Combining Options for Presbyopia

After age 40, the single pair of glasses or contact lenses you previously wore generally will no longer give you clear vision at all distances — or at least not without some compromises.

These vision problems are caused by presbyopia, which affects all of us beginning in middle age and reduces our ability to see at all distances.

Many vision correction options are available, such as presbyopia surgery and multifocal contact lenses or eyeglasses. If you need cataract surgery, you also have the option of choosing multifocal intraocular lenses to restore your ability to see at all distances.

In some cases, however, you may need to consider a combination of options to fully address problems caused by presbyopia.

If you're nearsighted, you have an advantage when you reach your 40s. Once presbyopia occurs, a nearsighted eye still sees well up-close — but only without the eyeglasses. Of course, with your glasses removed, distance vision is blurred. So you need to put your glasses back on to see something farther away.

The amount of nearsightedness you have determines how close or far you need to hold an item to see it clearly without your glasses on. If you are mildly nearsighted (with a prescription of -1.50 or -2.00 D, for example) you will see very well at a normal reading distance of 14 to 16 inches from your face. But if you're highly nearsighted (let's say -5.00 D or higher), you'll have to bring items much closer to your eyes to see them clearly. If that's the case, you may want to consider the next option.

Though it's certainly less convenient than wearing just one pair of eyeglasses with progressive lenses, bifocal lenses or trifocal lenses, many people over age 40 deal with presbyopia by purchasing two or more pairs of eyeglasses with single vision lenses. One pair can be prescribed for distance vision (driving, watching television, etc.) and a second pair with single vision lenses can be prescribed for computer work, reading and other near-vision tasks.

This option offers several visual advantages:

Depending on individual needs, some people find that using different types of lenses in eyeglasses is the best solution for presbyopia. For example, sunglasses with distance correction for nearsightedness might be considered for daytime driving and glasses with intermediate correction could be useful for computer work.

• Single vision lenses prescribed specifically for distance vision or near vision work better if you need to look upward or downward. If you've ever tried to sit back on your recliner or watch TV in bed while wearing eyeglasses with progressive lenses, you know that the near part of the lens interferes with your ability to see clearly across the room when your head is tilted back.
   
  Similarly, single vision lenses prescribed for near work are great for performing car repairs or other tasks where you need to see close-up objects above your head. So there's no need to crane your neck back or prop your glasses up to get into that near zone as you would with a bifocal, trifocal or progressive lens.
   
• Single vision lenses offer advantages for computer work or reading. Your eye doctor can customize the prescription for the exact working distance you prefer, and you get an unrestricted field of view at that distance.
   
  This is particularly important for sustained computer work, where standard bifocals and multifocal lenses (trifocal or progressive) can cause posture problems that contribute to computer vision syndrome.
   
• Multiple pairs of eyeglasses with single vision lenses enhance your peripheral vision and therefore your mobility. Particularly when you enter your 60s and 70s, normal, age-related changes reduce your peripheral vision, and progressive, bifocal and trifocal lenses can worsen the problem.
   
• Single vision lenses provide a wider zone of clear vision than progressive lenses, and they give you a much better view of your feet when you're looking down to step off a curb or onto an escalator or a flight of stairs. (It's very possible that some seniors who have fallen may not have done so had they been wearing single vision lenses.)

Even if you like wearing progressives, bifocals or trifocals most of the day, it's always nice to have a second pair of glasses with single vision lenses prescribed specifically for computer work or reading. Your eyes and neck will thank you!
 

If you wear contact lenses, a simple solution to restoring your near vision when you become presbyopic is to wear reading glasses with them. With this solution, there's no compromise in distance vision — just a need to lug around some reading glasses. Not exciting, but effective.

If you find you can't adjust to multifocal or bifocal contact lenses, this option may be best for you as a contact lens wearer with presbyopia.

Other combination options involving only contact lenses include:

• Monovision or modified monovision using contact lenses: Your eye care practitioner can advise you about the various types of contact lenses available for creating better near vision in one eye and distance vision in the other to compensate for focusing problems related to presbyopia. This approach creates monovision or modified monovision, depending on the type of lens used in each eye.

  Your doctor may choose to use single vision lenses for both eyes (monovision) or a multifocal lens on one or both eyes (modified monovision), with one lens "weighed" toward distance vision and the other for near. Though you still may need reading glasses on a limited basis, monovision or modified monovision contact lenses may give you better distance vision than multifocal lenses alone, while still providing adequate near vision for most of your routine daily activities.
   

• Different contact lenses at different times: Regardless of which contact lens option you choose, you may have the greatest success and satisfaction if you use different options at different times. For example, for that round of golf, regular (full distance correction) contact lenses on both eyes will give you the sharpest distance vision so you can enjoy your game. And in bright sunlight, your near vision should be adequate enough for you to see your scorecard without the need for reading glasses.

  But for dining out in the evening, you may find that monovision or modified monovision lenses are better because they eliminate your need for reading glasses to view a menu. These types of contact lenses also give you excellent vision across the table while providing comfortable distance vision for driving.

  Monovision doesn't work for everyone, however, so make sure you discuss these different scenarios and contact lens options with your eye doctor. Otherwise, you may find that having multiple contact lens solutions for different aspects of your life is the best option for you.
   

In some cases, a combination of surgical and non-surgical solutions is the best way to go when presbyopia sets in.

The most common combination solution is LASIK and reading glasses. Even if you have your LASIK surgery when you are in your 20s or 30s, you'll need those readers when you hit your mid-40s. Presbyopia spares no one!

Other combination options include:

LASIK can be used in combination with CK to create monovision for correcting presbyopia.

• LASIK with a single contact lens for near vision. This may be a good option for social events, where you want acceptable vision both far away and up close without having to carry your reading glasses with you.
   
  You'll be able to see in the distance with one of your LASIK-corrected eyes, while using the eye with the contact lens for near vision. This combination creates monovision. (One-day disposable contact lenses are great for this: you can just throw the lens away at the end of the night.)
   
• Monovision LASIK combined with single vision eyeglasses. Most people who have monovision LASIK (one eye corrected for distance and the other for near) benefit from eyeglasses with single vision lenses to enhance their near vision for close-up activities. Your eye doctor can prescribe lenses to balance the vision in your two eyes so they are both corrected for the same specific distance, such as the distance to your computer screen or to the novel you are reading.
   
  For the best results, measure how far away you like your computer screen, how far from your nose you are most comfortable holding a book when reading, etc. Take separate measurements for reading in your favorite chair and reading in bed — they will be different!
   
  Bring these measurements to your eye exam, and your doctor can tailor different prescriptions to optimize your vision for each activity. Though this may sound cumbersome, you'll find that the proper lenses will make reading and working on your computer less tiring and therefore more enjoyable.
   
• LASIK combined with wavefront eyeglasses. If after LASIK you are bothered by nighttime glare or halos around headlights and street lights, and your surgeon feels it's not in your best interest to have a second ("enhancement") laser surgery, a new eyeglass lens technology called wavefront lenses may be a good option.
   
  These lenses use computerized measurements of your eyes to detect any optical imperfections, called higher-order aberrations (HOAs), that remain after your LASIK surgery. Regular eyeglass lenses can't correct HOAs, but wavefront lenses can, and they may therefore be able to sharpen your night-driving vision. Ask your LASIK surgeon or eye doctor to tell you more about wavefront lenses.
   
• Multiple vision correction surgeries. Sometimes a combination of surgical procedures is the best choice for dealing with presbyopia. For example, if you had LASIK in your 30s, but now you're in your mid-40s and your near vision is getting fuzzy, PRK (photorefractive keratectomy) or CK (conductive keratoplasty) on one eye could help you see better up close by creating a monovision condition.

Corneal refractive surgeries like LASIK, PRK and CK can also be performed after cataract surgery to sharpen both your distance vision and your near vision. These follow-up procedures are especially helpful if some astigmatism remains after cataract surgery and you are a good candidate for monovision.

If you have cataracts, your eye surgeon may recommend one or more types of refractive intraocular lenses (IOLs) to restore your vision at all distances after cataract surgery. In some cases, a multifocal IOL that provides superior distance vision may be used for one eye, and one that provides better near vision may be recommended for your other eye.

If you are contemplating cataract surgery, ask your surgeon for more information about refractive IOLs and whether this "modified monovision" technique is a good solution for you. [Read more about mixing multifocal IOLs.]

Whatever choices you make, recognize that all presbyopia solutions involve some degree of compromise. No currently available corrective lenses or surgical techniques can completely restore the dynamic focusing flexibility your eyes had before presbyopia.

But that doesn't mean you have to subscribe to a one-size-fits-all mentality. Being adaptable is the key — and understanding that multiple solutions exist for all your over-40 vision needs. Your eyecare professional can help you decide which options are best for you.