It can be the bane of existence for those at midlife: the need to have reading glasses at the ready, particularly in darkened conditions like a dimly lit restaurant with a menu that lists dishes in type too small to decipher.
“Usually at around (age) 43 to 45, patients start noticing that they need to hold things farther out and they need more light,” says Dr. Daniel Durrie, clinical professor of ophthalmology at the University of Kansas Medical Center, and founder of Durrie Vision in Overland Park, Kan.
At the heart of this universal condition, known as presbyopia, is the lens in the eye. Our lenses naturally stiffen as we age, making it more difficult for them to change shape to focus on things close up. The stiffening is caused by “disulfide bonds” building up in the lens.
While the lens is still crystal clear at this point, the initial problem is getting it to focus for reading, Durrie says. This is known as stage 1 of dysfunctional lens syndrome. During stage 2, the lens begins turning yellow and gets a little bit hazy. By stage 3, the disulfide bonds build up so much, they block the light rays and cause a cataract, Durrie says.
Fortunately, for those in the early stages of presbyopia, there are a variety of options that can help minimize or even do away with the need for reading glasses. They include: corneal inlay devices; refractive surgery in one eye to help with reading and eye drop options now being tested in clinical trials that promise to temporarily enhance close-up work.
Pinhole Device Sharpens Vision
For patients with good distance vision who are frustrated by the idea of dependence on glasses for reading, a corneal inlay device in one eye may help provide near vision. Likewise, for those whose distance vision isn’t on par, it’s also possible to have that corrected first using refractive surgery, and then receive the inlay for near vision.
Currently, there is only one Food and Drug Administration (FDA)-approved corneal inlay: the Kamra (CorneaGen) inlay. This opaque, donut-shaped device is placed in the eye in front of the pupil, narrowing the pupil and producing a pinhole effect.
“What the Kamra does is it changes the optics of the cornea so that it’s like narrowing down the F-stop (aperature) in a camera,” Durrie says. “Any photographer would say, ‘Oh, that increases your depth-of-focus, so it gives you a better range.’”
The Kamra inlay is primarily for those whose lenses are just beginning to stiffen but are still clear, making it basically an option for people age 45 to 55. If the lens is already getting hazy, the Kamra inlay will only cut down further on the light, Durrie warned.
The Kamra inlay is placed in just one eye at a LASIK (laser-assisted in situ keratomileusis) surgery center in a 10- to 15-minute outpatient procedure. Unfortunately, neither Medicare nor private insurance cover this or other presbyopia procedures. Getting the inlay implanted in the eye costs around $2,000.
The ‘Blended Vision’ Technique
Another option for some patients may be “blended vision,” in which one eye is tweaked to allow for reading while the other is corrected for distance. In true monovision, one eye is fully corrected to see best for things near and the other completely for distance. With blended vision, there is less difference between the eyes, so the two prescriptions meld comfortably together. Durrie likens it to stereo music.
“In stereo music, everybody knows that the speakers are not playing the same song, but it sounds great,” he says.
The blended-vision correction, also known as mini-monovision, can be made with a laser procedure such as LASIK or PRK (photorefractive keratectomy), or with a technique known as SMILE (small incision lenticule extraction), says Dr. Richard L. Lindstrom, adjunct professor emeritus at the University of Minnesota in Minneapolis.
With LASIK and PRK, an excimer laser is used to reshape the cornea to let people read more easily. With SMILE, a femtosecond laser cuts a sliver of tissue beneath the surface, which is then removed through a tiny incision.
In some cases, this blended vision in which one eye is left slightly nearsighted, can provide patients with enough reading vision to make them happy, Lindstrom says. In other cases, however, this procedure may just be the first stage before implanting the Kamra inlay.
Lindstrom finds that the blended vision approach may work for patients up to about age 60. Even after this, it may be enough to give people good intermediate and distance vision and let them see their computer screen or their car’s dashboard.
Blended vision also is not covered by insurance. When done with LASIK, this runs about $1,950 per eye.
Eye Drops Being Tested
One non-surgical approach being tested in clinical trials is eye drops. There are two types of drops currently winding through the FDA regulatory process. Their availability is still several years out, and it’s too soon to tell what they will cost, but these could be a great option for people who want a less invasive solution.
“The first set of drops just make your pupils small,” Lindstrom says, adding that the drops employ the same principle of pinhole optics as the Kamra inlay to increase the patient’s depth of focus. The idea is to put the drops in both eyes to allow for better reading during a four-to-eight-hour period, he says.
Another type of eye drop aims to counteract the process that stiffens the lens, allowing it to be more flexible again. One clinical trial including 75 patients showed measurable improvement in near vision with this type of eye drop. Lindstrom expects those results could translate into about a five-year reduction in age for the eyes. So, if someone is 50, it will restore the eyes back to the way they were at, say, 45. However, it would actually take about 400 patients to confirm this, he noted.
“That would be very attractive; it would be like a fountain of youth for your eyes,” he says. Ultimately, in the end, all of these options can functionally help to turn back time.
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