PRESBYOPIA

Presbyopia: prevalence,
impact, and interventions
Ilesh Patel Sheila K West
Research Fellow El-Maghraby Professor of Preventive Ophthalmology

Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University,
600 N Wolfe St, Baltimore, MD, USA.

Presbyopia is an age-related loss of lens The degree of presbyopia was determined as

accommodation that results in an inability to the minimum amount of plus lens needed to
focus at near distances. It is the most achieve the maximum improvement in lines
common physiological change occurring in read to the end point (N8).
the adult eye and is thought to cause universal Using this definition, the prevalence of
near vision impairment with advancing age. presbyopia in this population was found to
People who become presbyopic may be 62 per cent, with prevalence increasing
complain of headaches and eye strain, and with age.1 Age-adjusted data showed higher
hold objects progressively further away from prevalence among women than men. In
their eyes in order to be able to focus on multivariate analysis, women had 46 per
them. However, while objects may then be cent higher odds (odds ratio of 1.46) of
in focus, they may become too small to be being presbyopic. Women also had more
identified. The length of the arm also limits severe presbyopia than men across all
this compensatory mechanism. The most age groups. Secondary education and
common remedy is the prescription of a pair residence in town (as opposed to a village)
of reading spectacles. were also significantly associated with a
It is now increasingly recognised that higher prevalence of presbyopia. Only six per
presbyopia is an aspect of refractive error cent of the people with presbyopia in our are associated with earlier onset of
that needs to be addressed. Good near vision study had the spectacles they needed. presbyopia.11,12,13
is important, even among populations who A survey of ocular morbidity in rural In summary, the studies to date of
use it for tasks other than reading and writing. Ugandan adults found presbyopia to be the presbyopia in low- and middle-income
most common cause of visual impairment in countries suggest the following:
Prevalence that country for which treatment was
• more than half of adults over the age of 30
sought. Patients with uncorrected
The prevalence of presbyopia in low- and have presbyopia
presbyopia accounted for 48 per cent of
middle-income countries is not well known, as • women have both a higher prevalence of,
those presenting with visual impairment.2
most studies of refractive error in these and more severe, presbyopia
Morny, using hospital chart reviews,
countries have been limited to distance vision. • the majority of those with presbyopia do
found a prevalence of presbyopia equal to
There are few presbyopia studies that have not have corrective spectacles.
65 per cent in Ghanaian women.3
used a population-based approach, making it
In southern India, Nirmalan et al. used
difficult to draw conclusions about the preva- Impact
the same definition for presbyopia. They
lence of presbyopia in the general population.
found a prevalence of 55 per cent in people Presbyopia affects quality of life. This seems
Another major problem with research in
aged 30 years and older.4 As in our study, straightforward in high-income countries,
this area is that there is no universally
prevalence of presbyopia worsened with where reading and writing are the main near
accepted definition of presbyopia and no
increasing age. Female sex, rural residence vision tasks undertaken. For example,
standardised technique to measure it. The
(as opposed to urban), myopia, and McDonnell et al. showed that presbyopia
prevalence of presbyopia will therefore
hyperopia were associated with presbyopia. was associated with substantial negative
depend on how it is defined, for example,
A third of subjects with presbyopia were effects on health-related quality of life in a
the end point chosen and the distance at
currently using spectacles. US population.14
which near vision is tested.
Duarte et al. in Brazil estimated the However, it is a misconception to think
Some studies, however, including our own
prevalence of presbyopia in 3,000 adults of that presbyopia has no impact on quality of
study in rural Tanzania, can be used to construct
30 years and older at 55 per cent.5 Once life in populations where reading and
a picture of the prevalence of presbyopia in
again, age and female sex were associated writing are less a part of daily life, for
low- and middle-income countries.
with higher prevalence. In those who had example in the rural populations of low-
For our study (of people aged 40 and
near vision spectacles, 30 per cent had and middle-income countries.
over), we used the N8 optotype (1M or
corrections that were ineffective. A total of Our study in Tanzania showed that in rural
20/50 Snellen acuity) as the end point of
58 per cent of the sample reported requiring communities, where near vision tasks other
near vision testing. This was selected as it
near vision for their routine daily tasks. than reading and writing are predominant,
matched the type size for newsprint in the
Studies of hospital patients conducted uncorrected presbyopia had a substantial
country. We measured near vision by
in Africa showed a younger onset of impact on quality of life.15 We found that
placing the near chart 40 cm away from
presbyopia and more severe prebyopia than near vision was needed for winnowing grain,
the subject.
studies conducted in Europe and North sorting rice, weeding, sewing, cooking food,
We defined people as presbyopic if both
America.6,7,8,9 Pointer, in his clinic-based dressing children, and lighting and adjusting
of the following were true:
study, observed that presbyopia affected lamps. Almost 80 per cent of people with
• they were unable to read the N8 optotype women earlier than men.10 In addition, presbyopia reported having problems with
with distance correction in place, if needed several studies have correlated geographical near vision and 71 per cent were dissatisfied
• they were able to read at least one more variations in the age at onset of presbyopia with their ability to do near work.
line with the addition of a plus lens. with latitude and climate; hotter climates Good near vision is needed in many work-

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 Ilesh Patel
presbyopia require modest expertise and
can be undertaken independently of fixed
optical services. The ScoJo Foundation,
which works in Africa, Latin America and
Asia, has demonstrated a sustainable
model to distribute high-quality, low-cost
reading spectacles in rural areas. This
organisation trains women to start their own
small business to prescribe and dispense
presbyopic spectacles at low prices. Such
an approach can be an independent but
integrated part of a comprehensive eye
health solution, as it may be the first point of
contact for those with other eye problems
and could identify those in need of further
eye care services (see box on page 44).

The future
Further research should be conducted to
determine why women and persons who live
in urban environments have more
presbyopia. As low- and middle-income
Near vision countries undergo the demographic
testing in a rural transition towards an ageing population, the
community.
number of people with presbyopia will
TANZANIA
increase. The impact on quality of life for
older persons is now clear and presbyopia
should be part of the WHO refractive error
agenda. Clearly, presbyopia poses an
important public health challenge, because
related tasks. For example, research in India improvements in overall quality of life. An
it affects older people’s ability to maintain
showed that presbyopic factory workers were appreciation of the usefulness of having
their economic independence. We need to
less productive than their co-workers adequate near vision made subjects willing
start working towards effective solutions.
(personal communication with Praveen K to pay for spectacles and obtain replace-
Nirmalan, LV Prasad Eye Institute, ments if the need arose. A high proportion References
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