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More than reading glasses — new options for ‘old’ eyes

The good news is that there are many ways to manage presbyopia

Perspective by Jill U. Adams for the Washington Post

July 17, 2022 at 7:18 a.m. EDT

The restaurant had tablecloths, low lighting and large, leather-bound menus with a fanciful script describing the fare. But these otherwise appealing features forced me to hold the oversize menu above the table at arm’s length to make out my choices. My table mates chuckled as they reached for their reading glasses.

Doctors call it presbyopia, a term rooted in Greek and meaning “old eye,” and it happens to everyone at some point. Some people notice their near vision starting to blur in their 40s, many of us experience this in our 50s and practically everyone deals with it after age 60.

“Your odds are 100 percent,” says Peter McDonnell, an ophthalmologist and the director of the Wilmer Eye Institute at Johns Hopkins University in Baltimore.

The good news is that there are many ways to manage presbyopia. But first, let’s see what’s happening in the eye to cause the blurriness.

Loss of elasticity

The lens of your eye sits right behind the colored iris. In young people, the lens is soft and flexible and able to change shape to switch one’s focus from far to near. As people age, however, “the internal lens loses its elasticity,” says ophthalmologist Brian Boxer Wachler, the founder of the Boxer Wachler Vision Institute in Beverly Hills, Calif.

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The change happens gradually, McDonnell says, and the process begins when you are still a young adult. People don’t notice until they’re in middle age because “we have accommodative reserve,” he says.

That means we start life with internal lenses so flexible that people can manage focus changes even after the stiffening begins. The age when people first experience vision changes varies a great deal and might be influenced by a person’s activities. For instance, people whose work requires close vision might notice their deficit sooner than those who don’t face such demands.

“We can compensate with things like long arms and large fonts,” says Karolinne Rocha, ophthalmologist at the Medical University of South Carolina’s Storm Eye Institute in Charleston. Rocha recently reviewed various treatments for presbyopia.

Working or reading in brighter light can help, too. “It’s giving more light to the retina at the back of the eye,” Boxer Wachler says. Bright light also causes the pupil to contract, fostering a pinhole effect, which reduces distortion by limiting your eyes to the straightest and most focused light rays.

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A grab bag of other lifestyle and environmental considerations: High contrast between text and page (or screen) aids reading as compared with yellowed pages or restaurant lighting. Fatigue plays a role; people may find it harder to focus first thing in the morning or when they’re sick. Distance matters, naturally, which means you might need those reading glasses when reading a novel but not when working at the computer.

What ‘cheaters’ do

There is a host of technological and medical fixes, too. Reading glasses, of course, also called “readers” or “cheaters,” are the first choice for many. They’re cheap, available at drugstores and come in a range of strengths. The ratings of +1, +1.25, +1.5 are in units of diopter strength. (Diopter refers to the focal length of a lens.)

McDonnell recommends trying on a few different-strength glasses and reading something — perhaps on your phone or in a magazine.

Choose the lowest reading power that allows you to focus while reading, Boxer Wachler says.

Presbyopia, Rocha says, “can be the first sign of aging for people with perfect vision.” Farsighted people might notice a need for reading glasses, while nearsighted people typically take off their regular glasses to read.

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If you already wear corrective lenses of some sort — glasses or contacts — you might consider bifocals or progressive lenses. These are lenses with distance correction at the top and reading correction on the bottom, allowing people to change their focus by adjusting the part of the lens they peer through.

Another option is the monovision approach. That means correcting one eye for distance (typically the dominant eye) and correcting the other eye for reading. It can take a little getting used to as the eyes and brain adapt to giving each eye a distinct job.

“In 90 percent of people that we test in the office, they adapt very well,” Boxer Wachler says. “In the other 10 percent, it doesn’t work.”

The eye drop alternative

An alternative to reading glasses or corrective contact lenses is prescription eye drops, sold under the brand name Vuity and approved by the Food and Drug Administration in 2021 for use. The drops, meant to be used once a day, contain a drug called pilocarpine that contracts the pupil to create the pinhole effect, limiting extraneous light rays from entering the eye with their extraneous information.

In studies, the drops were shown to improve near vision without affecting far vision for about six hours. Some people reported headaches as a side effect.

But the benefits were limited, Boxer Wachler says. Of those who used the drops daily for one month, 30 percent were able to read three additional lines of letters on a near-vision assessment chart.

“That means that 70 percent of people saw either no improvement or less than three lines improvement,” he says.

This modest effect might be most useful for people in the early stages of presbyopia, who don’t need much corrective help.

A second eye drop treatment, still under investigation, is purported to soften the lens itself.

Ophthalmologists might offer surgical procedures to fix presbyopia, such as corneal inlays, LASIK, photorefractive keratectomy and lens implants.

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If you experience changes in your vision, you can buy a pair of reading glasses. But McDonnell says it might be worth a visit to an eye doctor.

“When you start to reach the age of wisdom,” he says, meaning one’s 60s, it’s worth getting checked for other age-related eye conditions such as cataracts, macular degeneration and glaucoma. Eye doctors can help advise you about the many options for presbyopia.

It’s a universal problem that affects quality of life — a subject McDonnell studied some years ago. But with all the options out there, you should be able to customize a fix that works for you.