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Presbyopia Challenge | Sept '13

Presbyopia: A Degenerative Medical Condition?

Not young enough to be a Millennial, I recently celebrated the dubious milestone affectionately known as the “big 4-0”—complete with black-colored decorations and condolences regarding my senility. The only thing lacking was a pair of reading glasses. I didn’t need any reminding of my impending presbyopia, since I’m already starting to feel its symptoms.

I work with presbyopic patients on a daily basis, but feeling the effects of this “age-related focus dysfunction” first-hand is reshaping my perspective. As a life-long glasses-free emmetrope, I dread the day that I’ll need to reach for reading glasses. I like reading apps like MillennialEYE on my iPhone without having to pull out my full-sized iPad!

The “Presbyopia Challenge” column will seek to highlight issues related to this refractive disorder, its treatment, and what the future may hold. Because any decision to perform presbyopia-correcting surgery depends on weighing the risks and benefits of surgical versus nonsurgical treatment options, this column would like to challenge the conventional perspective on this universal sign of “getting old.”

Traditionally, presbyopia is considered a normal part of aging. When patients present with near-vision symptoms, they are usually reassured and dismissed with instructions to get reading glasses. Most patients—even postrefractive patients—must then concede to a life-long dependence on glasses.

What if we think of presbyopia as a degenerative medical condition? Acquired “accommodative vision loss” is a chronic, progressive, irreversible, permanent disease process that results in disability with the loss of multiple lines of visual acuity. Quality of life is most definitely affected on a daily basis, and there is no medical treatment or prevention. The standard-of-care treatment involves the use of reading or bifocal glasses that restore some of the lost visual function. These glasses have their own associated morbidities, including visual field constriction, distortion, peripheral field loss, aesthenopia, contact irritation, and increased risk of falls. They can be easily scratched, damaged, or lost; and they require frequent cleaning and replacement. While generally not an issue in developed counties, access to such optical devices can be a significant issue in the developing world where the vast majority of visual impairment from uncorrected presbyopia exists.

We don’t often think of presbyopia this way because the universal integration and acceptance of this acquired disability discounts its negative lifestyle effects. Nevertheless, as surgical treatments of presbyopia increase in safety and efficacy, the decreasing risks associated with correcting presbyopia should be fairly weighed against the disabling affects of its not being treated.

The surgical correction of refractive error with cataract surgery has gone from impossible to possible to expected. The surgical correction of presbyopia will likely follow a similar course, with technology and financial considerations determining how rapidly it is adopted by patients and surgeons. Am I currently offering presbyopia-correcting surgery to every 40-year-old patient who loses his or her near vision? Not yet, but perhaps that day will come before this Gen-X’er retires.

Daniel H. Chang, MD

Daniel H. Chang, MD, is in private practice at Empire Eye and Laser Center in Bakersfield, California. Dr.Chang is a consultant to Abbot Medical Optics. He may be reached at (661) 325-3937; dchang@empireeyeandlaser.com

Sept '13