Refractive Surgery for Presbyopia

Presbyopia, also known as “age-related farsightedness,” typically appears between the ages of 40 and 45 and is caused by the progressive loss of elasticity of the crystalline lens, the eye’s natural lens.

This loss of flexibility makes it difficult to focus on nearby objects, often requiring the use of reading glasses or multifocal lenses.

Once presbyopia is established, it is very difficult to achieve a perfect solution, since the eye’s natural ability to accommodate has been lost.

However, there are several surgical and optical options that can significantly improve vision and reduce dependence on glasses, each with its own advantages, limitations, and varying long-term durability.

1. Monovision with Ablative Refractive Surgery (LASIK, PRK, or SMILE)

One of the most common strategies to correct presbyopia is monovision, where one eye is adjusted for distance vision and the other for near vision.

This can be achieved through different laser-based procedures:

• LASIK: Highly precise technique with rapid visual recovery.

• PRK: A safe option for thinner or slightly irregular corneas.

• SMILE(Small Incision Lenticule Extraction): A minimally invasive femtosecond laser technique that does not require lifting a corneal flap, preserving corneal biomechanics and offering excellent long-term stability.

Before surgery, a contact lens trial is performed to simulate the postoperative result.

This step is essential to determine whether the patient can comfortably adapt to a small difference in prescription between the two eyes.

Advantages:

Significant reduction in dependence on glasses.

Safe and precise procedures with rapid recovery.

Possibility of adjustment or reversal (in LASIK or PRK).

With SMILE, reduced postoperative dryness and a more comfortable recovery.

Limitations and Longevity of Results:

A slight loss of stereopsis (depth perception) may occur.

Over time, natural aging changes in the crystalline lens can lead to cataract formation, meaning the effect of ablative techniques is not permanent throughout life.

In such cases, the definitive treatment will be cataract or refractive lens surgery (phaco-refractive surgery).

These procedures can be safely performed from around age 40, following a complete ophthalmic evaluation.

2. Advanced Techniques: PRESBYOND® (ZEISS) and Equivalent Platforms (READ® by Alcon, Schwind, etc.)

Advanced presbyopia laser treatments have evolved considerably.

Examples include PRESBYOND® Laser Blended Vision by ZEISS, or its equivalent on the Alcon EX500 platform, known as READ® (Refractive Enhanced Aging Design), as well as other systems from brands such as Schwind.

These techniques modify corneal spherical aberrations to increase depth of focus, combining the principles of monovision with an optimized ablation profile that extends the range of clear vision without compromising visual quality.

Advantages:

Good vision at multiple distances (far, intermediate, and near).

No intraocular implants required.

Rapid visual recovery.

In expert hands, these techniques can offer excellent visual quality and a significant reduction in dependence on glasses, especially for patients with active lifestyles or demanding visual needs.

Limitations and Longevity of Results:

The concept is still based on an advanced form of monovision.

Some dependence on glasses for prolonged reading or very close work may persist.

As with any ablative technique, its effect may diminish over time due to natural lens aging.

With age, patients may develop cataracts, progressively reducing the effectiveness of the treatment.

In these cases, the definitive treatment will be cataract or phaco-refractive surgery.

These techniques are appropriate for patients aged 40 and above, provided preoperative testing confirms ocular health and refractive stability.

Another important limitation is cost, since each platform (such as PRESBYOND® or READ®) requires the acquisition of specific software licenses for the customized ablation algorithms that create multifocality and increased depth of focus.

In addition, it is recommended that corneal flap creation be performed with a femtosecond laser rather than a mechanical microkeratome, which further increases the final cost of the procedure.

3. Presbyopia Surgery with Intraocular Lenses (Phaco-Refractive Surgery)

Another option is intraocular lens surgery, also known as phaco-refractive surgery, especially suitable for patients with advanced presbyopia or early cataracts.

In this procedure, the natural crystalline lens is replaced with an intraocular lens (IOL) that corrects refractive errors.

Types of Intraocular Lenses:

• Monofocal Lenses: Provide maximum image sharpness for a single distance (usually far).

Reading or near vision still requires glasses.

Ideal for patients who prioritize maximum optical quality and wish to avoid visual side effects.

• Toric Monofocal Lenses: Correct significant regular astigmatism, offering clearer, more stable vision.

• Extended Depth of Focus (EDOF) Lenses: Provide good vision at multiple distances with excellent optical quality and minimal nighttime halos.

Represent an intermediate option between monofocal and multifocal designs.

• Multifocal or Trifocal Lenses: Offer maximum independence from glasses for distance, intermediate, and near vision.

However, they can produce halos or glare at night, especially during the initial adaptation period.

Advantages and Longevity of the Procedure:

Phaco-refractive surgery is a definitive and permanent solution, as it replaces the natural lens with an artificial lens that does not age.

Designed to last for the rest of the patient’s life.

A predictable, stable procedure with rapid visual recovery.

Typically recommended from around age 50, following a comprehensive ophthalmologic evaluation and complementary testing.

Limitations:

No surgical option is perfect — each lens type involves a trade-off between optical quality and spectacle independence.

Monofocal lenses provide the best image quality and contrast, but they do not restore near vision, so reading glasses are usually needed.

EDOF and multifocal lenses offer greater freedom from glasses, but may cause nighttime halos or glare, which some patients find bothersome.

In rare cases, a secondary laser enhancement or fine refractive adjustment may be required to optimize the final result.

Personalized Evaluation and Surgical Expertise

Each case of presbyopia must be evaluated individually, taking into account:

Visual needs (reading, computer use, night driving).

Profession and daily activities.

Personal tolerance to monovision or to optical phenomena associated with premium lenses.

In my practice, I perform all available techniques, from the most advanced laser-based options (such as SMILE®, PRESBYOND®, or READ®) to premium intraocular lens surgeries (monofocal, EDOF, and multifocal), always seeking the ideal balance between visual independence and optical quality.