forward to what the future holds in terms of innovation for this common condition.
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