Explaining the ABCs of Presbyopia

Patients need to understand what is going on with their changing vision.

By David I. Geffen, OD

This issue of Advanced Ocular Care, with its Cover Focus on the latest technology and feature series on presbyopia in particular, offers articles on the latest advances and newest approaches. But before eye care providers can discuss these options with patients who are approaching or are in the throes of presbyopia, we have to be sure that they understand what the condition actually is. For many patients, we must explain presbyopia in the simplest, yet most accurate way possible, so that they can grasp exactly what is happening to their vision. Only then can they make informed decisions regarding how to deal with this new visual experience.

We have all heard the complaints and queries about developing presbyopia, often from individuals who have been our patients for many years. “If I’m nearsighted, how come I can’t see up close anymore?” And the classic: “I can still read the phone book, doctor, but my arms are not long enough.” And from those who may have undergone a previous refractive surgical procedure: “Doctor, my LASIK surgery was no good; it’s wearing off.”

When patients are just beginning to struggle with presbyopia and present with questions like these, how do we make the concept understandable? Do you have a preferred way of explaining the phenomenon of presbyopia? I have developed a few strategies that usually help to reassure and educate my patients entering their presbyopic years.


People are spending more and more time reading and looking at videos on their smartphones and tablets, as well as using standard desktop or laptop computers. Therefore, it is now common for individuals 38 to 42 years old to come into the office complaining of mild asthenopia. It is not that they are seeing poorly, but rather more that their eyes are tired.

I ask them, “It’s 3:00 in the afternoon; do you feel like your eyes are fatigued? Do you feel like you’re straining?” If they say yes, then I have to recommend something that will help them, and that is when the discussion of presbyopia begins.

To start the discussion, I use an analogy that I have found to be helpful. I say, “Imagine that you leave your house every day with a dollar to spend on focusing your vision. When you were 20 years old, you came home, and you still had 95 cents left in your pocket. But as you age, you start to spend more and more of that dollar each day. When you reach age 35 or 38, maybe you come home with 10 cents left. And then by around 40 years of age, that dollar is gone by 3:00 pm, and now you’re on borrowed time.”

That’s right: Just like in real life, the dollar does not go as far as it used to.

Patients seem to “get” this explanation. To make up for the 25 cents that they no longer have, they must replace it in some way. To replenish that energy, they need to spend on focus every day, they have to get it from somewhere, and that typically is some kind of correction, whether reading glasses, contact lenses, or a surgical procedure.


Once the concept has been introduced with the dollar analogy, we can explore the issue further with patients. Many patients have the idea that presbyopia is a muscle problem, but we explain that it is not. Rather, it is a hardening of the lens inside the eye. In the youthful eye, the ciliary muscle squeezes the lens, flattening it to focus light for near vision. But as we age, the lens hardens, so that the muscle can no longer exert enough power to flatten it and achieve that near focus. This is why the patient now needs our help.

We also explain that, as the patient is losing this ability to focus at near, the lens is also changing shape. It tends to swell a bit with age, and that swelling causes a shift in any existing distance vision prescription. For most people with myopia, this shift means a slight decrease in their nearsightedness. That is, not only are they losing the ability to focus at near, but also their distance prescription is changing, so things in the distance are more fuzzy as well. We explain to patients that, as part of the whole process of presbyopia progression, they will be coming back to the office more frequently to make prescription changes—not only to increase their reading add, but also to adjust their distance prescription.

And unfortunately, this process will continue for another 10 years. We tell patients that, because of the changes in their crystalline lens, they are going to have to change their contact lens or eyeglass prescription, possibly as frequently as every 4 to 5 months instead of every year as they may be accustomed to.


Most people grasp these explanations. They know they are not seeing well. They realize that something is happening, and their eyes are changing. They feel the headaches and eye strain, they sense the difference in close vision, they experience the difficulty of working 8 hours on a computer. The symptoms help them to grasp that things are changing, and something must be done.

So the motivation is there for newly presbyopic patients to try something to improve their vision and quality of life. They do not want things to continue as they are. Generally, therefore, patients tend to comply with a more frequent visit schedule to monitor the progression of their changing vision.

Fortunately, most people do not have rapid, dramatic shifts in their prescriptions. They can tolerate the changes for 6 to 12 months before they really start to feel the fatigue again and have to come in for an adjustment of their reading add or distance prescription.

As for that patient I mentioned earlier who thinks his or her LASIK is wearing off, that requires a separate discussion. I explain that, 6 months after LASIK, the surgery’s effect on vision is finalized. I say, “Your LASIK didn’t change, but your eyes changed. Your eyes are human tissue, and human tissue changes throughout life. This onset of presbyopia is one of the processes that your eye goes through. Your LASIK is fine.”


In my practice, I find that discussion and explanation, rather than videos or other educational aids, are the best ways to reach patients and explain the concept of presbyopia and what is happening to their eyes. Videos may work for some, but I find that they can complicate things instead of simplifying them, and patients often do not understand them.

Instead, I prefer to lay out my analogy and explain the basic concepts face to face. This allows patients to ask questions and follow up if there is something that is bothering them or that they do not understand.

As with many things in eye care, I find that patients are responsive to the personalized attention, and they appreciate the physician’s time and interest in their condition. Considering the fact that they will be saddled with the burden of presbyopia for the foreseeable future, it is worth investing the time to be sure they understand what is happening to their eyes.

David I. Geffen, OD, is a partner with Gordon Weiss Schanzlin Vision Institute in San Diego. Dr. Geffen may be reached at (858) 455-9950; dig2020@aol.com.