A NEW PARADIGM SHIFT IN PRESBYOPIA: Part I. Managing Patients With Progressive Disease

DUE TO THE AGING OF THE population, most of our population will spend roughly half of their lives as presbyopes.1 The etiology of presbyopia has been poorly understood, and treatment options have failed to address the true issues with the disease, creating compromises in vision that patients are eager to find a solution for, not expecting to have their daily lives affected. There is both an overlooked etiology regarding the mechanism of presbyopia in the medical community, as well as a lack of awareness in the presbyopic population in general.

If we are to be successful in implementing presbyopic solutions that address the pathogenesis, onset, and progressive compounding of the clinical manifestations that accompany presbyopia, there must be an effort toward shifting the paradigm of education and awareness toward the real issues that provoke this elusive age-related disease. Furthermore, understanding its impact on functional vision and, most importantly, patient satisfaction, will motivate patients to seek presbyopia solutions other than spectacles, which is of utmost importance.

One important consideration in the development of a new paradigm for presbyopia education and awareness is understanding the motivation for choosing surgical or therapeutic solutions over “appliances” (reading glasses and contact lenses) to treat presbyopia. The loss of functional vision for near and intermediate tasks is generally perceived as a “normal sign of age.” Participant responses from a UK study demonstrated that not only is the deterioration of vision expected with age and accepted as “normal,” but reading glasses were also identified as the only expected mode of near vision correction.1 Alternatives are rarely known, let alone considered, especially for emmetropic presbyopes, who are rarely seen in ophthalmology or optometry practices since they typically have no purpose for utilizing these resources. In addition, the term “presbyopia” was not recognized by a majority of the participants, and most were not familiar with the symptoms or exactly what the condition was. In addition, more than two-thirds of the patients were unaware of any treatment solutions for presbyopia aside from reading glasses.1 The study breakdown showed that most of the participants were wearing reading glasses, and most participants also accepted that presbyopia was a “normal” accepted age-related condition. Surprisingly, despite 80% of participants being motivated to treat presbyopia due to cost over time and for convenience, almost 65% of the participants were reluctant to pursue surgical correction of presbyopia. Unlike distance correction solutions, patients were not as inclined to accept the current near vision correction solutions.1


Moreover, another study showed that there is an even poorer understanding of presbyopia interventions than of conventional cataract surgery.2 These data are strong indicators that there is a need for a paradigm shift in patient education and awareness, as well as among physicians in the management of presbyopia patients, to improve presbyopia interventions, patient expectations, and outcomes.

“Paradigm shifts” occur when situations or “anomalies” happen which no longer fit the expected pattern to such an extent that the original “paradigm” needs to be rethought.3 So far, we have failed to establish a working paradigm in the awareness, education, prevention and intervention of presbyopia as a disease process. To successfully invoke a paradigm shift, one critical factor to consider is the implementation of improvements in physician awareness of presbyopia as a disease process. Further education specifically related to the pathogenesis and nature of presbyopia development are never taught and reside outside the core education of optometry and ophthalmology training. This is especially true for those functions related to the laws of mechanics and specifically biomechanics. The recognition of the “act” of accommodation as a neuromuscular-driven biomechanical event is also paramount in recognizing the impact on not only the optical functions of the eye but also on the physiological and neurological processes that are affected by age.4

To date, “presbyopic solutions” have been “optically driven,” focusing almost entirely on vision correction by exchanging optics either at the cornea or at the lens. There has been no attempt to address the biomechanical dysfunction that occurs with the age-related changes that occur in the ocular connective tissues that impact the dynamic range of focus (DRoF) function of the eye. DRoF is the eye’s natural biomechanical ability to adjust the lens to focus at various distances, and it includes a visual adaptable change in the pinhole effect of the sphincter pupillae (pupillary muscle), accommodation, depth of focus, spherical aberrations, and higher-order aberrations.

The laws of mechanics have largely been ignored by the eye care industry, likely due to a lack of access to multidisciplinary knowledge. Moreover, stunted technological innovation in diagnostic devices, which would allow for simultaneous biometry and optical evaluation to further the evidentiary proofs in the field of accommodation biomechanics, are only newly emerging.5 These important constructs would finally allow clinicians to visualize the dynamic biomechanical movements, alongside the quantification of optical performance.

Further to this lack of visualization, wavefront aberrometry technologies are scant and are aimed at corneal or lens-based assessments, which are independent of one another and do not include the entire accommodative structures. In addition, they only measure that which can be viewed in the optical axis and are limited by the pupil size. This leaves 80% or more of the lenticular aberrations and biomechanics.5

Another fundamental component of the presbyopia conundrum is the progressive nature of the disease. Therefore, it is not only elemental, but necessary, to change the foundational constructs that guide the education, evaluation, and treatment conventions. Modification of the treatment paradigm, which works within this patient population wherever they are within the cycle of age, is essential. This is the most grossly overlooked key issue in realizing a model that applies to the presbyopia population from onset to maturity, evidenced by the lack of success thus far in addressing this market. The issue is further validated by the studies in this patient population, which have determined that the unmet needs of this population are largely due to a lack of health promotion and education about presbyopia.6 The loss of DRoF is progressive; therefore, our treatment paradigms must be dynamic in response to this phenomenon.

Another key component motivating a paradigm shift in this market is that patient expectations continue to be elusive due to the lack of awareness about today’s treatment regimens. The current thinking in presbyopia treatment is “near vision correction,” often referred to as “one and done” procedures. Given the progressive nature of presbyopia, managing the expectations of our patients has, not surprisingly, been largely unsuccessful to date.

Compounding these issues is that patient expectations are undoubtedly the most influential indicator of patient satisfaction, regardless of the success of “vision correction” outcomes.7 Healthcare utilization is determined by the need for care, by whether people know that they need care, by whether they want to obtain care, by whether care can be accessed, and with what solution at which timepoint.8

In addition, studies in other medical fields have shown that one of the most important determinants of patient satisfaction is patient education, while a lack of information is one of the most common sources of patient dissatisfaction.9 Therefore, it is essential to revisit the fundamental problems of presbyopia pathogenesis, as well as progression, to change patient education and awareness accordingly and build the necessary constructs to shift the paradigm to address the presbyopic disease process. ■


  1. Hutchins B, Huntjens B. Patients’ attitudes and beliefs to presbyopia and its correction. Journal of Optometry 2021; 14: 127-132.
  2. Masket S. Results from Independent Harris Interactive Poll. In: Annual Meeting of the American Society of Cataract and Refractive Surgeons. San Diego, CA, 2007.
  3. Kuhn TS. The structure of scientific revolutions. Chicago University of Chicago Press, 1970.
  4. Koshits IN, Svetlova OV, Egemberdiev MB, Guseva MG, Makarov FN, Kesada NMR. Theory: Morphological and functional features of the structure of the Zonula Lens Fibers as a key executive link in the mechanism of the human eye accommodation. Journal of Clinical Research and Ophthalmology 2020; 7: 061-074.
  5. Liang J, Grimm B, Goelz S, Bille JF. Objective measurement of wave aberrations of the human eye with the use of a Hartmann–Shack wave-front sensor. JOSA A 1994; 11: 1949-1957.
  6. Girum M, Gudeta AD, Alemu DS. Determinants of high unmet need for presbyopia correction: a community-based study in Northwest Ethiopia. Clinical Optometry 2017; 9: 25.
  7. Charman WN. Developments in the correction of presbyopia I: spectacle and contact lenses. Ophthalmic and Physiological Optics 2014; 34: 8-29.
  8. National Academies of Sciences E, Medicine. Health-care utilization as a proxy in disability determination. 2018.
  9. Pager C. Randomised controlled trial of preoperative information to improve satisfaction with cataract surgery. British Journal of ophthalmology 2005; 89: 10-13.