Presbyopia is the progressive, age-related decline in the eye’s ability to focus on near objects, typically starting around age 40. This loss of near focusing power, known as accommodation, occurs as the natural lens inside the eye becomes less flexible and harder over time. While reading glasses are a common solution, ophthalmic surgery now offers several sophisticated, long-term options for patients seeking independence from corrective eyewear. These surgical approaches fundamentally alter the eye’s optics to restore a functional range of vision.
Corrective Procedures Targeting the Cornea
One category of surgical correction focuses on reshaping or modifying the cornea, the clear front surface of the eye, to adjust its refractive power. The most common technique is Monovision LASIK, a variation of standard laser vision correction. In this procedure, the dominant eye is fully corrected for clear distance vision, while the non-dominant eye is intentionally made slightly nearsighted for clear near vision. The brain then learns to seamlessly integrate the images from both eyes, creating a blended visual field for both far and near tasks.
Corneal Inlays are tiny devices placed within the corneal tissue of the non-dominant eye. Some inlays use the pinhole principle, creating a small central aperture that increases the depth of field by blocking unfocused light. Other inlays physically alter the central cornea’s curvature, inducing a slight steepening to enhance near focus. Refractive inlays are designed with a bifocal effect to split light for both distance and near vision.
Conductive Keratoplasty (CK) uses radiofrequency energy to strategically shrink collagen fibers in a ring pattern on the peripheral cornea. This shrinkage causes the central cornea to steepen, increasing its focusing power and creating a mild nearsighted effect. CK is typically performed on only one eye to achieve a functional monovision outcome. This procedure is generally reserved for patients needing a minimal boost in near correction who already have good uncorrected distance vision.
Corrective Procedures Targeting the Lens
A major surgical category for presbyopia is Refractive Lens Exchange (RLE), which involves replacing the eye’s natural lens with an artificial Intraocular Lens (IOL). This technique is nearly identical to cataract surgery, but is performed before a cataract develops, removing the clear yet non-flexible lens. Once the natural lens is removed, an advanced IOL is inserted into the lens capsule.
Advanced IOLs are available to specifically address presbyopia and restore a wider range of vision. Multifocal IOLs use concentric rings or zones to split light into two distinct focal points, providing simultaneous distance and near vision. Trifocal IOLs split light into three focal points to provide clear vision at far, intermediate (e.g., computer distance), and near ranges.
Extended Depth-of-Focus (EDOF) IOLs create a single elongated focal point to provide a continuous range of vision, primarily from distance to intermediate, with functional near vision. Accommodating IOLs are designed with hinges or moving parts that shift the lens position slightly in response to the eye’s focusing muscles, mimicking the natural process of accommodation.
Assessing Suitability and Candidacy
Determining the appropriate surgical approach requires a comprehensive assessment of the patient’s overall eye health and specific visual needs. A stable vision prescription is required, meaning no significant changes in corrective power for at least one year prior to surgery. The presence of other eye conditions, such as uncontrolled glaucoma, severe dry eye disease, or certain corneal irregularities, can disqualify a patient from corneal-based procedures.
The patient’s age and the condition of their natural lens influence the decision. RLE is often preferred for older patients whose lens is showing early signs of clouding or dysfunction. Lifestyle factors play a significant role, with high-demand visual activities like night driving or prolonged reading guiding the choice between a monovision outcome and a multifocal lens. Candidacy hinges on a realistic understanding of potential outcomes, ensuring expectations align with what the chosen procedure can deliver.
Expected Outcomes and Potential Tradeoffs
Both corneal and lens-based corrections aim to reduce reliance on glasses, but they come with different visual tradeoffs. Procedures that create a monovision effect, such as Monovision LASIK or CK, may result in a mild reduction in depth perception and binocular visual acuity. Patients undergoing RLE with multifocal or trifocal IOLs may experience visual phenomena such as nighttime halos or glare around bright lights.
These IOLs may also cause a mild decrease in contrast sensitivity, making fine details in low-light conditions more challenging. EDOF lenses are designed to minimize these visual disturbances but may offer less potent near vision compared to a dedicated trifocal lens. Regardless of the method, some patients may require an enhancement procedure or supplemental reading glasses for very fine print or highly demanding visual tasks.