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Presbyopia Challenge | May/June '16

Through a Patient’s Eyes

What is it like to be presbyopic? As a young surgeon reading this column, how do you empathize with your aging presbyopic patients? What is it like to have trouble with seeing near activities? How do you interpret the relevancy of clinical studies and testing of near vision? We never quite know how our patients are seeing; but as this emmetropic Gen X surgeon begins the dark journey into presbyopia, I hope to shine some light on the matter.


We all have a chance to experience presbyopia firsthand—accommodative visual loss is only a dilating drop away. I distinctly remember a day in my early 30s when I got dilated. It wasn’t for a planned eye exam; I was going through morning clinic when I noticed a scintillating scotoma. By the time I realized what it was, the dilation was at full strength and my accommodation was gone. I still had a full schedule of clinic patients to see while cyclopleged. A quick trip to my optical shop helped me get by, and I had fun explaining to my refractive cataract patients why their young surgeon needed reading glasses. It didn’t take long to realize how inconvenient presbyopia would be.

Now in my early 40s, I notice my own steady (and irreversible) journey to presbyopic purgatory. I can still read my charts, sign checks (far too many of them!), and work on my iPhone. I can still get down to J1+ on a high-contrast near card better than most of my patients. However, there are two significant—and rather unexpected—areas in my life where I am noting the inevitable descent into the accommodative abyss.

My first nonpharmacologic symptoms of presbyopia actually came during my monthly ritual of—that’s right—cutting my kids’ fingernails. Ever since they were infants, I’ve enjoyed snuggling my daughters on my lap, talking and singing to them, and trimming their nails. Recently, I’ve noticed that it’s been getting more difficult to see their cuticles clearly. It doesn’t help that they wiggle around, but now I have to turn up the light to see them well.

The second area in which I notice my impending presbyopia is eating. I can see menus and the food on my plate just fine. The problem is, when I bring food up to my mouth, or if I look at the food that I am holding, it moves too close for me to distinguish clearly. Where I used to be able to glance at my food for the next bite, I now get a blurred image.

I test fine clinically, so why is presbyopia starting to affect me? Let’s take a closer look. Why do these two tasks affect me in a way that a near card doesn’t reveal? In the first case, it’s lighting and contrast. I typically cut my daughters’ nails in the evening in their dimly lit room, and their cuticles are low-contrast objects. Going from mesopic to photopic lighting helps the problem—at least for now. What about eating? As I move my food up and down, it moves through my accommodative near point. Eating is the ultimate push up and push down test. When a piece of the food that I’m eating crosses my accommodative near point, it blurs. Holding things a little further back helps—until my arms get too short.


Common clinical testing for near vision clearly does not fully characterize our daily visual needs and experience. Most patients have more problems seeing to do their hobbies than they do reading or driving. Distance, illumination, contrast, color, and even texture affect our daily visual experience in ways that a black-and-white eye chart cannot measure. Near visual acuity testing does provide a foundation from which we can begin to comprehend our patients’ experience, but we should always remember that there is much more to our patients’ visual experience than what we measure on a chart.

While more subjective than visual acuity data, validated patient reported outcomes, or PROs, can provide important insights into how our patients respond to new treatments for presbyopia. Ultimately, our patients’ ability to read an eye chart is nice, but their ability to live the lifestyle they want without the hindrance of presbyopia should be our ultimate goal.

Daniel Chang, MD
Daniel Chang, MD
  • Private practice at Empire Eye and Laser Center in Bakersfield, California
  • dchang@empireeyeandlaser.com
  • Financial interest: None acknowledged