Imagine this: A 45-year-old patient presents as a new patient complaining of near vision changes: “My vision was always great,” the patient tells you, incredulously, “but now to read a book or menu and look at my phone, I have to extend my arms. What’s going on?” Given that an estimated 128 million Americans older than age 45 have presbyopia,1 and that roughly 60% of the country is comprised of those 44 and older2, this scenario is likely not so hard for the primary care optometrist to imagine.
What can be hard, however, is explaining to these patients why their vision has changed and what they can expect from the available presbyopia treatment options.
The good news? Four optometrists who see many of these patients have got you covered with successful patient-facing scripts. These ODs: Roya Habibi, of Tamarindo, Costa Rica (and Optometric Management’s “Presbyopia” columnist), Jacob Lang, of Stillwater, Minnesota, Justin Schweitzer, of Sioux Falls, South Dakota, and Jessilin Quint, who practices at a multilocation practice in Maine.
Pro tip: Save chair time by asking the patient what their visual goals are, as their answer will reveal both an early option to discuss and the direction for your targeted outcome, say Drs. Lang and Habibi.
The Presbyopia Diagnosis
Dr. Schweitzer: “Our eye contains a lens that helps to focus light to help us see. Over time, it becomes less flexible. As a result, we start to notice that our up-close vision isn’t as good as it was. The medical term for this is ‘presbyopia,’ and I want to ensure you that it is a normal process that everyone undergoes. Additionally, several options are available to treat it, but it’s important you understand that none of them will provide you with the exact vision you had before your lens started to become less flexible.”
Dr. Quint: “As we have more birthdays, our up-close visual demands start to change. This is called presbyopia and it eventually happens to everyone. That said, several options are available to treat it. To manage your expectations, I need to tell you that none of the options available are going to allow you to see like you did when you were 20, but you and I can figure out which one or more options are going to make you happy.”
Spectacle Lenses
All those interviewed say they discuss progressive lenses with new-onset presbyopic patients because these patients typically don’t want to have lines in their lenses unless that’s their only option due to issues, such as vertigo.
Dr. Lang: “Lenses called ‘progressives’ enable you to see clearly at every working distance because they include multiple powers. Because of this feature, items may look a little different, especially in your peripheral vision and toward your feet, and therefore, require a period of adaptation. Essentially, you have to learn where to look and how to position your head to get the maximum vision out of these lenses.”
Dr. Habibi: “The modern progressive is excellent, but it is a new visual experience considering the layout of the lens. To succeed, you must practice using it correctly and give your brain time to learn how to see through the lens. You’ll need to allow your eyes some time to adapt. There is a bonus to using these lenses, because they encourage good posture for them to work. Previously you would just look around at what you are seeing, but when looking at your phone with your new lenses, you won’t tilt your chin down, you’ll actually look down with your eyes.”
Dr. Quint: “Progressive lenses will enable you to see most items clearly, as they contain several prescriptions in one lens. You might experience certain instances where a separate pair of glasses, such as computer lenses, will be needed to achieve clearer vision. Because progressives contain several prescriptions in one lens, it’s going to take roughly 2 weeks for your eyes to adapt to looking through the different portions of the lens. Headaches and items appearing as if you’re looking through a fishbowl are normal during this period of adaptation.”
Contact Lenses
Dr. Lang: “Contact lenses are available that con-tain more than 2 prescriptions, and in something called monovision. The former options require you to give up a little crispness in the distance, but they boost your near vision. The latter is where one lens provides distance vision and the other lens provides near vision. There is usually a bit of a time commitment in determining which option is best for you, and you’ll need to learn lens insertion, removal, and handling, which my staff can help you with.”
Dr. Habibi: “While progressives have a large amount of real estate to see well, contact lenses have multiple prescriptions packed into a very small space. If your vision is an A+ in glasses, expect a B+/A- in contact lenses. There are different ways we can go about correcting the vision based on your goals, but as long as your expectation is right, you’ll end up very happy with your contact lens option. Regardless of the method used, be patient and give your brain some time to adapt to them.”
Dr. Quint: “In addition to glasses, contact lenses are available that can give you near and distance vision. There are 2 choices here: a multifocal contact lens, which provides both types of vision in each lens, and a monofocal contact lens, which provides the near prescription in one lens and the distance prescription in the other lens. I typically prescribe a multifocal because my personal belief is that if we can have both eyes seeing distance and near, you’ll experience better overall depth perception and adaptation to the vision the lens provides. I typically reserve monovision for patients who either have high astigmatism, which is a condition that causes distorted or blurred vision, or in patients whose prescriptions don’t fit with the available multifocal options.”
Intraocular Lenses
All the ODs interviewed here stressed the importance of both assessing the health of the ocular surface and treating the presence of dry eye disease (DED) before acquiring biometry readings and having the patient undergo cataract surgery. Their reasons: DED worsens visual acuity and can exacerbate the temporary ocular dryness that can occur postoperatively.
Dr. Lang: “There is something called an intraocular lens that will replace your natural lens via a surgical procedure an ophthalmologist will perform. This lens is available in a multifocal prescription, which will enable you to see at varying distances. There is also a lens available in a monofocal, where one lens will provide you with near vision and the other lens will provide you with distance vision. To determine the best lens for you, do you want to see as perfect as possible for faraway things, for up-close things, or do you want to have a range of vision?”
Dr. Quint: “A successful cataract surgery is removing the cataract and returning you to the vision you had before your cataract with a replacement lens called an intraocular lens. Since you have presbyopia and you’ve never worn glasses or contact lenses before, I’m thinking you may want to opt for a multifocal replacement lens. This lens will provide you with a range of vision and can cause glare and halos, which most patients are not bothered by.”
Dr. Schweitzer: “If we decide to do a diffractive implant, like a trifocal implant, you can expect to do about 90% of the things you want to do in life without glasses: You may be able to drive, you’re going to be able to look at a computer, read a menu, and look at your phone. What I would expect you won’t be able to do with this implant is be able to look at tiny print on the back of a medicine bottle or tie a fishing lure. Something else to be aware of: Multifocal implants can cause some glare and halos especially at night.”
Refractive Lens Exchange
Dr. Lang: “Lens implants are available that enable you to see both far away and up close, but none of the ones currently available will restore your vision to exactly what it was. Additionally, you may notice more glare and halos around lights, especially at night, with these implants. The surgery to do so is proven safe, but as with any surgery, there are risks.”
Dr. Habibi: “Lens implants are available to replace your natural lens with your prescription via surgery. This option is technically cataract surgery… except you don’t have cataracts. So, while it is more invasive than LASIK or photorefractive keratectomy, it doesn’t change the corneal shape and, thus, can arguably be better in the long run if surgery is the route you want to go.”
Dr. Schweitzer: “If you’d prefer not to have glasses or contact lenses, a surgery is available to replace your natural lens with a multifocal or trifocal implant that’s more of a permanent fix that will provide you 90% of the things you want to do in life without glasses far away, intermediate, and up close.”
Presbyopic Drops
Dr. Lang: “Eye drops are available that can temporarily boost your up-close vision. Patients who have used them usually notice a pretty good boost in their up-close vision that gets better with additional use and adaptation. These same patients have reported stinging or burning upon instillation and a slight headache when the drop activates the muscle to correct the presbyopia. Patients have also mentioned a bit of a dimming effect. These experiences are infrequent, but you should know about them in case you experience them.”
Dr. Habibi: “Eye drops are available that temporarily correct your presbyopia. They are a great option for a dinner party or a day out when you don’t want to have to wear glasses or contact lenses. While there are side effects, like discomfort with instillation and it’s a little harder to see at night time, this is a good option to use from time to time.”
Dr. Schweitzer: “These drops are a lifestyle, as-needed use type of drop. You could use them when you want to be able to be functional up close in a different way and there are times where you don’t need that functional vision. It’s an as-needed type of process.”
Being Transparent
“In being transparent about the options these patients show interest in and asking them how they feel about the characteristics of these options, we can arrive at a point where we will know where they are willing to compromise,” notes Dr. Quint. OM
References
1. American Optometric Association. AOA Focus: according to a recent American Optometric Association Health Policy Institute brief. For 128 million U.S. presbyopes, doctors of optometry can provide treatment options. https://www.aoa.org/news/clinical-eye-care/diseases-and-conditions/for-128-million-us-presbyopes-doctors-of-optometry-can-provide-treatment-options (Accessed June 16, 2025)
2. Statista. Population distribution in the United States in 2024, by generation. https://www.statista.com/statistics/296974/us-population-share-by-generation/ (Accessed June 16, 2025)