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PRESBYOPIA

PRESBYOPIA. PRESBYOPIA: PROGRAM. Presbyopia: program . Definition The start and influential factors Symptoms and signs Determination of the addition Prescription Resolution of clinical cases. PRESBYOPIA: DEFINITION. Presbyopia: definition .

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PRESBYOPIA

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  1. PRESBYOPIA

  2. PRESBYOPIA: PROGRAM

  3. Presbyopia: program • Definition • The start and influential factors • Symptoms and signs • Determination of the addition • Prescription • Resolution of clinical cases

  4. PRESBYOPIA: DEFINITION

  5. Presbyopia: definition • Difficulty focusing on objects because of an insufficient amplitude of accomodation for working comfortably in NV, supposing a well compensated refractive defect from far. • It is a normal physiological state due to the loss of the accomodative capacity with the passage of time. • The NPA moves away and the habitual work distance remains outside of the zone of comfortable and clear vision

  6. PRESBYOPIA: THE START AND INFLUENCING FACTORS

  7. Presbyopia: factors I • The age at which the presbyopia appears depends on: • The accomodative capacity of the person • The habitual work distance (near) • The visual demand at near distances • The refractive error • Nutritional and geographical factors

  8. Presbyopia: factors II • Accomodative capacity of the person • A method used to determine the amplitude of accomodation • Intersubject variability • Accomodation in comfortable vision

  9. Presbyopia: factors III • Habitual, near work distance: • Habit and anthropometric characteristics • At the beginning a slight distancing of the material allows for comfortable vision

  10. Presbyopia: factors IV • The visual demand at near distances: • Does not diminish the accomodative capacity • Can make the symptoms more severe.

  11. Presbyopia: factors V • Refractive error in DV: • Myopia / Hypermetropia • Use of glasses / Contact lenses

  12. Presbyopia: factors VI • Nutritional and geographical factors

  13. PRESBYOPIA: SYMPTOMS AND SIGNS

  14. Presbyopia: symptoms and signs I • Symptoms: • Blurry vision in NV • Distancing the reading material • Ocular fatigue • Headaches • In principle it can include blurry vision in DV (after working in NV)

  15. Presbyopia: symptoms and signs II • Signs: • Reduced amplitude of accomodation in order to work comfortably at the habitual reading distance. • The amplitude of accomodation is determined with the necessary refraction in DV and through any of these methods: • Methods (already seen) • Donders • Sheard • Hofstetter’s formula: Average amp acc = 18,5 – age x 0,3

  16. Age Rx NPA Amp Acc Real Ano Acc Comfortable Amo Acc Average Observations 45 -1 cc 25cm 60 +4 cc  55 -4 sc 15cm 50 -2 sc 16,5cm Presbyopia: symptoms and signs III Averageexpected amp acc = 18,5 – age x 0,3 Examples:

  17. Age Rx NPA Amp acc Real Amp acc Comfortable Amp acc Average Observations 45 -1 cc 25cm 4,00D 2,00D 5,00D Amp acc is normal for the age. Will have presbyopia if the habitual work distance is <50cm approx. 60 +4 cc  0,00D 0,00D 0,50D Amp acc normal for the age. Has absolute presbyopia 55 -4 sc 15cm 2,66D 1,33D 2,00D Amp acc normal for the age. NoC can see between 15 and 25cm approx. 50 -2 sc 16,5cm 4,00D 2,00 3,50D Amp acc normal for the age. NoC can see between 16,5 and 50cm approx. Presbyopia: symptoms and signs III Averageexpected amp acc = 18,5 – age x 0,3 Examples:

  18. PRESBYOPIA: DETERMINATION OF THE ADDITION

  19. Presbyopia: determination of the addition I • Trial method • Amplitude of accomodation method • Cross-cylinder (near) method • Bichromatic test method • Age method

  20. Presbyopia: determination of the addition II • Trial method • Patient with Rx in DV, test to 40 cm (or habitual distance of NV) well lit • Mono and/or binocularly • Cover LE and go on adding +0.25D in the RE until the patient sees clearly • The same for LE • Refine the result adding  0.25D binocularly

  21. Presbyopia: determination of the addition III • Amplitude of Accomodation method • Takes into account that 1/2 the amplitude of accomodation (amp acc) remains in reserve • With the adequate Rx for DV, determine the amp acc through the push-up method • Apply the formula: • Addition = 1/dt (m) - amp acc/2 dt = work distance • Example: • Amp acc=2D; dt= 33 cm • Ad=1/0,33 - 2/2= 2 D

  22. Presbyopia: determination of the addition IV • Cross-cylinder method from near: • Patient with Rx for DV • Dim lighting • Grid optotype at habitual distance in NV • Cross-cylinder with negative axis at 90°. Ask which lines he/she sees more clearly: • We hope they are the horizontal lines • Add positive lenses until verticle and horizontal lines are seen equally clearly • Can be done monocularly or binocularly

  23. Presbyopia: determination of the addition V • Bichromatic method: • Patient with Rx for DV • Bichrome test at the habitual distance in NV • Ask on which background the patient sees the letters more clearly • We hope it is the green background • Add positive spheres until he/she says “better on the red background” • Reduce positives until he/she sees equally in both eyes • In case of doubt allow slightly better vision in the red background

  24. Presbyopia: determination of the addition VI • The age method: • Empirical method based on clinical experience • Patient with Rx for DV • Reading test at a habitual distance in NV • There are approximated addition tables depending on age • Refine the result adding  0.25D binocularly

  25. Presbyopia: determination of the addition VI • The age method: • The tables can vary according to geographical zone Table proposed by Borish (1970)) Empirical table in Spain

  26. Presbyopia: determination of the addition VII • All of the previous methods are approximate • It is essential to make necessary adjustments with trial frames in a situation as similar to real life as possible • Demonstrate the steps of the accomodation check • Explain to the patient: • The need for distinct compensation in DV and NV • The expected evolution

  27. PRESBYOPIA: PRESCRIPTION

  28. Presbyopia: prescription I • It is important to determine the best form of compensation for the person’s visual needs: • Monofocal in NV • Bifocal • Progressives • Occupational lenses

  29. Presbyopia: prescription criteria I • Monofocal lenses • Useful for static, long-term tasks • The glasses should be taken off to see from distances • Bifocal lenses • For NV and DV • Inform about image jump and displacement • Progressive lenses • For DV, NV and intermediate distances • There are peripheral areas with optical aberrations • Very precise adaptation

  30. PRESBYOPIA: CASES

  31. Presbyopia: case 1-I • JAR, 46-year-old woman. High school teacher. • MC: Difficulty focusing on text in NV. Best vision when she distances the text. In DV she says she sees well with her glasses. • PH: Has worn glasses since the age of 9. No significant changes in the last 20 years. No illnesses or ingestion of medication. • FH: Unimportant.

  32. Presbyopia: case 1-II • Habitual Rx and AV in DV and NV: • RE: -4,50; 20/20; NV: 20/30 • LE: -5,00; 20/20; NV: 20/30-2 • Binocularity in habitual conditions: • Cover test: • DV: Ortho • NV: Low exophoria • Proximal convergence: 5/10cm

  33. Presbyopia: case 1-III • Retinoscopy: • RE: -4,50 • LE: -5,00 • Subjective DV and AV: • RE: -4,50; AV: 20/20 • LE: -5,00; AV: 20/20 • Addition in NV: +1,00; AV 20/20 in both eyes. Good comfort. • Vision check: from 20 to 60cm approximately • Ocular health exams: within normal limits

  34. Presbyopia: case 1-IV • Complete diagnosis of the case • Proposed treatment and plan of revisions • Possible evolution of the condition

  35. Presbyopia: case 1-V • Complete diagnosis of the case • Simple myopia in both eyes • Presbyopia • Binocularity: within normal limits • Other tests are within normal limits

  36. Presbyopia: case 1-VI • Proposed treatment: • A change to the prescription in DV is not justified. • An addition in NV of +1,00D is necessary. • After discussing the possible options, a monofocal for NV is decided upon: • RE: -3,50 • LE: -4,00 • Use for tasks in NV. • Show the patient that with them the vision in DV is inadequate. • Revision in 1½-2 or before if there are symptoms. • Explain the condition to the patient.

  37. Presbyopia: case 1-VIII • Possible evolution of the condition: • Stability of the refractive defect in DV • Need for a new graduation for NV in about 2 years due to increase in the presbyopia.

  38. Presbyopia: case 2-I • MPA, 52-year-old male. Taxi driver. • MC: When he wants to read for a while he notices blurry vision in NV even with his glasses. Greater difficulty in low lighting. • PH: Wears bifocals when working and for NV since he was 6 or 7. No illnesses or ingestion of medication. • FH: Irrelevant.

  39. Presbyopia: case 2-II • Habitual Rx and AV in DV and NV: • RE: +0,50; AV:20/25; NV: +1,75; AV: 20/30-2 • LE: +0,50; AV:20/25; NV: +1,75; AV: 20/40 • Binocularity in habitual conditions: • Cover test: • DV: Ortho • NV: Ortho • Proximal convergence: 10/15cm

  40. Presbyopia: case 2-III • Retinoscopy: • RE: +1,50-0,50x180º • LE: +1,75-0,25x180º • Subjective DV and AV: • RE: +1,50-0,50x180º; AV: 20/20 • LE: +1,75-0,25x180º; AV: 20/20 • Addition in NV: +1,75; AV 20/20 in both eyes. Habitual work distance: 45cm • Vision check: from 30 to 55cm approximately • Ocular health exams: within normal limits

  41. Presbyopia: case 2-IV • Complete diagnosis of the case • Proposed treatment and plan of revisions • Possible evolution of the condition

  42. Presbyopia: case 2-V • Complete diagnosis of the case • Low hypermetropis manifested in both eyes • Low, direct astigmatism in both eyes • Presbyopia • Binocularity: within normal limits • Other tests within normal limits

  43. Presbyopia: case 2-VI • Proposed treatment: • After discussing the possible options, progressives have been decided upon: • RE: +1,50-0,50x180º; Ad: +1,75 • LE: +1,75-0,25x180º; Ad: +1,75 • Habitual use. • Revision within 1½-2 years or before if symptoms reappear. • Explain the condition to the patient.

  44. Presbyopia: case 2-VIII • Possible evolution of the condition: • Stability of the refractive defect in VA • Need for a new graduation for NV in a few years due to slight increase in the presbyopia.

  45. PRESBYOPIA: BIBLIOGRAPHY

  46. Presbyopia: Bibliography • Amos JF. Diagnosis and management in vision care. Butterworth-Heinemann, 1987 • Milder B, Rubin ML. The fine art of prescribing glasses (2nd edition). Triad Publishing company, 1991 • Brookman KE. Refractive management of ametropia. Butterworth-Heinemann, 1996 • Werner DL, Press LJ. Clinical pearls in refractive care. Butterworth-Heinemann, 2002 • Eskridge JB, Amos JF, Barlett JD. Clinical procedures in optometry. Lippincott Co, 1991.

  47. Presbyopia: web pages • http://www.emedicine.com/oph/topic724.htm • http://www.emedicine.com/oph/topic699.htm • http://www.tarso.com/Presbyopia.html • http://www.nlm.nih.gov/medlineplus/spanish/ency/article/001026.htm • http://www.agingeye.net/otheragingeye/presbyopia.php • http://en.wikipedia.org/wiki/Presbyopia • http://www.eyetopics.com/articles/48/1/Presbyopia

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