Treatment of presbyopia

Meanwhile, a person’s eyesight naturally deteriorates after the age of 40, and it has nothing to do with possible defects such as myopia, hyperopia (farsightedness) or astigmatism. Not only that: it also appears in people who have never been diagnosed with any visual defect. This is because presbyopia is associated with progressive stiffening of the lens and weakening of the eye’s accommodative ability (accommodative muscles are getting weaker). These changes cannot be prevented – they result from the natural wear and tear of our body. Even the healthiest lifestyle will not make them pass us by. It is worth adding that some diseases, such as diabetes, or the use of antihistamines or antidepressants can accelerate the development of presbyopia.

It is estimated that by 2020 the number of people struggling with presbyopia worldwide will be around 1.3 billion. It is a problem that is easy to diagnose and possible to correct. So it’s worth reaching out for help from a specialist.

“Too short hands”, or a farsighted person reads a newspaper

The first symptoms of presbyopia are impossible not to feel: disruption of accommodation is felt as a great discomfort. This first stage of lens stiffening occurs by leaps and bounds, and at some point the process slows down and rolls less rapidly. Every two to three years is a loss of visual acuity by a quarter or half diopter of near vision correction. We then laugh that our hands are too short for reading – that is, we can’t move the text we’re reading away from our eye enough to see it clearly – and refer to ourselves as farsighted. But in fact, “ordinary” farsightedness (hyperopia) doesn’t have to be involved at all, or it’s not just that. It’s evolving presbyopia, also referred to as presbyopia or presbyopia farsightedness, which gives the following symptoms:

• inability to read text up close – the smaller the letters, the greater the trouble (text message, footnote in a book, menu in a restaurant, text on a computer monitor)
• Headache and visual fatigue when looking up close
• Problems with visual accommodation in the so-called. The gray hour (when darkness falls or just after it falls)

It is important to be aware that already after the age of 35 our eyesight, regardless of previously diagnosed defects, begins to deteriorate . Presbyopia It is usually diagnosed as early as 40. year of life, and its highest intensity is when we are 40-55 years old. Around the age of 60 (some believe between 65 and 70) this process comes to a halt.

We can easily check whether the onset of presbyopia has touched us. Let’s concentrate on reading text up close, and then quickly look away – for example, at a window, a painting or a TV. If it takes a few seconds to shift our eyes to distance vision (until we see a sharp image again), we should seek eye care.

Correction of presbyopia

Presbyopia easily lends itself to eyeglass correction, but if you lead an active lifestyle, it’s worth seeking other solutions as well.

Reading glasses

If the symptoms of presbyopia appeared in a person with a diagnosed visual impairment, until recently he or she had to get two pairs of glasses – the first adequate for his or her defect and the second for reading.

Then came bifocal eyeglasses, i.e. eyeglasses in which two powers are built in – in the main area (when looking straight ahead) the power for seeing at a distance, and in its lower segment – a higher power to facilitate reading. However, the transition from one area to the other is very unnatural for the eye, taking place in leaps and bounds, and not every patient was able to get used to wearing bifocal glasses. So progressive glasses were created. With progressive eyeglasses, the change of the corrective value on the surface of the lens is made not in leaps and bounds, but smoothly. The upper part of the corrective glass is used to see objects far away, lower its power increases so that you can see intermediate distances (from a few meters to a few tens of centimeters) sharply. The lower area is for reading and looking at a distance of less than half a meter. Progressive glasses can also have lenses that correct other vision defects.

Two pairs, bifocal lenses and progressive lenses

If the symptoms of presbyopia appeared in a person diagnosed with myopia, until recently he or she had to get two pairs of glasses – the first adequate for his or her visual impairment and the second for reading. Then came bifocal lenses, that is, lenses in which two powers are built in – in the main area (when looking straight ahead) a power for seeing at a distance, and in its lower segment – a higher power to facilitate reading.

However, the transition from one area to the other is very unnatural for the eye, taking place in leaps and bounds, and not every patient was able to get used to wearing bifocal glasses. So progressive lenses were created.

With progressive lenses, the change of the corrective value on the surface of the lens is made not in leaps and bounds, but smoothly. The upper part of the lens is used to see objects far away, lower its power increases in such a way as to see intermediate distances (from a few meters to a few tens of centimeters) sharply.

The lower area is for reading and looking at a distance of less than half a meter. With progressive eyeglasses, you can have lenses with vision correction.

Contact lenses

In the correction of presbyopia, multifocal lenses are very effective. They are multifocal, allowing you to see both far away and up close. Multifocal lenses look the same as other contact lenses, but are constructed to allow vision regardless of distance. The center of the lens has a different breaking of light than the periphery, allowing clear perception of objects at most distances.

However, it is worth knowing that the period of adaptation to the comfortable wearing of multifocal contact lenses can be quite long, and in the case of people with bifocals (a different defect in each eye), adaptation may not only be significantly difficult, but often even impossible, and will require trial and error searching.

Monovision

Monovision can be performed in a variety of ways: with contact lenses, through correction with an ophthalmic laser , or with intraocular lens implants.

Monovision is a method of vision correction used in offsetting the effects of presbyopia that involves subjecting each eye to a different correction in order to prepare one eye for long-distance vision and the other for near-distance vision.

In short: one short-sighted and one long-sighted eye is artificially created.

Laser vision correction in presbyopia

Depending on whether presbyopia is the only eye dysfunction or is accompanied by vision defects, the patient can choose from the following laser correction methods:

• without any other vision defect – /Femto-LASIK/Monovision PresbyMAX/ lens replacement, phakic lens
• Hyperopia/myopia +3 to -5 Femto-LASIK/Monovision PresbyMAX/LASIK inpresbyopia,
• all vision defects – lens replacement with monofocal or multifocal implants and EDOF

LASIK (laser assisted in situ keratomileusis): a two-step technique; the cornea is incised with a scalpel (microkeratome), and then the surface inside the cornea is modeled so that it can properly focus the image onto the retina.

Femto-LASIK (All-Laser-LASIK): With a precise femtosecond laser, the surgeon makes a cut into the cornea, creating a thin flap 0.1 mm thick – a flap. He uses an excimer laser to reshape the previously exposed cornea for a few seconds, then the flap is closed back up; it attaches and forms a protective corneal barrier. This method allows for multifocal correction and monovision.

Lens replacement, also known as refractive lens replacement, can be performed with a variety of customized lenses. In the treatment of presbyopia, the following are used:

• Multifocal lenses of the latest generation (trifocal lenses, EDOF, for near and far vision and intermediate area);
• Monofocal lenses (also known as “enhancement lenses,” often used in cataract surgery);
• Toric lenses (for astigmatism correction);
• Toric trifocal lenses (correct presbyopia and astigmatism);
• FAKIJNE lenses implanted in addition to the natural lens.

Treatment of presbyopia – step by step

Before the surgery – preliminary examinations

At the beginning of the first visit, we conduct a comprehensive anamnestic interview. At that time, we not only record the patient’s previous illnesses, surgeries performed and medications taken, but also explain what is particularly troublesome about presbyopia and what methods of correction are involved. We provide comprehensive information on the various options for correcting presbyopia.

Full eye control

Then we carefully examine the eyes. We determine the exact visual acuity and the exact degree of presbyopia. We examine the retina and measure the pressure inside the eye. These tests are used to determine whether other eye diseases are also present. In the next step, we measure the eye and perform optical biometry, considered the most precise method of measuring the length of the axis and partial sections of the eyeball. We also record the curvature of the cornea – this is done completely non-contact using a laser that takes measurements along the axis of the eye. This method is completely safe and excludes measurement errors that occur when measuring with ultrasound.

Corneal examination

In order to make the optimal correction of presbyopia, an accurate map of the cornea is made. Using corneal tomography, the anterior and posterior walls and thickness of the cornea are precisely measured. This examination is used to determine all anatomical properties of the cornea. On the basis of such a “map” the refractive power of the eye is determined, which plays a very important role during the correction operation.

In addition, we offer another painless examination of the anterior corneal wall – optical coherence tomography of the anterior segment of the eye. The test is non-contact and can be compared to an ultrasound, but laser light is used instead of sound.

Wavefront study

A wavefront study is then conducted. A beam of light is sent to the eye, focused precisely on the retina. From this point, a light wave front propagates through the lens and cornea. Using this method, it is possible to determine exactly where lasing is required to optimize visual power.

Important for preliminary examination

Do not wear soft contact lenses for one week and hard contact lenses for three weeks before the test.
Eye drops are used during the test to dilate the pupils. This causes a higher sensitivity to light, and for this reason you should not drive or operate machinery for two to three hours after the test.

What is the next step?

After an initial examination, it is discussed whether ophthalmic laser surgery is appropriate in your case. The patient is informed about the course of the operation, the risks and side effects, and further treatment.

Making an appointment

If a patient decides to have presbyopia corrected, we work together to set up a perfectly suitable date. Up to two days before the operation, contact lenses can be worn again.

Laser correction of presbyopia

Two different lasers are used in this modern method, which allows the wearer to dispense with glasses. A small incision is made in the cornea using a state-of-the-art femtosecond laser. An excimer laser is then used. To be able to see up close and far again sharply, with the laser, the dominant eye is set to good vision for distance, while the other eye is set to myopia between -0.5 and -1.5 diopters. To keep spatial vision as limited as possible, we make sure that the difference between the eyes does not exceed 1.5 diopters. Of course, there are significant differences in the needs of near and far vision on a case-by-case basis.

Anyone who plays golf as a hobby and travels extensively by car on business needs better long-distance vision, and is therefore more willing to accept slight disadvantages (such as wearing glasses when driving at night). On the other hand, someone who sits in front of a computer all day and likes to read in the evening will prefer to have better vision up close and slightly worse vision at a distance. If the procedure is performed in the second phase of life, there may be problems with three-dimensional vision afterwards.

The prince of poets, Johann Wolfgang von Goethe, had an innate monovision, hence today it is called Goethe’s vision

Before the procedure is performed, a specific type of vision is simulated with contact lenses. This is done as part of the preliminary examination. If the initial test is not sufficient to definitively assess tolerance, the trial can continue with different contact lenses, including for several days. About 80% of people do well, 20% do worse. However, other methods of correcting presbyopia can be found for the latter group.

It is important to give yourself time to become familiar with your new vision. This means that the visual apparatus may need a few days to readjust and see normally again – without presbyopia.

Correction with implants

Presbyopia can be treated with special lens implants. This method is called early cataract surgery because it involves removing the presbyopic lens from the eye and replacing it with artificial lenses that cannot contract cataracts.

The procedure is performed on an outpatient basis, after a comprehensive eye examination. After anesthetizing the cornea with drops, a small incision is made at the edge of the cornea. This cut is so small that no suture is needed afterwards. The natural lens is crushed and aspirated using an ultrasonic device. The lens bag remains intact at all times. A coiled artificial lens is then inserted through a tiny incision, which unfolds on its own and fits snugly into the eye. All this is painless for the patient. After the procedure, the eye is covered with a bandage, and the patient can leave the clinic with a companion.

Multifocal lenses

The multifocal lens is very suitable for the correction of presbyopia. It consists of several rings, each of which has a different focusing ability. This creates several focal points in the eye that allow both near and far vision. The disadvantage of multifocal lenses is that they make night driving difficult (light rings and reflections form around headlights and other light sources).

Trifocal lenses

These state-of-the-art multifocal lenses also create several focal points in the eye. They are sufficient for near and far vision and the intermediate area. With them, you can see well even from a distance of 60 to 80 cm. In addition, they improve visibility at night. In our practice, we use only multifocal lenses of the latest generation.

Day of operation

On the day of the operation, you should come with a companion. Do not use any creams, powders, makeup, mascara, aftershave or other substances applied to the face on this day. This is important for preventing eye infections. You can eat and drink normally. What follows is a clarification of recent issues. Patients are also given medications and instructions on how to use them after surgery. Before we start, we make a follow-up appointment for the next morning. The procedure itself is very quick – it takes only 10-20 minutes and does not cause any pain.

 

And after the treatment?

After the eye correction is performed, the patient gets protective glasses and can go home with a companion. He may experience symptoms such as watery eyes, a slight burning sensation or a sense of the presence of a foreign body. On this day, the eyes should be closed as much as possible (except, for example, when going to the toilet or eating). Avoid watching TV, reading, working on the computer, using smartphones, etc. The eyelids put pressure on the cornea, which accelerates its healing. To prevent boredom, you can listen to an audiobook or music. Other than that, it is important to remain calm.

Safety glasses should also be worn at night to prevent accidental eye injuries. Avoid rubbing or applying pressure to the eyes in the first few days after surgery. After laser surgery, no makeup should be worn for two weeks to avoid eye infections. Once the lenses are replaced, the “makeup ban” is in effect for four weeks. For two weeks, do not take a bath, go to a spa or sauna, or take a shower with your face directly in the direction of the water stream. You should also avoid drafts, smoky, windy and dusty rooms for two weeks. This includes physical exertion.

We provide patients with an eye drop plan and two types of drops (cortisone drops and antibiotic drops). The plan indicates when and with what medications you should eye drop.

On the day after the operation, come in for another appointment. Usually on this day, patients have no complaints and recover about 90% of their vision. The next survey is scheduled for next month.

 

Summary

Several methods of permanent correction of presbyopia are available. All procedures can be performed on an outpatient basis and are completely painless for the patient.

Monovision is a method suitable for the elderly who do well with their far and near vision (simulation with contact lenses is performed before surgery).
Lens replacement is needed if laser correction is not an option, the patient is over 50, and his natural lens is already slightly cloudy (the onset of cataracts).

In refractive lens replacement, the natural lens is removed using computer-controlled ultrasound and replaced with a suitable artificial lens.

At SwissLaser, we use state-of-the-art multifocal lenses (trifocal lenses) that allow for good near and far vision and excellent coverage of the area between near and far vision (the intermediate area).

Just a few days after the operation, the patient regains good vision and no longer needs to use glasses.

If there are still residual vision defects after lens replacement, they can generally be corrected with laser correction.