Presbyopia and Techniques of
Measurement
Um-e-Farwa Mahar
Lecturer
Isra School of Optometry
Al-Ibrahim Eye Hospital
LAYOUT
o Introduction
o Types of presbyopia
o Risk factors
o Symptoms and signs
o Refractive error and presbyopia
o Methods of determining near add.
o Management of presbyopia
Definition
o Presbyopia (from Greek presbys = old man
+ ops = see like, sight)
o Gradual, irreversible decrease in amplitude of
accommodation as expected with age
o Normal physiological state
Pathophysiology
Lenticular and extra-lenticular theories
• Lenticular
sclerosis of the nuclear lens tissue
lens capsule with age becomes thicker
• Extra-lenticular
loss of elasticity in the zonules
Optics of Presbyopia
Types of Presbyopia
Nocturnal
Premature Manifest
Incipient Presbyopia Absolute
Risk Factors
o Ocular disease or trauma
Removal or damage to lens, zonules, or ciliary muscle
o Systemic disease
Diabetes mellitus; multiple sclerosis
o Drugs
e.g., alcohol, antianxiety agents, antidepressants,
antipsychotics,
Risk Factors
o Iatrogenic factors
Scatter (panretinal) laser photocoagulation; intraocular
surgery
o Geographic factors
greater exposure to ultraviolet radiation)
o Other
Poor nutrition
Symptoms and Signs
“My arms are not long enough to see up close anymore”
"I have to hold my book further away"
“Newspaper print is not what it used to be"
Symptoms and Signs
o Blurred vision and the inability to see fine details at the
customary near working distance
o Other common symptoms are delays in focusing at near or
distance, ocular discomfort, headache, aesthenopia, neck &
back ache, redness & watering, fatigue or drowsiness from
near work, increased working distance, need for brighter
light for reading, squinting & diplopia
SIGNS Reduced amplitude of accommodation
The vision with Presbyopia
Distance Intermediate Near
Basic Principles
oFind refractive error for distance and correct it first
oFind presbyopic correction needed in each eye separately
and add it to distance correction
oNear point should be taken consideration according to
profession of pt.
Basic Principles
oOver correction should be avoided
oAdditional correction for intermediate distance may be
required
oPresbyopic add should leave certain percentage of AA in
reserve
AA in Reserve
oAmount of a new addition should permit a certain
percentage of the AA to remain in reserve
oRule-of-thumb
- Leaving one-half of the AA in reserve
(Lawrence and Maxwell)
- Leaving one-third of the AA in reserve
(Sheard and Giles)
Example 1
oWorking distance (WD)= 40cm
RAF (AA) = 2.00D
What should be the near addition
Accommodation required for WD = 2.50 D
Accommodation in Reserve = 1.00D
Amount of accommodation left = 1.00D
Amount of Near addition = (2.50 –1.00)
= +1.50D
Example 2
oWorking distance (WD)= 25cm
RAF (AA) = 1.50D
What should be the near addition
Accommodation required for WD = 4.00 D
Accommodation in Reserve = 0.50D
Amount of accommodation left = 1.00D
Amount of Near addition = (4.00 –1.00)
= +3.00D
Methods of
Determining Near Add
o Addition based on amplitude of accommodation
o Tentative addition based on age
o Plus build-up method
o Bichrome method
o Cross-cylinder method
o Relative accommodation method
o Dynamic Retinoscopy
Tentative add based on
Amplitude of Accommodation
oAmplitude of accommodation decreases with age
- Presbyopia is reported when NPA exceeds 8 inches
(22cm) i.e, AA = 4.50D (Donders)
oPresbyopia exists when amplitude of accommodation is
less than 5D (Morgan)
Hofstetter’s
Table of Age and Amplitude
Age of Range (Years) Range of Near Add in Diopter for
40 cm.
35 to 40 +0.75 to +1.00
40 to 45 +1.00 to +1.50
50 +1.75 to +2.00
55 to 59 +2.25 to +2.50
60 and over +2.50 to +2.75
Plus build-up Method
oWorks best when the corrected VA is normal at distance
oCan be done binocularly or monocularly
Plus lenses are increased in steps of 0.25D to the
amount necessary to first read the desired letters at
a customary working distance
The power of add is then increased in 0.25D steps
to the amount preferred by the pt.
Plus build-up Method
o Monocular build-up usually lands in more amount of
near addition
Since less accommodation
is available because of a
lack of convergence
accommodation
Bichrome Method
oBased on natural chromatic aberration of eye
oWidely used for determining spherical component of
distant correction
oWhen an ametropic eye is out of
focus for distance,
- red target is clearer in myopia
- green target in hyperopia
oThe same principles apply at near distance
Bichrome Method
o For presbyopic pts. red & green are focused behind the
retina with red farther away
o For Uncorrected or undercorrected presbyopic pt.
- letters on green background clearer
o An overcorrection for a near target
- the letters on red background clearer
Bichrome Method
Appropriate
correction
Over corrected
Uncorrected or
under corrected
Bichrome Method
o Pt.’s distance correction is placed on a trial frame
o Bichrome target is placed at habitual near distance (40cm)
o Tell the pt. to look at letters on both Green and red
background carefully
o Ask the pt. which side has the sharper and clearer letters
- Green clear : add plus in 0.25 step
- red clear : remove plus
- until pt. sees letters equally clear in both background
Bichrome Method
Demerits of Bichrome test
o With the older patients,
- the crystalline lens becomes markedly yellow
- blue green light being partially absorbed and scattered
- gives a red bias to the test
o Difficult in protanopic patient; since the red background
will appear much dimmer than the green
o Precaution : the subject is instructed to emphasize on
clarity of letters and not the background
The Cross Cylinder
Method
o Used to establish the point of accommodation for a
customary near WD (40 cm), adding plus lenses until the
horizontal and vertical lines on the cross cylinder grid
subjectively appeared equally clear
o The target consists of 4 to 5 vertical and horizontal lines
presented to pt. at 40 cm
o Illumination is sufficient to allow pt. to see target
satisfactorily
The Cross Cylinder
Method
+0.50DC -0.50DC +0.50DS/-1.00DCꭓ180
The Cross Cylinder
Method
The Cross Cylinder
Method
o Place the pt.’s best distance correction on the phoropter
(trial frame)
o Put the cross cylinder grid at pt.’s customary near working
distance (40cm)
o Place the Jackson Cross Cylinder in front of both of the pt.’s
eyes, with the minus cylinder axis at 900 (Red marks vertical)
(be cautious not to change the axis of the correcting cylinder)
The Cross Cylinder
Method
o Cross cylinder creates artificial astigmatism with an
interval of Sturm of 1.00D
o If pt. accommodates exactly for the target, both sets of
lines are equally clear
o If pt. under-accommodates, the horizontal lines appear
clear
o Can be done monocularly or binocularly
The Cross Cylinder
Method
Two variations of technique
Without
With Myopisation
Myopisation
The Cross Cylinder
Method
With Myopisation
o A +3.00 D lens is added binocularly to the distance
correction of pt. such that the individual can see the
vertical lines more sharply
o The add is then decreased binocularly in 0.25 D steps until
both the vertical and horizontal lines appeared equally
clear
The Cross Cylinder
Method
Without Myopisation
o With the distance correction placed in the phoropter, pt. is
asked which lines appear clearer, sharper or blacker
o If the horizontal lines are clearer, plus lenses are added
binocularly in 0.25 D steps until equality is reached
o Power of the plus lenses added is the tentative add
o In pt. initially appreciate the vertical lines or both more
clearly, the addition is recorded as zero
Relative Accommodation
Method
o NRA - measure of maximum ability to relax
accommodation while maintaining clear, single binocular
vision of a test object at a specified distance
o PRA - measure of the maximum ability to accommodate
while maintaining clear, single binocular vision of a target
at a specified distance
o The difference between the NRA and the PRA is called the
relative accommodative amplitude
Relative Accommodation
Method
o To measure NRA and PRA,
- pt.'s distance refraction and a tentative add is placed
in the phoropter (Trial frame)
- the near point test card (N6 target) is placed at the
reading distance (usually 40 cm)
Relative Accommodation
Method
o NRA is determined by adding plus power lenses binocularly
until the pt. is no longer able to read the fine print on the
test card
o PRA is determined by adding minus power lenses until the
pt. is no longer able to read the fine print
o Near add = (NRA+PRA)/2
Example
oNRA= +2.00 DS
oPRA= -1.00 DS
oADD= ?
{+2.00+(-1.00)}/2 =
+1.00/2 = +0.50 DS
Refractive Error and
Presbyopia
HYPEROPES
EMMETROPES
MYOPES
Management of Presbyopia
Contact Lenses Spectacles
Surgery
Management of Presbyopia
o A variety of options are available
o Recommendations are made on the basis of the pt.'s
specific vocational and avocational needs
o Success of treatment depends on
- the lens power
- the specific visual tasks and characteristics of the
individual pt.
- the appropriate pt. education given by the practitioner
Management of Presbyopia
Optical Correction with Spectacle Lenses
o Single vision lenses
o Bifocal lenses
o Trifocal lenses
o Progressive addition lenses
Management of Presbyopia
Optical Correction with Contact Lenses
o Single vision contact lenses
o Bifocal and multifocal contact lenses
- Alternating vision bifocal contact lenses
- Simultaneous vision contact lenses
o Monovision contact lenses
Management of Presbyopia
Surgical Treatment
oLaser in-situ keratomileusis (LASIK)
oMultifocal intraocular lens (IOL)
oAccommodating intraocular lens implants
oConductive keratoplasty (monovision)
For Further
Reading
o Clinical Procedures in Optometry by J.D. Bartlett, J.B.
Eskridge, J.F. Amos
o Primary Care Optometry by Theodere Grosvenor
o Borish’s Clinical Refraction by W.J. Benjamin
o Clinical Procedures for Ocular examination by Carlson et al
o American Academy of Ophthalmology
o Optometric Clinical Practice Guideline by American
Optometric Association
o Internet
