Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)

Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) PRESBYOPIA This section’s objectives are: Relate the presbyopia to age, symptomology, and visual needs of the subjects. Present some of the methods most commonly used clinically in order to determine the necessary prescription in presbyope people.. This section is structured for: 2 hours of theory 1 task to be done outside of the classroom It does not present directly associated practice. It does recommend, simultaneously, that the students continue practicing clinical techniques of refraction.

Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) PRESBYOPIA: PROGRAM

Presbyopia: program Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Definition The start and influential factors Symptoms and signs Determination of the addition Prescription Resolution of clinical cases In the “Definition” and “The start and influential factors” sections, the goal is to refresh the student’s previous knowledge regarding the variation of the accomodative function with age, which has been touched on in previous modules. Consequently it does not need to be an attended class. Students can count on spending between 1 and 2 hours of work recovering their previous knowledge. We recommend that the students work in groups of 3-4, guided by the professor in the following phases: Recuperation of the previous information possessed from other courses Recommendation of the bibliography or some web pages on presbyopia An interview between each group and the professor in which the strong and weak points of the summary made up to that point will be detected. Elaboration along with necessary amplification for each group. Hand in a definitive draft of the work to the professor who can decide if it will or will not form part of the system of evaluation. A final draft to hand in indicating the quality of the work and the capacity of synthesis.

PRESBYOPIA: DEFINITION
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) PRESBYOPIA: DEFINITION

Presbyopia: definition
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: definition Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 The eye’s focusing power, which depends on the inherent plasticity of the crytalline, is lost gradually as we age. This provokes a gradual diminishment of the eye’s ability to focus on objects at near distances. Around 45 years of age, a person might realize that he/she needs to have reading material at a greater distance in order to focus on it better. Presbyopia presents itself in all people, though at different levels, as a normal consequence of aging.

PRESBYOPIA: THE START AND INFLUENCING FACTORS
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) PRESBYOPIA: THE START AND INFLUENCING FACTORS

Presbyopia: factors I Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 As has been mentioned, presbyopia ends up affecting 100% of the population, but at the start it is not the same for all of them. In the following slides some characteristics that will facilitate the student’s comprehension of the theme will be addressed. Concretely, reference will be made to: The age at which the presbyopia appears: normally, presbyopia appears between the ages of 40 and 50 years of age, but it depends on various factors The relationship between the accomodative capacity and the appearance of symptoms of presbyopia How habitual, near work distances and the visual needs of the person affect the appearance of symptoms of presbyopia The relationship between the refractive defect from far, the type of optical compensation, and the appearance of symptoms of presbyopia.

Presbyopia: factors II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: factors II Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Accomodative capacity of the person A method used to determine the amplitude of accomodation Intersubject variability Accomodation in comfortable vision The accomodative capacity. It is true that there are charts depicting the expected normality of accomodative capacity according to age. It is also true that there is a wide range of variation between individual subjects. Thus, variations in the range of ±2,00 with respect to the expected values from Donders’ or Duane’s tables are accepted as normal. For example, if at 40 years of age the value of amplitude of accomodation in the tables is 6,00 dioptres, values between 4 and 8 dioptres are considered normal. In addition, the determined accomodation in a patient depends on the method used. It is accepted that the amp acc through the method using negative lenses, (Sheard’s method) can be 2 dioptres lower than the value determined using Donders’ method. Another concept to analyze is the “amplitude of accomodation in comfortable vision”. It is obvious that one cannot constantly be exercising the maximum accomodative capacity, since the symptoms of visual fatigue would appear rapidly. The majority of authors think that between 1/3 and 1/2 of the amplitude of accomodation should be maintained in reserve. In this chapter, being conservative, we will consider maintaining half of the amplitude of accomodation in reserve as advisable. Nevertheless, this does not have to be true for all people and it remains an agreement based on clinical experience but with variables between distinct subjects.

Presbyopia: factors III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: factors III Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Habitual, near work distance: Habit and anthropometric characteristics At the beginning a slight distancing of the material allows for comfortable vision Another factor that will determine the moment that presbyopia appears is the habitual, near work distance. It will depend on: The inertia of the person. Each individual has acquired over the years a customary and determined position and a habitual distance when reading or performing other visual tasks from near. The person’s height and the length of his/her forearms. It is logical to think that, as a general rule, smaller people present nearer work distances. Consequently, the accomodative demand is greater and the symptoms of presbyopia appear earlier. We also emphasize that the natural response when faced with the appearance of presbyopia is a slight distancing of the reading material. This natural defense also allows the subject to delay a visit to a vision specialist for a few months.

Presbyopia: factors IV
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: factors IV Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) The visual demand at near distances: Does not diminish the accomodative capacity Can make the symptoms more severe. Many patients justify the appearance of presbyopia as the consequence of maintained use of near vision over the years. It is important to undermine this belief. Presbyopia appears independently of the use of near vision that the person has made. It is another issue that if a person reads or sews, for example, for several hours per day, the symptoms will be more severe than if the person only made exact use of their near vision.

Presbyopia: factors V Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Refractive error in DV: Myopia / Hypermetropia Use of glasses / Contact lenses The appearance of presbyopia also depends on the refractive error that a person presents and the type of correction that he/she utilizes. We must accept that an emmetrope, when looking at an object at 20cm, accomodates 5D. A corrected ametrope of up to 2-3,00 dioptrías, independently of being myope or hypermetrope, realizes a similar magnitude of accomodation. For individual myopes with a correction above 4-5 dioptres: When compensating in glasses the accomodative stimulus is less than for the emmetrope. Thus, in order to focus on the example object situated at 20cm, a myope of -10,00D requires an accomodation slightly higher than 3-3,50 dioptres When compensating through contact lenses, the accomodative stimulus is similar to that of the emmetrope. For hypermetrope individuals with a correction higher than 4-5 dioptres: When compensating in glasses the accomodative stimulus is superior to that of the emmetrope. Thus, in order to focus on the example object situated at 20cm, a hypermetrope of +10,00D requires an accomodation near 7 dioptres. When compensating with contact lenses, the accomodative stimulus is similar to that of emmetropes.

Presbyopia: factors VI
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: factors VI Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Nutritional and geographical factors Nutritional and geographical also influence the accomodative capacity: Inadequate hygienic and nutritional conditions contribute to the proliferation of illnesses that can make the metabolic function of the crystalline or of the Ciliary muscle more difficult, thereby affecting the accomodative process. Diverse studies have shown that in countries close to the equator, presbyopia appears at earlier ages. This discovery tends to be attributed to prolonged exposure to higher temperatures and to ultraviolet rays in the range of nm. Both factors do not have to be mutually exclusive, but, in fact, can be related.

PRESBYOPIA: SYMPTOMS AND SIGNS
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) PRESBYOPIA: SYMPTOMS AND SIGNS

Presbyopia: symptoms and signs I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: symptoms and signs I Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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) In the slide the characteristic symptoms of presbyopia are shown, assuming in all cases that the refraction in distance vision is perfectly compensated. It will not be difficult for the student to easily identify the symptoms and to understand the reasons behind them.

Presbyopia: symptoms and signs II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: symptoms and signs II Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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: The characteristic sign is a reduced amplitude of accomodation which allows the individual a comfortable way to complete habitual, near tasks. We must remember that there are various clinical methods to determine the amplitude of accomodation (that have been addressed in the module on accomodation); but that there are also some empirical formulas proposed by Hofstetter that can be of great use. It would be convenient to remember the usefulness of Hofstetter’s formula for the average expected amplitude of accomodation through some examples. In these examples, we will reinforce the concept that the amplitude of accomodation implies that the refractive defect is appropriately compensated. Some examples are presented in the next slide. Clearly similar examples can also be found in the Hypermetropia theme. Average amp acc = 18,5 – age x 0,3

Presbyopia: symptoms and signs III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: symptoms and signs III Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Examples: Averageexpected amp acc = 18,5 – age x 0,3 Amo Acc Average Ano Acc Comfortable 16,5cm -2 sc 50 15cm -4 sc 55  +4 cc 60 25cm -1 cc 45 Observations Amp Acc Real NPA Rx Age In these examples: Rx: refraction in DV. It is possible that: NoC: without correction: does not wear the Rx in DV at the time of the test C: with correction: does wear the Rx at the time of the test NPA: Near point of accomodation determined using the Donders’ method (push-up). The use or not of the Rx will influence the results. Amp acc real: Individual’s amplitude of accomodation. To determine the amplitude of accomodation, whether or not the subject is wearing the refraction for DV must be kept in mind. Amp acc comfortable: we have used, as reference, ½ the value of the amp acc. Amp acc Average: value of the expected amp acc for the age according to Hofstetter’s formula. It would be appropriate to put the exercise in front of the students and allow them 15 minutes to discuss and resolve in groups of 3 or 4.

Presbyopia: symptoms and signs III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: symptoms and signs III Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Averageexpected amp acc = 18,5 – age x 0,3 Examples: 3,50D 2,00D 0,50D 5,00D Amp acc Average 2,00 1,33D 0,00D Comfortable Amp acc normal for the age. NoC can see between 16,5 and 50cm approx. 4,00D 16,5cm -2 sc 50 NoC can see between 15 and 25cm approx. 2,66D 15cm -4 sc 55 Amp acc normal for the age. Has absolute presbyopia  +4 cc 60 Amp acc is normal for the age. Will have presbyopia if the habitual work distance is <50cm approx. 25cm -1 cc 45 Observations Real NPA Rx Age Resolution of the previous exercise.

PRESBYOPIA: DETERMINATION OF THE ADDITION
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) PRESBYOPIA: DETERMINATION OF THE ADDITION

Presbyopia: determination of the addition I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Presbyopia: determination of the addition I Trial method Amplitude of accomodation method Cross-cylinder (near) method Bichromatic test method Age method There are various methods to determine the addition in a presbyope and some of the most useful are named in the slide. Below each of them is addressed. We only comment in a general way for all of them that, as will be shown in the slides, we can: Begin the exam in a monocular way: first in the RE (with LE covered), later in LE (with RE covered) and finally in the binocular way. If this procedure is realized and the resulting additions in RE and LE are different: Try to equalize the addition in both In cases of marked difference between both eyes: think, as the first option, that the subjective exam in DV was not properly realized. The amplitude of accomodation is different in both eyes in very few cases. It could be due to a monocular ocular pathology or to a case of amblyopia. Even in these cases the most appropriate action will be to give the same addtion to both eyes. The exam can be realized from the very beginning in binocular conditions. For many authors, this option is the most advisable since it lessens the accomodative demand, habitual conditions are respected, and it provides additions to a lesser extent. Upon finishing the exam, no matter which method was used, a test to run through and check up on the clarity of vision should be realized, as well as an evaluation to ensure the person’s visual needs have been met.

Presbyopia: determination of the addition II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: determination of the addition II Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 The trial method consists in adding positive lenses on the refraction of DV until the patient mentions good comfort at his/her habitual distance in NV. Important: The refraction of the DV must be correct The person performing the test should ask the patient about his/her habitual work distance. Good lighting on the reading material It can be done monocular or binocularly. Adding positive lenses in steps of small magnitude until the patient mentions clear and comfortable vision of the reading material. Test finally, as will be indicated a bit further on, a check for clear vision.

Presbyopia: determination of the addition III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: determination of the addition III Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 The amplitude of accomodation method consists in determining the amplitude of accomodation and in calculating the necessary addition for the habitual work distance, accepting that the person will work comfortably if only using half of his/her accomodative capacity. Important: The refraction of DV must be correct Good illumination of the reading material when determining amplitude of accomodation It can be done monocularly or binocularly Ask the person about his/her habitual work distance in NV (dt). Determine the accomodative demand: value, in dioptres, of his/her habitual dt. Test lastly, as has been indicated previously, the functional clarity of vision.

Presbyopia: determination of the addition IV
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: determination of the addition IV Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 The cross-cylinder method from near consists in putting a cross-cylinder in front of the eyes that provokes formation of Sturn’s conoid. After that, the necessary positive lenses are put in front as well in order to situate the circle of least confusion on the retina. Important: The refraction of DV must be correct Situate the grid test at 5 arms at the person’s habitual work distance. The illumination during the test must be dim (around 20 lux). It can be done monocularly or binocularly. Put the cross-cylinder with the negative axis at 90º in front of the person. Given that the person is appropriately compensated for DV, this will provoke Sturn’s conoid with less focal distance for the image of the horizontal lines. Since this person is presbyope this image will form behind the retina. The objective is to put the necessary positive lenses in front of the person in order to supplant the conoid and situate the circle of least confusion on the retina. In this moment, the subject will indicate that he/she sees the vertical and horizontal lines equally clearly. Test lastly, just as mentioned before, functioning clarity of vision.

Presbyopia: determination of the addition V
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 The bichrome method is based on the same principle, and is done in an analogous way, as that explained for refining the sphere in the chapter on the subjective exam from distances. Important: The refraction of DV must be correct Keep the bichromatic test of NV at the patient’s habitual reading distance. Good lighting. It can be done monocularly or binocularly. Given that the person is presbyope, he/she is always expected to indicate better vision on the green background. After that, positive lenses are added until achieving clear and similar vision on both backgrounds. Test lastly, as has been indicated before, functioning, clear vision.

Presbyopia: determination of the addition VI
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: determination of the addition VI Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 The age method is based on the examiner’s experience in order to determine an approximate value of addition. In the next slide, some examples of tables with the expected addition according to age are shown, but all of the factors mentioned at the beginning of this chapter must be kept in mind. Point out, perhaps, that the habitual work distance, as well as geographical factors, will modify the results in a substantial way. Important: The refraction of DV must be correct Good lighting on the reading material. Depending on the experience or the existing tables, choose the addition that seems most appropriate for the person’s age and his/her habitual work distance from near. Place this test lens and realize the necessary adjustments with lenses of ±0,25D It can be done monocularly and/or binocularly Make sure at the end, as has been previously mentioned, to check for clear, functioning vision.

Presbyopia: determination of the addition VI
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: determination of the addition VI Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) The age method: The tables can vary according to geographical zone Table proposed by Borish (1970)) Empirical table in Spain In the slide, some tables with the expected value of the addition for NV depending on the age of the presbyope patient are shown.

Presbyopia: determination of the addition VII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: determination of the addition VII Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 At the end, emphasize that, utilizing any of the methods listed, an approximate addition is determined, since a check of the comfortable and clear vision still needs to be done, as well as any small binocular variation that might be necessary. It is advisable to place the addition in the trial frames so the patient can test the range of focalization that will adequately cover his/her visual needs. Thus, for example, with a person with a habitual work distance of 40cm we may observe a maintenance of satisfactory vision from 33 to 60cm, but when said person raises his/her vision to speak with us, it is not completely clear. Equally, he/she will see the test of AV in DV as out of focus. This practice is very advisable so that the patient understands what presbyopia means and that the graduation for DV and NV cannot coincide. It is also advisable to explain to the patient that, starting with a new graduation with presbyopia, he/she will see very well up close, but after 2-3 years the symptoms in NV can recur and it will be necessary to realize a new graduation with a slightly higher power. We can also explain to the patient that, in time, the graduation for near vision will stabilize.

PRESBYOPIA: PRESCRIPTION
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) PRESBYOPIA: PRESCRIPTION

Presbyopia: prescription I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: prescription I Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) It is important to determine the best form of compensation for the person’s visual needs: Monofocal in NV Bifocal Progressives Occupational lenses These are the greatest challenges in prescribing for presbyope patients: Adequately determining the necessary addition for each individual, depending on the habits and visual demands. We have been addressing this in prior points. Finding the best form of optical compensation, remembering that the graduations necessary for DV and NV are different.

Presbyopia: prescription criteria I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: prescription criteria I Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 Each of the options presented in the slide have their advantages and inconveniences and there is no perfect solution for all people. We should make assesments, depending on the characteristics of their visual demands, in order to find the best solution for each particular person. On some occasions, one solution will not be sufficient and different situations can require different solutions. In the slide, a summary of the characteristics of the possible forms of optical compensation are shown. For a more in depth analysis of these characteristics, consulting the section dedicated to optical technology is suggested.

Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) PRESBYOPIA: CASES Next, two cases with presbyope patients are investigated. The objective is to present the cases to the students and to allow them a period of 15 minutes during which they can try to resolve the issues shown at the end. Group work may be appropriate.

Presbyopia: case 1-I Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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. Some clarifications about the slide: JAR are the patient’s initials. Laws in existence to protect patients’ personal information prohibit revealing any patient’s name. MC: main reason for the consultation PH: personal history FH: family history

Presbyopia: case 1-II Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 Results of the first clinical exams realized. We observe: The patient wears glasses and the prescription seems to have been stable for several years. With her regular correction the AV in DV is good. Decrease in the AV in NV. This fact, the age of the patient, and the symptoms she has point to the appearance of presbyopia.

Presbyopia: case 1-III Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 Some comments on the contents of the slide: The values of the retinoscopy and the subjective are equal and indentical in their habitual prescription; in addition, the AV in DV is correct in both eyes. The addition has been determined and a check for clear vision from near has been done. A thorough check has been done and the patient’s habitual work distance is more or less in the central zone.

Presbyopia: case 1-IV Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Complete diagnosis of the case Proposed treatment and plan of revisions Possible evolution of the condition These are the issues that the students must try to resolve.

Presbyopia: case 1-V Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Complete diagnosis of the case Simple myopia in both eyes Presbyopia Binocularity: within normal limits Other tests are within normal limits The diagnosis is shown in the slide. Perhaps indicate that no special mention of the anisometropia has been made since a difference of graduation between both eyes of 0,50D is totally irrelevant. More tests of binocularity with the addition in NV could have been done, but it seemed more logical to wait for the patient’s vision to adapt to the new conditions. Also, the addition is of small magnitude.

Presbyopia: case 1-VI Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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. The proposed course of action is shown in the slide. Point out that the patient has been told the possible options: Monofocal in NV Bifocal Progressives But given that the blurry-vision-from-near problem is only noticed after minutes of maintained work, and that the patient can still realize brief tasks from near with the habitual glasses, we have opted for a monofocal for NV with an addition. It is important to emphasize that in time the symptoms will reappear and that a new prescription will be necessary for NV. Also emphasize the necessity for periodical check-ups.

Presbyopia: case 1-VIII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: case 1-VIII Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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. It is hoped that the refractive defect found in DV will not change in the next few years. The presbyopia will increase over the years until it eventually stabilizes.

Presbyopia: case 2-I Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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. Some clarifications about the slide: MPA are the patient’s initials. Laws in existence to protect patients’ personal information prohibit revealing any patient’s name. MC: main reason for the consultation PH: personal history FH: family history

Presbyopia: case 2-II Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 Results of the first clinical exams realized. We observe: The monocular AV is diminished as much in DV as in NV. This data points to the possible existence of hypermetropia and/or hypermetropic astigmatism, as well as presbyopia.

Presbyopia: case 2-III Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 Some comments on the contents of the slide: The values of the retinoscopy and the subjective are equal; also, the AV in DV is correct in both eyes. The addition has been determined and a check of the clarity of vision from near has been done. A thorough check is observed and the patient’s habitual work distance is more or less in the central zone.

Presbyopia: case 2-IV Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) Complete diagnosis of the case Proposed treatment and plan of revisions Possible evolution of the condition These are the issues that the students must resolve.

Presbyopia: case 2-V Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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 The diagnosis is shown in the slide. Perhaps indicate that there has been no special mention of the anisometropia since a difference of graduation between both eyes of 0,25D is totally irrelevant. More tests of binocularity with an addition in NV could have been done but it seemed more logical to wait until the patient’s vision adapts to the new conditions.

Presbyopia: case 2-VI Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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. The proposed course of action is shown in the slide. Point out that the possible options were discussed with the patient: Monofocal in NV Bifocals Progressives But due to the visual demands of his work we have opted for the use of progressives. It is important to emphasize that within a few years the symptoms can reappear and a new prescription may be necessary for NV. Also emphasize the need for periodical revisions.

Presbyopia: case 2-VIII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: case 2-VIII Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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. It is hoped that the refractive defect found in DV will not change in the next few years. The presbyopia will increase over the next few years until it stabilizes.

PRESBYOPIA: BIBLIOGRAPHY
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) PRESBYOPIA: BIBLIOGRAPHY

Presbyopia: Bibliography
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda) Presbyopia: Bibliography Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha) 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.

Presbyopia: web pages Asignatura Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)

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