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