The Presbyopic Tsunami: More Than Just a Refractive Error

AS TREATMENT OPTIONS EVOLVE TO MEET THE HIGH VISUAL demands of the growing number of presbyopes, astute practitioners will expand their practices by developing individualized treatment plans to offer multiple options and enhance the quality of life of those with presbyopia.

The prevalence of unmanaged presbyopia is up to 50% in those older than 50 in developing nations due to a lack of awareness and poor accessibility of affordable treatment. The prevalence in developed countries is as high as 34%. Moreover, the Millennial generation (born 1981-1996) is entering its 40s, so the number of presbyopes is expected to increase. Millennials are now the largest adult cohort worldwide at 72.1 million, surpassing the size of the Baby Boomer population (born 1946-1964) of 71.6 million.1 Add these aging Millennials to the 65.2 million people who make up Generation X (born 1965-1980), and the total number of presbyopes requiring vision correction will increase substantially.1,2 With today’s presbyopes comprising 58% of the workforce (25% Baby Boomers and 33% Gen X) and 65% of Boomers planning to work past age 65, the robust visual needs of this high-performing group have never been greater.3

A recent consensus publication, “Classification of Presbyopia by Severity,” graded presbyopia according to mild, moderate, or advanced severity.4 These levels directly relate to the accommodative reserve of the lens and refer to lenticular dysfunction. The presbyopia panel proposed that “the required add power for the distance-corrected eye to produce functional near vision is the best means of classifying presbyopia by severity” regardless of age, with mild presbyopia requiring ≤+1.25D add power, moderate presbyopia requiring between >+1.25D and +2.00D add power, and advanced presbyopia requiring >+2.00D of add power.

All presbyopic correction methods have pros and cons. More than 33 million Americans self-prescribe over-the-counter (OTC) reading glasses, the most common solution for presbyopia.5 These patients lose the opportunity to discuss further treatment options with their doctors. Other options include prescription progressive or bifocal glasses, multifocal or monovision contact lenses, intraocular lenses (IOLs), including multifocal and accommodating designs, corneal procedures, including inlays and laser refractive procedures, and scleral surgical interventions. Future options may include antioxidant drops, which cleave disulfide bonds and restore lenticular elasticity.

As eyecare professionals address the challenges of fulfilling presbyopic visual needs, spectacle lens options are certainly the first line of defense and an essential complement to other forms of correction. Thanks to technological advancements, progressive lens designs have improved over the years to meet today’s high visual demands of transitioning among distance, intermediate, and near vision.

When progressive lenses were first available on the market in 1959, there were many inherent side effects, mainly peripheral distortions off the optical center of the lens, along with a limited range of quality vision. Patients struggled with adjusting their head position to find the “sweet spot” of best vision, and adaptation was challenging for many. Since its inception, progressive lens technology has continued to advance significantly with designs that, when properly fit, eliminate distortion, have larger areas of coverage to provide sharp vision at all focal points, and are widely available.

Improved optics in modern progressives also permit quick adaptation, allowing for enhanced visual performance with the multitude of digital devices that presbyopes use today. A 2021 study evaluated computer vision syndrome (CVS) in 69 presbyopic digital device workers with a mean age of 54.7 years old.6 More than 78% were ametropes, 65.2% had advanced presbyopia, and 56.2% used digital devices more than 6 hours per day at work. The prevalence of CVS after wearing progressive addition lenses (PALs) or occupational lenses for 3 months was reduced (68.1%, 33.3%, and 18.8%, respectively).

While progressive lenses are an excellent option for presbyopic patients, many people using other corrective options are unsatisfied with their current presbyopia correction choices. A recent study conducted via an online questionnaire evaluated the perceived impact of presbyopia on quality of life and the factors relevant to patients who were considering using presbyopia-correcting eye drops.4 One thousand adults aged 40-70 years old in a demographically balanced sample who were already using reading glasses, bifocal or trifocal glasses, or multifocal contact lenses to correct near vision were surveyed about presbyopia and presbyopia-correcting eye drops. Patients were given generic descriptions of the drops and their theoretical characteristics.

Survey respondents described their quality of life as being more affected by the loss of near vision (37%) than by arthritis (21%), high blood pressure (17%), hearing loss (16%), dry eyes (5%), or high cholesterol (4%). Interest in presbyopia drops was high across all demographic groups, with 88% saying they would “definitely” or “probably” try presbyopia-correcting drops if their eye doctor recommended them. Among the most motivated segments were artificial tear users (92% “definitely” or “probably”), IOL patients (91%), and contact lens wearers (89%).4 Those who wore reading glasses in addition to contact lenses were more interested than those who wore multifocal contact lenses.

To respondents, the most attractive feature of potential presbyopia eye drops was the improvement in near vision that matched eyeglasses or contact lenses and has a long effective duration with mild or infrequent side effects. The majority said they would use the drops daily (57%) or on weekdays (25%), with 17% expecting to be situational or part-time users. As clinical options for correcting presbyopia evolve, practitioners will have the flexibility to use multiple treatment options to meet a patient’s varied visual demands.

About half of presbyopes are nearly emmetropic, and presbyopia may be the first condition to motivate them to come in for an eye examination. Therefore, one benefit of presbyopic treatment drops is that they could drive patients into our practices to offer unparalleled opportunities for ocular and systemic health care.7

With multiple presbyopia treatment options, we can personalize the management strategy for each patient and customize options to fit their needs. More importantly, it is an excellent time for practitioners to lead the conversation on the increased risk of life- and sight-threatening conditions as patients age. Age-related macular degeneration is the leading cause of vision loss for those aged 50 and older, along with the increased morbidity and mortality from cardiovascular disease (increasing from 40% for people aged 40-59 to more than 70% for those 60-79 years old).8 Eyecare professionals can engage in timely discussions about the vital importance of a healthy lifestyle and diet.

Modern presbyopes lead demanding lives with high visual demands at all distances. Computer and digital device use has changed how we view the world and contributes to patients noticing symptoms of presbyopia earlier in life. Proactive discussions about presbyopia are essential, even years before the condition’s onset. It is critical to educate patients that there are many options to correct presbyopia, including progressive lenses, contact lenses, and pharmaceutical and surgical options. Just like having multiple pairs of shoes, it is possible to have different management options for different situations. Early diagnosis, education, and implementation of customized treatment plans are the keys to better outcomes. The presbyopic years bring more than just the opportunity to efficiently correct near blur; they highlight the critical role that primary eyecare providers play in educating patients about their overall well-being. Eyecare providers are at the forefront of helping presbyopes lead full, healthy lives while preserving their precious sight. ■


  1. Fry R. Millennials overtake Baby Boomers as America’s largest generation. Pew Research Center website. April 28, 2020. Accessed April 2, 2022.
  2. Neufeld D. There are 1.8 billion millennials on earth. Here’s where they live. World Economic Forum website. November 8, 2021. Accessed April 2, 2022.
  3. Generational differences in the workplace. Purdue University Global website. Accessed July 1, 2022.
  4. McDonald MB, Barnett M, Gaddie IB, et al. Classification of presbyopia by severity. Ophthalmol Ther. 2021;11(1):1-11.
  5. Barnett M, Jasper A. Patient motivations and expectations for presbyopia-correcting drops. Poster presented at: Annual meeting of the American Academy of Optometry; November 4, 2021; Boston, MA.
  6. Sánchez-Brau M, Domenech-Amigot B, Brocal-Fernández F, et al. Computer vision syndrome in presbyopic digital device workers and progressive lens design. Ophthalmic Physiol Opt. 2021;41(4):922-931.
  7. See the full picture of your health with an annual comprehensive eye exam. American Optometric Association website. Accessed May 20, 2022.
  8. Yazdanar A, Newman AB. The burden of cardiovascular disease in the elderly: morbidity, mortality, and costs. Clin Geriatr Med. 2009;25(4):563-577.